Werbart Levander 2005 Understanding Psychosis

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discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/7738789
Understanding the incomprehensible: Private

theories of first-episode psychotic patients and
their therapists
ARTICLE in BULLETIN OF THE MENNINGER CLINIC FEBRUARY 2005
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Werbart and Levander

Private theories about psychosis
Understanding the incomprehensible:

Private theories of firstepisode
psychotic patients and their therapists
Andrzej Werbart, PhD
Sonja Levander, PhD
Private theories about psychosis, its background, and cure were
studied using narratives of firsttime psychotic patients and their
therapists. Both patients and their therapists were interviewed on
three occasions over a period of 1 1/2 years. Three cases were chosen
as dyads in point in order to highlight different relations between the
patients and the therapists private theories, different patterns of
recovery from psychosis, and different outcomes. The cases are
contrasted by paired comparisons. The study indicates that an
awareness and joint discussion of incompatibilities between the two
participants private theories might be a substantial contribution to
the process of recovery from psychosis. (Bulletin of the Menninger
Clinic, 69[2], 103-136)
Our interest in doing research in the area of psychosis is related to our
clinically founded conviction that the subjective meaning constructions
of psychotic patients constitute an important source of knowledge and
a potential contribution to the process of recovery, as described, for example, by Arieti (1963, 1979), Searles (1967/1979b), Selzer, Sullivan,
Carsky, & Terkelsen, (1989), and Strauss (1992; Strauss, Harding,
Hafez, & Lieberman, 1987). Today, when the emphasis in psychiatric
treatment of psychosis is overwhelmingly psychopharmacological, often in combination with psychoeducation and cognitivebehavioral
techniques (Fenton, 2000; Haddock et al., 1998; Hogarty & Flesher,
1999a; 1999b; Rector & Beck, 2001), there is a risk of disregarding the
person with psychosis as an actively interpreting subject who attempts
to understand his or her difficulties. As stressed by several psychoanaDr. Werbart is an associate professor and a training analyst at the Swedish
Psychoanalytical Society, Research Director at the Institute of Psychotherapy,
Stockholm County Council, Sweden. Dr. Levander is a member of the Swedish
Psychoanalytical Society and a researcher at the Stockholm Center of Of Public
Health, Unit of Mental Health, Sweden. Correspondence may be sent to Dr. Werbart
at the Institute of Psychotherapy, Bjrngrdsgatan 25, SE118 52 Stockholm Sweden;
e-mail: andrzej.werbart@sll.se or andrzej@werbart.se. (Copyright 2005 The
Menninger Foundation)
Vol. 69, No. 2 (Spring 2005)
103

lytic writers (cf. Bion, 1967; Frosch, 1983; Katan, 1954; Ogden, 1989;
D. Rosenfeld, 1992; H. Rosenfeld, 1965; Volkan, 1976, 1995;
Winnicott, 1945/1975), the relationship between the healthy and psychotic parts of the personality resembles a precarious compromise,
which can easily break down, a constantly varying balance between
states of mental integration and disintegration. In our own understanding of psychosis, we subscribe to the hypotheses formulated by
Grotstein (1990) that psychosis per se is a defense against the absolute
catastrophic state with its disintegration anxiety. Perhaps psychosis is a
delusional form of Steiners (1993) psychic retreats. To preserve their
psychic equilibrium, patients use the retreat as a protective armor from
strain and anxiety at the cost of an almost complete standstill in development. This attempt at selfcure, which can also be secured by spontaneous remissions or by drug treatment, counteracts the psychoanalytic
treatment aim to recover the unity and completeness of the subjects
self. However, when the analytic process facilitates integration and getting closer to the patients emotions and vitality, there is the risk of a
new crisis and relapse (Capozzi & De Masi, 2001). A close monitoring
of the patients own understanding of experiences that seem incomprehensible can help the therapist to move along the patient (Rogan,
2000) and promote moments of meeting (Stern, 2004; Stern et al.,
1998), thus contributing to psychic change while balancing the risks.
The focus of the present study is the patients and the therapists construction of private explanatory systems, as unfolded in a series of interviews during the process of recovery. The question at issue is based on
the epistemological assumption that the unspoken, implicit knowledge
of the participants in a therapeutic undertaking, if made more explicit
and systematic (Frommer & Langenbach, 2001), is a fruitful complement to the professional knowledge acquired by clinicians in their professional education, in treatment situations and systematized in public
reports. For that reason, we asked patients as well as their therapists
about their attempts to understand the problems that brought the patient to the psychiatric unit. Their accounts entail subjective ideas of
what might be behind the problems and what could be the best solution
to them. Such private theories of pathogenesis and cure can be seen as a
common human way of coping with painful experiences that threaten
our physical or mental cohesion (Becker, 1997; Brody, 1987;
DreifussKattan, 1990; Flick, 1991; Kleinman, 1988; Verres, 1986).
Every person of psychological necessity creates implicit explanatory
meaning constructions about difficulties in life and ways of approaching them. When we feel exposed to something unpredictable, when we
encounter gaps in the context of meaning of our lifeworld, we try to rebuild a sense of meaning and coherence (cf. Antonovsky, 1988;
104
Bulletin of the Menninger Clinic

Polkinghorne, 1988) by filling in the gaps with fantasies, folk ideas, and
available pieces of fragmentary or misinterpreted information, as well
as recurrent story lines from myths, fairy tales, art, and products of
mass media. By including the new or frightening emotional experiences
in a narrative, we place them within a certain framework that makes
them easier to manage. The need for talking about difficult experiences
is common among people with psychosis, and it might be invaluable for
the subject if even just a minor part of the experiences can be understood by another person. If recognized by somebody else, it is not totally unique anymorenor so mad or sickthat others have to
turn away in anguish or contempt. The need to relate ones thoughts
and ideas usually is not dealt with in common psychiatric practice, nor
is the psychotic patients message seen as something containing
valuable information.
As professionals, we are also preoccupied with our own attempts to
understand and interpret what our patients tell us. When listening to a
patients story, we often create our own contexts of meaning, built on
our ideas about the dynamics or the pathology behind the things that
we are told. Because we cannot refrain from interpreting what we hear,
we easily confirm our previous convictions. Starting from our own experience and knowledge as well as from the culture at the institution at
which we are working, we meet our patients with questions and comments such as: How are you? Do you experience anxiety? Do you hear
voices? How is your contact with your parents? Aspects related to our
own prejudices are in focus, and the content of the patients own attempts at understanding are lost. Often strong evidence is needed for us
to change our comprehension of the situation.
Private theories and related phenomena
The origins of psychoanalysis were connected with a move away from
the prevailing knowledge of psychiatry and neurophysiology toward serious listening to the individuals subjective account. GrubrichSimitis
(1996) documented how Freud constructed theoretical concepts starting
with the formulations of his patients. He repeatedly exhorted himself to
listen without prejudice or preconceived ideas. However, the psychoanalytic assumption that the narrator is not conscious of motives hidden behind the manifest narrative brings about the risk of imputing to the
patient the private theories of the interpreter. If the clinician in addition
assumes that a person with psychosis is incapacitated and confused, the
risk is further increased. Psychoanalytic knowledge about
countertransference phenomena is still the best instrument for unmask-
Vol. 69, No. 2 (Spring 2005)
105

