Treating the 'Untreatable': Healing in the Realms of Madness

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Treating the 'Untreatable' offers the hope of recovery, healing and cure for the most severe psychotic disturbances, schizophrenia and delusional disorder. Through a psychotherapeutic exploration of hallucinations, delusions and thought disorder, even the most hopeless and "untreatable" patients have a chance for returning to a life of relationships and function even after years, if not decades, of disturbance. These studies in the intensive psychotherapy of schizophrenia and delusional disorders demonstrate that recovery, healing and cure can be achieved in those most disturbed.In this era of treating schizophrenic and delusional patients with a primarily antipsychotic drug oriented approach, a more thorough exploration of the meaning to the patient of his psychosis - with judicious antipsychotic use, when indicated - leads to internal character and external behavioral change that is far more lasting than with antipsychotic use alone. With such a psychodynamic approach, some of these previously chaotic, disturbed and heavily medicated people were able to understand the symbolism and the origin of their psychotic productions and go off antipsychotic medication altogether.Treating the 'Untreatable' provides an overview of the chaotic world of the schizophrenic or delusional patient, a history of intensive psychotherapy with such patients, and twelve case histories demonstrating varying degrees of recovery, healing and cure. Some of the patients were able to integrate delusional systems that had persisted for many years and give up previous extensive antipsychotic medication, as they understood and worked through psychological issues underlying their psychotic orientation.The book offers compelling stories for the general reader and teaching tales for students and mental health practitioners who want to work in the realm of madness. These clinical cases demonstrate the efficacy of an intensive psychotherapy of schizophrenia and delusional states, combined with the judicious use of antipsychotics. These tales show that even seemingly "untreatable" and "hopeless" psychotic patients may recover and heal in the course of an inquiring psychodynamic psychotherapy aimed at understanding and working through the symbolic meaning of his or her hallucinations, delusions and bizarre thoughts and actions. Such an approach has led to some maintaining their gains for decades.Treating the 'Untreatable' ultimately questions why patients who responded to an insight oriented psychotherapy were previously viewed as 'untreatable' and given high doses of antipsychotic medication. In addition, the book talks about some of the factors that have led the field of psychiatry to pursue a primarily antipsychotic medication approach in patients so disturbed, rather than integrating a potentially healing dynamic psychotherapy into one's therapeutic armamentarium.

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CHAPTER ONE: Delusional reality

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Aperson's behaviour is determined by his conscious and unconscious beliefs. We each have a Weltanschauung, a belief system that guides us and serves as an internal compass. Some people have trouble if their convictions conflict with each other; this is the pain of neurosis. Some have a great deal of trouble if their beliefs collide with other people's beliefs; here, issues of insecurity and conformity become paramount. Some people stick to their convictions about generally agreed reality in the face of all evidence to the contrary; this is the realm of psychosis and delusional belief.

A delusion is a firmly held belief in something false, a belief in something untrue for the rest of us, a set of ideas and concepts that guide and predetermine a person's behaviour, without adequate external corroboration. By definition, a delusion is clung to in the face of objections and rational arguments from others. Delusions make it impossible for a person to accurately perceive and function in day-to-day life.

 

CHAPTER TWO: The psychotherapy of delusional states

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In the field of treating the very disturbed and delusional, there is a long tradition of offering humane environments and understanding psychotherapeutic attitudes that can lead to the melting of psychosis and the dissolution of delusional ideas. This is wonderful when it happens; medication, group and psychotherapeutic support may heal the isolation that leads to withdrawal into delusional beliefs. Unfortunately, fewer and fewer of these humane environments are available. When they are available, little attention is focused on the symbolic meaning of delusions and hallucinations to patients, with the result that schizophrenic and delusional patients are often objectified and treated as the “other”. A primarily antipsychotic medication approach furthers the view that psychotic patients are different from us and that their productions have little meaning.

