Psychotherapy of Direct Confrontation February Newsletter, 1999

Schizophrenia is a condition that develops over a period of time. This condition may have an organic base but environmental conditions need to exist for the illness to eventually erupt, surface and become a single reality in that persons' life. The beginnings develop early and grows usually without it being perceived by the patient and/or her family. There are indications of some disturbances in that person, however, the problems and developing conflicts are difficult to isolate, not only by those around the patient, but even by the professional psychotherapist or psychiatrist. Schizophrenia is very poorly defined in the literature even though Morel, Kraeplain, Bleuler,Schneider and Langfeldt have classified and reclassified the symptoms and characteristics of schizophrenia, as has the DSM codes of the American Psychiatric Association. The symptoms and characteristics do not explain this human process, which has been defined more accurately as a syndrome or many related disorders that could be caused by a multitude of factors. It is vital that this condition is clarified in terms that suggests a sense of logic that demystifies the condition and allows all of us a better understanding of these individuals not only for treatment purposes, but for the sake of their humanity. I will suggest a simple definition that might clarify the issues of schizophrenia after its apparent early onset. It should be understood that even though it seems to surface suddenly, that it has been growing in that person for years. So to repeat, the onset is not a quick reaction, but is preceded by a pre-morbid condition that is indicative of this serious mental disharmony. The beginning phase is one filled with terror. These are terrified human beings and that great fear leads to a disintegration and dissolution of that persons identity. She doesn't know who she is or where she comes from. She has annihilation fantasies and fears destruction. This enormous fear drives the person backwards until she can develop around her a system of defenses. The fear is processed by the person into a number of symptoms, such as delusions, hallucinations and paranoia. There are those who believe that this represents the organisms attempt to cure itself. It does serve to reduce that great fear and out of this comes a new identity with its own logic and language, that we call schizophrenia. This system of life is to that person a survival mechanism that becomes resistant to change, because it represents life to that person. With these thoughts in mind, it is imperative that we understand that the patient may see herself as being well and often denies that she is sick or needs help. How can we contact that human being in such a way that she will allow us into her life and the bond between psychotherapist and patient will grow strong enough to begin the process of recovery. I will attempt to explain a psychotherapeutic method that points out one of the roads that we can take in sharing with the patient, the agony of her existence. However, we must make an honest evaluation of treatment and with an open mind allow ourselves to acknowledge our failures so we can create more effective treatment methods Traditional psychotherapy and other treatment modalities have not succeeded well enough with patients who are diagnosed as schizophrenic, because their approach has been focused on the patient gaining insight and dealing with intrapsychic conflicts. With the long term schizophrenic patient, we have found that in many cases, these patients cannot process insights well enough to effect behavioral changes. We are proposing a treatment, that is not a priori, but a result of many years of experience and that has as its first step the establishment of relatedness. If we do not succeed in this first step, treatment cannot go

beyond the initial stage. Our active and direct treatment methods have a design that depends on this first step. It focuses on the present dysfunctional behaviors of the patient, so that reality has a stronger part in the life of the patient. We believe that an emphasis on problem solving and reality based goals lead to achievements that are ego building and tend to reduce delusional conflicts and effect a sense of relief, freedom and reward. Psychotherapeutic efforts are directed towards building on the positive and healthy parts of the patient, that aids in remotivating that person to look towards reality, rather than wallow in the defenses that the psychosis has persuaded her to build. If properly nurtured, this first step, the establishment of relatedness, leads to a collaborative effort that becomes an alliance between the patient and psychotherapist. Without this alliance, there is no treatment. However, it is essential that we understand the treatment alliance is not necessarily constant during the course of psychotherapy and the allied treatment modalities. The psychotherapist and other members of the treatment team and the patient often, unconsciously, say or do things that rupture or break the alliance. The treatment team must always be alert and sensitive to these possibilities and should it happen, bend their collective efforts at repairing the breach in this critical relationship. This rupture in the alliance happens with some frequency as the struggle to change takes place. However, every time this breach in the alliance is resolved, the relationship becomes stronger. I must repeat, it is critical for the psychotherapist to understand that treatment that leads to corrective behavioral changes cannot take place without making contact with the patient that leads to a therapeutic alliance. Let me add, that even those psychiatrists who prescribe medication, must develop such a relationship with the patient in order for medication to have a maximum effect. Psychotherapy can be called strategic if the clinician initiates what happens during therapy and designs a particular approach for each problem. He must identify solvable problems, set goals, design interventions to achieve these goals, examine the responses he received to correct his approach and examine the outcome of his therapy to see if it has been effective. During the first half of this century, clinicians were trained to avoid planning or initiating what was to happen in therapy and to wait for the patient to say or do something. Only then, could the therapist act. Under the influence of psychoanalysis, Rogerian (Carl Rogers) therapy and psychodynamic therapy, the idea developed that the person who does not know what to do and is seeking help, should determine what happens in the therapeutic encounter. The clinician was expected to sit passively and only interpret or reflect back to the patient what he was saying and doing. He could offer only one approach no matter how different the kinds of people or what the problems were. This passive approach lost for the clinical profession many effective therapeutic strategies. Strategic therapy is not a particular approach or theory, but it is simply a name for those types of therapy where the therapist takes responsibility for directly influencing people. Before and in the 1950s a number of strategic therapists began to grow. Family therapy and the conditioning therapies and the direct therapies started with the early Freudians and continues now with the work of a growing number of active psychotherapies. Today, the issue of psychotherapy with schizophrenia is confusing to many people in the field, because of the conflict between active and passive methods of interaction. We should understand that decades ago psychotherapists were persuaded to stop talking and start listening. So completely was this achieved, that the great need today is to start the psychotherapist

