New Ways in Psychoanalysis: Volume 105 (The International Library of Psychology : Psychoanalysis)
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His personal portfolio of 18 patients, together with other patients, is an excellent example of pioneering work, which he has written up in his book "Experiences of Schizophrenia" and many papers, and in which he provides rich details of his clinical findings, views and conclusions [ 13 ]. His lifetime's work relates his successes as well as those of his cases that did not succeed in alleviating the patient's distress.
He looks objectively at the possible reasons that might account for the failures, and has been able to describe half of his patients, 9 out of 18, as having had "positive outcomes", 6 of these being "very successful". A further patient's therapy has been written up in his paper "The successful psychoanalytic therapy of a schizophrenic woman" [ 14 ]. He is a trained Psychiatrist and Psychoanalyst, and has been able to gain understanding of schizophrenia and schizophrenic patients at a deep level. He adheres to a hierarchical understanding of the illness that involves molecular biology, neurobiology, neurochemistry, psychoanalysis, interpersonal psychology, family systems, sociology and cultural anthropology.
Like almost every clinician who works with schizophrenia, he acknowledges the place of medication in the treatment of his patients, who have been based at the Maclean Hospital in Massachusetts while they received psychoanalytic treatment from him in his consulting room. In his book he expresses intense gratitude to the staff there for their management of his patients, as is the case for most therapeutic clinicians who work with very mentally ill individuals who require hospitalization while receiving their treatment.
One of his remarkable results has been that he has been able to stage the progress in treatment of all of the patients whom he has treated, a sequence of 7 Stages Table 1. All of his patients follow this process, even if they were not able to complete their therapy. His approach has been to deliver psychoanalytic psychotherapy to all his patients, and to observe how they have progressed in his care.
He writes of the healing power of love, and with this ethos has nurtured all of his patients as far as they were able to proceed in treatment with him. The full therapy process involves two major phases; initially the patient is very ill and can only relate to him from their unhealthy, schizophrenic perspective. After this the patient goes through the second phase, that of relating more normally to the analyst, in which phase the Stages of the process lead to therapeutic termination.
Table 1: Stages in the psychological resolution of schizophrenia. View Table 1. When the patient enters therapy they are invariably severely afflicted mentally. They have been unable to develop normally, whatever their individual experiences have been, and their minds are unhealthily distorted so that they have become unable to function properly where they have found themselves trying to live.
As a result, they find interaction with others very difficult indeed, and experience great if not impossible difficulty in asserting themselves as they would like to in order to overcome the frustrations of one situation after another. Relating to their analyst is no exception. Apart from the anxiety that this unusual situation causes them, where they are, and where they experience being under the scrutiny of a professional person, they generally suffer acute difficulty in comprehension and emotional pain at some level during their clinical interactions.
Dr Robbins describes this relationship, in Stage 1, as "Protopathosymbiosis" or "parasitism". The patient contributes little to the relationship, being completely dependent upon the analyst for steering it along therapeutic lines. The patient's identity is invested in her psychotic state and she is incapable of helping herself very much at this Stage.
That she has turned up, and continues to turn up daily at her analyst's consulting room is as much as she can do for herself. She has been selected for therapy because of previous evidence of stamina and achievement in her earlier life, but now she has disintegrated due to circumstance, and all of what is still healthy in her psyche, her non-psychotic mind, strains to co-operate with the analyst to move forward psychologically. Due to her efforts, she may succeed in engaging with the analyst.
If she has given him a chance by listening to him and drawing some benefit from his words, she may develop for herself some lifelines of emotional security, good humour, tolerance, appreciation of his interest in her and absorb some of his tenacity for continuing with her sessions.
However, her sense of her individuality is threatened, because he may be saying things to her with which she disagrees but has to continue to listen to. This is hard for her. She may feel that some of her loyalties are threatened, but that she can do nothing about this, even apparently in her own self-defence. Most patients in this Stage, Stage 2, continue to assert their own, schizophrenic and ill, perspective, consequently finding the sessions irksome and annoying, frustrating and sometimes miserable.
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She has become used to her own false assumptions, biased opinions, unrealistic expectations and possibly questionable family values. But the analyst must continue to assert reality to her. It is essential that if she is to become well she must renounce every part of the false world within which she has been living. She is probably unaware at the commencement of her treatment of just how distorted her schizophrenic thinking is.
It is the distorted views, biased perspectives and egregious interpretations of reality which together largely underpin her schizophrenia or schizoaffective disorder, compounded by emotional difficulties, and probable slight brain dysfunction affecting her reward centres, executive function and cognition. It is extremely taxing for her to attend her analyst, return to hospital for ward care, and return to her analyst the next day, 4 or 5 days every week for years between short breaks for holidays.
Her perspective on the world is extremely bleak, and she may at a deep level be extremely miserable. The hospital staff must be alert at all times on a continuous suicide watch, for her as for all their other patients. This is the main reason why patient selection for this treatment has to be so cautious, and why care by the hospital unit must be so effectively secure.
Schizophrenia and schizoaffective disorder are life-threatening conditions, but this therapy can lower the suicide threshold for intervals of time during phases of growth in the treatment, and the hospital staff cannot always know, within their daily routines, exactly when these times are occurring. Kindness and firmness are probably the nursing techniques that are most effective in sustaining patient morale, within the consistent environment and ambience of security.
This relationship between the patient and her analyst, where the patient is very ill and trying to hang on to her sessions while feeling confused and misunderstood, except on the few occasions when her analyst says something to her which she understands clearly, and can accept without feeling threatened, is termed by Dr Robbins as "Pathosymbiosis". It spells difficulty for the patient, as outlined above. But it can also present particular difficulties for the analyst. It may be tempting for him to collude with the patient.
