The Psychotherapy of Schizophrenia

The Psychotherapy of Schizophrenia

The Psychotherapy of Sch izophrenia EDITED BY JOHN S. STRAUSS MALCOLM BOWERS T. WAYNE DOWNEY STEPHEN FLECK STANLEY JACKSON AND IRA LEVINE Yale University School of Medicine New Haven, Connecticut PLENUM MEDICAL BOOK COMPANY New York and London

Main entry under title: Library of Congress Cataloging in Publication Data The Psychotherapy of schizophrenia. Includes index. 1. Schizophrenia-Addresses, essays, Schizophrenia - Therapy -Congresses. P97441979) RC514.C58 lectures. I. Strauss, John S. [DNLM: 1. 2. Psychotherapy-Congresses. WM203 616.89'8206 80 16524 ISBN-13: 978-1-4684-3772-0 DOl: 10.1007/978-1-4684-3770-6 e-isbn-13: 978-1-4684-3770-6 1980 Plenum Publishing Corporation Softcover reprint of the hardcover I st edition 1980 227 West 17th Street, New York, N.Y. 10011 Plenum Medical Book Company is an imprint of Plenum Publishing Corporation All rights reserved No part of this book may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the Publisher

Contributors YRJO ALANEN, M.D. Professor of Psychiatry, University of Turku, Finland SIDNEY J. BLATT, PH.D. Professor of Psychology and Psychiatry, Yale University MALCOLM B. BOWERS, JR., M.D. Professor of Psychiatry, Yale University School of Medicine; Chief of Psychiatry, Yale-New Haven Hospital C. BROOKS BRENNElS, PH.D. Clinical Faculty, Department of Psychology and Psychiatry, University of Wisconsin EUGENE B. BRODY, M.D. Professor of Psychiatry and Human Behavior, University of Maryland at Baltimore; Formerly Chairman, Department of Psychiatry HILDE BRUCH, M.D. Professor Emeritus of Psychiatry, Baylor College of Medicine WILLIAM T. CARPENTER, JR., M.D. Director, Maryland Psychiatric Research Center; Professor of Psychiatry, University of Maryland School of Medicine JOHN P. DOCHERTY, M.D. Director of Education, Yale Psychiatric Institute T. WAYNE DOWNEY, M.D. Associate Clinical Professor of Pediatrics and Psychiatry, Yale Child Study Center STEPHEN FLECK, M.D. Professor of Psychiatry and Public Health and Deputy Chairman, Department of Psychiatry, Yale University School of Medicine MICHAEL J. GOLDSTEIN, PH.D. Professor of Psychology, University of California at Los Angeles BEVERLY GOMES-SCHWARTZ, PH.D. Assistant Psychologist, McLean Hospital, Blemont, Massachusetts; Instructor in Psychiatry, Harvard Medical School v

vi CONTRIBUTORS DAVID GREENFELD, M.D. Assistant Clinical Professor, Department of Psychiatry, Yale University DOUGLAS W. HEINRICHS, M.D. Department of Psychiatry, University of Maryland JUHANI LAAKSO, M.D. Department of Psychiatry, University of Turku, Finland ROBERT P. LIBERMAN, M.D. Professor of Psychiatry, University of California at Los Angeles, School of Medicine; Director, Mental Health Clinical Research Center for the study of Schizophrenia PHILIP R. A. MAY, M.D. Director, Health Service Research and Development Laboratory, Brentwood V.A. Hospital, Los Angeles, California GORDON L. PAUL, PH.D. Department of Psychology, University of Houston, Houston, Texas; Director, Clinical Research Unit, Adolf Meyer Mental Health Center VILJO RAKKOLAINEN, M.D. Department of Psychiatry, University of Turku, Finland RUTTA RASIMUS, M.D. Department of Psychiatry, University of Turku, Finland CLINTON RUST, M.P.A. Executive Director, Camarillo State Hospital JEAN G. SCHIMEK, PH.D. Associate Professor of Psychology, New York University CLARENCE G. SCHULZ, M.D. Senior Psychiatrist, The Sheppard and Enoch Pratt Hospital DANIEL P. SCHWARTZ, M.D. Medical Director, Austen Riggs Center, Inc. KAREN S. SNYDER, M.A. Research Associate, University of California at Los Angeles ALFRED H. STANTON, M.D. Professor of Psychiatry, Harvard Medical School; Psychiatrist, McLean Hospital HELM STIERLIN, M.D. Division of Psychoanalysis and Family Therapy, University of Heidelberg, Germany JOHN S. STRAUSS, M.D. Professor of Psychiatry, Yale University School of Medicine A. HUSSAIN TUMA, PH.D. Acting Chief, Clinical Research Branch, National Institute of Mental Health CHRISTINE E. VAUGHN, PH.D. Associate Research Psychologist, University of California at Los Angeles CHARLES J. WALLACE, PH.D. Associate Director, Mental Health Clinical Research Center, University of California at Los Angeles OTTO A. WILL, JR., M.D. Clinical Director, Adolescent and Young Adult Inpatient Service, Mt. Zion Hospital, San Francisco, California LYMAN C. WYNNE, M.D., PH.D. Professor of Psychiatry, University of Rochester School of Medicine and Dentistry

