Successful Drug-Free Psychotherapy for Schizophrenia

Revella Levin

• Publisher: Routledge
• Year: 2018
• ISBN:
  9781351122290
• Edition: 1
• Topic: Psychologie
• Subtopic: Psychopathologie

Successful Drug-Free Psychotherapy for Schizophrenia offers a close examination of how to treat schizophrenic patients using psychotherapy rather than drugs, applying derivatives of psychodynamic principles in treating patients. The author provides real examples throughout of how therapists can resolve patients' emotional conflicts with better outcomes than by resorting to drugs. She presents methods that allow patients to avoid the neurological damage and obesity that can often result from the use of anti-psychotic drugs. The practical techniques and advice this book offers enable therapists to resolve the chaos of schizophrenia using psychotherapy alone. Theoretically, this book can also be useful for work with depressives.

1

Introduction

When I was 14, I was one of those fortunate people who knew what I wanted to do when I grew up. The story is rather amusing. A couple who were both social workers happened to be visiting at our home. They asked me what I wanted to do when I grew up. I said shyly, as adolescents sometimes do (surprisingly, I can still hear the sound of my voice in my mind when I said it), “I don’t know.” They persisted with “Well, what do you like to do?” I replied, “I like to figure out people and I like to help them.” They replied, “That is social work.” I said, “That’s a job?” I was very surprised and said, “Do you mean they pay you for that?” They laughed. From an emotional point of view, it took me many years to get over my surprise that I could be paid for doing something I would enjoy so much.

As the years went by, my interests gradually became more specific. But it was in my Master’s Rorschach class at City College of New York that I discovered exactly what I wanted to do. Again, I was fortunate because our professor was Ruth Monroe, the foremost expert in the city on Rorschach at that time. Near the end of the semester, she handed us the record of a hebephrenic, saying “I know you won’t be able to do the dynamics of this patient, but do the best you can.”

I read it, and, almost immediately, I felt I understood it. I was completely taken by surprise. But an argument started in my mind, “Ruth Monroe said it couldn’t be done. How come I did it?” Her assistant graded the paper with a “C,” writing “fancy.” But I knew I had something. I consulted a senior analyst and she told me about John Rosen, saying “He is a Freudian but he likes his patients.” I read his book and came to the conclusion that it wasn’t the Freudian approach that cured his patients but the fact that he really liked them. (I had been studying the neo-Freudians at that time, i.e., Horney, Fromm, and Sullivan. And we students used to make jokes about Freud.)

But I was fascinated and decided I wanted to work for Rosen as one of the assistants he used. I got an interview and, in a few months, I was called and driven to a rented house in Bucks County, Pennsylvania, with a patient. The patient was so sick that she couldn’t even form a coherent delusion. Again, fortune smiled on me. The psychiatrist fellow who was supposed to be in charge of her training with Rosen became ill, and I was put in charge of the patient. Rosen would come to visit three times a week to supervise my work. He was no feminist. I was expected to do four hours of housework and permitted to try to do therapy with my patient for another four hours. I was on duty 24/7.

I quickly learned that I had been wrong in assuming that his Freudian approach was irrelevant. My patient sounded, as I often said, as if she had read Freud in order to know the “correct” way to be schizophrenic. She was, as schizophrenics are, concrete. I had to learn the “language” in order to understand her and interpret so I would be meaningful to her. I came to call the language “schizophrenese.” And I learned it the same way I learned German or French. I would translate what she said in my mind into regular English, then translate my English response into schizophrenese.

Often, I would make incorrect interpretations and I would be ignored. It was frustrating but I would wrack my brain until I find a correct one, to which she would instantly respond. That, to me, is one of the exciting things about working with schizophrenics. With neurotics, one generally has to wait, and/or the response is more likely to be partial or ambiguous.

I should say at this point that Rosen was a very intuitive person but not a good theoretician. Fortunately, I am the reverse. So, we made a good team. What was truly remarkable about him is the respect he showed for patients. I remember the surprise I felt when I first heard him speak to my patient. He approached her with as much respect as if she had come to his Park Avenue office with an intestinal problem. Until I saw this, I had not realized with how much contempt people usually talk to schizophrenics. To him, patients were truly human.

