Gaetano Benedetti, Swiss psychiatrist-psychoanalyst and co-founder of ISPS (see www.isps-us.org and www.isps.org) in 1956, after a long career as a psychotherapist to psychotic persons spanning well over 50 years, concluded that in order for the work to happen, the following factors must be established:

1) “Psychotherapy with the psychotic patient requires a major effort and it demands the therapist motivation to identify themselves with the patient. The identification, even though a partial one, with the ‘lunatic’ creates considerable resistance particularly in those institutions based on rules and norms. Because of this identification with those who are outside the norm, the therapist is in a position of potential conflict with the institution.

2) The therapist-patient and patient therapist identification, even partial, paves the way for therapeutic symbiosis which is the alpha and the omega of psychotherapy of the psychoses. The therapist usually has a number of internal resistances to re-experience symbiotic events [e.g., the therapist’s, as with people in general, discomfort with prolonged silences in the session]. I will never forget [the words of Harold Searles]...which has always inspired me: ‘The reason why psychotherapy of the psychoses lasts so long is connected to both patient and therapist resistances to enter therapeutic symbiosis.

3) The needs and conflicts of the psychotic patient are of a preverbal nature and they reactivate preverbal conflicts and needs in the therapist’s countertransference. In my opinion these conflicts and needs must be dealt with by preverbal psychotherapeutic instruments [nonverbal stance of acceptance and empathic attunement to the p[atient in the present moment of the therapy] before they can be verbalized. Just as many patients cannot be reached by mere words, similarly the therapist needs preverbal [sensitivity]instruments... to elaborate the countertransference activated by the symbiotic needs of the patient

4) The therapist of a psychotic patient requires a reference group within the institution in which they work and with which they can share psychotherapeutic experiences that can be seriously regressive and intense.

5) The reference group within the institution supports the therapist in the process of partial identification with the psychotic patient, reducing their loneliness and their possible ‘estrangement’ feeling, helping them to face the ‘norm’ of the institution.

6) Within the reference group, group experiences and seminars including preverbal communication ways are fundamental in order to bring therapists closer to therapeutic symbiosis and to train them. This can cause, and indeed it always causes, some resistances in a number of therapists, however the most of the group benefits dramatically from a ‘group symbiosis.’ In the relationship with the patient, those who have already experienced preverbal symbiosis with their colleagues, are much more confident and open to question themselves in order to come closer to the fragmented experience of the patient.

Brian Koehler PhD
Postdoctoral Faculty
New York University
80 East 11th Street #339
New York NY 10003
212.533.5687
brian_koehler@psychoanalysis.net

Brian: WIth all due respect to Dr. Benedetti, it seems to me that more is needed to explicate his remarks. I can imagine a number of pathways to recovery that do not involve the steps that Benedetti has outlined. Prominent among these are Sullivan's work at Sheppard-Pratt and George Brooks' work in Vermont (i.e. the treatment intervention in Harding's longitudinal research).

To clarify Dr. B's remarks, we need to know what he (or you) meant by "in order for the work to happen". Does "work" denote a specific set of treatment objectives which can only be achieved by the remarks below, or does it mean a specific psychotherapeutic approach? Could you please clarify Dr. B's intent?

Thanks,
Joel Kanter

Dear Joel:
We are not sure what happened in those relationships on Sullivan's ward and in the Vermont study. We are given social recovery data. For Sullivan's ward in Towson, MD, I believe, it was not long-term follow-up data. Benedetti is referring to actual repair of the psychotic structure. His group published a study of 50 patients in long-term psychotherapy in which all of the therapists were in group supervision. The latter was seen as essential to providing the necessary relational conditions to help the dyad not be thrown off by deep emotional closeness, nor, on the other hand, be trapped in the symbiosis (the writings and descriptions of Harold Searles illuminate this territory to be traversed by the dyad). This successful study (it took, on average, five years for significant improvement to occur) was published under the title "Individual psychoanalytic psychotherapy of schizophrenia (with Pier Maria Furlan, M.D.)" and is included in the English collection of his papers "Psychotherapy of Schizophrenia" published by New York University Press in 1987. I am including some material I wrote on Benedetti following this post.

Benedetti is concerned with the retreat from ongoing emotional involvement with patients. The illnesses, from my perspective, are more subcortically-based than cortically-based. They involve the most ancient 'circuits of the soul'-the limbic system. Emotional needs and conflicts override prefrontally-based executive functioning. The deep loneliness and terror we often see cannot be mitigated by words apart from a deep emotional commitment on the part of the therapist and the patient's social milieu. Therefore reason and logic often do not suffice.

Stephen Fleck (1993) believed that dyadic psychotherapy requires the use of one’s whole self on behalf of another person, including aspects of oneself with which one would prefer not to have contact. In psychoanalytic psychotherapeutic work with persons with schizophrenia, acquaintance with these archaic and disturbing aspects of oneself and the other may be more important than our knowledge of neural and cognitive development.