Hopefully, Marius Romme and Sandra Escher's “Hearing Voices Movement”, artfully chronicled by Daniel Smith in Muses, Madmen, and Prophets (2007), will begin to have an effect on how patients and therapists see hallucinations and delusions. But here too, it will be necessary for patients and therapists to fully comprehend the symbolic meaning of each patient's creative productions, and use antipsychotic medications judiciously, rather than just waiting for the right antipsychotic medication to get rid of the voices.

 

CHAPTER THREE: Causes of a delusional orientation

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Some people become delusional when their ability to cope is overwhelmed by mood, intense feeling or drugs. Mind-expanding drugs, manic mood or intense anxiety may speed stimuli to such an extent that the person cannot adequately integrate the sensations and ideas floating through his mind. It becomes impossible to tell when a shadow is a shadow and when it is an attacker. Mania may lead to grandiosity, omnipotence and paranoia. Depressed mood, with the attendant slowing of physical and mental stimuli, may lead to delusions of inadequacy, self-recrimination and hypochondria. For patients whose delusions are secondary to a mood disorder, it is of the utmost importance to try and treat the underlying mood disorder with appropriate antimanic, mood stabilising, antidepressant and tranquillising medications. Psychotherapy is helpful in the reintegration of such patients, but is secondary to treating the underlying mood disorder with appropriate medications. For depressed patients, the armamentarium of antidepressant drugs and augmenting agents should be tried in addition to psychotherapy. In some forms of severe treatment-resistant depression, this combination of drugs and psychotherapy becomes a most important vehicle for change.

 

CHAPTER FOUR: The method

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The psychiatric literature over the last forty years has increasingly emphasised the efficacy of antipsychotic medication and supportive psychotherapy, psychiatric day care and halfway houses in the treatment of schizophrenia. It is often felt that individual psychotherapy is of little or no use; cognitive therapy, antipsychotic medication, group therapy, psychiatric day care, and training in social skills are often the only care offered. Advocates of an intensive, psychoanalytically oriented psychotherapy find themselves on the defensive and are told that the burden of proof is on them to demonstrate that this approach works.

In the hope of generating some fruitful discussion and inquiry into the possibility that there are some schizophrenics and delusional people who respond to an insight-oriented, relatively drug-free, outpatient psychotherapy, I'd like to present twelve case studies—some long, some short—of the successful long-term intensive sychotherapy of schizophrenia and delusional states. These cases demonstrate the usefulness in a primarily outpatient, minimal medication setting, of an intensive, psychoanalytically oriented exploratory psychotherapy of schizophrenia and delusional states. Such a psychotherapy isbuilt upon the cornerstones of a belief in unconscious motivation, the existence of transference, countertransference and resistance in the course of psychotherapy, and the benefits of interpretations of these factors aimed at promoting insight, change and growth.

 

CHAPTER FIVE: The history of the psychotherapy of schizophrenia and delusional states

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The conventional wisdom, after May (1968) and Grinspoon (1967), is that antipsychotics, alone or with supportive psychotherapy, are the ideal and most cost effective approach to treating schizophrenia. Without antipsychotic medication, many relapse, even with psychotherapy. Klein states that “the addition of psychotherapy to a drug regimen is of no incremental benefit to schizophrenics” (1980, p. 132). May's study has several flaws, however, since therapists were inexperienced and therapy lasted an average of only 49 sessions. This leaves open the strong possibility that experienced therapists over a much longer course might be more successful in the use of a psychodynamic psychotherapy of schizophrenia.

Grinspoon found that in the psychotherapy of schizophrenics with senior therapists twice weekly over a two-year period, those treated with psychotherapy and antipsychotics (thioridazine) did better than those on psychotherapy and placebo; in addition, he found that they didn't fare as well as the state hospital controls who were treated with high doses of phenothiazines. Over the two-year period, Grinspoon found that those receiving psychotherapy were nearly twice as likely to be living out of the hospital as those treatedwith a high dose of phenothiazines. In fact, results from the third year of therapy show that patients who remained in psychotherapy continued to improve, leaving the results of this study equivocal. This study too leaves open the question of whether a more prolonged and intensive psychotherapy might better provide help to these most disturbed patients.