ing the therapists picture of the patient when it is distorted by a mixture
of professional and private theories.
From the psychoanalytic perspective, the narratives concerning
pathogenesis and curein terms of the content and formal aspectsare allied with such phenomena as screen memories (Freud,
1899/1962), sexual theories of children (Fenichel, 1928; Freud,
1908/1959b; Sandler, 1987), family romance (Freud, 1909/1959a),
and personal myths (Kris, 1956). The presence of private theories of
this kind within the psychoanalytic process has attracted some attention in the literature (Abend, 1979; Arlow, 1981, 1986; Goldberg,
1991, 1994; Sandler, 1983). Sandler (1987) made a distinction between
preconscious theories and unconscious fantasies. For example, the infantile notions about adult sexuality are seen as preconscious theories,
and not as fantasies. Private theoriesdefined in this article as notions
about, and explanations of, bewildering aspects of the external world,
as colored by elements of wishfulfillment in fantasythus also seem
related to Sandlers preconscious theories.
Sandler (1983) and Meissner (1984) have shown that in the context
of psychoanalytic treatment both the patient and the analyst are influenced by implicit private theories about pathogenesis and cure, and that
those of the analyst often are confused with the declared, conscious theoretical standpoints. Earlier, Abend (1979) had shown how unconscious fantasies infiltrate psychoanalytic writings and influence
theoretical formulations. According to Sandler (1983), the analysts
private, preconscious theories often fit better with the patients material
than do official, consciously adopted theories. In the same way, Brenner
(1996) pointed out that when the patient and analyst differ, the patient
is not necessarily closer to the objective truth. Hamilton (1996)
showed how the analysts preconscious ideas and explanations diverge
from his or her public theories and influence the analytic work.
The construction of private explanatory systems is also studied empirically in developmental psychology, in the tradition of theory of
mind, in social anthropology, in attributional theories, and in folk
psychology. However, the role played by private theories of
pathogenesis and cure in various forms of treatment has yet to be systematically explored. As a result, changes in private theories in connection with psychotic breakdown and recovery remain largely
unexamined. Even less is known about the relationship between the patients and the therapists private theories and its possible effects on the
courses of psychosis.
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Aim
In our research, we relate the patients own subjective understanding of
his or her problems to the clinicians more or less implicit theories about
the patients problems and how the problems might be remedied. Our
aim is to investigate the longterm consequences of disregard or unawareness of the relationship between the patients and the clinicians
private theories.1 Thus, we are investigating the changes in the parties
private theories and not the treatment process as such.
Material and method
In an exploratory study, we chose the group of firstepisode psychotic
patients in order to study private explanatory systems for pathogenesis
and cure from their inception, that is, the early efforts of the patient and
the clinician to comprehend and make sense of incomprehensible psychotic experiences. The group of chronic psychotic patients provided
an opportunity to compare private theories in statu nascendi with presumably already wellestablished systems of ideas and fantasies. The
data collection was carried out at three occasions during a period of 1
1/2 years.
In a psychiatric center specially tailored to firstepisode psychosis,
we interviewed six consecutively admitted patients and their therapists
within 2 weeks of admission. The treatment approach, often used in the
Scandinavian countries, included crisis intervention with attempts to
understand the underlying dynamics, in addition to supportive interventions aimed at helping the patient to recover the coping patterns
needed in his or her life situation. The patients were assigned a therapist
or clinician on the team who was to work individually with the patient,
if possible for a period of 5 years. The group of patients with first-episode psychosis consisted of three men and three women. The average
age at inclusion was 27 years (range, 2230). Cases with previous psychotic episodes, with prominent drug abuse or identified neurological
problems, were excluded.
In another clinic with an integrative, psychosocial approach, we interviewed six patients with longterm psychotic problems and at least a
5-year history of psychiatric care after the first episode, as well as their
clinicians. The group of patients with chronic psychosis included four
men and two women with the average age at inclusion of 39 years
1. This project was supported by grants from the Swedish Council for Social Research
and Stockholm County Council.
Vol. 69, No. 2 (Spring 2005)
107

(range, 27 47). The average time since first observed psychotic episode
was 11 years (range, 618) and diagnoses included schizophrenia with
paranoid features in five cases and cycloid psychosis with religious features in one case. The interviewees in the chronic group were selected by
the clinicians interested in participating in the study.
The interviews were repeated after 6 and 18 months. The professionals in both groups were mental health nurses, psychologists, and psychiatrists, all with at least basic psychotherapeutic training. Four of the
total of 12 patients (two in each group) had to change therapist during
the data collection period because the therapist moved from the area or
because the patient wanted to change for reasons that were considered
reasonable. An overview of the research sample, inclusive of the patients and their clinicians initial problem formulations and theories of
background, is presented in Appendix 1.
In audiotaped interviews, five questions were asked: What is the
problem? When did the problems start? How did the problems arise?
How can the problems be remedied? How does your therapist/patient
view the problems? The interviewees were asked to give concrete examples and to tell about relevant specific episodes. Further questions were
asked for clarification only. Each interview took about 45 minutes and
was not preceded by any introductory contact. The interviews were
conducted by the authors of this article, one interviewing the patient
and the other the clinician. The informants were not offered any
compensation for their participation.
The research design of multiple parallel case studies was used (Yin,
2002). Each case study was based on three interviews with the patient
and three interviews with the clinician. Altogether, 36 interviews were
conducted with the firstepisode group and 32 with the chronic group
(as not all patients could be interviewed on each occasion). Thus, we
were not studying the actual interchanges between patient and therapist
or clinician, nor the actual courses of psychosis or the treatment, but the
subjective accounts of the two participants in the treatment collaboration. Our assumption was that in studying such subjective phenomena
as private theories, one has to ask the subjects explicitly to tell about
their thoughts and memories.
The interviews were transcribed verbatim, each transcript running
15 to 20 pages. The qualitative analysis of transcripts comes close to the
hermeneutic and narrative research tradition. It followed a systematic,
stepbystep procedure with demonstrated good interrater reliability
(PTI Coding Manual; Ginner, Werbart, Levander, & Sahlberg, 2001;
see also Appendix 2). All transcripts were independently coded by three
psychoanalytically trained judges. The coding procedure involved four
steps:
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1. Focusing on each informants private theories. Each interview
transcript was read separately. Statements were identified and
sorted into one of the five thematic groups: problem formulations, central episodes, theories of background, theories of cure,
and ideas of the other partys view. At this step, categorization
of meaning was used (Kvale, 1996).
2. Condensing meaning and coding of central themes. The utterances
were formulated in a more concise way, for example, long sentences were shortened by deleting redundant spoken language
(concentration of meaning; Kvale, 1996). Repetitive and adjacent formulations were put together and subthemes were formulated. Any use of theoretical or technical terms was avoided.
Central themes created in this way caught the focal meaning or
point in the informants narrative close to the informants own
wording and phrasing.
3. Formal analysis. Formal aspects of the narratives were described
in terms of significant points of time, places, and objects; degree
of elaboration in the narrative; openness to alternative explanations; and the heros activity. (The results from this step were not
used in this presentation.)
4. Comparative analysis. Similarities and differences between the patients and the clinicians narratives from the same point in time
were summarized and commented on. At the second and third
points in data collection, changes across time in the informants
private theories were examined.
Printouts of the processed material were distributed to the judges involved. Consensus meetings were held for each dyad and each point
in time separately, and discord between the judges was negotiated until
a group consensus was reached. Finally, a comprehensive case study
was established (approximately 20,000 words) based on six interviews
(three points in time, patient and therapist, respectively) for each case.
The following presentation is based on consensus formulations from
these case studies. Quotation marks are used to indicate direct citations
from interview transcripts. Three cases of firstepisode psychosis (the
data collected in 18 interviews) were chosen as dyads in point in order
to highlight (1) different relationships between private theories of the
patients and those of their therapists, (2) different patterns of recovery
from psychosis, and (3) different outcomes. The cases are contrasted by
paired comparisons. Thus, Andreas and Agnes represent dyads with
more or less concordant private theories in the patient and the therapist.
However, the two patients had contrasting ideas of cure as well as recovery styles. In the case of Axel, the parties had discordant private theVol. 69, No. 2 (Spring 2005)
109

