Journal of Psychology & Psychotherapy
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How Does Psychoanalysis Work With Persons Afflicted By Schizophrenia?

Wilfried Ver Eecke^{* *}Correspondence: Wilfried Ver Eecke, Department of Philosophy, Washington D.C. Metro Area, USA, Tel: + (202)803-8633, Email:

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Introduction

In the abstract of their article “The Comprehensive Open-Dialogue Approach in Western Lapland” the authors, Jaakko Seikkula, Birgitta Alakare & Jukka Aaltonen, write: “In a two-year follow-up of two consecutive periods during the 1990s (1992–3 and 1994–7) it was found that 81% of patients did not have any residual psychotic symptoms […] 84% had returned to full-time employment or studies. Only 33% had used neuroleptic medication” [1]

When a schizophrenic breakdown occurs, the “Open Dialogue" method consists in the following steps [2]; Three mental health professionals visit the home of the patient. These mental health professionals do not come to hospitalize the patient. Instead, they talk to the family and the patient. They hereby avoid the stigma of hospitalization and the further stigma of diagnosis of mental illness. Next, the three mental health professionals talk to each other and ask the family and the patient what they picked up from the discussion. The three professionals do that, at first, every day; then every week and then every month. During this process 81% of the patients recover [1].

Proven success of psychoanalytic approaches to Schizophrenia

What is worth noticing in the “Open Dialogue” method is the unusual form of communication. The three mental health professionals do not talk in a normal way to the mentally ill person. Instead, the three mental health professionals talk to each other. They talk in the presence of both the mentally ill person and his or her family. Then they ask the mentally ill person and his family what he or she picked up from the conversation.

In a real conversation “I” and a “Thou” address each other and regularly change positions, as speaker and listener [3]. This is not how the talking takes place in the “Open Dialogue” method. The three mental health professionals talk with each other with the intention of providing linguistic material for the patient. Then they ask and encourage the patient and the family members to tell the mental health professionals what they picked up from the conversation. In the words of Seikkula, Alakare & Aaltonen, “the team should focus on generating dialogue in the joint therapy meetings, in order to create new words and a new joint language for experiences that previously did not have words” [1].

Over a period of one to two years, the patient is able to use this artificial form of conversation as a means to restructure him or herself. He or she does that by restructuring his or her relationships with the important others in his or her life. As mentioned above, Jaakko Seikkula, Birgitta Alakare & Jukka Aaltonen reports that, by this restructuring, 81% of the patients did not have any psychotic symptoms two years after the treatment. And, 84% of the schizophrenic patients were able to return to daily life [1].

The results, achieved by the “Open Dialogue” method, demonstrate that a linguistic approach to the treatment of schizophrenia can be very effective. The “Open Dialogue” method uses little or no medication. This method relies almost exclusively on the appropriate usage of the spoken word [4]. This Finnish success in the treatment of schizophrenia invites us to replace a biological explanation of schizophrenia with a psycho-social and linguistic one. This is what Lacan did in a life-long reflection on mental illness [5].

Literature Review

Lacanian explanation of Schizophrenia

Let us start with a couple of cases. One schizophrenic patient told her therapist that she had no hands. When the therapist asked the patient how she knew, the patient said that her father had told her so, that very morning. To the question by the therapist as to what the father had said, the patient answered: “My father told me that I was handicapped.” The conversation was in Dutch where the words for “handicapped” sounds like “handicut.” Thus, the patient had interpreted the sentence of the father literally. She interpreted “handicapped” not metaphorically as being disabled but literally as having one’s hands cut. The case of this patient illustrates Lacan’s theory that schizophrenic persons have a deficient relationship to language. In the case of this first patient, language could not be fully used in its metaphorical dimension.

