Medical Psychotherapy of Schizophrenia

A Dynamic/Supportive Approach
Richard B. Corradi

Abstract: Split psychiatric treatmenta psychiatrist prescribing medication while a

nonphysician provides or coordinates psychosocial treatmentsis common practice,
especially in the managed care setting. This influence, along with a focus on the biology of mental illness, has shifted the emphasis in psychiatric education and practice
away from psychotherapy. In particular, psychotherapy of schizophrenia has gotten
short shrift. Since our drugs for schizophrenia do not cure, but only ameliorate, it
would be unfortunate if psychiatrists were to become marginalized in a largely prescriptive role. This paper discusses medical psychotherapy of schizophreniaan integrated treatment in which the psychiatrist provides the comprehensive care that such a
chronic biopsychosocial illness requires.

Individual psychotherapytherapeutic listening and talking on the part of

a psychiatristseems to have little currency in the contemporary treatment of
schizophrenic patients. Split psychiatric treatment, that is, pharmacotherapy
performed by a psychiatrist and psychosocial interventions by a nonphysician, is common practice (Gabbard & Kay, 2001). Psychosocial treatments by
nonmedical practioners may include case management, community-based social skills and educational rehabilitation programs, and psychoeducational
family therapy (Bustillo Lauriello, Horan, & Keith, 2001). If psychotherapy
is included it tends to be cognitive-behavioral, with a focus on acute symptoms (Garety, Fowler, & Kuipers, 2000). In many clinical settings, diagnosis
and drug management have become virtually the only functions of the psychiatrist.
A confluence of forces seems to be responsible. Emphasis on the biology
of mental illness, as well as the pervasiveness of managed care, has influenced training and practice toward the split treatment service delivery model
(Hoge, Jacobs, & Belitsky, 2000; Detre & McDonald, 1997). The DSM-IV
(American Psychiatric Association, 1994) focus on a symptom checklist limits appreciation of the complex human dimensions of schizophrenia and favors drug-targeting of symptoms (Tasman, 2002). The backlash against clasRichard B. Corradi, M.D., Professor of Psychiatry, Case Western Reserve University School
of Medicine, Cleveland, Ohio. Staff Psychiatrist, Louis Stokes Cleveland Veterans Administration Medical Center, and University Hospitals of Cleveland, Cleveland, Ohio.
The author thanks Ruth C. Beach for her editorial assistance.
Journal of The American Academy of Psychoanalysis and Dynamic Psychiatry, 32(4), 633643, 2004
2004 The American Academy of Psychoanalysis and Dynamic Psychiatry

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sical psychoanalysis has prejudiced academia against dynamic psychotherapy

generally, and certainly in its application to schizophrenia (Lehman &
Steinwachs, 1998).

SCHIZOPHRENIA AS A BIOPSYCHOSOCIAL ILLNESS

Individualized treatment of schizophrenic patients in the post-World War
II period was largely psychoanalytically based. Techniques used in treating
the neuroses were applied to schizophrenia with only slight modification.
Failure to demonstrate efficacy (May, 1968; Stanton et al., 1984), as well as a
psychosocial developmental hypothesis that attributed schizophrenia to maternal deficiencies (Hartwell, 1996), led to its fall from grace. The void left in
the psychotherapy of schizophrenia went unfilled as the biologic revolution in
psychiatry led to use of antipsychotic medication as the primary treatment
modality. Drugs, however, proved to be more successful against the acute and
florid symptoms of schizophreniaagitation, hallucinations, delusionsthan
against the more chronic deficit symptomsavolition, anhedonia, affective
blunting (Miyamoto, Duncan, & Goff, 2002). Consequently, there resulted a
deinstitutionalized population badly in need of social and rehabilitative services. The psychosocial treatment strategies that have emerged have been
performed largely by persons other than the medication-prescribing physician. Although the current vulnerability-stress hypothesis of schizophrenia reflects the complex interrelatedness of biologic, developmental, social, and environmental factors in the onset, course and outcome of schizophrenia, the
contemporary role of the psychiatrist has been progressively narrowed.
Some recent attempts to integrate psychosocial strategies with individualized psychotherapy have shown promise. Personal therapy, developed by
Hogarty and colleagues (1997), which utilized stress reducing and coping
skills training along with individual therapy sessions, improved social skills
and personal adjustment for some patients. Individual cognitive behavioral
therapy (CBT) has shown a salutary effect on targeted psychotic symptoms,
such as hallucinations and delusions, although its effectiveness as a treatment
for schizophrenia remains controversial (Sensky et al., 2000; Turkington &
McKenna, 2003). Fenton (2000) has defined a flexible psychotherapy
based on integrative biopsychosocial assumptions about schizophrenia. These
include consideration of biologic and environmental aspects on both sides of
the vulnerability-stress equation, individualized and phase-specific therapeutic interventions, and regard for the doctor-patient relationship as the bedrock
that underlies the success of all prescribed therapies.
Read, Perry, Moskowitz, and Connolly (2001) have extended the biopsychosocial model beyond the assumption that the schizophrenic biologic