 

CHAPTER SIX: Psychotherapeutic technique and stages in the psychotherapy of delusional states

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In patients who are chronically delusional or schizophrenic, and have been so for many years, psychotherapy has many phases. First there is an attempt to assess the situation and see when the psychotic material began. Next is the requirement to try to reality test, and when that fails (as is likely), to try and understand the need for delusions or hallucinations, and when and how they became apparent. Such an approach will lead through many turns and curves, detours and crevices as we go deeper into the origin of psychosis. At some time historically, we reach the point where delusional belief or hallucinations began. Perhaps it was to diminish loneliness or assuage terror. Perhaps it's a chthonic, preverbal pain beyond all articulation, from which the patient is attempting to flee via restitutive imaginary friends.

In the course of our work, the feeling states of sadness, terror, loneliness, or depression will be experienced by the delusional patient. Gradually we begin to see how it all began, and slowly we provide a road map of our understanding to the patient. Comprehending the origin of delusions and schizophrenic thought is important. Toreconstruct the feelings and choices of the child or young adult who adopts (or is forced into) a delusional or schizophrenic orientation is quintessential.

 

APOLOGIA AND CLINICAL PRESENTATION

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At the risk of issuing testimonials for myself and this intensive psychotherapeutic approach, I would like to present a number of reasonably successful case examples demonstrating the efficacy of an intensive psychodynamic psychotherapy in patients suffering from schizophrenia or delusional disorder. Of course, not every patient will respond to this intensive psychotherapeutic approach. Some may bolt from treatment, either as a transference reaction or as an acting out of their psychosis. Would that they had stayed and had the chance to reap the benefits of an intensive psychotherapy of psychosis, as did the patients described in this book.

My purpose is twofold. Clearly I want to demonstrate the effectiveness of an intensive psychotherapy in even the most disturbed schizophrenic and delusional patients. In addition, these tales may serve as hortatory teaching illustrations and help to provide courage and the outline of a game plan to therapists willing to work in the realms of madness. I hope the examples speak for themselves.

 

CHAPTER SEVEN: The Good Angel, the Bad Devil, the Smiling Man's Voice and Mother-God

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Judith was a tall, thin, blonde woman in her early twenties when I first met her, while I was working in a psychiatric emergency room. Her much loved psychiatrist, whom she had seen for five years, was on holiday. She had cut herself four times prior to coming to the emergency room.

When she explained what had happened, and I had taken appropriate medical action (for these were more than superficial cuts), I asked why she had cut herself. She had no idea. Did the number of cuts (four) have any significance for her? Were there any feelings going through her prior to and at the time of cutting herself? She stopped short and looked perplexed: for whatever reason she was not accustomed to exploring the meaning of her behaviour. She hadn't questioned, merely acted.

She quickly began to wonder what she had been doing and why she had been acting so strangely. The number four meant four years old to her. Did such an age mean anything to her? Judith didn't know. And underlying feelings? She responded with the obvious, that she was angry that her therapist was away. Why cut? Again, she didn't know, but it was a release of her feelings.In our short interview, my approach of trying to decipher the psychological origins of her cutting herself and attempting to make sense of previously unexamined actions was so different from the supportive handholding treatment she was accustomed to that she began to discuss with her therapist and parents the idea of beginning treatment with me. Several months later, when the treating psychiatrist concurred, she began a more exploratory insight-oriented psychotherapy with me which revealed much more clearly what her thinking was and how it arose.