Another patient, diagnosed as schizophrenic, stated: “If I relate to the world with my senses, the world is infinitely rich. If I describe this sensual world, I lose the richness of the sensual impressions of that world.” This patient was acutely aware of the loss involved in the use of language to describe the world. As part of my protocol to treat patients afflicted by schizophrenia, I describe for such patients the figures and colors of the rug in the consulting room [6-8]. This patient was a student at one of the top US universities. I never saw a patient so fascinated as this patient was with my description of the figures and colors of the rug in the room. In describing linguistically the sensual impressions of the room, I did for the patient what the patient himself felt to be a frustrating experience. In the process, the patient also experienced a positive function of language. The patient experienced that in me describing for him the room, he and me belonged to the same world. His loneliness diminished.

In the two examples of patients suffering from schizophrenia, we discovered a defective relationship to language. Lacan attributes the deficient relationship to language of such patients to the absence of what he calls: the paternal metaphor [9]. By this concept, Lacan did something that Freud had already done. Lacan, like Freud, stressed the fact that the introduction of the paternal function—i.e., the Oedipus complex-- invites the child to reconstruct its psyche. Differently than Freud, Lacan stresses the idea that the introduction of the paternal function invites the child to master the metaphorical dimension of language [9]. To explain this claim of Lacan, we need to understand the change in psychic structure in the infant, when the figure of the father is introduced. But first we need to understand the psychic structure of the infant shortly after birth.

When a human baby is born, the child is totally dependent upon another, i.e., the mother or a mother figure. But a human baby already develops consciousness. Total dependence upon another is not acceptable for a conscious being. To solve this unacceptable position, the human baby develops two fantasies. First, it imagines that the mother has what it needs. This fantasy about the mother reassures the child that the mother is fully capable of protecting and providing for the child. The child develops also a second fantasy: it imagines it is everything that the mother can wish. To make this fantasy realistic the child “tries to become what it thinks the mother is interested in” [10]. This second fantasy reassures the child that the mother will take care of it. Lacan refers to this second fantasy by his concept of demand present in the child’s attitude to its mother. This demand is expressed, among others, by the crying of the baby [11].

Everything changes for the child when, between two and three years of age, the child notices that the mother has an interest in a third, normally the father. Lacan sees this move by the child as a linguistic move. He states that the child internalizes the “Name-of- the-Father” [12]. That discovery by the child destroys the two fantasies it created to deal with its dependency. The child learns that the mother does not have it all, since she shows an interest in a third. But if the mother misses something, and looks to the father for what she misses, then it, the child, is not able to fill the lack or the gap in the mother [10]. As a consequence, the child needs to change the conception of itself. One way to do so is to look at what mark in the father is so attractive to the mother. The child can then take this mark as the basis of its own identity. Lacan refers to this mark in the father as the “Name-of- the-Father” [13]. But the child knows that it is not the father. Hence, the child must accept that it will have to work to become what it wants to be, but is not yet.

The child, in its news self-conception, must not only accept to have to work. The child must also accept to have to develop patience and to make the future the most import dimension of time. Lacan makes use of Freud’s idea of “Bejahung” to give a name to this new attitude of the child. That new attitude includes the ability to commit to something [12]. The child hereby becomes a different person.

But as different person the child remains the same biological child it was before. It remains the child of Mrs. X and Mr. Y and thus keeps the same name. In becoming different while remaining the same person, the child embodies the essence of becoming a metaphor [12].

Indeed, for Lacan the introduction of the “Name-of-the-Father” invites or forces the child to change its psychic structure. The child thus becomes a different child while remaining the same person.

Lacan calls this change in the child a metaphor. As this change in the child is introduced by the figure of the father, Lacan refers to this change as the work of the “paternal metaphor.

Lacan argues that schizophrenia is marked by a defective relationship to language. That defective relationship to language is clearly visible in the difficulty that persons afflicted by schizophrenia have with metaphors. Again, according to Lacan, the linguistic difficulty with metaphors is connected with the lack of a proper oedipal experience. In a proper oedipal experience, a third is integrated in the psychic structure of the child [9]. Indeed, the internalization of that third, normally the father, makes that the same child becomes psychologically different. We can thus say that the child has made a metaphorical move.

