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Clinical Case Studies 8(6) 417 –423

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DOI: 10.1177/1534650109351930 http://ccs.sagepub.com

Psychotherapy of Schizophrenia: A Brief History and the Potential to Promote Recovery

Paul H. Lysaker1 and Steven M. Silverstein2

Abstract

With growing awareness of the likelihood of recovery from schizophrenia, interest has arisen about the potential role of psychotherapy within emerging treatment regimens. Could psychotherapy uniquely promote recovery by addressing symptoms, the achievement of psychosocial milestones, and/or helping to enhance the extent to which persons diagnosed with schizophrenia experience themselves as meaningful agents in the world? As an introduction to a set of case studies of how psychotherapy can promote recovery this article briefly reviews the history of the psychotherapy of schizophrenia. In particular the appearance and course of psychoanalytically oriented treatments, as well as cognitively and interpersonally based treatments are detailed. Evidence supporting these approaches and remaining questions for research are discussed.

Keywords

schizophrenia, recovery, psychotherapy, psychosis

Recent reviews have suggested that contrary to long-standing pessimistic views, most people with schizophrenia do not experience lifelong dysfunction. Instead, most with this condition move meaningfully toward or achieve recovery over the course of their lives (Bellack, 2006; Lysaker & Buck, 2008; Silverstein, Spaulding, & Menditto, 2006). They may not only experience improve- ments with regard to symptoms or function, but also positive changes in how persons think about and experience themselves as individual human beings in the world (Resnick, Rosenheck, & Lehman, 2004; Roe, 2001; Silverstein & Bellack, 2008). As a result of growing awareness of this possibility, interest has arisen in whether some forms of psychotherapy could play an important role in treatment. Given literature suggesting psychotherapy may help a wide range of people without psychosis to develop both a richer sense of self and a more adaptive self-concept (Hermans & Dimaggio, 2005), it is now asked whether it could do the same for many with schizo- phrenia and thereby uniquely promote recovery (Lysaker & Lysaker, 2008).

To explore this question and a wide range of related concerns, this issue of Clinical Case Stud- ies is devoted to case studies of the processes by which individual psychotherapy can promote recovery. Therapies which range from office to community based and from existential to

1Indiana University School of Medicine 2University of Medicine and Dentistry of New Jersey, Piscataway

Corresponding Author: Paul H. Lysaker, 1481 West 10 street, Indiana University School of Medicine, Indianapolis, IN 46202 Email: [email protected]

418 Clinical Case Studies 8(6)

metacognitive to cognitive behavioral are presented with the unifying question of how they are able to promote wellness. Before beginning with the first, however, it seems important to note that any advancement in this area should be considered in the context of the long and controver- sial past of the psychotherapy of schizophrenia, a past which, almost as much as any, contains a range of of conflicting scientific claims and emotional ladden debates. To provide a framework for considering how to think about contemporary developments in schizophrenia, the current article first offers a brief overview of the history of the psychotherapy of schizophrenia and then highlights some of the continuing points of contention.

The History of the Psychotherapy of Schizophrenia Often overlooked is that one of the first clinicians to seriously advocate for individual psycho- therapy for people with schizophrenia was Jung (1907/1960). Jung (1907/1960, 1939/1960, 1958) treated many hospitalized and significantly ill patients in the early part of the 20th century and contrary to the zeitgeist, argued that persons with schizophrenia could accept and benefit from a psychotherapy with certain modifications. Jung suggested that even the most profoundly disturbed aspects of illness were connected in some meaningful way to the life history and self- concept of the patient. As such Jung asserted that much of the work of therapy necessarily involved increasing the patient’s understanding of his or her self-concept.

Initially though, Jung was alone in this pursuit, as Freud (1957) had firmly announced that psychoanalysis with people with schizophrenia was impossible given that persons with schizo- phrenia could not form a proper attachment to a therapist. And psychotherapy for schizophrenia briefly then vanished more or less once Jung left the Burghölzli and with a few notable excep- tions (Fierz, 1991; Perry, 2005), abandoned his interest in schizophrenia.

