Introduction: Psychotherapy for Psychosis

Since the beginning of psychoanalysis a century ago, each generation has seen a small (but persistent) number of clinicians advance the cause of psychotherapy for psychosis (Stone, 1999). Paul Federn, a psychoanalyst and Freud’s contemporary, was the first psychodynamic clinician to write at length about the psychopathology of psychosis and recommended modifications of the technique required to treat it. A long list of distinguished clinicians and theoreticians have followed, including Melanie Klein, Hanna Segal, Herbert Rosenfeld, Harry Stack Sullivan, Wilfred Bion, Frieda Fromm-Reichman, Sylvano Arieti, Harold Searles, and more recently Bertram Karon, Michael Eigen, Thomas Ogden, Michael Robbins, David Garfield, Christopher Bollas, Arhild Lauvang, Deborah Lampshire, and the members of ISPS (The International Society for Psychological and Social Approaches to Psychosis). The current issue of the American Journal of Psychotherapy contains eight papers by a distinguished group of contemporary clinicians who treat psychosis with psychotherapy. Taken together, these papers offer an overview of the evidence base, linking psychosis to a psychological etiology, a general psychological theory of psychosis, and a range of psychotherapy techniques employed by different clinicians, included psychodynamic, cognitive behavioral, and method of level (MOL) approaches.

In the first paper, Social Adversity in the Etiology of Psychosis, Longden and Read review the evidence base linking psychosis to traumatic adverse life events. In addition to documenting the increased incidence of psychosis in psychologically traumatized individuals, the authors outline the traumagenic neurodevelopmental model of psychosis that attributes many of the brain changes observed in psychosis to the effects of psychological trauma and neuroleptic medication rather than genetically determined brain disease to which they are usually ascribed. The paper includes an extensive bibliography in support of their view.

In the second paper, Psychosis, Trauma, and Ordinary Mental Life, I outline a general psychological theory that views psychotic symptoms as the intrusion into adult mental life of primitive psychological processes that are normal in childhood. These processes, when brought to the foreground of consciousness by adverse life events, constitute the psychology of psychosis. This paper discusses several key concepts in the psychological theory of psychosis, including primitive internal object-related phantasies, a turn away from verbal thinking to perceptual experience, concrete metaphor, a breakdown in “ego boundaries,” and the role of logic in the maintenance of psychotic symptoms. A postscript shows how the clinical concepts and examples in each of the papers in this volume illustrate one or more of these key concepts.

In the third paper, Psychotherapy Techniques for Patients Diagnosed with Schizophrenia, Lotterman lists five areas of psychological disturbance in psychosis and describes a number of specific techniques designed to address these issues in psychotherapy. His overall goal as a clinician is to help the patient express his or her mental life in words. He advises the therapist to pay particular attention to defining the real boundaries of the therapeutic relationship and to being sensitive to real disappointments the patient may feel with the therapist, which, when unexpressed, are a resistance in the treatment. Lotterman’s recommendations on technique include the therapist revealing to the patient what the therapist is feeling about a circumstance in the treatment, and techniques for directed free association, including naming feelings and “enlargement.”

In the fourth paper, Going Blind to See: The Psychoanalytic Treatment of Trauma, Regression, and Psychosis, Knafo provides a moving account of her six year psychoanalytic treatment of a psychotic man. Her paper emphasizes the power of the relationship between patient and therapist to effect change. Her work is guided by Winnicott: To effect deep change, a person with psychosis must return to that point when the mind failed to progress and work through this original traumatic state. She describes the developmental origins of her patient’s psychotic illness and how his early life was played out in interpersonal relationships (including the transference) later in life. The paper provides a detailed description of what goes on in the mind of an experienced clinician working with a psychotic patient, including her counter-transference reactions. Knafo provides an element seldom included in clinical case histories—an ongoing real-time bibliography of her conceptual thinking and her associations to the writings of other clinicians that helped guide her understanding and technique at points along the way.

In the fifth paper, Hidden in Plain Sight on Locked Wards: On Finding and Being Found, Margulies describes clinical encounters with two different patients that occurred on an acute inpatient psychiatric service in the course of his hour-long teaching rounds for medical students and psychiatric residents. The vignettes show how much can be understood about the meaning of psychotic symptoms, and how much can be accomplished in a brief encounter with severely ill patient when an empathic clinician strives to find the essential human being lost in the seemingly uncanny.

In the sixth paper, Cognitive-Behavioral Therapy for Olfactory Hallucinations and Associated Delusions, Kimhy outlines his successful treatment of a delusional man with olfactory hallucinations who believed he had a bad smell. Using a cognitive behavioral approach, the therapist developed a formulation that integrated the patient’s real medical problems, current stress at work, and history of alcohol use that led to alternate explanations of the patient’s experience. In the course of the treatment Kimhy employed a variety of CBT techniques, in particular, behavioral experiments to test the possible alternate beliefs developed with the patient. The case history illustrates how a behavioral experiment, developed with patient collaboration to the design, can be a very effective technique. In contrast to the therapist mounting a rarely-if-ever-effective direct frontal assault on the delusional belief, behavioral experiments allow the person with psychosis to accumulate new real-world experience that foster new reality-oriented beliefs.

In the seventh paper An Introduction to Using the Method of Levels (MOL) To Work with People Experiencing Psychosis, Tai provides an overview of the theory and practice of method of levels therapy based on perceptual control theory. Method of levels is a recently developed approach that shares some elements with psychodynamic technique (in particular, free association), cognitive behavioral therapy, and motivational interviewing, but operates from a different theoretical premise. Psychotic symptoms are assumed to be meaningful attempts to achieve preferred states of mind in the face of conflicting goals. The MOL therapist facilitates problem solving by responding to the patient with an ongoing series of questions that guide the patient’s thinking in a more adaptive direction. The flexibility of timing and frequency of sessions of the MOL allows its practice in settings where more traditional regular “by appointment” psychotherapy may not be practical.