ories and the differences between the patients and the therapists ideas
increased over time. Axels ideas about the cure resembled those of
Agnes, but the outcome of treatment was different in the two cases. The
group of patients with longterm psychosis is used in this presentation
only as comparison material, presenting already wellestablished private theories. Findings from the interviews with the chronic group are
included only in the discussion.
Case studies
Andreas phantom in the closet
Andreas was a 29yearold stockbroker who arrived at the center
heavily drugged after a week at an acute psychiatric ward. When asked
about his problem, he said that he had not committed any crime. Instead he was too kindhearted. His performance anxiety had put him under pressure. Another problem was his difficulty trusting women, but
he was not gay. According to him, things had gone wrong some weeks
earlier, late in the evening on October 30 at the Heartbreak Hotel in
Stockholm, which he visited with his colleagues from the job he had just
started. Andreas questioned the new boss, even if on the whole he did
not want to criticize him. At the bar he was given a drink poisoned
with cocaine and felt himself pursued by foreign secret service agents.
A few days after this episode, he was due to sign a lease for an apartment
with his new girlfriend. Andreas continued saying that the whole thing
had actually started on January 28 the same year in Copenhagen, when
the company he was working for had been sold to its rival. Simultaneously he found out that his girlfriend at that time had been unfaithful
to him for 8 months with an older man, who worked as a secret agent.
Andreas said that she betrayed him in spite of his being as faithful as a
dog to her. He thought that it would be of help to him to get all these
painful things out of his system, to work on them on his own, and then
to forget all about it.
Six months later, Andreas told the interviewer that he did not have
any problems at all and was no longer affected by his former psychosis.
He thought that he as a person was not marked by the illness, but was
his former self again. The problems had disappeared by the 28th of January the next year; the anniversary of the day when he found out that he
had been betrayed by his girlfriend. That incident still had a central position in Andreass explanatory system, at the same time as the idea of
the poisonous drink had faded out. In the second interview, he instead
formulated an idea about the background of the problem in terms of
what he called his closet theory. When he found out that his former
girlfriend had deceived him, he repressed everything and shut the
110

phantom in the closet. He had to use all his energy to keep the door
locked. His psychotic breakdown came when his body was no longer
strong enough to put his weight against the door because of new demands and strains in his life, and the phantom came out and caught
him. In this narrative, the psychotic breakdown thus appeared as a failure of the cure. A new locking up of the phantom in the closet was the
only cure possible, which he also attained on the anniversary of finding
out about the unfaithfulness of his girlfriend.
In the third interview 1 1/2 years later, Andreas said that a long time
ago he had suddenly become psychotic without knowing what was
happening to him. He had been really miserable, but at the present time
he felt in good health and had no psychological problems. All of that
was past history. Of course he had some practical problems in connection with moving to the south of Sweden, but those were the kind of
problems that anybody might meet with. His private theories still circled around the unfaithfulness and the accumulation of stress factors at
the time when he had become psychotic, and his closet theory was
supplemented with new metaphors. He was determined to see the years
with the old girlfriend as a concluded chapter and that he had to try
to write new pages about the life with N, his new girlfriend. The book
about the old girlfriend has to be left on the bookshelf.
The therapist conceived of Andreass psychotic reaction as being
triggered by current stressesthe new job, the decision to move to a
new apartment with a new girlfriend, and so forth. He thought that the
strains dated back to his exgirlfriends deceit the previous year, which
he had not been able to manage. The problems also were connected
with Andreass personality with heavy demands on himself, typical of
the far northern region of Sweden. The therapist thought that network
therapy, therapeutic support of his reality testing and some medication
would be of help to Andreas. Six months later, the therapist thought
that Andreas had to express and do away with all those difficult feelings
amassed inside him after the painful separation and had also adopted
Andreass closet theory. The therapist said that he believed in the validity of this model when expressed in psychological terms, even if he
(the therapist) spoke about locking up a corpse instead of a phantom. Eighteen months later, they were no longer in contact with each
other, but the therapist at that time was convinced that Andreas by necessity had to lock the closet door, and he hoped that in the future
Andreas would be better prepared to manage that.
Thus, a high degree of concordance was observed between Andreas
and his therapist as to their problem formulations and theories of
pathogenesis. However, in the first interview they had contradictory
ideas about the cure. Andreas wanted to get rid of painful feelings and to
Vol. 69, No. 2 (Spring 2005)
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work with them on his own, whereas his therapist at that point wanted to
strengthen his social network and his capacity for reality testing. He also
wanted Andreas to take some medication. Six months later, a joint intention to keep the phantom or corpse securely locked up in the closet
was noted. The initially incompatible theories of cure thus became more
similar over time. In the last interview, Andreas and his former therapist
were both convinced that it was Andreass own effort that had led to the
successful recovery from psychosis. Both of them thought that Andreas
did not have any difficulties remaining, other than ordinary everyday
strains, and they shared the view that it was important for Andreas to go
on by himself instead of looking back. Neither of them found any reason
for continuing a therapeutic contact, even though the therapist (at the
same time) indicated some new dimensions of Andreass difficulties not
mentioned before. He wondered whether Andreas had failed to separate
from his mother, who had had trouble looking after him after a serious
traffic accident. The therapist also described his own role as that of a
good paternal object who might help Andreas find an improved balance
between his male strivings and his limitations.
Axels choice of path
Axel was a 22yearold student at an advanced training program in
classical music. He looked tired when he came for the first interview
with a bandaged forehead. Very slowly and incoherently he told that his
problems had all started on Easter Sunday the same year while he was
walking the streets of Gothenburg, where he had an important performance. Suddenly, memories made him flare up and he was overwhelmed by pictures of something in the past that had never been
brought to an end. He felt as if he had never moved away from his parents, even though he had left home at the age of 16. Once back in Stockholm after the successful tour, he cut his forehead with a knife and
appeared on stage in this condition. This led to his being admitted to
psychiatric care. According to Axel, his problem was that he lacked a
way to handle his relationship to his parents, which had to do with his
own personality and negative selfimage. He added that he had a lot of
anxiety and sleeping difficulties.
The first time Axel had experienced the flaring up was in January
the same year, when sitting on a seat between two sections of an articulated bus traveling from the Stockholm airport. But it had really started
4 or 5 years earlier, when he was studying in Gothenburg where his former girlfriend was living. Everything then became too much; his problems caught up with him and he felt himself to be an inferior person.
Actually, he continued, his difficulties could be traced to an episode in
his hometown when he was 14 years old. On the 13th of December dur112