The above ideas provide insights into what the therapy of persons, afflicted by schizophrenia, should concentrate upon. A psychoanalytic treatment of such patients should try to enrich the relationship of the patient to language. The treatment should also make the patient capable of relating to a third. Still, every successful treatment of persons suffering from schizophrenia should start with the assumption that the patient is not capable of a relationship to a third. Indeed, a schizophrenic person tends to fuse with and thus to please the person he is in contact with [14]. When asked if he wants to meet tomorrow at 3:00PM for a coffee, a schizophrenic person will tend to agree. He will agree even, if a couple of hours ago, he had agreed already to meet another person at that same time.

We will now take a look at the treatment method for patients suffering from schizophrenia developed by three therapists: Gary Prouty, Bertram Karon and Palle Villemoes. Each of these therapists incorporated in their method the idea that schizophrenic patients are not incorporating psychically the idea of a third.

Prouty’s approach

Garry Prouty calls his method “pre-therapy” [15,16]. He considers his therapy a specification of the patient centered therapy developed by Carl Rogers. Like Rogers, Prouty recommends two attitudes for the therapist. These two attitudes try to make the dual relationship of patient/therapist the sole relevant relationship. These attitudes try to make irrelevant the considerations of a third party. That third party, e.g., the parents, might push the patient to respect the currently accepted civilized behavior patterns.

In a first recommendation, Prouty advocates an unconditional positive regard for the patient. Prouty defines unconditional positive regard as “a warm acceptance of each aspect of the client’s experience” [17]. In a second recommendation, Prouty advocates that the therapist have empathy. Prouty defines empathy as “sensing the client’s private world as if it were [his] own” [17].

Technically, Prouty recommends that the therapist sit in front of the patient. The therapist must imitate each of the patient’s bodily gestures. The therapist must imitate the patient even if the patient lifts his arm for hours. In imitating each gesture of the patient, the therapist shows the patient that he, the patient, has an impact on the therapist. In this part of Prouty’s therapy method, the communication between the catatonic schizophrenic patient and Prouty remains limited to mirroring. Thus, Prouty’s therapy remains a purely dual relationship between the patient and the therapist. When the patient starts showing facial expressions like being sad or even having a tear in his eyes, Prouty and his followers radically change, in my opinion, their approach to their patients. Instead of communicating with their patients by pure mirroring, they now introduce linguistic communication and say: “You look sad” or even more concretely “There are tears in your eyes” [17].

Often, the patient responds to the therapist by mumbling. Hence, only one or a couple of words are understandable. The therapist, then, repeats forcefully those understood words and says, for instance, “ run… three… paper” [16]. Hereby, a catatonic patient is a speaking being in principle. The patient, himself, introduces the third, i.e., the outside world. That outside world is for this patient captured by three words: “run…three…paper.”

Prouty recommends not asking explanations to the patient. Asking questions would assume that the patient is a dialogue partner, who has access to a world, i.e., a third. Instead, Prouty recommends that the therapist respect the dominance of the dual relationship and simply repeats the words “run.. three… paper” [16]. In doing so, Prouty demonstrates to the patient that he is heard. Prouty also gives the impression that he is not looking for an explanation. Rather, Prouty gives the impression to the patient that he is totally interested in the patient. In response, the patient normally reveals more of his own “I” as it is importantly connected with the words “run…three…paper” [16].

One could ask, how does Prouty succeed in introducing the third in the psychic structure of his patients? We find a solution to this question by a third recommendation for his therapy. That third recommendation is also borrowed from Rogers and is called “congruence.” Congruence is defined as “the therapist being freely and deeply himself, with his actual experience being presented by his awareness of himself” [17]. Thus, Prouty recommends that a therapist in doing his kind of therapy split himself in two parts. One part is unconditionally empathic with the patient. The other part of the therapist remains who he is. It is the part of the therapist who is his real self and who makes judgements about the patient and the direction of the therapy. Prouty uses his patient Laura to explain his method. Prouty realized that Laura wanted more than she could do. So, Prouty decided that he had to pay attention to Laura’s limits and, if necessary, had to reestablish those limits [16]. Prouty reports that when he did set respectfully limits to Laura and did so by means of the word “waiting”, “Laura became more open to language. As a consequence, she could deal increasingly better with various situations in everyday life” [16].