To my surprise, he treated my amateurish attempts with respect. The approach he had written about when he had treated schizophrenics was that their problems began in the oral phase. But my patient, a post-partum psychotic who had majored in English in college, seemed to constantly offer anal material. Rosen did not dispute me, and allowed me to proceed as I had been doing. (Of course, as a beginner, I was not at all sure I was working correctly.)

During the six months I worked with Alice, I took full notes. Unfortunately, those notes were “stolen.” (I am sometimes shocked to think how naïve I was, as a young woman, that I would loan to someone what I now realize were terribly valuable notes.) But I have found a few notes that I took near the end that were separate from the lengthy, almost verbatim notes I had made through the treatment. I will offer a few of those notes that seem most instructive to me and some that I remember.

Alice was 5’8” and weighed 180 pounds (I was 5’4” and weighed 120). We kept her in a straitjacket for several months at first because when she first came into the house where we would live, she deliberately knocked a lamp over. Secondly, the precipitating factor had been that she had tried to kill her husband.

One summer day when she was much better, four months into the treatment, we felt that it was safe to let her out of the straitjacket. No one was in the house and the phone was out of order. She grabbed me and held me hard against her, with her hands over my wrists. I was startled. I spontaneously yelled “Alice!” We were near the back door. I thought I could certainly run faster than she could. I felt that if I pulled my hands down hard, I could get away and run to the village. But I feared that, standing next to the kitchen as she was, she might hurt herself with a knife. Further, four months of very intensive and valuable work would go down the drain.

Then, I remembered being told that if one was in trouble, one should kick the patient with one’s knee in the belly. But I couldn’t do that because Alice had me so hard up against her that I couldn’t get my knee up. Then, I also remembered learning one could make a transference interpretation, so I yelled as loud as I could without hostility “I am not your mother!” (One has to yell in order to overcome the noisy superego in the patient’s head.) She dropped her hands. We waited one hour till some men who lived in our house came home. (During that time, I suggested to her that she put her straitjacket on, which she used to feel comfortable in, but she refused.)

Needless to say, I did not risk any more interpretations till the men came home. But the incident had a salutary effect on me. First, I was angry with the more experienced men for having left me alone. But, prior to that, I believe I have always been more afraid of being hit than most people. Following that incident, I was never again afraid of being with a schizophrenic.

Of course, Alice was often verbally hostile. Indeed, once Rosen expressed concern about me for fear my feelings would be hurt because of it. But I knew it was only transferential hostility, so I had a firm conviction the hostility was not aimed at me. It belonged only to the transferential object. I replied honestly, “It’s like water off a duck’s back.” Indeed, that attitude must be firmly in the therapist’s emotional armamentarium, or the work will be erroneous, not to mention too painful.

People often ask me if my work is not depressing. My answer is, “On the contrary, it’s very exciting. When the patient gets an insight, it is very dramatic.” I don’t deny that it is hard work, but it is very rewarding.

Alice’s primary delusion was that she had not given birth to her child. She had many different theories as to how that had happened. Among them was that the “state” had given it to her. I could never figure out the meaning of that particular one until she came out of her delusion. When I asked her why she thought that, she told me it was the state of pregnancy. How correct Rosen was when he described schizophrenia as a walking dream. That concept has stood me in good stead through the years.

One of the symptoms of resistance is what I call dopiness. This state is when the patient appears half-asleep. In this state, Alice complained that something was the matter with her eyes. It appears useless to try to interpret when the patient is in that state. I, at least, have never been able to get through.

I interpreted it anally because she complained of emptiness. She said, “I see what Valerie (my nickname is Val) means when she talks of fear of losing shit.” The feeling was, as I came to understand it, that when she got pregnant she felt full. But when she gave birth under anesthetic, the obstetrician had “stolen” her big belly from her. Worse yet, the baby probably was a demanding one, as most babies are. As a result, Alice became even more “empty.” I believe that such “emptying out” may be the cause of post-partum depression in general.

As you see, the problem was an economic one. One delusion was a complaint that she had been forced into prostitution. I interpreted this as having given up her soul for food. After that, I heard no more about prostitution.