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635

diathesis is mainly genetic. Their traumagenic neurodevelopmental hypothesis suggests that adverse psychosocial events, such as childhood abuse, may
contribute to the diathesis via long-lasting neurobiological effects. Apart from
its implications for research, this hypothesis underscores the importance of
eliciting the schizophrenic patients life narrative.
Certainly, in our present state of knowledge it is simplistic to regard schizophrenia unidimensionally as a brain disorder. Despite dramatic advances in
neuroscience, the only clinically applicable biotherapy for schizophrenia still
consists of drugs that ameliorate but do not cure. Consequently, a psychiatry
marginalized to a largely prescriptive role in its treatment does patients a disservice. Integrated psychiatric treatment, of the psychosocial as well as the
bio, addresses schizophrenia as a human process reflecting a complex adaptational struggle. In the sense that it is a truly biopsychosocial illness (Engel,
1980), with interacting psychosocial and neurobiological components, it requires psychiatrists whose psychotherapeutic skills are as important as their
pharmacotherapeutic ones.
Medical psychotherapy integrates biologic and psychologic treatment of
schizophrenia. This paper outlines a psychotherapy that incorporates psychodynamic insights into a supportive psychotherapy framework. While classical psychoanalysis per se is not an appropriate treatment of the psychoses, the
application of some of its insights can be of great help to schizophrenic patients. These include the therapeutic efficacy of the doctor-patient relationship (Meissner, 1996), how psychosis affects personality (ego) functions
(Federn, 1952), the psychodynamics of loss (Bibring, 1953; Freud, 1915/
1957), and how the concept of defense mechanisms (Vailliant, 1993) illuminates schizophrenic symptomatology. These inform and enhance standard
supportive techniques, such as providing a climate of empathic affirmation
and measured dependence while utilizing direction, advice, reassurance, and
education (Dewald, 1994).

PSYCHOTHERAPY OF SCHIZOPHRENIAAN OVERVIEW

The following overview of the basic elements of dynamic/supportive psychotherapy offers a conceptual and operational framework for its application. It is useful to psychiatrists trained in the biologic, split treatment orientation, for whom psychotherapy of schizophrenia may be a foreign
concept, as well as to the psychodynamically oriented, for whom integration
of dynamic with supportive and psychosocial modalities may seem equally
foreign.
Dynamic/supportive psychotherapy of schizophrenia is comprised of the
following elements: the therapeutic alliance; education and empathic reality

