Psychosis and individual psychodynamic psychotherapy

Psychosis and individual psychodynamic psychotherapy

Psychosis and individual psychodynamic psychotherapy 12 Bent Rosenbaum1,2 1 Institute of Psychology, University of Copenhagen, Denmark, 2Head of Psy...

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Psychosis and individual psychodynamic psychotherapy


Bent Rosenbaum1,2 1 Institute of Psychology, University of Copenhagen, Denmark, 2Head of Psychotherapy Research, Psychiatric Center Copenhagen, Clinic of Psychotherapy

More than 100 years after the publication of the first cases of psychoanalytic psychotherapy of patients with psychosis (Bertschinger & Allen, 1916; Bjerre, 1912; Waelder, 1925), no uniform treatment method has achieved the status of being considered the psychodynamic treatment of choice for individuals with psychosis. Such uniformity may, however, not have been expected, since psychoanalytic psychotherapy is directed at the person as a whole—an emphasis on the unique history, subjectivity, and psychological complexity of each individual. In the period from World War I to the decade after World War II, investigations of psychotherapy of psychosis (mainly schizophrenia) were presented as case descriptions and as retrospective studies of small groups without any follow-up after termination of therapy (Beck, 1952; Federn, 1953; Sechehaye, 1950). From the 1960s a number of systematized comparative studies were carried through, and some of them demonstrated a positive effect by adding individual psychotherapy to treatment as usual (Frank & Gunderson, 1990; Karon & VandenBos, 1981; Sjo¨stro¨m, 1985). Most of the published case studies after World War II were long-term therapies with chronic psychosis patients; however, successful short-term cases also surfaced (Beck, 1952; Donelly, 1966). A multitude of guidelines appeared, most of them of great value to therapists, who could apply an array of recommendations from experts to their own patients (e.g., Arieti, 1974; Federn, 1953; Fromm-Reichmann, 1959; Gunderson & Mosher, 1975; Searles, 1965), but these guidelines were never systematized and tested in empirical trials. Thus the generalizability of such recommendations was neither confirmed nor disconfirmed, particularly with respect to the spectrum of psychosis and varying pathogenic courses. The term psychodynamic psychotherapy of psychosis was conceived of as referring to a broad, inclusive, and integrative form of modified psychoanalytic psychotherapy, forming the background to the comparative studies of psychotherapy of schizophrenia (Summers & Rosenbaum, 2013) or studies in which intervention effect size could be calculated (Gottdiener & Haslam, 2002). In the 1990s devaluing reviews of psychodynamic psychotherapy for psychosis appeared in major psychiatric journals (e.g., Lehman & Steinwachs, 1998). Thereafter, only one prospective comparative study has been published (Harder, Koester, Valbak, & Rosenbaum, 2014; Rosenbaum, Harder, & Knudsen, 2012), which happened to demonstrate advantages of adding individual psychodynamic psychotherapy to treatment as usual. Contemporary Psychodynamic Psychotherapy. DOI: © 2019 Elsevier Inc. All rights reserved.


