Schizophrenia and Psychotherapy
Dr Jonathan Haverkampf
About 2% of the population will suffer from schizophrenia in their lifetime. This may not seem much, but there are two reasons why schizophrenia is maybe the preeminent psychiatric condition. One is that it can cause immense suffering and has, with some exceptions, only really become treatable over the last decades. The other reason is that it produces some of the strangest symptoms, which have found their way repeatedly into literature and film.
This rate is roughly similar across cultures and continents. Schizophrenia, a form of psychosis, is a severe mental health condition, which in previous centuries usually meant a complete withdrawal from social life and life-long commitment to a mental institution, where treatment was in the best case largely ineffective and in the worst cases barbaric and inhumane.
There have been famous individuals, like the impressionist painter Vincent Van Gogh, who used his art to communicate how differently he saw the world and some of the suffering that came with it. Many have tried to write or express themselves in other ways. I have seen a patient who thought of himself as the king of Sweden and his room had become an office to write correspondence to various members of the European high aristocracy, politicians and others he deemed worthy of corresponding with. Communication actually plays a large role in the development of the condition, as well as it should in its treatment. Someone suffering from schizophrenia does not seem to communicate in a normal way with the environment or himself or herself. Unfortunately, in many cases the communication environment provided in many institutions does not help the patient or those who provide treatment.
Schizophrenia is a condition which can severely reduce an individual’s quality of life over long periods of time, frequently a lifetime. Fortunately, new generations of medication and new lines of psychotherapeutic treatment have alleviated much of the suffering and allowed many patients to lead normal lives with families and professional careers. In fact, the advances on the medical side have in some respects sent more patients into psychotherapy because communication and self-reflection have become easier. The psychosis is still apparent, but therapy can be provided in more ‘normal’ intensity and frequency, which has been regarded as an important economic aspect.
A central theme of schizophrenia is that an individual can no longer distinguish between the world on the inside and on the outside. For example, thoughts become voices, while other people seem to influence one’s thoughts. Medication allows many individuals with schizophrenia to clearly distinguish again between what happens on the inside and what happens on the outside. However, it does not remove the issues encapsulated in the content of the voices and many unusual experiences. A sleeping pill can make someone sleep, and it might even affect one’s dreams in a global way, but it does not provide the information for a specific dream content. Psychotherapy can help with the content, which is very useful if the psychosis comes with paranoid and frightening thoughts. They do come from somewhere.
Any psychosis both affects and is maintained on the relationship level. Messages and people are interpreted differently by someone suffering from psychosis. Often this interpretation is related to a patient’s emotions. If there is fear a patient might believe that the other person is a secret agent tracking him, even if the fear is not directly related to the other person and objectively there is no reason to assume that the other person is a secret agent. Associations made in one’s mind in a psychosis can be experienced as facts in the real world.
Evers paranoid or schizophrenic symptom has a profound impact on the patient’s ability to communicate and interact with other people. But at the same time it is in the interaction between therapist and patient were some of the negative effects of the condition are treated.
Many individuals suffering from psychosis are very sensitive to the messages they receive from the world around them. Since their borders are more fluid, they often try to find structure and explanations for their own emotions and what they observe in the world around them. This can give rise to paranoid ideas and even hallucinations in an attempt to make sense of their perceptions on the inside and the outside. Medication can reduce or even eliminate these symptoms significantly, but therapy still requires a strong and empathic working relationship between therapist and patient.
Many people on medication can lead normal lives as managers, scientists, salespeople, husbands and wives. Individuals on the new neuroleptic agents (and sometimes older ones) have become virtually symptom free and indistinguishable from their ‘healthy’ counterparts. A trained mental health professional may still spot the odd little detail that gives the condition away, but it is remarkable that a condition which was untreatable for most of human history has over the last decades become manageable in most cases. Unfortunately, in an attempt to save costs, the emphasis is often put on medication alone. Many studies, however, have borne out clearly that medication alone is significantly inferior to a combination of psychotherapy and medication, especially when it comes to relapse prevention. Adequate psychotherapy thereby safes the much higher social and individual costs of permanent disability, repeated inpatient treatment and the unquantifiable reduction in the human quality of life.
The therapist needs to establish with the patient a stable working relationship that is strong enough to absorb and process the fears and doubts the patient may have. This requires empathy and an openness to accompany patients in their exploration of new perspectives and their own thought processes, while giving them the support necessary in dealing with everyday life. The shared world between therapist and patient should convey safety and be a platform for exploration. This is important because as the patient communicates more of the inner world in this space into the outer (real) world, it stabilizes a sense for the real world.
The therapist, while retaining the analytical and intervention tools of the trade, should give the patient the necessary freedom to choose a focus so that important areas of the patient’s life can be reflected upon. It not only helps the therapist to better understand the client, but also builds the absolutely critical therapeutic working relationship between patient and therapist. Especially in cases of paranoia and deep mistrust against society or institutions there is a need to carve out a secure platform from which to work therapeutically. Through the interaction with the therapist the patient learns to distinguish between the internal world of the mind and the external world we all live in. In the interaction with an experienced therapist the patient can so acquire a feeling for the boundaries between the inner and outer world. The patient’s interactions with other people help solidify and reinforce these boundaries, provided they are built on mutual respect and genuine interest.
Stressful issues should be cleared away in a psychotherapy away and involving partners and family can be of benefit. A special emphasis should be placed on transparency and clarity. The patient should be supported in developing own resources, but also in knowing their limits and establishing healthy boundaries. Medication supports this process because it can create a distance to stressful emotions and thoughts, so that the patient is less likely to feel overwhelmed or threatened by them. After all, it is the fear triggered by a patient’s own thoughts and feelings which leads to the paranoia vis-à-vis other people and institutions, such as being spied on by the mob, a government conspiracy, and the like.
Quite regularly patients suffering from schizophrenia seem to have very perceptive antenna for the emotional state of other people. On the other hand, this heightened sensitivity can lead to the projection of own emotions into another person’s otherwise relatively meaningless small gestures and remarks. This often requires helping patients in their approach to appropriate communication patterns with their environment, while recognizing the factors in the patient that might maintain paranoid believes, such as negative emotions caused by life events or unfulfilled needs and aspirations.
The goal in the treatment of schizophrenia is no longer for the patient to ‘function’ but to lead a fulfilled and happy life. This requires particular attention also be paid to the relationships and interactions the patient has with his or her environment, while working with the patient towards greater clarity on the values, needs and aspirations the patient holds.
© 2012, 2016 Christian Jonathan Haverkampf. All rights reserved.
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This paper is solely a basis for academic discussion, no medical advice can be given and no medical advice is given. Always consult a professional if you believe you might suffer from a medical condition.
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