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testing; medication use and compliance; treatment of post-psychotic depression; the holding environment; the facilitating environment; and the maintaining environment. Each will be described briefly.
The Therapeutic Alliance
As in the treatment of most chronic illnesses, the doctor-patient relationship is the crucial foundation of effective pharmacotherapy as well as psychotherapy (Frank & Gunderson, 1990). Establishing a therapeutic alliance is
a first principle in the treatment of schizophrenia; all else follows, including
effective use of antipsychotic medication (Docherty & Fiester, 1985). Building the therapeutic alliance is an intensive, laborious, often long-term process,
since relationships are profoundly impaired by schizophrenic psychopathology. It is frequently incomplete and, unfortunately, sometimes fails. Further,
it places significant emotional demands upon the therapist, who must confront another human being in profound psychic pain and mental disorganization, especially in the early phases of the illness. (The emotional distance that
it allows may be another factor that fosters split treatment.) With newly diagnosed or recently hospitalized patients, a minimal frequency of weekly appointments is often necessary.
The psychiatric evaluation of a schizophrenic patient may be less than
comprehensive if a careful developmental history is thought irrelevant because the illness is biological, or in a busy managed care setting in which
the physician has a largely prescriptive function. A trusting therapeutic alliance cannot be built upon a relationship consisting only of diagnosis and
medication management. The patients illness, however chronic, must be put
in a life context. Developmental stressors, premorbid functioning, precipitating events, and adaptive responses are all relevant to understanding schizophrenia as a human process rather than reductionistically as a brain disorder. Knowledge of the patients strengths, vulnerabilities, and trigger points
is also essential in the phase of treatment directed to optimizing independent
functioning. The possibility of a trusting alliance is fostered as the patient perceives that he or she is regarded as a whole person with an important life narrative to be listened to and understood.
In psychodynamic terms, the therapeutic alliance provides the patient with
a caring figure of stability in a chaotic world who helps with reality testing, is
an ally to a weakened ego, who can help make some sense of the psychotic
experience, and who can be identified with in the process of personal and social integration. These functions will be illustrated as additional elements in
the therapeutic process are discussed.
The psychiatrist must also maintain an alliance with the patients family,
especially the family member most involved in the patients care. Educating

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family about the illness, about the therapeutic process (including the importance of medication), about community resources, and about how they can
help their loved one, is crucial (Dixon, Adams, & Lucksted, 2000).
Education and Empathic Reality Testing
Patients undergoing the terrifying experience of psychosis, with its break
with reality, cognitive disorganization, and loss of self-control, need empathic
support and education about their experience. Knowledge of the variability of
course and outcome of the disorder guides the psychiatrist both in phase-specific supportive psychotherapy and in pharmacotherapy. Contrary to earlier
Kraepelinian notions, progressive deterioration is neither inevitable nor common in schizophrenia (Harding, Brooks, Ashikaga, Strauss, & Breier, 1987;
Leff, Sartorius, Jablensky, Korten, & Ernberg, 1992). While remissions and
relapses are common in early phases of the illness, therapy can often effectively address the factors associated with relapse, both the biologic (e.g., substance abuse, medication noncompliance) and psychosocial (e.g., environmental stressors). For example, a young man who had achieved a stable and
highly functional remission experienced several episodes of paranoid delusional thinking about people in his workplace. After determining that the
episodes were associated with troublesome homoerotic feelings toward new
male coworkers whom he perceived as overly friendly, his psychiatrist
helped him moderate the degree of closeness in the relationships so that they
were no longer threatening. This resulted not only in resolution of his thought
disorder but also in a greater sense of self-determination.
A much more intimate knowledge of the descriptive features of the illness
than garnered from the DSM-IV is also required (Bleuler, 1950). Although a
biologic or neurodevelopmental diathesis may be necessary to produce schizophrenia, its phenomenology is still comprehensible in psychodynamic terms;
that is, as a (mal)adaptive response to a devastating cognitive disorganization.
The use of defense mechanisms is an expectable response to ego fragmentation from any cause. It is helpful, for example, to our empathic understanding
of schizophrenic patients to appreciate their use of the defense mechanism of
regression (Fenichel, 1945). Delusions represent regression to primitive, prelogical forms of thinking (primary process), seen also in other cognitively impaired pathological states, such as delirium and dementia, and as a normal
cognitive developmental stage in very young children. Hallucinations also
reflect regression to a very early developmental stage, before the childs sense
of self allows discrimination between internal and external stimuli. Pathologic, regressive uses of the mechanisms of denial and projection are also
prominent (Freud, l922/1955). And the most reality-distorted form of reaction
formation is exemplified by the paranoid patients grandiose delusion of di-

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vinity as a defense against feelings of utter powerlessness and loss of control