Rosen told us that psychotics don’t dream except about food. After about six months, Alice had a dream. I don’t remember what it was about, except that there was lipstick in it (she was approaching the Oedipal phase). In Alice’s case, he certainly was right. I can’t remember just how I came to know it, but the delusion was over. Her mood was quite changed. She accepted the reality of the delivery of her child.

One of the people in the house pretended he had her delusion. The portrayal was quite good. I wish I had a picture of her face when he did that. She was clearly trying to be polite, but she definitely looked at him as if he were quite mad. When we asked her how her child was born, she gave us a very accurate description. I was certain all was well when she told me she felt like Rip Van Winkle. (A few times since then, I have had the experience of patients using those exact words. I had not mentioned that character to her or my other patients. I can tell you, it is an eerie feeling to hear other patients use the same analogy.)

Alice did often speak of her fear of my leaving. I assured her a crowbar couldn’t tear me away. She feared I would stop loving her if she became sane. She also feared her mother would hate her. I assured her that Rosen and I would protect her from her mother. Indeed, Rosen put her on the couch, as if she were neurotic, a few days after she had recovered from her delusion. (I have since learned not to do that. It produces too much anxiety. The patient being seated is quite adequate, although I heard that Hyman Spotnitz put his patients on the couch.)

I had been quite sincere in my promise not to leave her, but circumstances beyond my control forced me to. I subsequently heard that she had been correct in her fear of becoming sane. When I said goodbye, I was empathic with her pain and reassuring. I believe she knew I was heartbroken. But then, much later, I heard she broke down again.

Naturally, I felt terrible, but I knew nothing about transference then. Worse, I didn’t think she was right that, if I left, she would have been sick again.

Of course, these days no one would hire someone to work 24/7. So, I knew I had a most fortunate experience. Nothing is so convincing as to see such change happen before one’s very own eyes. Perhaps that was why people who came to see Rosen’s work were so skeptical. They either insisted that the patient wasn’t schizophrenic in the first place, or they weren’t really recovered, or that the patient was one of the assistants. But some seasoned professionals were convinced of the validity of Rosen’s work. For various reasons, Rosen later became unfashionable. All his work was done without psychotropic drugs, ECT, or hospitalization.

A Brief History of Madness

Centuries ago, the cause of madness was considered to be an invasion of demons. In 1817, McLean Hospital was established in Massachusetts. Bedlam, in London, was established even earlier. But in the late eighteenth century, the “moral movement” began. It was based on the idea that

Mad people were trapped in fantasy world, all too frequently the outgrowth of an unbridled imagination. They need to be treated essentially like children, who required a stiff dose of mental discipline, rectification and retraining in thinking and feeling. The madhouse should then become a reform school.

(Porter, 1987) (2)

Then, came electro-shock therapy and insulin therapy. In the mistaken idea that patients with epilepsy didn’t have schizophrenia, it was thought that “giving them epilepsy would cure them of schizophrenia” (3). The brain damage caused by shock treatment was pretty well ignored. Paul Hoch, Commissioner of Mental Health Hygiene in New York, said, “Is a certain amount of brain damage not necessary in this type of treatment? Frontal lobotomy indicates that improvement takes place by definite damage of certain parts of the brain” (Hoch, 1948) (4).

But in 2001, Assemblyman Martin Luster, Chairman of the Committee of Mental Health, held hearings on the effects of ECT. I attended the hearings in both New York City and Albany. About 150 patients testified that they had permanent memory loss as a result of their ECT treatment. In some cases, the loss was so severe that they could not recognize their spouses or perform on their jobs. Six psychiatrists insisted that memory loss was due to their psychiatric illness and could not be permanent. This idea is quite inconsistent with the present understanding of depression.

I have also heard stories about psychiatrists changing diagnoses from schizophrenia to depression, in order to justify giving ECT to patients, because ECT is currently supposed to be given only to depressed patients.

The history of the treatment of mental illness is a strange one, in that it seems to learn nothing from either its failures or its successes. In ancient Greece, mental illness in women was attributed to their wandering wombs (The Nation, May 15, 2017) (12).