Fleck noted:

“Using oneself in this total way on behalf of another, specifically a schizophrenic person, is anxiety-provoking as well as unbelievably fatiguing. Yet, without such total investment of oneself, I do not consider the psychotherapy of schizophrenic [persons] a valid endeavor, especially for therapy evaluation purposes...” (p. 56). The latter viewpoint was underscored in Yrjö Alanen’s (1997) formulations of need-adaptive treatment in schizophrenia research.

Each therapist must find her or his own way of working. From my perspective, the person who is the therapist is often the critical point and this requires a sensitivity to transference and countertransference experience. It is an impossible profession as Freud would say. These are my personal thoughts-they are not meant to be prescriptive for others-only what I have found essential in my experience.

Benedetti on Psychotherapy

Gaetano Benedetti (1987) described psychosis psychotherapy in the following terms: “...psychotherapy aims at the creation of a therapeutic integration of the patient, which does not work on the social level alone...but goes deep into the unconscious, so that within the patient an intrapsychic synthesis can be fostered through the mirror of what happens in the dual patient-therapist field. Such an integration is attempted by means of the capability of the therapeutic person to enter into the world of the [person with schizophenia], using shared symbols of the patient, the therapist’s creative fantasies, as well as ego-nourishing dynamic interpretations, all of which stimulate from within the psychotic world the necessary psychosynthetic forces” (p.79).

Benedetti believed that individual psychotherapy of the person with schizophrenia begins with the entrance of the psychotherapist into the actual situation and world of his partner. Dreams of the therapist may arise and suggest her or his unconscious concerns with the patient. Certain negative feelings of the patient are perceived by the therapist as her or his own. Mutual identification between the partners is the ground for a dual reality to emerge. Autistic protosymbols (Benedetti defines protosymbols as transitional phenomena on the way to becoming symbols) become, through the therapeutic relationship, dualized symbols of insight and communication.

Benedetti (1987) noted:

“The counteridentification of the patient with his therapeutic [partner] by means of the acceptance of the therapist’s interpretations appears to be possible only to the same degree that the therapist...identifies with the introjected, fragmented experiences of his patient. In the psychotherapy of schizophrenia, the patient learns to distinguish between object and self, to sense his surroundings, and to organize his fragmented ego functions by means of the therapist’s allowing himself to be used as a symbiotic object [and as Searles pointed out, the patient is a symbiotic object for the therapist as well]” (p. 81). Benedetti (1992) noted the schizophrenic patient’s difficulty in distinguishing self from non-self. The schizophrenic person lives in the unbearable paradox of needing to differentiate oneself from the colonizing influence of others in the merger experience, yet, to separate would mean loss of the self. The loss of one’s own identity is always the basic danger. The abiding presence of severe annihilation and psychic-somatic death anxiety attests to this conundrum. Benedetti wisely notes that the patient’s nascent self exists in the projections set before us, i.e., the hallucinations and delusions.

In regard to the latter, Benedetti concluded:

“This negative kind of semiotics may be understood by us in the following way: the alienated Self, no longer having an unconscious image of its own identity, looks about in the surrounding world no longer for an image of the internal image-in other words a symbol-but for a substitute for it. This Self searches for something which refers continuously to itself, but does not lead back to itself because, sensorially speaking, it substitutes an absence. Without this external, hallucinatory substitute, the patient could not perceive himself; hence his resistance to abandoning it in a psychoanalysis which proposes to reduce it for him to a concept of Self. So our task is to look for the lost Self in the sensorial images which it sets before us, not by interpreting these images for him, but by enriching them with our presence to the point where we give them the consistency of new, positive symbols” (p.7).

In the psychotherapy of persons with schizophrenia, Benedetti (1987) stated “...the patient learns to distinguish between object and self, to sense his surroundings, and to organize his fragmented ego functions by means of the therapist’s allowing himself to be used as a symbiotic object “ (p. 81). The role of interpretation in psychosis psychotherapy is different from the role of interpretation in the therapy of neurosis. Interpretations in the former address the structural needs of the person with schizophrenia: to help the patient discriminate self from non-self, to grasp the boundaries of the self, to achieve an intrapsychic coherence. Resistance to interpretations in psychosis psychotherapy involves an attempt at survival by means of organizing a psychotic identity in the vacuum of non-existence. Interpretations could not fill the terrible vacuum within patients with schizophrenia. Benedetti believed that these interpretations “...are aimed at putting ourselves into the psychotic world of the patient, then this psychotic world must become valuable to us as a message of a human longing for personal existence” (p. 86).

