October 10, 2004
A Person-Specific Psychotherapy in the Schizophrenias

The term “person-specific psychotherapy” is my attempt to build on the observations of such eminent schizophrenia researchers/clinicians as John Strauss and Larry Davidson of Yale University (see Davidson, L. (2003).  Living Outside Mental Illness: Qualitative Studies of Recovery in Schizophrenia. NY: New York University Press).  These investigators have made a good case for considering person-disorder interactions in the comprehensive understanding and treatment of the human illnesses we call the schizophrenias.  They have called for a return of the ‘person’ to psychiatry, not just ‘mind,’ as the former more readily includes a relational and cultural context, in our theories of severe mental illness.  This spirit of non-reductionism, as applied to genetics, is reflected in the approach of Harvard Professor Richard Lewontin as exemplified in his volume The Triple Helix: Gene, Organism, and Environment published by Harvard University Press in 2000.

In terms of a disorder-specific psychotherapy of severe mental illness, we need to have a good understanding of the shared factors across patients with this diagnosis (e.g., internal-external boundary confusion, referential thinking, persecutory feelings of external control, etc), although I have found some factors, particularly neurobiological factors, to be often non-specific to this diagnosis.  In a discussion I had years ago with neuroendocrinologist Bruce McEwen of Rockefeller University, NY, concerning the massive effects of profound anxiety and fear on neural functioning in patients diagnosed with schizophrenia, he suggested performing simple neuropsychological measures of temporal and prefrontal lobe functioning to assess the effects of psychotherapy on neurocognitive functioning.  He also saw the large overlap between the neuroscience of the schizophrenias and the neuroscience of profound stress and fear. 

There is also an overlap with bipolar disorder and PTSD (e.g., ventriculomegaly).  I had observed striking improvements in executive and memory functioning in state hospital patients treated with long-term psychotherapy and was hoping that we could demonstrate objectively such improvement-beyond DSM symptomatology (hallucinations, delusions, etc) as evidenced on a BPRS or similar rating scales.  It would not require access to fMRI, although the latter would be important in observing, in real time, metabolic energy use during ‘cognitive’ and ‘emotional’ tasks.  Perhaps this could be a future task of ISPS, i.e., to demonstrate with neuropsychological and neuroimaging tools the ‘objective’ effects of psychotherapy and psychosocial interventions on neuroaffective (eg, anxiety, depression, etc) and neurocognitive functioning in persons with a severe mental illness.

One of my current long-term patients has been undergoing periodic neuropsychological test batteries to assess the effects of different psychotropic agents on his neurocognitive functions.  He has been tried on every atypical agent, including aripiprazole, with the exception of clozaril ( for a good review of current psychotropic agents used in severe mental illness see Textbook of Psychopharmacology: Third Edition edited in 2004 by Alan Schatzberg and Charles Nemeroff for American Psychiatric Publishing, Inc.-this is one of the texts I use with my graduate students at NYU in my psychopharmacology course ).  His neurocognitive functioning has been gradually improving over time.  The question has never been raised by the psychiatrists treating him with medications (he has several consultants on his team-the patient himself is a Harvard trained physician)-whether the psychotherapy has played any role in his ‘neurocognitive’ recovery.  I believe it was Swiss social psychiatrist Luc Ciompi who demonstrated improvement in cognitive functioning in persons with schizophrenia as a result of improvements in their background sense of safety ( Joseph Sandler’s term) without direct cognitive remediation.