(Freud, 1911/1958).
The defenses, however primitive, mobilized in the acute phases of the illness serve the critical purpose of relieving the chaotic affective state, but do
so at the expense of loss of reality testing. A state of unbearably painful anxiety and depression may progress through thought disorder and delusion formation to an autistic state with deficit symptoms. Thus, in dynamic terms, the
affectless end stage sometimes seen in chronic schizophrenia is a desperate
solution to the intolerable affects of the acute illness. Such a conceptualization of the mental processes in dynamic terms in no way counters a neurobiological etiologic theory of schizophrenia. It does, however, serve several important functions. It provides the therapist an understanding of the illness that
lessens the tendency to regard it as alien to ordinary human experience and
amenable only to drug treatment. A dynamic conceptualization also provides
for the therapeutic use of the doctor-patient relationship, a tool that in the
long-term treatment of schizophrenia may be more effective than drugs.
Sensitive to these dynamic attempts to order a chaotic world, the psychiatrist listens empathically and helps with reality testing, educating about the
distortions produced by the illness and modeling adaptive skills. Cognitivebehavioral techniques may be among those helpful in the context of a trusting
therapeutic alliance. While a schizophrenic patient cannot be talked out of
his or her delusions, the psychiatrist who knows their utility uses his or her
human bond with the patient to ameliorate some of the pain behind them.
Medication Use and Compliance
It is difficult for anyone to take medications chronically, particularly when
they are not associated with apparent symptom relief. A psychotic patient
who does not realize that he or she has an illness lacks even a self-interested
motivation to medicate. Some patients incorporate medication into their delusional systems, ascribing malevolent intent to their being prescribed. Noncompliance with medication is a serious problem in the treatment of schizophrenia and a major reason why nonhospitalized patients relapse (Haywood
et al., 1995).
Pharmacotherapy is currently a cornerstone of modern treatment of schizophrenia. A crucial function of the doctor-patient relationship is keeping patients on medication. Often a patient takes medication only because of trust in
the physician. Building the trust requires frequent contact, patience, empathy,
and knowledge that an ongoing, intensive human relationship is as important
as medication; without it medication often will not be taken. One of the major
pitfalls of the split treatment model is the absence of a therapeutic alliance
when the psychiatrist sees patients only for med checks.
The therapeutic alliance must be strong enough to sustain repeated tests.

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Trials of various drugs are frequently necessary. Significant adverse effects

must be endured, symptomatic gains are slow, improvement is only partial,
and complete remission of symptoms is unusual. Although the new generation of antipsychotic drugs is somewhat more efficacious and less toxic than
the old, these drugs still do not cure. The difficulties of drug treatment of
schizophrenia are significant under the best of circumstances. When the patient has neither insight into his or her illness nor a close doctor-patient relationship, these difficulties can be insurmountable.
Treating Post-Psychotic Depression
Most patients achieve significant remissions from their acute illness. With
improvement, however, comes the awful awareness of being psychotic. Having gone crazy (as many patients express it) is a devastating blow to ones
sense of self. It is difficult to imagine an insult more profound than the loss of
those integrating cognitive, mental, and emotional functions that define both
ones humanity and individuality. Significant depression frequently follows
insight into ones illness. This depressive phase should be recognized as an
expectable component of the illness, particularly in young people who
achieve a good remission and have a good prognosis, and not be confused
with schizoaffective disorder. In fact, it typifies the psychodynamics of reactive depression in which depression is related to significant loss (Freud,
1915/1957). Antidepressant drugs may be quite helpful, as they are in most
major depressions; however, helping the patient reconstruct an identity incorporating the fact of having schizophrenia requires empathic psychotherapy in
the context of an established doctor-patient relationship.
The Holding Environment
The holding environment is how the doctor-patient relationship is conceptualized when education and reality testing, medication compliance, and
treatment of depression are primary foci of therapy. While the patient remains significantly symptomatic or in early remission, the therapeutic alliance serves as a safe and supportive haven. The psychiatrist provides nonjudgmental acceptance while encouraging participation in the therapeutic
process. The degree of dependence and support that the patient requires must
be balanced against an appreciation of his or her functional limitations. Family members need to be educated about their loved ones vulnerabilities, since
in their eagerness to see improvement they may expect too much. While still
acutely psychotic or in early remission, the patient is fragile and vulnerable to
relapse. Once trust is established, sometimes the patient will make strides
based simply upon the desire to please his or her physician. This may be the
only motivation for medication compliance, for example. Some patients do