For Prouty, the introduction of limit setting to Laura or the use of the three words “run… three… paper” is done only after the work of creating a dual union with the patient is established. Limit setting or repeating mumbled words is, in Prouty’s method, opening the patient to a third: the world in which the schizophrenic patient lives passively.

Bertram Karon’s approach to Schizophrenic patients

Bertram P. Karon co-authored with G.R. Vanden Bos, Psychotherapy of Schizophrenia: The treatment of Choice. In that book Bertram P. Karon argues that the therapist should not enter into a discussion with a schizophrenic patient. A therapist should certainly not argue that the facts of the world contradict the patients’ delusions. Karon gives as example a patient who claimed that something was wrong with his head. Hence, said the patient, he needed an operation [18]. Karon did not contradict his patient by saying that the medical profession does not use surgical operations for every pain in the head. Karon did not appeal to the authority of a third, the medical profession, to contradict his patient. Instead, Karon accepted the patient’s claim. He then used the patient’s claim to introduce, within the vocabulary of the patient’s delusion, the suggestion of talk therapy. Here is what Karon said: “Of course there is something wrong with your head if you hear voices” [18]. Karon then continued and stated: “The only operation you need is to talk to someone about your problems and about the reasons why you hear voices. Are you interested?” [18]. Karon reports that the patient relaxed and said “That sounds like a good idea” [18]. Karon could have made it clear that he, Karon, believed in a third authority, the medical profession. Karon then could have tried to convince the patient that he should incorporate in his view of the world the ideas of that third authority. Instead, Karon explicitly limits his discussion with the patient to the claims of the patient. He even accepts the point of view of the patient.

Karon explicitly states that the first task for the therapist is to create an environment which the patient experiences as protective. Karon aims at making the beginning therapeutic relationship importantly, if not exclusively, a relationship between the patient and the therapist. Karon does not make the beginning of the therapy mainly about the complaint. Karon makes the beginning of the therapy about the patient. Karon reports that he does so by first offering the patient a cup of coffee. Mostly the patient refuses the cup of coffee but is happy to refuse it [18].

Next, Karon listens to the fears or even terrors capturing the mind of the patient. Thus, one patient told Karon that the Athenian girls are laughing at him and that their breasts are poisoned. Karon did not present rational arguments to refute the basis of the fear and the terror of his patient. Instead, he simple stated that he, Karon, was stronger than the Athenian girls and that his milk was not poisoned. Karon reports that the patient asked for a first and a second glass of milk and showed no further fear of milk [18].

Karon illustrates his approach to the special treatment of schizophrenic patients by several further examples. In one case, the patient reported to Karon that every night he had terrible nightmares [18]. In the nightmares he was beaten by a stick by his stepmother. The patient asked Karon what would happen if he went home and killed his stepmother. Would the nightmares stop? Karon reports that he did not take the moral (in Lacan’s terminology the symbolic) position of trying to convince the patient that he should not kill his stepmother for moral and legal reasons. Instead, Karon addressed the imaginary vengeance of the patient and asked if somebody had told him that he could not kill his stepmother? Karon then continued by saying that his stepmother was an old bitch who deserved to be killed for what she had done to the patient [18]. Karon continued by saying that each time a person is hurt by somebody that person develops hate and even the feeling of wanting to kill the one harming him or her. But, declares Karon, this is healthy [18].

After having established contact with the imaginary dimension of the patient, Karon then addresses the full person, relating as a self to the world. Karon then says: “The only reason not to kill [your stepmother] is that you will be caught. If you are prepared to die for her, then you must feel that she is more important than you. That, I feel stupid. (But notice, I did not say that it would be bad). It would be stupid to kill her, but you certainly should want to kill such a bitch” [18].

