Effective Psychoanalytic Therapy of Schizophrenia and Other Severe Disorders

In Effective Psychoanalytic Therapy of Schizophrenia and Other Severe Disorders, Dr. Bertram P. Karon demonstrates this psychoanalytic approach to treating clients who have severe mental disorders. This approach focuses on providing a strong, safe relationship in which to explore the symptoms and possible sources of the client's disorder. In this session, Dr. Karon works with a 29-year-old woman with a possible history of childhood sexual abuse who has lately been hearing voices and exhibiting paranoid behaviors.

This video features a client portrayed by an actor on the basis of actual case material.

Precipitating Events

A few months ago, the day after the client's youngest daughter's birthday party, the client (Virginia) began to get very nervous, agitated, and extremely fearful of men in terms of her daughters' and her own safety. Virginia jumped if a man came close to her or her girls. She would grab the girls, hold them close, and order the man away. She was even suspect of her husband. She refused to sleep in the same room with him; rather she made a pallet for herself on the floor of the girls' shared bedroom. This went on for several weeks before her husband had her admitted to a psychiatric hospital. She was hospitalized for 3 weeks, stabilized on medications, discharged 2 weeks ago, and referred to Dr. Karon.

First hospitalization: At age 17, the patient was hospitalized after hallucinating that devil-like creatures were sticking knives into her body, hurting her in general, and perhaps trying to cut something out of her (details are unclear).

Second hospitalization: When the patient was 26 years old, just after her first daughter's second birthday, the patient was admitted to a psychiatric hospital. Virginia was convinced that the workmen in the neighborhood—electric company workers, trash collectors, letter carriers, and telephone linemen—were "mass murderers" who wanted to break into her house, rape and kill her, and kidnap her daughter. After locking herself and her daughter in the house for days on end with all the blinds drawn, her husband brought her to a psychiatric hospital where she was hospitalized for 3 weeks, treated with medication, and released on continuing medication.

When Virginia was 3 years old, her parents, Lou and Betty, were called to court on neglect charges. Lou had allegedly allowed different male friends of his to look at and touch his daughter on various occasions. Betty was not home on these occasions, and the men had been drinking in Lou and Betty's home. Virginia also may have been given beer to drink. Lou was not directly accused of any sexual violation of Virginia. Both parents denied that anything like this had happened. After investigation, the charges were dropped for lack of evidence.

When Virginia was 11 years old, the parents were again reported for neglect. The circumstances were essentially the same as in the previous charge, except that sexual intercourse was alleged to have occurred on several occasions. Virginia initially confirmed the sexual activity to a social worker, but later in the investigation denied that anything had occurred. The case was later dropped because of the inability of the social service staff to provide confirming evidence.

Psychological tests at the time of the second charge described Virginia as being in a "pre-borderline" condition. The psychologist predicted deteriorated functioning as Virginia moved into adolescence. These predictions were partially correct. When Virginia began menstruating at the age of 12, her academic performance deteriorated to a C level (after having been a B+ student), and she became more shy and withdrawn. Virginia rarely spontaneously interacted with either girls or boys her age (between the ages of 12 and 15). When she was 15 years old, Virginia again began to get better grades, and she became active in the science club, school newspaper, and yearbook. Throughout her middle adolescence, she was seen as a "loner" and did not date.

Previous Sessions

Session 1: Dr. Karon began by asking Virginia how he could help her. He learned that she had recently been hospitalized (for the third time) and that she was on medication. Virginia had considered stopping her medication, and Dr. Karon told her that she is the best judge of what she can tolerate, although he asked that if she was going to stop, that she just skip her dose before her second appointment "so that he can see her at her worst" rather than stopping completely. She agreed that she would do this if she decided to stop the medication. Dr. Karon asked Virginia to tell him about herself, her job, her children, her marital status, her childhood, and her relationship with her parents—which she did.

Session 2: Virginia did not take her medication, and she was somewhat scared. Dr. Karon talked to her about what might have been frightening her. She told him about her fears about her husband hurting their daughters. She also told Dr. Karon about her memories of going to court at age 11 or 12, and she had vague memories of men touching her sexually as a child. During the second session, Virginia began to hear rhyming voices, which frightened her.

Session 3: To be viewed.

This is a psychoanalytic approach that assumes that all the symptoms are meaningful and are related to the life history as subjectively experienced. The unconscious is taken seriously, and everything psychoanalysis has learned about human development and therapy is relevant.