In the 1930s and 40s, however, interest in the psychotherapy of schizophrenia suddenly appeared in a range of different settings. Psychoanalysts such as Fromm-Reichmann (1954), Hill (1957), Searles (1965), and Sullivan (1962) all produced reports which contended that meaningful intimate bonds with persons with schizophrenia could emerge in therapy. They noted patients with this condition were often eager for treatment and could utilize the bonds that formed with therapists as the basis of a movement toward health. These and other authors pro- duced a wealth of compelling anecdotal reports suggesting that persons with schizophrenia could accept and embrace psychotherapy as a means to make sense of their lives in a holistic manner they otherwise could not. Psychotherapy thus emerged as a treatment that might thereby help them develop both a healthier sense of themselves as beings in the world and richer experi- ences of daily life. As an illustration here is a quote from a person with schizophrenia about their experience of psychotherapy offered by Hayward and Taylor (1956):

Meeting you made me feel like a traveler who’s been lost in a land where no speaks his language. Worst of all, the traveler doesn’t even know where he should be going. He feels completely lost and helpless and alone. Then suddenly he meets a stranger who can speak English. . . it feels so much better to be able to share the problem. . . If you are not alone you don’t feel hopeless any more. Somehow it gives you life and a willingness to fight again. (p. 221)

While this literature produced a series of interesting though sometimes fantastic theories of the subjective experience of psychosis and its antecedents, there was little scientific evidence supporting its efficacy. As reviewed in a range of sources, controlled trials failed to find significant benefits for psychoanalytic psychotherapy (Drake & Sederer, 1986). For instance, in what was referred to as the Boston Psychotherapy Study, more than 160 adults with schizophrenia

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were randomly assigned to receive exploratory insight oriented therapy or a reality based supportive psychotherapy (Gunderson et al., 1984). Extensive efforts were devoted to the training of therapists, the selection of appropriate participants, assessment procedures and methods. Nevertheless, the most notable result was a drop rate of just more than 40% six months after assigned to treatment and a drop rate of nearly 70% two years following that. More detailed analyses of the results of those who remained in the study revealed some improvements in insight as well as improvements in negative symptoms among participants assigned to the more skilled therapists (Glass et al., 1989; Gunderson et al., 1984).

Beyond the findings of the Boston psychotherapy study, another blow was simultaneously dealt to the credibility of at least some psychoanalytic treatments for schizophrenia. In particular, a range of approaches to the psychotherapy were based on the idea that schizophrenia is primar- ily caused by pathological family dynamics (e.g., Karon 2003). Psychotherapy, according to this view was the treatment of choice as it alone could repair the damage done by caretakers to their children by too great, too little, or too confusing levels of involvement. Research, however, indi- cated that schizophrenia was instead a genetically influenced, neurobiological brain disorder involving distortion of basic human experience, one that could well develop regardless of family dynamics. Beyond pointing to the reality that families had been generically blamed without any basis, the issue here was raised of whether there was anything at all psychotherapy could offer, that is, beyond general human support. Drake and Sederer (1986), for instance likened some psychotherapies of schizophrenia to the pouring of burning oil over wounds, a medical practice that went for centuries without any medical basis. Nevertheless, when surveyed, 60% of men- tally ill persons and their families indicated that they were interested in psychotherapy, a rate that possibly echoes the finding that three in five participants remained in the Boston study at 6 months (Coursey, Keller, & Farrell, 1995; Hatfield, Gearon, & Coursey, 1996).

Following this, and concurrent with the recognition of recovery as a likely outcome of schizo- phrenia, a range of new possible rationales for psychotherapy for schizophrenia have been raised as well as empirical support for the efficacy of psychotherapy. Perhaps most prominent among these involve cognitive behavior therapy (CBT). Originally created to address depression, the use of CBT has steadily expanded to address schizophrenia and other psychotic disorders (Rector & Beck, 2002). Treatment from this perspective has stressed that the neurobiological processes of schizophrenia interact with social, developmental, and psychological factors resulting in mal- adaptive beliefs about the self, and tendencies to attribute malicious intentions to others in an overly rigid manner. CBT thus helps to correct those beliefs through a systematic, collaborative process of belief examination and prediction of the consequences of behaviors and events. Evi- dence supporting its efficacy includes controlled trials showing that persons with schizophrenia are willing to attend CBT and that CBT can reduce dysfunctional cognitions, leading to reduc- tions in positive and negative symptoms, and improvements in psychosocial function (Drury, Birchwood, Cochrane, & MacMillian, 1996; Gumley et al., 2003; Lysaker, Davis, Bryson, & Bell, 2009; Pilling et al., 2002; Sensky et al., 2000).

Diverging slightly from this line of thought, Chadwick (2006) developed Person-Based Cognitive Therapy for distressing psychosis, in an effort to move from a symptom-focused to a person-focused therapy. Person-Based Cognitive Therapy is an integrative form of treatment which draws on cognitive theory, mindfulness, client centered principles, and a social– developmental perspective which understands language as a socially available tool which persons use to make meaning of their daily activities. This approach uses cognitive and expe- riential techniques for working with pervasively negative self schemata and promoting self-acceptance and self-awareness. In parallel, case studies by other authors, have also sug- gested cognitive behavior therapy for psychosis can address the personal meaning of symptoms and psychosocial dilemmas (Davis & Lysaker, 2005; Silverstein, 2007).