ing the Lucia Day celebrations, he got drunk, was picked up by the police, who were friends of his fathers, and was driven to the hospital
with severe alcohol poisoning. The whole incident was written up in the
local newspaper. He felt terribly bad that he had put his father to shame
in this way. He connected this with having been bullied by his classmates in elementary school some years earlier. They had made fun of
him and told dreadful stories about his upperclass parents, who were
so different from other parents in the town. At that time, Axel had not
been able to defend his parents, nor was he capable of telling them
about what was going on. The original source of it all lay, he thought, in
his preschool years, when one day he had been terribly humiliated by
his father, who had angrily boxed his ears. But my parents were the
only ones I had, he added.
The therapist described Axels difficulties in terms of a selfdestructive and selfpunishing behavior rooted in guilt feelings toward his parents, to whom he had not been able to tell the truth. The therapist said
that Axel had cut off his personal history and was all closed up. He
also thought that Axel was unable to stand up for recognition and accept his professional success, a kind of success neurosis, as he had
demonstrated in slashing himself on the forehead. Furthermore, the
therapist reported that Axel had sleeping difficulties, much anxiety,
heard voices, and saw some kind of human creatures. The therapist also
thought that the deficit theory was relevant in this case, related to the
lack of trust and communication in the family.
In the first interview, Axel and his therapist described the problems
in a similar way, but their views of the background of the problems differed to some degree. In his diffuse way, Axel dealt with something he
remembered from the past as having to do with his present, whereas the
therapist described Axel as cut off from his past, even though Axel
also spoke of guilt toward his parents. Axel thought that all of his problems went back to the day when he was caught by the police, the worst
thing being that he didnt talk to his parents about why he had gotten
drunk. The flaring up was about guilt feelings toward his parents because he couldnt maintain the right distance. Another background
factor was the mocking by classmates because of his upperclass parents. Instead of noting Axels experience of an inability to maintain the
right distance from his parents, the therapist described it in terms of insufficient communication in the family as the cause of Axels developmental arrest. He saw Axels neurotic difficulty in accepting
professional success and its hypothesized relationship to guilt feelings
as the most important background factor.
As for the cure, the therapists and Axels theories differed considerably. In the first interview, Axel argued that he had to learn to accept his
Vol. 69, No. 2 (Spring 2005)
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background and to find a way of handling the relationship to his parents, the fault being his own. The therapist, in contrast, held that Axel
needed support from his parents. A renewal of family ties in family therapy was seen as the proper cure. Axel also needed to rest, to get in contact with his childhood, and to hear his family talk about it as a way of
communicating.
In the second interview 6 months later, Axel was occupied with inner
conflicts around his aggressiveness. He said that he did not get overtly
angry but turned his anger inward and disliked himself. The therapist,
however, described Axel as lost in his present life. Both of them at this
time linked Axels problems to the fact that he had been beaten by his
father when he was 5 years old. Axel thought that this experience basically changed his view of himself. Their remaining theories of the background of Axels difficulties were more divergent. The therapist
believed that the premature separation from the parents, whom Axel
both hated and longed for, was a crucial negative experience, which
made him lose his history. Axel emphasized how he himself stopped
talking to his parents after the police caught him. The depression in
connection with recognition and success was the therapists theory
and had no counterpart in Axels narrative. As for the cure, both still
maintained that the problem with the family had to be straightened out,
but neither suggested any strategy. In spite of this, they saw each other
twice a week. The therapist described that Axel in this process created
himself in the therapeutic flow, and he felt quite hopeful about Axels
potential for recovery. He openly formulated his gratefulness for having the opportunity to witness the creativity of Axel. Nevertheless, he
thought that Axel needed more structure in his daily life by visiting a
day center. Axel, on the other hand, did not demonstrate any interest in
family sessions or in daily outpatient care.
In the third interview, 1 1/2 years after the psychotic breakdown,
Axel was totally occupied with his negative view of himself, which had
left everything painted black and depressive. Most of all, he regretted
that he was such a selffocused person, with something inside that
colored his way of thinking. In this interview, Axel mentioned a new,
significant background factor. He had once made an important choice,
which led him to turn into a selffocused seeker. After leaving home
at age 16, he attended a school in another town and had felt free, because nobody knew him there. After a year, however, he decided to
leave the school to become the student of a highly reputed music
teacher. This meant returning to his hometown and facing the same difficulties as before. The therapist seemed to be unaware of this important choice of mentor and its consequences. Instead, he was
preoccupied with the impact of congenital deficit in Axels psychologi114

cal apparatus, a depressive lack of something in his head, and an
absence of an organizing structure. He described Axel as depressed,
passive, and lonely, totally lost in the world, and he thought that Axels
selfcontempt had a delusional quality. He again emphasized the
negative effect of the lack of support from the parents.
At this point in time, the private theories of cure were contrary on the
surface level as well. Axel thought of ending the treatment. He thought
that things were going a bit better during breaks in the therapy, including when the therapist had been on sick leave. He now had stopped taking his medicine, something he had done before without good results.
But he added that if things got worse, he probably would have to return
to the therapist. The therapist still thought that family work should be
done, even though the few family sessions at the beginning had not
proved helpful. He thought that the talking cure did not seem to
work with Axel, who became worse the more they talked, which did not
prevent the therapist from adding that perhaps they needed to intensify
their contact to make it work. The therapist thought that it was important that Axel had concluded his studies, worked with his music, and
took his antidepressant medicine. By this time, both of them seemed dispirited, listlessly suggesting measures that had already been tried without apparent benefit. In retrospect, it seemed as if Axels primary
situation had been reenacted. The therapist, like the parents, had not
been able to listen to Axel in a way that made it possible for him to talk
about his aggressive feelings and inner choices. Axel again planned to
leave the situation to try to manage by himself somewhere else. Yet he
had a feeling that, as in real life, he might not be able to move away
from home. By making the same choice again, he perhaps would have
to return to his therapist and the psychiatric treatment. A potential
opening was suggested when the therapist in the last interview mentioned that he had never sought supervision of his work with Axel,
although such a possibility actually existed.
To sum up, Axels theories about his problems and cure were available from the beginning and did not seem psychotic in the interviews,
even though we know that at that time he hallucinated and had delusions. He thought that his problems had to do with his difficulties talking to his parents about his experiences, and that this was related to
something within himself. In the following interviews 6 and 18 months
later, his theories remained unchanged, even though he further elaborated the theme about difficulties in handling aggressive feelings.
Changes in the therapists theories seem to result from a feeling of helplessness rather than a deepened understanding of Axels problems. In
the third interview, the therapists main explanation was a congenital
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tory explanations. In our retrospective analysis, we believed that the interaction between the two sets of theories had strengthened Axels
conflicts, hindering him from finding new solutions to his old problems.
Agness way through the circles of the Inferno
During a business trip to Scotland, Agnes, then 28 years old, became
convinced that she had a secret mission. As she related in the first interview, she believed that she had been chosen by God and the United Nations to find a solution to the worldwide problem of environmental
pollution. She saw her surrounding as false sidescenes set up to mislead her. During a lonely trip in the mountains, she had an experience of
elevation and clarity, suddenly understanding the connection between
her anxiety and a horrifying memory from childhood. She was 7 years
old and her mother had come home from the hospital with a new baby,
tired after the delivery and sick with a caked breast and tonsillitis. Her
grandmother, a soldier in the Salvation Army, who always saw her
and was there, left the house and she was alone with her drunk and aggressive stepfather. Agnes became convinced that he was on his way to
strangle her to death.
According to her initial private theory, the origin of her problems
was a lack of love in her parental environment, a clear precursor to
the worldwide problem of environmental pollution. Her immature
mother could not manage her any more and when Agnes was 5, she
had to go live with her beloved grandmother, but she lost her when she
had to move back to live with her pregnant mother and stepfather.
Agnes believed that no parents in the world were able to perceive the
needs and rights of children. Children never get the love that they
need, she said, and horror is often mistaken for aggression and evil.
Only children and madmen can understand the mysteries of a crazy,
evil world full of fear and lack of love . . . governed by a serial killer. As
for the cure, Agnes said that she wanted to breathe freely, to work
against the evil of the world, and to contribute to respect for the rights
of children.
According to Agness first therapist, too much happened to her during the trip to Scotland and she became psychotic. She had an insight
into a scandalous business deal and became flooded with more feelings
and thoughts than she could contain. The background was her rigid
personality organization, used as defense against anxiety, a consequence of her insecure childhood. She could not distinguish between
fantasy and reality, and needed time, flexibility, accessibility, cautious
questioning, respect, and an outlet for her flashing intelligence and
strength. She also needed her therapists help to work through her painful experiences of psychotic breakdown and an even more traumatic
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week of compulsory psychiatric care before she came to the center. The
therapist thought that if she could make a soft landing from psychosis,
her personality would be enriched and she would be able to have better
contact with her feelings.
Six months later, Agnes thought that she had been with the wrong
therapist in the wrong place, where nobody believed her account of
what had happened to her in Scotland. On the psychiatric ward, the aim
seemed to have been to break her down, and she needed to be like Superman in order to survive. She had fallen into a trap, somebody had
smashed her whole life into pieces, and she felt very, very lonely. It is
possible to expose a person to experiences that look like psychosis, she
said, and she added that somebody had tried to drive her mad. The most
important thing now was to make clear what had actually happened,
it is the only thing. She thought that her new therapist was a sane dialogue partner and was on her side. But perhaps it would help her to
travel to the former Indochina and find a warm place in the rain forest,
because she was freezing to death in this country.
The new therapist shared Agness view that she needed dialogue with
a person who, like her grandmother, could see her and respect her experiences rather than exercising compulsion and arguing whether her
ideas were true or false. It would be helpful for her to get her to understand her Scotland experience bit by bit. Perhaps a religious conversion would help her to fill in her deep hole and lend her a lasting father
imago.
One and half years later, shortly before the last interview, terrifying
memories of her stepfathers assault overwhelmed Agnes. In the past,
she had believed that her younger siblings had been victims of incest but
that she had escaped. She now began to think that she probably also
was a victim of incest. She further thought that perhaps she did not only
fear and hate her stepfather; maybe she also loved him. She felt that she
had to reappraise her previous conviction that she was the only one in
the family protected from the assaults and told that she now had to integrate herself as a person with her unique history. She told us once
again that she had lived for long periods with her grandmother when
her mother could not manage her anymore. The grandmother, however, died some years before the fateful trip to Scotland, and Agnes then
understood that she had made a serious mistake when she had relied on
her grandmother as her only safety catch instead of having distributed
the load among several catches. During the last interview Agnes for
the first time related positive experiences with her mother. She had been
a mascot to her incredibly immature mother when her mother met
gentlemen in restaurants. Agnes was paid a lot of attention and felt like
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a daughter to a movie star. The gentlemen also performed magic tricks
for her.
Agness core theory of cure in the third interview centered around
her second therapist, even though their contact had come to a close half
a year earlier. When describing their relationship, she used metaphors
from classic literature. Like Dantes Virgil, he escorted her, his Beatrice,
on her way through the circles of the Inferno. Accompanied by him, she
crossed deep waters of horrid but fascinating feelings, still experiencing
some kind of direction. Even though they would never arrive at anything and she had to abandon him, he would remain inside her like a
wise giant with his feet in the world and yet in heaven above. She said
that her only choice was to terminate therapy and leave him, because
she could not once again rely on a single safety catch. After moving to
another town, she found further direction through religion and the
reading of Strindbergs Inferno.
The second therapists theories of cure were in many respects complementary to those of Agnes. He saw as his task staying with her and
escorting her on her wandering, sharing her literary allusions as a way
of sidestepping psychiatric thinking. He said that he was her partner,
sharing her inner world, guiding her when she experienced double realities. He also thought that Agnes needed to find her way back to her inner images of her grandmother and of God. What was decisive for
positive development was, according to him, seeing the pathological
mourning and depression behind her paranoia.
Discussion
Changes over time in private theories
Our interviews with 12 psychotic patients confirmed that all patients
and their clinicians created more or less elaborate subjective explanatory systems. Both among firstepisode and among chronic psychotic
patients, the private theories of pathogenesis and cure centered around
clear, comprehensible psychological contexts, even though they were
sometimes formally contradictory or incoherent. Multiple theories
were found in every person, and none relied on only one theory. More
than half of the patients pointed to difficult circumstances during early
childhood, like Axels terrible humiliation when he was 5 years old and
his father angrily boxed his ears and Agness early years with her incredibly immature mother. From the first psychotic episode, and
probably even as far back as the long and painful prodromal phase of
the approaching collapse of meaning, patients had explanatory constructions of what was happening to themfrom the quite superficial
to the highly complex. In the beginning, most of the firstepisode psy118