At the same time, various researchers/clinicians such as Til Wykes from the Institute of Psychiatry in London, have demonstrated reversal of the ‘hypofrontality’ on a working memory task sometimes observed in patients with schizophrenia or a depressive disorder, through a psychological intervention which these investigators have termed ‘cognitive remediation’ (see also Til Wykes “Cognitive remediation is better than cognitive behaviour therapy” in Schizophrenia: Challenging the Orthodox edited by Colm McDonald et al in 2004 for Taylor & Francis).  I think part of our problem in reconciling whether schizophrenia should be considered more of an affective disease (as Ciompi does as well as many psychoanalysts from Jung on) or a cognitive disease (the leading view as reflected in neurodevelopmental and neurodegenerative models), is our tendency for polarized viewpoints ( analogously as in Piaget’s research in which the individual has difficulty keeping in mind simultaneously varying perceptual dimensions) and lack of knowledge about neural functioning.  Current neurological models have made strong cases for limbic representation throughout the CNS (Cytowic, R. (1996). The Neurological Side of Neuropsychology. Cambridge, MA: The MIT Press) as well as ‘cognitive’ functioning extending well beyond neocortical structures (Schulkin, J. 2004-Bodily Sensibility: Intelligent Action published by Oxford University Press).  Ed Hundert of Harvard Medical pointed out how difficult it is to tease out cognitive and affective elements in general and in such diagnostic categories as schizoaffective disorder (he saw the latter as a compromise over the recognition of the difficulties involved in isolating cognition from affect).

I prefer to think of contemporary psychoanalytic therapy as an affective-cognitive intervention, a person-specific therapy, with the emphasis on creating the capacity for secure emotional relatedness.  This is unlike CBT (which I value-and had been formally trained in through the Behavior Therapy Institute of New York back in the early 1990’s) -- particularly the excellent work of the researchers and clinicians in the UK.  Certainly generations of psychoanalysts have utilized cognitive interventions and problem solving with their patients, e.g., Arieti’s emphasis on establishing relatedness and then helping the patient see her/his ‘role’ in establishing the symptom as well as seeing and grasping the wider context-what he called expanding the ‘psycho-temporal field.  Analysis fosters awareness of how mood interacts with cognition to trigger the psychotic symptom.  Psychoanalysis may understand that the symptom, however problematic, may be serving needed functions for the patient- e.g., defense.  Likewise analysts reflect on impaired identity formation and relational competence (e.g., understanding auditory hallucinations and delusions as providing resonance, warding off annihilation anxieties, self-esteem maintenance, ensuring cohesion and continuity of self in a relational vacuum, identification with the aggressor as a way of coping with intense feelings of helplessness and vulnerability, etc).  Psychoanalysts also tend to rely more heavily on significant countertransference experience, including dreams about the patient and intense affect states, as messages which cannot be formed symbolically into words arising from the patient her/himself as well as reflecting foreclosed traumas from the previous generations. 

There are many attempts being made to construct a disorder-specific psychotherapy or psychosocial treatment for persons with a severe mental illness.  There are attempts to manualize these interventions in flexible ways.  I am definitely in favor of disorder-specific forms of psychotherapy/psychosocial interventions as long as they include person-specific processes, i.e., that clinicians are able to tolerate uncertainty and unconscious enactments of dissociated relational experience, and most importantly bracket their theoretical suppositions about the illnesses we call schizophrenia, and let the patient and her/his history (both the ‘big’ history of the culture and the ‘smaller’ individual history-thanks to Martti Siirala and Francoise Davoine and Jean-Max Gaudilliere for continuing to draw our attention to these interactions in the patient and treater.  See Siirala, M. (1983), From Transfer to Transference: Seven Essays on the Human Predicament. Helsinki University Press, and Davoine, F. & Gaudilliere, J-M. (2004). History Beyond Trauma. NY: Other Press).  They speak for themselves through and with the close affective-cognitive participation of the therapeutic partner.

I think it is time for ISPS to organize a major conference involving a dialogue between CBT researchers/clinicians, psychosocial therapists and more psychodynamically oriented researchers/clinicians in order to arrive at a comprehensive treatment model which is both disorder-specific as well as person-specific -- a model of treatment which integrates the best of these traditions.  And if this is not possible, we need to be able to investigate the possibilities of concurrent treatment approaches based on mutual respect and understanding.  I have referred one of my long-term psychotherapy patients diagnosed with schizoaffective disorder, obsessive-compulsive disorder and borderline personality disorder who had been chronically hospitalized in a state psychiatric facility, to a competent psychiatrist for psychopharmacological intervention (he is successfully reducing her multiple agents) and a cognitive-behavioral therapist to help her with her severe restrictions in living (Medicare has been her form of payment).  Together, along with the significant participation of the patient herself, we have helped her reclaim a viable and meaningful life.  In return, she has given us deep emotional contact and she has helped affirm our identities as therapists.


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