Preface This volume is dedicated to Theodore Lidz and Ruth W. Lidz, as was the conference on the Psychotherapy of Schizophrenia held on April 9 and 10, 1979, at which the materials here published were presented. This 1979 symposium replicated in some respects the one held at Yale University thirty years earlier, at a time when psychotherapy with schizophrenic patients was viewed with much optimism and enthusiasm. Ruth and Ted Lidz contributed to this earlier symposium also, emphasizing in their paper the intense mother-patient bond as a therapeutic issue. Since then, considerable strides have been made in the treatment of schizophrenic patients. The introduction of psychopharmacologic agents, the development of family therapy, and more sophisticated methods in community-based care for such patients, all have had important impacts. Psychotherapy with schizophrenics as such has remained a rather limited practice, partly because it is difficult and demanding of therapists' time and personal investment, and partly because documenting its effectiveness on a statistically or epidemiologically valid plane has eluded us. In fact, the use of psychotherapy for treating schizophrenic patients is one of the more controversial issues in psychiatry. Two factors besides questions of efficacy contribute to this controversy. First, psychotherapy as a treatment often gets confused with strongly held convictions about etiological questions. Second, the value of psychotherapy for learning about schizophrenia as well as treating it may be at stake. Many view psychotherapeutic exploration of the subjective experiences of schizophrenia as practically unique in providing valuable information for combining with objective data which by themselves consider only one aspect of an ongoing process and life. These and other issues are discussed in this volume. Brought together here are critics and defenders, all with knowledge of practice and methodology, but with various orientations and interpretations vii

viii PREFACE of both. For the practitioner and the investigator, we believe that the papers and discussions in this volume will help to clarify how practice and research can be improved, suggest areas where opposing views can produce a synthesis in which certain disagreements cease to make sense, and highlight continuing differences of opinion that at some point will have to be resolved. Despite the considerable progress over the three decades which the volume reflects, much remains to be discovered. The importance of subjective and objective data in research and treatment, and the apparent need for multilevel approaches for understanding schizophrenic patients, make this a complex field. However, the strengths and weaknesses of current views, and the directions for future research and treatment, are becoming clearer. We believe that this volume will help in this process. Yale University School of Medicine JOHN S. STRAUSS MALCOLM BOWERS T. WAYNE DOWNEY STEPHEN FLECK STANLEY JACKSON IRA LEVINE

Contents RATIONALE FOR THE PSYCHOTHERAPY OF SCHIZOPHRENIA PSYCHOTHERAPY IN SCHIZOPHRENIA: HISTORICAL CONSIDERATIONS......... 3 Hilde Bruch, M.D. 2 ON THE CENTRAL TASK OF PSYCHOTHERAPY: PSYCHOANALYTIC AND FAMILY PERSPECTIVES 13 Helm Stierlin, M.D. 3 SOCIAL AND FAMILY FACTORS IN THE COURSE OF SCHIZOPHRENIA: TOWARD AN INTERPERSONAL PROBLEM-SOLVING THERAPY FOR SCHIZOPHRENICS AND THEIR F AMIUES.................................. 21 Robert Paul Liberman, M.D.: Charles J. Wallace, Ph.D.: Christine E. Vaughn, Ph.D.: Karen S. Snyder, M.A.: and Clinton Rust, M.P.A. 4 SOME OBSERVATIONS ON THE NATURE AND VALUE OF PSYCHOTHERAPY WITH SCHIZOPHRENIC PATIENTS........................................ 55 Stephen Fleck, M.D. 5 DISCUSSION: RATIONALE FOR THE PSYCHOTHERAPY OF SCHIZOPHRENIA..... 65 Eugene B. Brody, M.D. 6 GENERAL DISCUSSION................................................. 71 ix