 

CHAPTER EIGHT: The pugilist, Mary, and the mother with the fiery halo

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When I first saw Daphne nearly thirty years ago, she was a brown haired woman in her mid-fifties. She was in the hospital for perhaps the thirty-fifth time in her life. Her psychiatrist of twenty years was retiring and transferring her to my care. She was alternately withdrawn or bellicose, and had been thrown out of several hospitals for her boxing skills, as she would physically attack other patients or staff.

She was an attractive married woman, a mother of two, who had made a number of suicide attempts over the previous thirty years. At one point she had jumped from the Golden Gate Bridge but had (seemingly miraculously) fallen on the catwalk below, broken many bones, and spent a number of months in the hospital recovering physically, if not psychologically. She had worked at several jobs, but had always lost them due to actions viewed as bizarre and idiosyncratic, for example writing strange notes in the margins of memos and verbally attacking her superiors.

Her history, as given by Daphne, her husband, and the referring psychiatrist, revealed periods of pressured, manic-seeming behaviour, accompanied by or alternating with profound and severe depression.She was diagnostically considered to be schizoaffective or somewhere on the bipolar spectrum of manic-depressive disorder, but couldn't be contained by the antipsychotic, antidepressant and mood stabilising medicines then available, including lithium. There was also the question of a schizophrenic quality, because she seemed so disturbed and strange at times, hallucinating and talking to herself.

 

CHAPTER NINE: Two rats and the extraterrestrial

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Lois was a depressed, withdrawn woman in her mid-thirties when she consulted me. She had a previous diagnosis of chronic paranoid schizophrenia, had been hospitalised several times, and had been treated for the previous seven years with antipsychotic medication. She had lived in a halfway house for the better part of a year and now stayed alone in a rooming house. She was unkempt, dishevelled, and clearly preoccupied and hallucinating. She had been married, but was now divorced. She had given up custody of her children, and had had a persistent delusion for years that two rats were gnawing away at her. She had little contact with anyone except for an old friend of hers who sent her to me. By everyone's account (previous friends, family, psychiatrists and ancillary staff), she was a hopeless case.

The diagnosis of chronic schizophrenia had been made during one of her first hospitalisations, when she told a psychiatrist about the two rats gnawing at her. The diagnosis was more correct than he knew, but by failing to help her try to fathom the meaning of the two rats gnawing at her, he missed the opportunity to open a pathway to an understanding of Lois’ projected imagination.

 

CHAPTER TEN: The ghost in the history

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The following is a shorter vignette, spread over nearly two years, perhaps fifty sessions in all. It will be clear that the intensity of the material is far less compelling than in some of the other cases, yet still demonstrates that even a short, infrequent, insight-oriented psychotherapy such as this one may have profound healing and curative effects. The reader will also notice, as I did during the course of this treatment, that the emerging psychological material is at a distance, serving an intellectualising defensive function for the patient. The reasons for this may be many. Dealing with another man and one's attendant fears may entail enlisting certain intellectual defences, rooted in anxiety. A short-term, less intensive therapy such as this one may be due to the patient's adjusting the frequency of visits, thereby limiting them to what he thinks he can handle.

Paranoid defences are intellectual ways of binding anxiety through leaping to conclusions, just as distancing from the therapist and the feared, potentially overwhelming intrapsychic and emotional material is another intellectual way to remove oneself from anxiety. Since the diagnosis here was paranoia, the hysterical and highly emotional defences seen in some of the other cases do not apply.At times, the truly paranoid person can seem like an old Western hero: calm, cool, collected and totally delusional. The calmness is the defence against overwhelming fear; the coolness is in the service of removing himself from his terror. Unfortunately, the collected appearance of such people is a cover for intense fear, in the service of premises and conclusions that do not bear any rational scrutiny.

 

CHAPTER ELEVEN: Stalemate

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The following psychotherapy, like the previous one, is a highly intellectualised, removed and less emotional one. The very nature of paranoia is that it is a projection onto others and a denial of responsibility for one's own feelings and underlying psychological issues. The material seems to the paranoid person to be coming from outside himself and to have little to do with him. Paranoid people have the logical concept of inference mixed up with the notion of implication. They think others are implying, whereas the paranoid person is really inferring.