Contemporary Psychodynamic Psychotherapy

One common denominator of the psychodynamic approach is the view of psychosis as states of mind resulting from psychic development and based in a mindbrain dialectic, which is supported by four decades of mother infant observation studies (Stern, 1985, 1994) and developmental research addressing symbolic integration and psychic stability (Harder & Rosenbaum, 2015). The development of psychosis encompasses several unconscious structural preconditions. This includes disturbed ego functions, which refers to withdrawal of interest and the psychic (drive) investment in the painfully perceived world, often characterized by experiences of trauma (de Masi, 2009; Kirshner, 2015; Read, Bruce, Moskowitz, & Connolly, 2001; Read & Ross, 2003), ego fragmentation, and blurred ego boundaries (Frosch, 1983; Robbins, 1993). These disturbances may lead to narcissistic isolation and incoherent thinking without stable goals and perspectives. Lack of capacity for repression is another precondition, implying an inability to protect the psychic apparatus from perceptions from outside and sensations, thoughts, and emotions from inside. The outcome of this lack of repression may be a mind overwhelmed by strong anxiety, rage, desperation, and hyperreflectivity (Sass, 2014). A third precondition is disturbed symbol formation, which includes difficulties in distinguishing what is universal or general from what is special or particular and in forming illusions temporarily. Furthermore, there are difficulties in understanding that something may have a meaning both for “me” and for “you” and that its meaning may not be exactly the same for the two of us. Related to this are challenges in understanding that “I” and “you” are both separated and closely linked subjects, in understanding that the content of the communication has to be validated consensually, and in considering the mind of the other and the minds of the collective. A final precondition concerns disturbed attachment patterns, especially dismissiveavoidant and disorganized attachment. Severe forms of disorganized attachment have been hypothesized to be involved in several areas of disturbed development related to psychosis, such as disturbed affect regulation, difficulties with interpersonal relationships, fragmentation of self-experience, and serious impairments in mentalization or metacognition, as well as the specific psychotic symptoms of delusions and hallucinations (Harder & Rosenbaum, 2015) These phenomena should always be in the mind of the therapist. They constitute the theoretical basis on which the (hopefully) creative part of the therapist’s experience will form the preferred technique with words and nonverbal attitudes that suit the specific moment of the intervention. It is also the transformation from theoretical thinking to uttered and nonuttered signifiers that may distinguish routine and inspired interventions—be they clarifications, confrontations, or interpretations.

Description of treatment approach Supportive psychodynamic psychotherapy (SPP) for psychosis is founded upon several core principles, which include the following: 1. A stable, yet flexible frame 2. The therapist’s attention to countertransference

Psychosis and individual psychodynamic psychotherapy


3. Clarification of the patient’s subjective experience, emotions, and interpersonal world, including efforts to give psychotic symptoms an understandable context in internal and external object relationships 4. Clear communication and attention to divergent perspectives 5. A supportive attitude on the part of the therapist, with an emphasis on clarifying and understanding interventions and including in-the-moment psychodynamic psychoeducation on the human condition in general (communication, habits, daily cultural life experiences, etc.)

The frame and setting of individual psychodynamic psychotherapy is defined by (1) its stability and regularity, (2) the therapist’s capacity for empathy and longterm interest in the other person’s psychic growth, and (3) the therapist’s capacity for containing misunderstandings, aggression, and hopelessness with integrity, responsiveness, and creativity. Moreover, in relation to the latter point, the frame is supported by the therapist’s capacity to clarify the dynamics of the interpersonal relations in the therapeutic sessions (transference, broadly speaking) and outside the therapy without creating an atmosphere of polarization. The setting should not be too rigid, especially during times of psychotic crisis. Length of sessions will vary; some sessions will contain a more conversational atmosphere (but without irrelevant statements from the therapist’s side), while in other sessions the therapist may be more silent, letting the patient take the lead. In some sessions the patient cannot sit still and has to move around in the room, and the therapist has to find ways to explore the reasons for this and at the same time has to calm the patient down. Altogether, the therapist’s attitude must vary according to the condition of the patient. With facial expression, gestures, voice, attitude of informality, and general demeanor, the therapist must do whatever is in his or her power to remove the fear that is automatically aroused by the fact that a human being (the therapist) wants to establish contact with a person in psychosis. Some therapists also suggest that it may be an advantage to see significant members of the family if the patient permits it. Such meetings could take the form of the psychotherapeutically oriented need-adapted treatment (Alanen, R¨akko¨l¨ainen, Laakso, Rasimus, & Kaljonen, 1986) in which all participants may have a chance to openly state their feelings and opinions on the situation here-and-now and intermediary conclusions may be reached in the presence and with confirmation of the patient. The risk of countertransference reactions is greater in treating persons in psychotic states of mind than in treatment with persons with neurotic and borderline states of mind (although the latter category of patients often creates great countertransference problems influencing the therapy). Fromm-Reichmann (1959, p. 215) formulates the issues along these lines: “Severe anxiety, withdrawn loneliness, aggressive hatred and lack of improvement of the psychotic patient may be contagious to therapists.” The disturbed symbol formation of the patient (see above) makes it difficult for the therapist to make proper use of his or her countertransference feelings. First, they usually appear too late in the therapist’s consciousness to be handled properly (starting as pure unconscious phenomena); second, the ways of transforming one’s countertransference confusion, anger, and anxiety are inhibited by the patient’s communication difficulties.