talking again. It should be clear that the contributions that the older psychotherapies have made, need to be acknowledged, but experience has pointed out, I believe, that this is the time for active therapies that stand in the sharpest contrast to psychoanalysis, both in their techniques and in their claims to be seen, as a result of studies in many parts of the world Psychoanalysis has proven itself remarkably able to understand patients, but point to the extraordinary difficulty it has changing the patients behavior, despite frequent and prolonged contact. Active therapists have been more successful in changing the patients without the same understanding of traditional psychotherapy and psychodynamics. We must always be open to change, as outcome and research studies mandate the need for change. I will make an effort to point out some of the significant features of direct confrontation. However, it is critical that one understands that confrontation is more than an overtly aggressive method of dealing with the long term schizophrenic and that one understands that confrontation can be subtle, with many other variations. Also, that it is a unilateral effort on the part of the psychotherapist that is basically designed to intrude on the patients sick behavior and disrupt the psychosis and produce different sets of behavior that are more consistent with the expectations and demands of society. The following will include the strategies that both the patient and the psychotherapist use in their respective efforts. The patients efforts at retaining her psychotic equilibrium and the therapists efforts at breaking down these defenses. Confrontation can be seen as a forceful intervention. The psychotherapist may make his remarks in a forceful rather than in a gentle fashion in order to make sure his patient hears what he has to say. However, depending on the patient as a unique individual, a gentle way of stating something or a bit of humor might confront her with something she has resisted. The term "force" can disturb people if it is not understood as being demanding of the patient to meet the treatment criteria. It is not in any sense abusive or disrespectful of the patient. We cannot forget that psychotherapy with long term schizophrenics is an influence process. We use psychotherapy to promote change. Many patients are not changed by insight, simply because the illness serves as a survival system and the patient refuses and fights against change. The psychotherapist when he confronts, has in mind getting the patients' attention, producing a reaction in her and demanding that she change. The strategies the psychotherapist has at his disposal are his own emotions and his understanding that he needs to use language to create a sense of reality in the patient. The psychotherapist must use words, at times, to shock the patient and make her aware that she is facing a person who is different than the other psychotherapists she has seen in the past. One of the important points of confrontation is unmasking or uncovering denial, which can take many forms. Another important treatment issue is making the patient aware of any behaviors that lead to disrupting regressive reactions, letting the patient know how her regressive unappreciative demanding behavior effects other people, including the therapist and that their are conditions to a relationship and that some behaviorisms are just not acceptable. He must insist that the patient become responsible for her behavior and that she control her impulses. As one uses confrontation methods properly, I believe they tell the patient that the therapist has a genuine interest in her and wants to help. Also that the psychotherapist is stronger than the overwhelming aspects of the patients' schizophrenia. There is a sense of safety and security in this realization. The character structure of a patient can determine her response to a confrontation, it is important to continue the confrontation as long as the patient distorts her perception of the psychotherapists meaning and continues to manipulate those

people who are treating her in order to perpetuate her condition. Anger on the psychotherapists part is not necessarily counter-transference, but should also be seen as one human beings response to another persons unacceptable behavior. We must accept the reality of our emotions in the context of treatment and in an acceptable way permit the patient to know how we feel about her. Confrontation is helpful in establishing a therapeutic alliance and useful in reconstructing the healthier defenses in the patients' life when the disturbed defensive strategies of the patient are overcome. This in brief are some ideas that can actively involve the schizophrenic patient in treatment. Until we meet again, Jack Rosberg