chotic patients worked on multiple parallel theories without any attempts to integrate them. These component explanations can be seen as
an expression of the patients eager attempt to understand the incomprehensible. Incidental conditions before and during the psychotic
breakdown were ascribed great significance, and associative links were
often made to crucial episodes earlier in life. Some of the difficulties
were externalized, like the poisoned drink, the foreign secret service,
and the worldwide problem of environmental pollution.
In the early stages of construction, private explanatory systems for
psychosis were characterized by disorientation in time and space. Most
patients did not know which way to turn, a confusion often marked by
literal geographic moves (as in the cases of Andreas, Axel, and Agnes)
between different significant places. In some cases (e.g., Agnes), the disorientation in time and space was followed by a feeling of freedom,
sometimes frightening and sometimes rescuing, but mostly brought
about by a paranoid reconstruction of frames and meaning. Another
characteristic of early explanatory constructions was a seeming disorientation as to the relationships to primary objects or their representatives, manifest in Andreass idea of secret agents, depriving him of his
woman and poisoning him when he questioned his boss; in Axels difficulties in maintaining the right distance from his parents; and in Agness
idea of her parents being incapable of perceiving the needs and rights of
children. In the latter two examples, the disorientations can also be seen
as symboliclike descriptions of something that was perceived as concrete. As time went by, the narratives tended to crystallize around a few
key themes with a hierarchical structure of core and subsidiary explanations, and a quasicausal link between theories of pathogenesis and
cure, as in Andreass closet theory. Previously pertinent themes often
disappeared and the narratives became more coherent, yet also more
constricted.
From a linguistic and philosophical perspective, Lakoff and Johnson
(1980) described metaphors, from the most concrete to the more abstract, as structuring elements of our experiential world, which influence new perceptions and experiences. The private explanatory systems
for psychosis often center around some core metaphors, such as the
phantom in the closet in the case of Andreas, something that flares
up in the case of Axel, and the wandering through the circles of the
Inferno in the case of Agnes. Even if these metaphors contribute to the
creation of a context of meaning, they cannot be seen as identical with
private theories of pathogenesis and cure. Such metaphors, rather, are
used as building blocks for private theories or as elements around which
these constructions crystallize themselves.
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Development of private theories in the two groups of patients
The design of our study allowed us to compare early theories with those
held by people who had been psychotic for many years. We found that
firstepisode psychotic patients had more theories about their problems
than did longterm psychotic patients, and also that the number of theories tended to lessen over the 18 months between the first and third interviews. In the group of chronic psychotic patients, the theories were
more coherent, and it was striking how vivid their narratives still were
when they spoke of the circumstances that preceded the first psychotic
episode. One example:
Christian, now 30 years old, told us that he could not distinguish between dream and reality as a result of a blockage in his brain caused by
an injury to the brainstem after a motor scooter accident when he was
14. The accident deprived him of his sense of balance due to damage to
the emitting sensor organ in his left ear. Things had become worse 10
years ago, when his father decided that Christians antique car, a Morris Minor, could no longer remain in the garage of their home. He put it
in the driveway and the car began to rust. In December the preceding
year, he had failed as a man when he visited his former sweetheart to
give her a Christmas flower and was rejected. Already at the age of 12 or
13, he had fallen in love with a girl, but one of his buddies told him to
keep away from her. Since then, he had felt under observation and ridiculed by other men. Now he needed the right doses of coffee, cigarettes,
and medicines to maintain a balance between wakefulness and sleep.
However hard he tried, he never got it right. An underlying, repetitive
theme in his narrative was the impossibility of balance between his father and mother, and between his own male strivings and his passive
longings.
Our study indicates that the building of private explanatory systems
never stops. It is an ongoing process after the psychotic breakdown. Minor details of theories, as well as the relative weight of different partial
explanations, change over time, whereas the basic elements seem to be
remarkably stable. Furthermore, our material suggests that patients retain their initial theories to a greater degree than do their therapists.
Two patterns of recovery from psychosis
Two distinct strategies for restoring a sense of coherence after the collapse of meaning can be found in cases such as those included in the
present study. For some, the psychotic experience in retrospect represented a hole in the context of meaning that needed to be encapsulated or a gulf that must be bridged or sealed overthereby
leaving the incomprehensible and terrifying behind, and turning in another direction. In such cases, narratives become less conflictridden
120