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not improve beyond this treatment stage. For others it is prolonged and
progress is erratic. For all of them the goal is to optimize functioning within
their limitations.
The Facilitating Environment
At this stage the focus is to help the patient reconstruct his or her life, moving from a dependent to a more autonomous position. The illness typically
strikes in early adulthood, often significantly impairing development of the
social and educational skills specific to that period. The patient must deal not
only with residual symptoms, but also with learning these missed skills. This
requires a practical here-and-now education in life management: habilitation rather than rehabilitation. Educating the patient in problem solving as
life issues arise, judicious advice giving, and modeling behaviors are all part
of this process. A variety of behavioral techniques, such as progressive task
assignment and role playing, may be useful. In dynamic terms, this is a
process involving the critical developmental mechanism of identification, in
which the patient incorporates ego-adaptive coping skills demonstrated by the
therapist. Identification is one of the most powerful therapeutic aspects of the
doctor-patient relationship. As such, one makes deliberate use of it and the
therapist makes fewer active supportive interventions as the patients ego
functions improve.
Adjunctive to individual therapy, community agencies that provide social,
vocational, and other services for the mentally ill can be very helpful during
this phase of treatment. The patients family as well as the patient should be
educated about these resources. Expectations should be carefully geared to
the patients level of recovery. Sending a patient back prematurely to an environment that may have played a role in precipitating the illness invites relapse. For example, a student who decompensated in a residential college environment may need to take a course at a community college while living at
home before resuming a more ambitious academic program. An intimate
knowledge of the patient, including premorbid level of functioning, medication compliance, degree of illness remission, precipitating factors and vulnerabilities, and social and family support systems, is required to maximize the
patients recovery. This treatment phase, often lengthy and variably successful but decisive in determining the patients subsequent level of functioning,
requires patience and a recognition that the therapeutic alliance is an essential
foundation of successful treatment.
The Maintaining Environment
From education and reality testing, through excursions into greater self-determination and independence, the doctor-patient relationship ultimately as-

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sumes a function similar to that required by any patient with a chronic medical
illness. Frequency of appointments, level of support, and therapist activity are
all determined by the degree of illness remission. Schizophrenia is a devastating illness and outcomes vary widely. For some, the prognosis is poor under the
best of circumstances, and others require intensive treatment to maintain even
a marginal adjustment. However, many patients who receive optimal biopsychosocial treatment will avoid hospitalization, require minimal medication,
and achieve a stable remission. Many enjoy a life of gratifying work and relationships, including successful marriage, parenthood, and career.

DISCUSSION
Contemporary psychiatric treatment of schizophrenia focuses largely on
the biologic. Advances in the neurosciences and the strong focus on pharmacology in the treatment of mental illness have directed psychiatric education
and practice away from psychotherapy. The biologic emphasis makes common cause with the split treatment model of managed care, in which the psychiatrist performs drug treatment while nonphysicians carry out psychosocial
interventions. Absent both definitive knowledge of the etiology of schizophrenia and a curative biotherapy however, a narrowing of our treatment
focus to the biologic is premature. Although a neurobiological vulnerability
may be necessary to produce the illness, its course is affected by psychosocial
factors. Some vulnerable individuals seem to require environmental or psychological stressors to develop the illness. Currently, then, it is in the best interest of patients with schizophrenia to provide them with the comprehensive
care that a chronic biopsychosocial illness requires. Comprehensive psychiatric treatment integrates pharmacotherapy with psychodynamically informed
psychotherapy that exploits the healing potential of the doctor-patient relationship.
It is the thesis of this paper that schizophrenic patients are most likely to
achieve their optimal improvement in the context of a long-term therapeutic
alliance with a psychiatrist who appreciates the biopsychosocial dimensions
of schizophrenia. Clinical research studies that compare the split treatment
model with an integrated dynamic/supportive approach such as outlined in
this paper are needed.
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Louis Stokes Cleveland VA Medical Center
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