Schizophrenia is a chronic terror syndrome. Patients who develop psychotic symptoms have had lives that would cause profound distress in anyone. It is necessary to create a therapeutic alliance by offering real help with what the patient perceives as the problem. Severely disturbed patients need a warm, strong therapist who will deal with anything. The sicker the patient, the more structure and support the therapist must provide. Conscious insight is helpful, but it is only bearable within a strong, safe relationship. Hallucinations are understood and interpreted like dreams. Delusions are understood primarily as

• transference to the world at large,
• defenses against pseudo-homosexual anxiety (as described by Freud in the Schreber case)
• concepts and meanings idiosyncratic to a particular family, and
• an attempt to make sense out of one's world and life despite strange experiences and symptoms.

The patient uses the therapist for corrective identifications. The therapist is internalized as a less destructive superego, replacing the punitive conscience that is based on the parents. The therapist also provides a model for the ego—how one might be. The relationship with the therapist is internalized as what a human relationship might be like. The patient only keeps internalizations that are useful. As the patient gets healthier, the patient takes a more active role (and the therapist a less active one) in the therapy, and the process becomes like the psychoanalytic therapy of neurotics.

Bertram P. Karon, PhD, is a professor of clinical psychology at Michigan State University, who received his PhD from Princeton University. He is currently president of the Michigan Psychoanalytic Council and past president of the American Psychological Association's (APA) division of psychoanalysis, as well as of Psychologists Interested in the Study of Psychoanalysis and of the Michigan Society for Psychoanalytic Psychology.

Awards Karon has earned include Outstanding Publication Relevant to Psychoanalysis (for Karon & VandenBos, Psychotherapy of Schizophrenia: The Treatment of Choice) and the Distinguished Psychoanalyst Award, both from the New York Society for Psychoanalytic Training; and the Fowler Award for Distinguished Graduate Training, APA Graduate Students.

He is an APA fellow of Divisions 12 and 29, diplomate in clinical psychology, and principal investigator for the Michigan State Psychotherapy Research Project (psychotherapy vs. medication for schizophrenics).

• Benedetti, G., & Furlan, P. M. (Eds.). (1993). The psychotherapy of schizophrenia: Effective clinical approaches-Controversies, critiques and recommendations. Gottingen, Germany: Hogrefe & Huber.
• Karon, B. P. (1989a). On the formation of delusions. Psychoanalytic Psychology, 6(2), 169–185.
• Karon, B. P. (1989b). The state of the art of psychoanalysis: Science, hope, and kindness in psychoanalytic technique. Psychoanalysis and Psychotherapy, 7, 99–115.
• Karon, B. P. (1992). The fear of understanding schizophrenia. Psychoanalytic Psychology, 9, 191–211.
• Karon, B. P., & VandenBos, G. R. (1981). Psychotherapy of schizophrenia: The treatment of choice. Northvale, NJ: Jason Aronson.
• Karon, B. P., & Widener, A. J. (1994). Is there really a schizophrenogenic parent? Psychoanalytic Psychology, 11, 47–61.
• VandenBos, G. R., & Karon, B. P. (1981). The treatment of severely disturbed patients, with attention to the relative cost-effectiveness of psychotherapy and medication. In B. Christiansen (Ed.), Does psychotherapy return its costs? (pp. 77–99). Oslo, Norway: Norwegian Research Council.
• Werbart, A., & Cullberg, J. (Eds.). (1992). Psychotherapy of schizophrenia: Facilitating and obstructive factors. Oslo, Norway: Scandinavian University Press.

APA Videos

• Adolescents With Bipolar Disorder
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• Cognitive Therapy for Borderline Personality Disorder
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• Cognitive Therapy for Panic Disorder
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• Depression
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• Psychoanalytic Therapy Over Time
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APA Books

• Origins and Development of Schizophrenia: Advances in Experimental Psychopathology
  Edited by Mark F. Lenzenweger and Robert H. Dworkin
• Recovery in Mental Illness: Broadening Our Understanding of Wellness
  Edited by Ruth O. Ralph and Patrick W. Corrigan
• Schizophrenia in Late Life: Aging Effects on Symptoms and Course of Illness
  Philip D. Harvey
• Social Cognition and Schizophrenia
  Edited by Patrick W. Corrigan and David L. Penn