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Interest has also increased in using a modified form of psychoanalytic therapy for people with schizophrenia. Bachmann, Resch, and Mundt (2003), has suggested that psychoanalytic psycho- therapy for people with schizophrenia may beneficially foster an experience of the self and the therapist as two separate people that share a relationship, leading to the stabilization of a sense of personal identity, and the integration of the psychotic experience. Some evidence suggests that such an approach can be helpful, at least for people who are more clinically stable at the outset of treatment (Hauff et al., 2002). Rosenbaum et al. (2005) have also indicated that among more than 560 first episode patients, those who received supportive individual psychodynamic psy- chotherapy or an integrated treatment had better overall functional outcomes after 1 year of treatment than those who received treatment as usual.

At perhaps an even larger holistic level, attention has turned to whether psychotherapy might promote recovery by helping some with schizophrenia develop a richer sense of personal identity as embedded with that person’s unique personal history or narrative (France & Uhlin, 2006; Lysaker, Buck, & Roe 2007; Silverstein et al., 2006). Beyond exploring the validity of a particu- lar conclusion or response to a particular symptom, psychotherapy has been suggested as something that could, as it does for many others (Adler, Skalina, & McAdams, 2008; Neimeyer & Raskin, 2000), represent a place where persons develop richer and more layered stories about who they are in the present, the person they have been across the course of their life and what is possible in the future for them. A deepened personal narrative might then naturally be an oppor- tunity for experience of oneself as an active agent who prevails in the face of adversity. Providing some support for this possibility are case studies suggesting that improvements in the richness of personal narratives may result during the course of individual psychotherapy of persons with schizophrenia and may be linked with other indicators of recovery (Lysaker, Davis, Jones, Strasburger, & Hunter, 2007; Lysaker et al., 2005), that self concept is a meaningful predictor of outcome in both first episode (Harder, 2006) and more advanced phases of illness (Lysaker, Buck, Hammoud, Taylor, & Roe, 2006). Finally, in the face of evidence that many with schizo- phrenia experience difficulties with metacognition, or thinking about thinking (Brune, 2005; Lafargue & Frank, 2009; McGlade et al., 2008; Stratta et al., 2007), others have suggested that psychotherapy could promote recovery by helping persons to develop metacognitive capacity (Lysaker, Buck, & Ringer, 2007). Just as psychotherapy has been found to promote metacogni- tion in persons who do not suffer from psychosis (Bateman & Fonegy, 2001; Choi-Kain & Gunderson, 2008; Dimaggio, Semerari, Carcione, Nicolò, & Procacci, 2007), could it be tailored to help persons with schizophrenia make better sense of their own mental states and the mental states of others and thereby evolve a complex storied understanding of one’s life? Evidence of this possibility includes some case studies (Lysaker et al., 2007) suggesting that psychotherapy interventions can be used to target metacognitive capacity as well as empirical studies suggesting that metacognitive deficits indeed limit personal narrative beyond the effects of other aspects of psychopathology and social factors such as stigma (Corcoran & Frith, 2003; Lysaker, Buck, Taylor, & Roe, 2008).

Summary and Questions In summary, the history of the psychotherapy of schizophrenia contains a series of different epochs. Most recently we have observed a rise in possible rationales for how psychotherapy could promote recovery. These include approaches which address a wide array of phenomenon, some at the level of symptoms and others at the level of personal narrative and the quality of self-experience. Many questions however, remain. Whereas the efficacy of symptom-focused approaches are supported in part by randomized trials, more holistic approaches are still develop- ing and awaiting more rigorous testing. Beyond that it remains to be articulated to what extent

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the emerging cognitive, dynamic, interpersonal, and phenomenological approaches differ from one another. Are there key principles which might unite these in some ways? Do they approach the issue of recovery in fundamentally different ways? Is it possible that each may be appropriate for some but not all with schizophrenia? We hope that in the following set of case studies the detailed descriptions of the psychotherapy processes may provide some partial answers to these questions and push further the development of interventions which assist persons with schizo- phrenia to achieve and sustain recovery.

Declaration of Conflicting Interests

The authors declared that they had no conflicts of interests with respect to their authorship or the publica- tion of this article.

Funding

The authors received no financial support for the research and/or authorship of this article.

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Bio

Paul H. Lysaker is a clinical psychologist at the Roudebush VA Medical Center and Associate Professor of Clinical Psychology at the Indiana University School of Medicine. His ongoing research concerns the role of metacognitive deficits in schizophrenia and psychotherapeutic interventions aimed at improving func- tion among persons with severe mental illness.