and new material is used to confirm an ever more schematic, fixed explanation. Other patients attempt to integrate psychotic experiences
into an existing context of meaning, which for some includes a painful
reappraisal of previous constructions. Such integrative narratives are
not present from the beginning and often accumulate more material
about both old and current conflicts than earlier versions. Thus, the
study confirms the distinction between sealingover and integration as
two distinct pathways to recovery from psychosis, originally formulated by McGlashan in the 1970s (Levy, McGlashan, & Carpenter,
1975; McGlashan, 1982; McGlashan, Docherty, & Siris, 1976;
McGlashan, Levy, & Carpenter, 1975).
The strategy of sealingover is illustrated by the case of Andreas.
Both the patient and his therapist found relief in their shared closet
theory, even though the therapists theory also contained parts not
shared by the patient. In his final interview, Andreas recounted how he
sometimes felt a pain in his chest when he gazed over the expanse of water separating Sweden from Denmark. It seems that the experience of
the terrible deceit by his former, unfaithful Danish girlfriend remained
unchanged, located for Andreas somewhere on the other side of the
strait.
The case of Agnes and her second therapist is a good example of the
alternative strategy of integrating psychotic experiences into a meaningful context, paralleled by a painful reappraisal of previous constructions. There were, however, some differences between her and her
second therapists complementary theories of pathogenesis and cure.
Agnes referred to her mistake of relying on only one safety catch in
her life, whereas her therapist referred to a depression behind her paranoia. Classic literature and a religious belief were seen by both as a cure.
However, the most important factor was their shared experience while
passing the circles of the Inferno.
In the case of Axel and his therapist, the theories of cure contained
contradictory strategies. Axel seemed to want to integrate his psychotic
experiences into a meaningful context by trying to understand his important choices of path in life and his contradictory feelings toward his
father and other paternal figures. However, he did not seem to get any
help with this task and his integrative attempt ended in a new failure.
The therapist, on his part, tried to cover up or seal over what was incomprehensible by searching for deficits as well as a creative flow in
what Axel tried to communicate.
It is also worth noticing that Andreass storytelling in fact covered
only the year before his breakdown and very little was mentioned by
him or by his therapist about previous life experiences. In contrast, the
narratives of the patients attempting an integration, Agnes as well as
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Axel, included life experiences from early childhood until the present
day, past and current episodes connected by subtle associative links.
Differences between the patients and the therapists private theories
Are the differences found between the theories of the three patients and
their therapists representative of those among the nine remaining cases
studied? Surprisingly, the problems in most cases tended to be described
in a similar way, which probably means that the therapists in our study
usually had listened closely to what the patients had told them. On the
other hand, theories about the background of the problems often diverged. Theories of cure, which were usually related to those of the
background, differed even more, often to the extent that therapists and
patients held contrary views (as was the case with Axel). What the patient thought would be good for him or her the therapist thought would
be bad or inadequate, and vice versa. Examples of private theories,
which from the psychoanalytic point of view seemed collusive (e.g., the
closet theory held by Andreas and his therapist), were also found in
the rest of our material. By collusion we mean private theories that are
similar in content and include comparable themes seen from the same
point of view, while at the same time both parties unconsciously avoid
certain areas that appear problematic to them. This has to be distinguished from complementary private theories of cure, relatively rare in
our material, but represented here by those of Agnes and her second
therapist.
We also observed that the initial differences between the patients and
the therapists did not seem to diminish over time, that is, with increased
possibility of learning about each others thinking. In firstepisode psychotic patients and their therapists, the differences were at least as
great, if not greater, after 1 1/2 years of contact. How do we understand
these divergences, and what do they mean in therapeutic work with psychotic patients? Two of the six firstepisode psychotic patients appeared to have recovered after 1 1/2 years (Andreas and Agnes) and had
therapists who stated in the interviews that although their thoughts
more or less differed from those of their patients, they nevertheless respected the patients own explanatory systems. This was never articulated by the other therapists. In the case of Andreas, both parties knew
about their different views. At the second interview, they were also in
agreement that it could be dangerous for Andreas to explore what he
was hiding in the closet and consequently they had to conclude their
contact. Agnes experienced her first therapist as not respecting her experiences but rather as trying to convince her that her own construction
of meaning was erroneous and sick. With her second therapist, she had
an ongoing dialogue about the similarities and differences in their
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views. In the last interview, she related that she would keep her therapist inside her like a wise giant rather than once again relying on a
single safety catch. Accordingly, she had to abandon him, and the
therapy was terminated. In contrast to these two cases, Axels striving
for understanding his experiences in life and handling his conflictual
feelings was never taken up by his therapist, and 18 months after the
first psychotic episode Axel was still in a state of psychotic
disintegration.
Theoretical considerations
The interest in the patients private theories and the consequences of
different ways of managing or disregarding concordance or discord
between the patients and the clinicians private theories fits well into
current developments in psychotherapy research. Nowadays, relational aspects, often formulated in terms of common factors, rather
than specific therapeutic techniques, are stressed as the core of the
therapeutic action in different therapeutic modalities (Lambert,
2004; Wampold, 2001). Rogerss (1951/1965, 1961) principles for
clientcentered therapy were based on such common factors as accurate empathy, nonpossessive warmth, and genuineness. Moderating
patient variables are repeatedly implicated by research, and the need
to integrate patient, therapist, procedural, and relationship factors is
the major priority for future research (Lambert, 2004, p. 292). In our
view, such integration has to include the relationship between the patients and the therapists private theories, the therapists use of the
patients theories, and ways of managing differences between the
parties. Perhaps this is one of several important specific therapeutic
factors hidden behind common factors.
Also in contemporary psychoanalysis, the relational aspects are often emphasized at the expense of intrapsychic aspects (cf. Aron, 1990;
Jones, 1997; Michels, 1985; Mitchell, 1988). The importance of new
relational experiences was stressed, among others, by Balint
(1932/1985), Alexander (1946), and Winnicott (1954/1987). Loewald
(1960, 1973) described the therapeutic action of psychoanalysis in
terms of internalization of the interaction with the analyst as a new object. In self psychology, the idea of mirroring as a curative action in
cases of selfobject deficiencies is postulated (Kohut, 1984). In the narrative tradition, the joint creation of a life story by the patient and the
analyst is seen as curative (Schafer, 1992; Spence, 1982). Goldberg
(1994) stressed interpersonal aspects in the patients construction of a
theory of pathogenesis as an everevolving product of the analytic
collaboration that has to be a subject of ongoing analysis and
selfinquiry.
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Other current contributions to our understanding of what is curative
in psychoanalytic therapy, especially with psychotic patients, come
from research on child development. With reference to failures of the
ongoing affect attunement of the infant and child, the intersubjective
school focuses on the mutual regulation of affective experience and the
development of moments of meeting in therapy. In such special new
moments of intimate connection, both participants in the therapeutic
dyad recognize sharing of something important and transforming, that
is, a noninterpretative mechanism involving both parties implicit relational knowing (Stern, 2004; Stern et al., 1998). Previously,
Grotstein (1986) wrote about interactional regulation as a curative factor. In a series of writings, Ogden (1986, 1989, 1994a, 1994b, 1994c,
1995, 2004) developed a theory of the unconscious, intersubjective
third between the patient and analyst. With severely disturbed patients,
the coming into being of an interpreting subject presupposes creation of
an analytic space that permits recognition of differences, and in which a
multiplicity of meanings can be entertained and played with. Our research suggests that the therapists interest in, and respect for, the patients private theories of pathogenesis and cure, as well as a critical
examination of his or her private theories, might play an essential role
in this process.
Clinical implications
Our study suggests that the accounts of psychotic patients contain implicit knowledge about the psychotic process. In this way, we follow
Freuds original hypothesis, according to which personal explanatory
constructions created by children and psychotic patients always contain a kernel of truth (Freud, 1908/1959b, 1937/1964). Furthermore, Freud (1911/1958) considered delusions as attempts at
explaining what is not understood, a reconstruction of meaning after a
breakdown (such as the end of the world in the case of Schreber). All
patients in our study tried to formulate something that they had experienced, and they looked for possible explanations to their problems. An
openminded listening to the patients own thinking increases the possibility of obtaining useful information about the psychological context
of psychotic breakdown. As professionals, we by necessity have to rely
on the patients subjective experiences. That is knowledge we cannot
obtain from our own theories and experiences (like the thoughts about
Andreass northern personality and Axels success neurosis). Theories and concepts used by the therapist in order to understand the patient must be combined with knowledge about the personal situation
and history of the unique individual. The poison in the drink at the
Heartbreak Hotel acquires another meaning when you become aware
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of the fact that Andreass older, Danish rival worked as a security manager at a competing company. Axels cutting of his forehead acquires a
specific meaning when you consider his fathers box on his ear for
something Axel had done when he was 5 years old. In a similar way,
Agness preoccupation with environmental pollution, the mysteries of a
crazy, evil world, and the rights of children acquires a very concrete dimension when you think of her frightening realization that she, like her
sister, might have been exposed to her stepfathers sexual assault.
Agness second therapist was not sure whether her idea of incest was a
historical truth or a paranoid idea, but his attitude was to help his
patient consider different alternatives without questioning what
seemed real to her.
A precondition for psychotherapeutic work on private theories of
psychotic patients is that we consider such constructions to be an intentional creation of the narrator and an attempt to create an inner, mental
space (Grotstein, 1978; Resnik, 1995) for metabolizing incomprehensible experiences. However, psychosis may interfere with the symbolic
function of thinking while abolishing the capacity to represent wishes
and emotions (cf. Bion, 1967; De Masi, 2000; Segal, 1991). As suggested by Winnicott (1945/1975), sometimes we have to presume this
potential before it is actually realized by the narrator.
Therapeutic work aims to give psychotic experiences psychological
meaning, that is, to help the patient reinterpret what has been lived
through in terms of inner conflicts and to assist the patient in identifying
his or her own contributions to the repetitive enactment in ongoing life
situations. With the psychotic patient, we need to create a feeling of temporality and an experience of a common history out of a state of timelessness and eternal repetition. Our task is to establish a relationship that
cannot be destroyed and one in which the therapist establishes himself or
herself as a less devastating, more integrated primary object (Werbart &
LindbomJacobson, 2001). In this process, the patients private theories
can be used as a source of clinically relevant information, helping us to
pay attention both to the patients own tenacious clinging to the illness
(Searles, 1967/1979b, p. 22) and to the patients destructive attacks on
his or her own capacity to perceive, feel, and think (Bion, 1967). Listening to the patients private theories can be a substantial contribution to
close monitoring of the seductive power of psychotic solutions. It can
also help the clinician to avoid the pitfall of becoming the dedicated
physician (Searles, 1967/1979a), wholly responsible for the patients illness, able to rescue the patient from the dragon of schizophrenia, and
unaware of any hatred or anger toward the patient.
For those working in psychiatric care, with the current emphasis on
training staff and patients to identify relapse signatures, interest in
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and understanding of the patients own private theories of pathogenesis
and cure can be a necessary ingredient, as strikingly illustrated by the
successful cases of Andreas and Agnes in our material, and, on the other
hand, by Axels persistent difficulties. We would like to emphasize here
that this conclusion is valid not only for psychoanalytic psychotherapy
but also for all kinds of supportive treatments, and is not limited to patients attempting integration, like Agnes and Axel. Actually, the case of
Andreas illustrates the significance of such a dialogue in cases of successful the strategy of sealingover. Rogan (2000) described moving
along a patient with schizophrenia, a case in which some of the implicit relational knowing (Stern et al., 1998) was transformed into explicit knowledge. We agree with Rogans conclusion that the same
noninterpretative mechanism involved in moments of meeting may
be even more important in supportive treatments.
APPENDIX 1. Overview of the Research Sample: The Patients and