x CONTENTS II RESEARCH 7 FAMILY THERAPY DURING THE AFTERCARE TREATMENT OF ACUTE SCHIZOPHRENIA.... 77 Michael J. Goldstein, Ph.D. 8 PSYCHOTHERAPY OF SCHIZOPHRENIA: CAN WE MAKE IT WORK?....... 91 PhilipR.A. May, M.D. 9 THE NATURE OF THE PSYCHOTIC EXPERIENCE AND ITS IMPLICATIONS FOR THE THERAPEUTIC PROCESS... 101 Sidney J. Blatt, Ph.D.: Jean G. Schimek, Ph.D.: and C. Brooks Brenneis, Ph.D. 10 PROBLEMS INHERENT IN THE STUDY OF PSYCHOTHERAPY OF PSYCHOSES: CONCLUSIONS FROM A COMMUNITY PSYCHIATRIC ACTION RESEARCH STUDY. 115 Yrjo O. Alanen, Vi/jo Riikkoliiinen,luhani Laakso, and Riita Rasimus II INSIGHT AND SELF-OBSERVATION: THEIR ROLE IN THE ANALYSIS OF THE ETIOLOGY OF ILLNESS................................................ 131 Alfred H. Stanton, M.D. 12 DISCUSSION... 145 A. Hussain Tuma, Ph.D. 13 GENERAL DISCUSSION................................................. 151 III THE PRACTICE OF PSYCHOTHERAPY WITH SCHIZOPHRENICS 14 COMMENTS ON THE "ELEMENTS" OF SCHIZOPHRENIA, PSYCHOTHERAPY, AND THE SCHIZOPHRENIC PERSON...................................... 157 Otto Allen WiII,lr., M.D. 15 COMPREHENSIVE PSYCHOSOCIAL TREATMENT: BEYOND TRADITIONAL PSYCHOTHERAPY..................................................... 167 Gordon L. Paul, Ph.D. 16 ALL-OR-NoNE PHENOMENA IN THE PSYCHOTHERAPY OF SEVERE DISORDERS... 181 Clarence G. Schulz; M.D.

CONTENTS xi 17 PARADOXICAL INTERVENTIONS: LEVERAGE FOR THERAPEUTIC CHANGE IN INDIVIDUAL AND FAMILY SYSTEMS 191 Lyman C. Wynne, M.D., Ph.D. 18 DISCUSSION: THE PRACTICE OF PSYCHOTHERAPY WITH SCHIZOPHRENICS 203 Daniel P. Schwartz, M.D. 19 GENERAL DISCUSSION........................................ 209 IV NEW DIRECTIONS 20 THE DEVELOPING GUIDELINES TO THE PSYCHOTHERAPY OF SCHIZOPHRENIA... 217 Theodore Lidz, M.D. 21 MEDICATION AND PSYCHOTHERAPY IN OUTPATIENTS VULNERABLE TO PSYCHOSIS... 227 Malcolm Baker Bowers,Jr., M.D. and David George Greenfeld, M.D. 22 THE ROLE FOR PSYCHODYNAMIC PSYCHIATRY IN THE TREATMENT OF SCHIZOPHRENIC PATIENTS............................................. 239 William T. Carpenter, Jr., M.D. and Douglas W. Heinrichs, M.D. 23 THE QUALITY OF OUTCOME FROM PSYCHOTHERAPY OF SCHIZOPHRENIA..... 257 John G. Gunderson, M.D. and Beverly Gomes-Schwartz, Ph.D. 24 TOWARD COMPREHENSIVE UNDERSTANDING AND TREATMENT OF SCHIZOPHRENIA...................................................... 277 John S. Strauss, M.D.; John P. Docherty, M.D.; and T. Wayne Downey, M.D. 25 DISCUSSION: NEW DIRECTIONS......................................... 287 Morris B. Parloff, Ph.D. 26 GENERAL DISCUSSION................................................. 293 INDEX.............................................................. 297

Acknowledgments The editors wish to extend special thanks to the following organizations that contributed to the support of the Psychotherapy of Schizophrenia conference and thus made this volume possible: The Center for Studies of Schizophrenia and the Psychotherapy and Behavioral Intervention Section, both from the Clinical Research Branch of the National Institute of Mental Health; Hoffman-LaRoche, Inc.; Sandoz Pharmaceuticals; E. R. Squibb and Sons, Inc., The Warner/Chilcott Co. xiii