To make a distinction between what one wishes and what should or should not be done is introducing a non-imaginary dimension. In Lacanian term, it is introducing the symbolic dimension where language and linguistic arguments dominate: i.e., if… then, or more concretely if you do not want the consequences of your act, do not do your act. But Karon introduces an idea contradicting the delusional fantasies of the patient only after a profound dual relationship has been established between the therapist and the schizophrenic patient. Karon introduces such an idea as the continuation or implication of the delusional idea.

Ego-structuring method as treatment for persons suffering from Schizophrenia

Villemoes noticed that persons afflicted with schizophrenia do not use properly the pronouns. Thus, one patient asked whether his parents liked him answered with the statement: “No, I did not like them” [6]. This patient confused the two points of view of liking: the parents liking him and he liking his parents. From such observations Villemoes concluded that persons afflicted by schizophrenia cannot be dialogue partners. Hence, a therapist treating persons afflicted by schizophrenia cannot talk in a normal way to such patients.

Like in all psychodynamic therapies, ego-structuring therapy requires the creation of transference from the patient to the therapist. Creating such transference is the task of the first phase of ego-structuring. This is done by means of several strategies. The first strategy is prescribing a particular position for the patient and the therapist. Instead of looking at each other, ego-structuring demands that the therapist and the patient sit next to each other with a table in between to avoid hetero- or homo-sexual feelings. Therapist and patient look together in the same direction.

Second, the therapist describes the consultation room. Finally, the therapist describes the patient’s own room [6]. By this last step, the therapist elevates the patient to the guarantor of the truth, because only the patient knows what his room looks like. This last step satisfies the narcissism of the patient and thereby increases the patient’s transference to the therapist. This is the moment when ego-structuring starts the second phase of the therapy: the working phase. The therapist explains that in this new phase of the therapy, the working phase, the therapy is now interested in the memories of the earliest objects of the patient as a child. The therapist also states that the patient is responsible for ending the session. The patient is hereby given the last word in each session. The patient is invited to become an active agent in the therapy.

During the working phase the patient is asked to describe the remembered objects from his or her earliest memory. While describing those objects the patient slowly, but without exception, introduces the people with whom he interacted. This process allows the patient to discover who he or she has become. When the patient’s whole history has been told, and there are no periods in the patient’s life which have been left out, then the working phase is finished. This is the reason to start the third phase which involves ending the therapy. A date is then chosen by the patient on a calendar when the therapy will end [6]. The purpose of the third phase is to return the transference projected onto the therapist back to the patient. This happens by the therapist saying very little and when saying something stating that he, the therapist, does not know that. When the date chosen for ending the therapy arrives, the patient leaves happily while the therapist feels a loss.

Discussion

The statistics of the Finnish “Open Dialogue” method demonstrate that talk therapy can be healing for patients afflicted with schizophrenia. I then analyzed the methods developed by Prouty, Karon and Villemoes to treat such patients. All three therapists argue that a therapist treating persons afflicted by schizophrenia must respect the delusional world of such patients and cannot argue against their views by referring to facts of the world. This would introduce a third phenomenon used antagonistically against the delusion of the patient. Instead, all three therapists begin by accepting the imaginary illusions of the patient. All three then introduce the structuring function of language. Prouty introduces language after having mirrored all gestures of the patient by naming a facial expression: “There are tears in your eyes” [17]. Karon uses language as used by the patient to invite the patient to talk therapy by saying to a patient asking for an operation on his head because of his headaches: “Of course there is something wrong with your head if you hear voices…the only operation you need is to talk to someone about your problems and about the reasons why you hear voices. Are you interested?” [18]. The imaginary is used as a pathway to symbolic talk.

Conclusion

Villemoes in his ego-structuring method accepts the Lacanian thesis that a person afflicted by schizophrenia lacks the psychic ability to integrate a third in his personality. Hence such a person has the psychic structure of an infant needing an omnipotent mother protecting the patient. Ego-structuring uses the slow process of reconstructing in words the history of the patient as the third. This process allows the patient to discover and to create himself as a separate individual. But Villemoes stresses the idea that in psycho-therapy one should not contradict a person afflicted with schizophrenia. Such a person relates to others, originally, by the fusion that is typical for mother-child relationships.

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