Such was the situation in the following clinical example. In the process of trying to get away from his difficulties, the patient, Peter, toned down the underlying emotions and conflicts. Our sense of him is dimmer, in part because the diminishing of intensity is part of the mechanism of paranoia: the intent is to isolate and remove feelings that are sensed to be overwhelming. For various reasons it is too painful to feel one's feelings, so one invents fantastical stories for oneself to assuage one's hurt, isolation, resentment and need for another person.

 

CHAPTER TWELVE: Maya, Little, and the world of illusion

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World view is the result of the developing child's behaviour and fantasy interacting with the environment. Repeatedly harsh responses at an early age in a particularly intelligent, creative and sensitive individual can lead to an underground and hidden delusional split in her sense of herself. Such a fragmented psyche undermines her very personhood, her sense of volition and her ability to observe herself and others. Once she is delusional, it becomes impossible to cope as a unitary being in the world. A fragmented psyche destroys her functional ability and makes it extremely difficult for consistency in thought and behaviour to develop.

This was the case with Gretchen, a woman now in middle age, who was an adolescent when I first saw her early in my psychiatric training. She had come in for some vague difficulties in life: trouble with school work, resentment towards her divorced parents, occasional suicidality, lack of motivation, depression and self-mutilation. These issues required twice weekly psychotherapy and were gradually ameliorated over the course of a year.

 

CHAPTER THIRTEEN: Death, Egyptian style

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The following is a short vignette of a young man who had been delusional from the age of ten. It was a short therapy, perhaps a year and a half, punctuated with hospitalisations of several days’ duration when the patient was seriously suicidal, but it does provide a look at the emotions and psychological anguish that can lead to delusion formation.

Some people live to be dead. Such was the case with Daniel, a thin, pinched, blond, sad looking young man in his early twenties who was preoccupied by the desire to die. He had a traumatic upbringing in a small town, had been molested at a young age, and was felt to be “queer” by the local townspeople. He had made several suicide attempts in his adolescence, had a number of psychiatric hospitalisations, and was given shock treatment at the age of sixteen to try to rid him of his homosexual urges. Needless to say, by the time he moved to San Francisco he was in terrible shape. Even though he was accepted by the gay community, Daniel could never accept himself. He was preoccupied with death, wanting to kill himself. And try suicide he did, numerous times, numerous ways. Towards the end of my psychiatric training, we met in a crisis clinic after one of his many overdoses.We came to that interview from opposite poles and vantage points. He was dressed in purple, with a long sash dangling from his waist and a necklace portraying (he told me) Nekhbet, the winged Vulture Goddess, the Lady of Heaven; a scarab ring was on one finger. He spoke most deferentially, always calling me Sir. But I quickly found that his mind was keen and active.

 

CHAPTER FOURTEEN: Nobody

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O ccasionally a chronically suffering, deeply disturbed person, with diagnoses ranging from paranoid schizophrenia to schizoaffective depression to bipolar disorder, will respond to a more exploratory, uncovering psychotherapy, even if it is of short duration. Such was the case with Pamela, whom I saw in consultation for fewer than ten sessions. She was a professional woman in her mid-fifties, well educated, and married. She had made a number of serious suicide attempts, had hospitalisations both long and short, and had recently been in the hospital for several months after a suicide attempt. She had seen another psychiatrist for four years, as well as other therapists, with no amelioration of a worsening condition of auditory hallucinations and delusions which had persisted intermittently since college, when she was found shouting at the voices that pursued her. Most recently she had slashed herself in a serious suicide attempt leading to a hospitalisation where high doses of several antipsychotics and antidepressants were instituted.