Contemporary Psychodynamic Psychotherapy

During the entire course of therapy a supportive psychodynamic attitude should be embedded in the style of the therapist. The following are some principles: 1. The patient’s enunciations—regardless of their “normality” or “pathology”—are conceived as subjective truths that shall be clarified and explored rather than corrected. 2. Even though there is always more to the patient’s problem than what is obvious, commonsensical, and capable of being simply unlearned, the content of the therapy should be focused and with references as clear as possible to the issues talked about in the dialogue. The therapist is aware of the polysemous and associative nature of language but is at the same time aware that polysemy and too many associations may be confusing to the patient. 3. The therapist must help the patient to make sense of and better understand his or her feelings, attitudes, and subjective intentions in concrete interpersonal relationships. Often, clarifying step by step in the interactions may be helpful in understanding the interpersonal dynamics (e.g., what goes on and what may have been avoided), while at other times, the step-by-step method may lead to too much information and be undigestible at that time. 4. Diverging viewpoints between patient and therapist should never develop into entrenched positions, offensive defensive fixations, or any other forms of polarization. 5. An ongoing task of the therapist is to structure the meeting with the patient to ensure that the patient feels listened to. This in turn may, by means of increasing internal safety, help the patient to start listening to not only the therapist’s viewpoints, but also to the patient’s own. 6. The aim of securing structure is to counterbalance dissolution and breakdown and counterbalance the patient’s negative and self-denigrating attitude. 7. Finally, the therapist’s attitude should encompass—when necessary and in order to contain the patient’s painful state of mind—the use of modified psychoanalytic techniques such as clarifications, affirmations, and suggestions; maximizing adaptive strategies and encouraging patient activities; and helping the patient to understand how psychotic mechanisms work psychologically in the individual and in specific interactions with others and how other people might be expected to react (with commonsense reactions). This kind of intervention may be labeled in-the-moment psychodynamic psychoeducation.

The initial sessions The main objectives of the initial phase are to forge a constructive working relationship with the patient, to develop a sense of the patient’s history with both its traumatic and helpful events, and to situate the patient’s symptoms in the context of his or her subjective experience and social functioning. It is important in the first meeting to persuade the patient that the therapist is interested in understanding the patient as a human being and as a person with a history that can be meaningfully connected with the patient’s present painful situation. Could you tell me about yourself in such a way that I can get a picture of you as the person you are? I am interested in hearing what you feel is characteristic for the way you see and think about yourself and the problems in your life as they relate to the course of your life.

Psychosis and individual psychodynamic psychotherapy


In a collaborative atmosphere the therapist and patient develop a narrative biography of the patient’s life, including its normal and pathological aspects, according to the ideas of developmental psychopathology (Cicchetti & Cohen, 2006). This includes hypotheses about the dynamics of the patient’s current interpersonal problems, associated pathological grieving processes (e.g., loss of friends, loss of daily functions, loss of safety), and defensive experiences due to anxiety. Useful questions could include the following: What do you find to be your most important problems? Where do you think your problems stem from? What situation(s) might worsen your problems or symptoms, and what may ease them? Who or what do you think could help to solve the problems? Tell me what, in your opinion, led to this situation in which you conclude that you need help from other persons, professionals that you do not know. Did you feel it was you who came to this conclusion or did you feel that others’ conclusions were imposed on you?

Drawing a life-line with major significant events (objectively) described on the one side (i.e., what happened seen from a third-person perspective) and (subjectively) described on the other side of the line (e.g., “This memory—how do you think you experienced it when it happened and how do you experience it today? What does it mean for you in your daily life?”). These objectively and subjectively described events may function as guidelines for the understanding of the internal object relations that structure and color the patient’s understanding of what happens in his or her daily life and in the transference. Symptoms should also be investigated and understood in the context of the patient’s developmental trajectory. When exploring hallucinations of voices, for instance, the therapist might ask questions such as the following: When did the voices start speaking to you? What did they say? Was their message meaningful to you? What happened in your life when the voices started? Do you find any connections between those life events and the message of the voices? Were the voices hostile from the beginning or did they begin their intrusion with kind messages—maybe even useful for you? What was happening in your life when the voices grew more hostile and persecuting?