For whatever reason, possibly flattery by a weaker individual, or enjoyment of the patient's dependence upon him, or a sense of power over her, the analyst may unconsciously wish and enact that the treatment continues on an indefinite, interminable path. This is very rare, but the analyst should be aware of its possibility in himself with each of his patients, as it will definitely interfere with the patient's progress and may prevent her otherwise expected recovery.
The analyst is responsible for avoiding collusion because the patient can do nothing about it. She turns up for treatment, and the analyst must guide the treatment process towards its intended conclusion. If he does not avoid collusion, therapeutic stalemate ensues, and consequent premature termination of therapy. This is Stage 3 of Dr Robbins' 7 Stages of psychoanalytic psychotherapy for schizophrenic patients. Stage 4 is also a difficult hurdle for the patient to overcome. Here she must succeed in relinquishing the views, attitudes, assumptions and some of the beliefs that she held when her treatment began.
As explained above, it is these aspects of her mind that her family may have inculcated into her as a family member, and which hold her in her schizophrenic mindset. If there has really been a very serious problem for her in her family, such as molestation or another form of difficulty or abuse, these aspects of her mindset will probably have developed in her because of the ways she has tried to overcome the pain and trauma of what happened to her in the family.
So from a process of generalization, most of her mind is related to this trauma in the family, eg: all her family relationships have developed awry due to misunderstandings and objections and despair. Consequently, to alleviate herself of her schizophrenia she has to reject all of this pathology and turn her back on all the ideas that her family use and which trapped her in her pathogenic situation within which she had no room or scope to flex her mind constructively. She has to construct her whole life again, ignoring the influence of her family.
This can be very hard for her, because if there was otherwise a lot of love in the family, or from a good parent, as well as with her siblings, what in effect she has to do is to throw her family out with the bathwater, ie. If she is especially vulnerable, or quite young, or unable to assert herself adequately, she may not be able to achieve all this.
The success of her therapy depends as much on her resilience and determination as on all the other factors that have been mentioned, never forgetting patient security. Disengagement from her false, family-influenced self, and engaging fully with her analyst on his terms of full and comprehensive reality-testing and psychic strength may coincide with her determination to be well and to live her own active and productive life. Early on in her treatment she may scarcely be aware of some of these factors, but trust and belief in goodness can help her persevere, despite sometimes feeling this is against the odds.
As always, the enduring kindness of her analyst and kind hospital staff help on a daily basis to maintain her morale and feed into her own systems of survival and optimism. Stage 5 of Dr Robbins' therapeutic process consists of more normal symbiosis, in which the patient now appreciates normality in what the analyst says to her in his interpretations, and its realism.
She becomes ever better able to apply what he says to her in her life during the 23 hours around her therapeutic hour with him. This Stage is growth-promoting, and now she may find that she begins to flourish somewhat in her other relationships besides her therapeutic relationship. It is gratifying for her to experience happiness in these, and to be able to organize her life now seen in a positive light rather than as utterly without light at all, when she floundered in darkness and misery.
The despair felt by schizophrenic patients cannot be overestimated, and it is brave hospital staff as well as psychoanalysts who work daily to sustain the hope and wellbeing of schizophrenic patients on their wards and in the community. Schizophrenia is an illness where absolutely nothing seems to fit with anything else, and it is experienced like this because the patient's separate, individual experiences over their lifetime are not internally consistent.
Part of themselves gets left behind during one experience, and another part of themselves gets left behind during another experience. They lose track of who they are because when addressed by another person they have responded while something else lay heavily on their mind so that they were unable to absorb the full meaning of what was said to them.
Then, assumptions are made by the other person that are beyond what the schizophrenic patient can work out. Misunderstandings of this kind recur time after time for the patient, who feels like the loneliest person in the world, understood by no-one they know, which in a young person is commonly their entire family.
This terrible situation is addressed by the psychoanalyst, who makes themselves available to struggling and terrified patients such as these. By now the patient has learned what it is about themselves that needs rectification, they have rectified some of this, and in Stage 5 they continue to put it into practice.
In Stage 6, the patient has achieved psychic differentiation, so that they have developed some of their own healthy attitudes to important aspects of their lives eg. They have also integrated, so that all of their outward looking and inward looking perspectives, their feelings for other people and parts of their environments, and their daily experiences have become confluent with each other, and this seamlessness within themselves gives the patient confidence in themselves as a person they understand.
They are not, now, afflicted with self-doubt in the way that prior to treatment they suffered repeatedly. By Stage 7, the patient's mind is self-sufficient and independent, and they are able to leave treatment after a therapeutic termination. The PPCC Theory [ 15 ] is a psychoanalytic theory of the functional psychoses that illustrates the progress of a schizophrenic or schizoaffective patient treated with psychoanalytic psychotherapy into mental health.
It provides evidence from a schizoaffective patient of how the patient's mind changes in psychoanalytic psychotherapy [ 15 ]. The PPCC Theory uses shapes to represent features of the schizoaffective mind as it changes, for example when the analyst is internalized by the patient; when the patient becomes able to endorse and encapsulate calmly the totality of their psychotic experiences lived through in the past, orientated healthily in time, place and person; and when their mind loses its sharp or disorganized edges and becomes a mature, rounded personality Figure 1.
These changes were documented in the schizoaffective patient studied by Dr Steggles [ 15 ]. View Figure 1. The PPCC Theory was developed from a case study of an individual schizoaffective patient who identified, through a small study of her own mind, her Representational World [ 16 ]. Educational Psychology. Emotion Science. Environmental Psychology. Evolutionary Psychology. Forensic and Legal Psychology. Gender, Sex and Sexuality Studies. Health Psychology.
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