the Clinicians Initial Problem Formulations and Theories of
Background
Patients with first-episode psychosis (N = 6)
Ardovan, 27-year-old male
Patient: Caught psychosis. Lack a filter, wasting away, and there is
nothing to be done about it. It is about stress and fatigue, and
caused by inability to assert and say no.
Therapist: Patient stricken with psychosis. A young man lost in life
and having difficulty passing from youth into adulthood. Had
been controlled by his parents and his culture, and therefore
never had a platform of his own.
Agnes, 30-year-old female (changed therapist between first and second interviews)
Patient: Nobody in the world understands me and sees the evil in the
world. Given a secret mission to find a solution to the problem of
environmental pollution. Lacked love in the parental environment; no parents are able to perceive the needs and rights of
children.
Therapist: Patient became psychotic when she obtained insight into a
scandalous business deal and became flooded with more feelings
and thoughts than she managed to contain. Her rigid personality
organization is a consequence of her insecure childhood.
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Andreas, 29-year-old male
Patient: Performance anxiety created pressure. Difficult to trust
women. Questioned new boss. Poisoned with cocaine in a drink.
Betrayed by former girlfriend the previous year.
Therapist: Patients psychotic reaction triggered by current stresses:
the new job and the decision to move to a new apartment with a
new girlfriend. The strains date back to his ex-girlfriends deceit
the previous year. Insecure personality and heavy demands on
himself.
Anne, 26-year-old female
Patient: Persecuted and locked in by what people say. Adopted feelings of being anxious, down and boring so that nobody will
have to interact. Alone too often. Harassed by a teacher. Was not
ready to get a grant and lost my freedom as an artist.
Therapist: Patient unable to defend herself against others opinions
of her works of art. Psychosis triggered by her vulnerable, dependent personality and propensity for conflict, lack of social
network after move to another city, and perhaps sexual advances
made by her teacher.
Astrid, 27-year-old female (changed therapist between second and
third interviews)
Patient: Anxious when faced with move from mothers home. Never
left in peace by crazy, sad, infantile mother. Feels confused, the
school is confusing. Shut off all feelings and became as stiff as
a walking poker when favorite dog was lost.
Therapist: Patient dissociated and agitated as a person; creates confusion around her. Believes she has a psychic connection with a
TV celebrity. According to her father, addicted to alcohol. Unrelieved sexual tension or sexual abuse in combination with strong
parapsychological interest.
Axel, 22-year-old male
Patient: Memories caused flare up; a lot of anxiety and sleeping
difficulties. Lacks a way to handle relationship to parents, which
had to do with own personality and negative self-image. Bullied
in elementary school for his upper-class parents.
Therapist: Patient is self-destructive. Self-punishing behavior rooted
in guilt toward parents. Sleeping difficulties, anxiety, voices and
hallucinations. Had cut off his personal history. Lack of trust
and communication in the family. Unable to stand up for
professional success.
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Patients with chronic psychosis (N = 6)
Christian, 30-year-old male, schizophrenia with paranoid features, 6
years since first psychotic episode (changed therapist between
second and third interview)
Patient: Cant tolerate stress; need to be calm and balance coffee and
cigarette consumption to keep from becoming paranoid. A traffic
accident in teens injured left ear, damaged sense of balance, and
was thus left behind by the other boys.
Clinician: Patient unable to match ambitions and resources. A congenital defect in mental apparatus for reality control makes it
difficult to differentiate between fantasy and reality. His parents
were not able to give him adequate help after the traffic accident.
Carl, 43-year-old male, schizophrenia with paranoid features, 14
years since first psychotic episode
Patient: Sleeping difficulties and restlessness. Ruminates and cant
concentrate on writing a book. Feels vulnerable after returning
home from India, where he worked as a development worker;
cant come to terms with the life in Sweden.
Clinician: Patient has narcissistic difficulties concerning autonomy
and resentment leading to isolation, paranoia, and horror. Struggles for freedom combined with dependency on his dominating
mother. Vulnerability; probably traumatized in India, which
became too much for him.
Claude, 39-year-old male, schizophrenia with paranoid, features, 16
Patient: Disturbances in diurnal rhythm and fluctuations between
nice dreams and nightmares leading to chaos. Without a good
rhythm, hit the bottle, overcome by terrifying thoughts, and
frightened by stray dogs. Difficult to liberate from my parents.
Clinician: Patient too ambitious compared to his own resources.
Tendency to addiction. Gets stuck, cant decide; problems grow
mountainous and his thoughts get muddled. Perhaps there was
too little place for him in his family, perhaps he had difficulty in
asserting himself.
Cindy, 45-year-old female, schizophrenia with paranoid features, 8
Patient: Anxiety and fear of men. Passive and stuck in memories.
Waste money, buy a lot of books, and collect things. Sexually
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abused as child. Mistreated by mother and sister. Struggled in
vain to recognize what I was exposed to.
Clinician: Patient alone and desperate. Tries to supply her emptiness
with shopping, leaving no place for herself in the apartment. Always discontented, with a permanent feeling of being unfairly
treated and exploited; which is self-fulfilling. A downward spiral,
functioning worse and worse.
Clara, 47-year-old female, cycloid psychosis with religious features,
18 years since first psychotic episode
Patient: Have a cyclic illness coming back at different intervals and
causing dependency on round-the-clock care, but an ordinary
healthy person in between bouts. Enormous trials in life can
mean absolutely nothing, yet a small extra strain later on can be
the straw that breaks the camels back. Never found an identity in
teenage years and betrayed my religious faith.
Clinician: Patient subjected to recurrent nightmare-like dramatic
cycloid psychoses; totally healthy in-between. Congenital vulnerability in an enormously gifted woman. Engaged in church; her
life has a spiritual dimension. Strain of work and economic pressure results in psychotic breakdowns.
Cedric, 27-year-old male, schizophrenia with paranoid features, 6
years since psychotic episode (change of therapist between second and third interviews)
Patient: Enormously low self-esteem and fear of people. Placed on
the outside of life; a big torment and never-ending struggle. Mom
threw shit on me and stepfather assaulted me; the traumata that
made it went constantly downward and there is nothing to be
done about it.
Clinician: Patient has deep paranoid psychoses with imperative
voices. Probably not so gifted as he pretends to be. A fragile plant
in wrong earth; going astray as he lacked a father able to lend him
a hand. Congenital vulnerability or perhaps hereditary
schizophrenia.
Vol. 69, No. 2 (Spring 2005)
129