 

CHAPTER FIFTEEN: The voice didn't win

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Rachel was a petite, wan, twenty-year-old young woman with blond hair over her face when I first saw her on the psychiatry ward, after her third hospitalisation in eight months for serious suicide attempts, self-mutilation, and psychotic behaviour. As she had been after the other suicide attempts, she was withdrawn and hallucinating; she looked blank, her attention on inward preoccupations. On two previous occasions she had overdosed; this time she had been found, dazed and confused, wandering on the Golden Gate Bridge. There were reddish lines on her forearms from cutting at herself with a safety pin.

Rachel didn't particularly want to talk to me, but I had been called in to see her since she was on such a downhill, negative course. Her family was concerned that they might lose their daughter during one of these psychotic and suicidal episodes. Initially, Rachel was mute as I sat quietly with her. Gradually, she talked reluctantly, still immersed in whatever she was seeing and hearing. In response to questions, I learned that she was the eldest of four in a business family, with a sister 16 months younger and twin brothers five yearsyounger. Her father was seen as authoritarian and rigid, her mother as inhibited and too tolerant of her father's tyrannical behaviour.

 

CHAPTER SIXTEEN: The world class artist of the symbolic world: the Mafia, the movie stars and the “Unconscious God”

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A number of years ago a colleague told me that a man in his early forties, whom she had seen twenty-five years earlier while he was a student at a nearby boarding school, had contacted her. He had been at a famous hospital—let's call it Cotswald's—for ten years, continued to be severely paranoid, and wanted to leave. My colleague had discussed the case with the administrative psychiatrist at Cotswald's, read a number of treatment and discharge summaries, and decided that her half-time practice would not afford the best treatment for the patient. Uncomfortable with her former patient's therapeutic progress since she had last seen him, she asked me to take a look at the material.

The clinical resumes were daunting, with diagnoses like schizophrenia, paranoid, chronic on Axis I, and borderline personality as Axis II. To quote from the summaries after ten years in a hospital and halfway house setting at Cotswald's, “he demonstrated the same characteristics and symptom complex that were present when he first came to Cotswald's”. In addition to his “ineffective coping outside a structured setting” the patient showed disordered thinking”dominated by a paranoid delusion that included receiving special messages from the television and radio and feeling that he could communicate (via an implanted transmitter) through his teeth and that anything spoken would happen […] This made it extremely difficult to communicate with the patient at all.” In addition to an “escalating daily franticness”, the patient was frequently suicidal and had been so at the time of his last full-time hospitalisation at Cotswald's. This did not present an auspicious picture.

 

CHAPTER SEVENTEEN: Can anyone that evil ever really die?

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Multiple personality, the source of myths about witchcraft, cures by exorcism, and possession by demons, is an oft maligned diagnostic category. Therapists who contend that these patients exist have run into the contempt of their peers, and are often criticised for being gullible and credulous, or for creating iatrogenic disease. Over the last thirty years, it has become a more acceptable diagnosis.

At its most severe, multiple personality disorder is a delusional disorder. Patients believing that they are more than one being must be delusional, believing that they are possessed or just different people at different times. As with the other delusional disorders delineated in this book, multiple personality disorder is amenable to an intensive psychotherapeutic exploration and treatment, as the following case amply demonstrates.

Since the field of multiple personality disorder, its origin and treatment has created so much discussion and question, I refer the reader to Frank Putnam's excellent monograph Diagnosis and Treatment of Multiple Personality Disorder (1989) for a more thorough understanding of this disorder. He and I disagree, however, on the usefulness of, or necessity for, hypnosis in the treatment of such patients.Janet postulated that hysterical symptoms such as amnesia, fugue, conversion symptoms and “successive existences” were a result of patients having split off certain aspects of their personalities, aspects that began to take on a life of their own, with no central unifying ego (Putnam, 1989, p. 2). Janet further demonstrated that these dissociated elements had their origin in past traumatic experiences, and that treatment and change could occur when split off affects and memories were brought into consciousness (Ellenberger, 1970).

 

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