Benedetti (1987) emphasized that the role of interpretation in the psychotherapy of schizophrenia is different from its use in psychoanalysis. The schizophrenic patient is not just shown the “psychodynamic linings of the clothes of his illness,” but is also confronted with his potential image in ourselves and “the meaning his existence holds for our own.” Based on his over 50 years experience in the psychotherapeutic treatment of psychotic patients, Benedetti defined the turning point in therapy to occur when “the loss has been compensated for, not only by full participation in the patient’s situation but also by the introjection of this patient’s image, which allows him, conversely, to introject the therapist as a love object, as the Ego’s ideal, thus stimulating development of the Self” (p. 130. The loss Benedetti refers to is a loss causing a narcissistic gap deriving from loss of the ideal Ego.

Benedetti defined the latter as “a superegoic image of the self needed by the Ego in order to unconsciously idealize itself, and thus fully accept itself” (p. 9).

Benedetti and Peciccia (1998) have identified pathological symbiosis (the fusion transference with the world evident in such symptoms as referential thinking and auditory hallucinations), splitting and autism as the basis of the ego structure of the person with schizophrenia. These clinicians have identified the psychotic structure to be the result of a lack of integration of the separate and symbiotic selves ( Peciccia & Benedetti, 1996). Splitting causes the ideal Ego to be perceived as an alien voice or visual hallucination. With the narcissistic loss which brings about loss and fragmentation of the nascent self, the ego no longer understands itself, it is in shreds, resulting in an idealized, grandiose, omnipotent self, as a defense against organismic panic and helplessness resulting in a pathological reorganization of self (Pao, 1979). In schizophrenia, the patient is both persecutor and persecuted. According to Benedetti (1990) because of splitting and the impaired ego structure of the schizophrenic patient, the psychoanalyst has a new task, unlike in the case of anaclitic depression in which the analyst must interpret the perverse relationship between the ego and ego-destructive superego (Bion’s term) and the conscious impotence and unconscious omnipotence. Instead, the psychoanalyst “must first of all provide the Ego with that amount of narcissism it needs to integrate and understand itself...Psychotherapy is, first and foremost, a positivization of the patient as a person” (p. 11).

Benedetti (Benedetti & Peciccia, 1998) remarked: “The partial identification with the suffering of these patients encouraged me to dare seek out the places in our unconscious where human existence comes into contact with death” (p. 170). Benedetti also believed, and to this I can readily concur along with Searles (1979) and Herbert Rosenfeld (1987), that deeper contact with psychotic patients, the kind of emotional contact upon which they depend for psychic survival, stirs up the psychoanalysts own psychotic anxieties, but this loses power to be harmful because it is taken up into the “dialogic interweave” between patient and analyst and this duality becomes the symbol of the self and is therefore ‘anti-psychotic.’

Brian Koehler PhD
Postdoctoral Faculty
New York University
80 East 11th Street #339
New York NY 10003
212.533.5687
brian_koehler@psychoanalysis.net

Brian: Thanks for your response. What I seem to take away from it is that Benedetti's meaning of "work" (as in "in order for the work to happen") or "psychotherapy" essentially means intensive psychoanalytic psychotherapy. I'm assuming that both you and Fleck use the term "psychotherapy" the same way--with the objective of "actual repair of the psychotic structure".

I think it is safe to say that neither H.S. Sullivan (re his work at Sheppard-Pratt in the 20's) nor George Brooks was conducting intensive psychoanalytic psychotherapy (IPP).

Given the diversity of psychotherapeutic approaches within ISPS, I think it would be helpful if people clearly identified the psychotherapeutic approach they are using.

Re the content of Benedetti's thinking, I think there are certainly instances of profound "repair" without IPP. And there have sadly been many patients treated with intensive psychoanalytic psychotherapy who never achieved either structural "repair" or even "social recovery". (Both the McGlashan/Fenton Chestnut Lodge studies and the Stanton/Gunderson research make it clear that psychoanalytic psychotherapy rarely achieves even a .300 batting average when it comes to profound recovery. Allegedly, Fromm-Reichmann only achieved an outcome of profound "repair" with two patients.)

In this regard, I highly recommend McGlashan and Nayfack's case report: "Psychotherapeutic Models and the Treatment of Schizophrenia: Three Successive Psychotherapists with One Patient" ( Psychiatry, Nov 1988). Dr. A, reputedly Searles, engages in 10 years of IPP, yet little progress is made and the patient remains hospitalized. It is only when Dr. C uses a psychoanalytically-informed supportive psychotherapy that the patient begins to make significant gains, leaves the hospital, and makes a life for herself in the community.

Now, you may be suggesting that Benedetti was a far more successful therapist than his American colleagues (Searles, Fromm-Reichmann, etc).

But I think that we need to recognize--after considerable clinical experience between the 1930's through the 1980's--that a substantial group of patients are not helped significantly by IPP and that we need to focus our energies on alternative psychotherapeutic approaches which may have at least partial success where IPP has largely failed.

Joel Kanter