APPENDIX 2. PTI Coding System (abbreviated).
1. What is the problem?
1.1 How does the patient/clinician describe the patients current difficulties and problems? (Indicate which is the first formulation)
1.2 Inferences: Recurring themes in the patients/clinicians descriptions of the patients problems and their nature.
2. When did the problems start?
2.1 Description of the episodes in the order in which the patient/clinician perceives them to have occurred. (Indicate the first episode
to be related)
2.2 Inferences: The central episodes in the patients/clinicians narrative. (Note every indication of how these episodes appear in the
subjective chronology; e.g. It actually started when...)
3. How did the problems arise?
3.1 How does the patient/clinician describe the background to the
current difficulties and problems?
3.2 Inferences: Recurring themes and private theories in the patients/clinicians narratives about the background to the
problems.
4. How can the problems be remedied?
4.1 What are the patients/clinicians notions of help and obstacles?
4.2 Inferences: Recurring themes and private theories in the patients/clinicians narratives about how the problems may be
remedied.
5. How does the other party view the problems?
5.1 How does the patient/clinician describe the others view of the
patients problems, their origin, and the cure?
5.2 Inferences: Recurring themes in the narratives about the other
partys view of the patients problems, their origin, and the cure.
6. Formal and qualitative aspects
Descriptions are made as concrete as possible from the manifest material in the patients/clinicians narratives.
6.1 Central scenes in the patients/clinicians narrative (picturing of a
scene brings together a significant point of time, place and persons or other objects).
130

6.2 Describe the patients/clinicians narrative in terms of how elaborated, rich in detail, lucid, and coherent vs. how simple, stereotype, or contradictory it is.
6.3 Describe how open the patients/clinicians theories are to alternative possibilities and explanations, or how fixed and immutable. Knows nothing, wonders, knows precisely?
6.4 Describe how much the patient is perceived as participating in
the pathogenesis and the cure. How active or passive is the patient as a gestalt in the clinicians narrative? As an agent in his or
her own life or as a victim? How unavoidable was that which occurred? How feasible is the cure?
7. The central unconscious fantasy
7.1 Describe the patients/clinicians unconscious fantasy regarding
the problems, their origin, and the cure. In the case of the clinician, the latters fantasy actualized by the patient is also to be
included.
7.2 What role is played by the primary objects, their representatives,
and the other party in this fantasy?
8. Comparison of the two parties
8.1 Compare the similarities and differences between the patients
and the clinicians narratives from the same point in time.
8.2 Describe the degree of the parties consciousness of similarities
and differences.
8.3 What are the consequences of concordance and discrepancy, respectively, for the dialogue between them? What is covered in the
dialogue? What is omitted?
9. Comparison of points of time
9.1 Compare the similarities and differences between points in time
in the patients and the clinicians narratives.
9.2 Summarize the patterns of change and stability over time in the
manifest narratives, private theories, and unconscious fantasies
about the problems, their origin, and the cure.
Vol. 69, No. 2 (Spring 2005)
131

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Bulletin of the Menninger Clinic

Private theories about psychosis

Vol. 69, No. 2 (Spring 2005)

Werbart and Levander

Bulletin of the Menninger Clinic

Private theories about psychosis

Werbart and Levander

Bulletin of the Menninger Clinic

Private theories about psychosis

Werbart and Levander

Bulletin of the Menninger Clinic

Private theories about psychosis

Werbart and Levander

Bulletin of the Menninger Clinic

Private theories about psychosis

Werbart and Levander

Bulletin of the Menninger Clinic

Private theories about psychosis

Werbart and Levander

Bulletin of the Menninger Clinic

Private theories about psychosis

Vol. 69, No. 2 (Spring 2005)

Werbart and Levander

Bulletin of the Menninger Clinic

Private theories about psychosis

Vol. 69, No. 2 (Spring 2005)

Werbart and Levander

Bulletin of the Menninger Clinic

Private theories about psychosis

Werbart and Levander

Bulletin of the Menninger Clinic

Private theories about psychosis

Werbart and Levander

Bulletin of the Menninger Clinic

Private theories about psychosis

Werbart and Levander

APPENDIX 1. Overview of the Research Sample: The Patients and

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Private theories about psychosis

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Bulletin of the Menninger Clinic

Private theories about psychosis

Vol. 69, No. 2 (Spring 2005)

Werbart and Levander

Bulletin of the Menninger Clinic

Private theories about psychosis

Vol. 69, No. 2 (Spring 2005)

Werbart and Levander

Bulletin of the Menninger Clinic

Private theories about psychosis

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Bulletin of the Menninger Clinic

Private theories about psychosis

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