Treatment in the eighteenth century was limited to various forms of cruelty, i.e., restraints, chains, blood-letting, what we could call water boarding, etc. The patients included King George III, who, it was later decided, suffered from porphyria, a rare genetic disease which can lead to high levels of toxic substances that cause temporary delirium.

But such was not the case with most mentally ill patients. Treatment in France and England was of the physical kind, causing unimaginable pain to patients and curing no one. But Philippe Pinel, around the time of the French Revolution, had a different idea. “He noticed that if the patients were not treated cruelly, they behaved in an orderly fashion. The ranting and ravings, the tearing of clothes, were primarily protests over inhumane treatment” (Porter, 1987) (5).

During the same period, Quakers in York, England, instituted moral treatment. This led to remaking care of the insane in America (6). They opened small homes with all the domestic amenities, gardening, reading, writing, chess playing, etc. Poetry was seen as particularly therapeutic (shades of Freud’s free association). The Quakers borrowed their ‘medical’ philosophy from the ancient wisdom of Aeschylus: “Soft speech is to distempered wrath, medicinal” (7). The discharge rate was 50%.

But the success of this treatment was ignored because it became more expensive than government would tolerate. Hospitals had to become larger. And perhaps more important, it threatened physicians’ livelihood, since it could be managed by non-medical men. They complained that “such treatment was a product of Quaker religious beliefs that love and empathy could have restorative powers” (Ibid.) (8). Besides, such treatment did not require neurologists, since the cure did not require medicine. The fact that moral treatment was successful was irrelevant. The result was that treatment of the insane went backwards to physical means. And once again, attempts to treat patients were on the basis of how the patient appeared to the treater, how different he was from the ordinary people. That was the objective view. No one seemed interested in the subjective view, i.e., how the patient felt.

My papers are written as I began to understand or more clearly understand concepts, for example, the difference between omnipotence and grandiosity. As a result of that understanding, I learned not to interfere with omnipotence, however irrational it may appear, as an example of the utility of that concept.

I can hardly claim credit for being the first person to try to do psychotherapy with schizophrenics. Rather too often, except for Bertram Karon, Austin Riggs, and Chestnut Lodge, the idea has been discarded because drugs were easier and cheaper. The fact that so often patients hated the drugs and the drugs didn’t cure anything was ignored.

When, for example, the idea of drugs was presented to the New York State legislature, as a way of emptying out the state hospitals and presumably saving a lot of money, drugs were seized on as a great solution. Clearly, the disadvan...

Table of contents

• Cover
• Title
• Copyright
• Dedication
• Contents
• Acknowledgements
• 1 Introduction
• 2 Awakening the Schizophrenic Dreamer
• 3 The Difference Between Infantile Omnipotence and Grandiosity
• 4 Bathsheba: A 19-Year Recalcitrant Case of Schizophrenic Requiring 20 Months to Get to the Neurotic Level
• 5 “Black Hole” Phenomenon: Deficit or Defense? A Case Report
• 6 Addendum to “Black Hole” Phenomenon: Deficit or Defense? A Case Report
• 7 Faith, Paranoia, and Trust in the Psychoanalytic Relationship
• 8 John Rosen: Genius or Quack? Historical Reflections of a Former Student
• 9 Five Errors in Freud’s Structural Theory and Their Consequences
• 10 Communicating with the Schizophrenic Superego
• 11 Communicating with the Schizophrenic Superego Revisited: A New Technique
• 12 Identification with the Schizophrenic Superego
• 13 “Out, Damned Spot! Out, I Say”; or, Karl Abraham Revisited
• 14 Opposing Opinions as to Treatment of Wishes and Hopes Pathology: A Response to Salman Akhtar
• 15 The Excuses for “Supportive” Rather Than “Active” Psychotherapy
• 16 Toward a More Optimistic View of What Analysts Can Achieve
• 17 The Burned-Out Therapist
• 18 How to Decrease Your Chances of Getting Hurt or Killed When Working with a Schizophrenic Patient
• 19 Technique: Dos and Don’ts
• 20 Side Effects of Anti-Psychotic Drugs
• 21 Epilogue
• Index