Such questions are not meant to correct the patient’s hallucinatory modes of perceiving the world. Rather, they are necessary clarifications in order to understand the dynamics of the hallucinations (as potentially reflecting the dynamics of internal and external object relations). These clarifications are intended not only to inform the imagination of the therapist, but also to slowly promote the patient’s understanding of how the hallucinations are psychic phenomena embedded in previously inscribed experiences of a more or less traumatic kind. Thus the aim of such an investigation differs from that of an ordinary psychiatric diagnostic interview. It is important in the initial sessions to give the patient a feeling that the therapist also has an eye for and is genuinely interested in creative aspects of life (e.g.,


Contemporary Psychodynamic Psychotherapy

music, dance, painting, sport, theater, film, literature) as well as the human emotional repertoire consisting of sadness, isolation, aggression, suicidal impulses, and other self-destructive and violent thoughts and acts. The therapist would want to plant a seed in the patient’s mind that the therapist is prepared to help the patient avoid self-destructive aspects being carried out, even though they may be felt as meaningful for the patient at the time when these aspects were dominating daily life. It is equally important that the therapist, together with the patient, clarify the possibilities for—and the obstacles against—the creation of a therapeutic alliance with some degree of stability. Different openings can be used by the therapist, for example, with questions like the following: What can lead you to not attend our scheduled meetings? Are there topics that you in this moment feel will cause so much aversion in you that they may be a reason for you to stay away from being helped by psychotherapy? What can I do to help you overcoming negative feelings about coming to the sessions?

Of course, it is countertherapeutic to ask all these questions in one intervening statement. When the therapist has posed a question that he or she believes is of importance, the answers should be explored, the depth of exploration depending on the patient’s state of mind and the therapist’s skills. The initial phase thus involves the development of a creative way of working that involves the therapist’s responsiveness to the patient’s state of mind, such as becoming more exploratory if the patient can tolerate this. Such explorations depend on the therapist’s experience, expertise, and intuition. Different metaphors may be employed as working tools to make the patient feel safe enough to begin a journey, bringing hope into the patient’s mental life. Agreement and disagreement about what is said in the communication, what the words mean, and what the statements are used for are key elements during the first phase of the therapy. In this phase the therapist always has to look for opportunities to join with, rather than confront, the patient. Disagreement, particularly in the early stages of treatment, tends to have relationship-ending connotations and often leads to premature cessation of treatment (Robbins, 1993). Confrontations, therefore, belong more to the middle phase of the therapy.

The middle phase As the phase of treatment involving more focused work on symptoms, conflicts, and self-understanding, the middle phase of psychodynamic psychotherapy with individuals with psychosis may be particularly difficult. Finding directions in the open ocean, where neither the shores of departure nor the shores of arrival can be seen and located, is an immense challenge—for both therapists and patients. One major task is to relieve the patient of the experiences of imminent crisis by advising and guiding the patient in a concrete way as to how he or she should tackle, and

Psychosis and individual psychodynamic psychotherapy


not allow himself or herself to be governed by, the symptoms. Mastery of symptoms means being able to keep them at a distance, which implies an understanding of their function in interpersonal scenarios in which the symptoms are reinforced or attenuated. It is recommended that the therapist always clarify and analyze the symptoms within the interpersonal context (including the transference). However, timing is essential. Sometimes patients do not want to understand their symptoms within a social context. As the result of traumatic and deficient attachment experiences, resulting in feelings of not being emotionally understood, patients might just want to regard their symptoms as something foreign and painful that they should get rid of as soon as possible and as something that they do not want to talk about. This paradox of wanting to get rid of their symptoms but not knowing how to do it and, at the same time, not feeling that the therapist is trustworthy creates situations that often challenge therapists and lead to deadlocks. In such phases or moments it may be more important to downplay the exploration of psychotic experiences and anxiety-provoking conflicts and instead focus on securing the patient’s feeling of safety as much as possible in order to achieve better resocialization. Countertransference feelings become centrally important in these moments of therapy. All in all, even in situations in which major psychotic symptoms are dominating, the therapist needs to trust that development of the self can provide the patient with qualities that go beyond the effect of medication. Therapists need to trust in the existence of some normally functioning aspects to the patient’s personality (Bion, 1957; Freud, 1940; Lotterman, 2015; Summers & Martindale, 2013) and support these more sane parts in a consistent and straightforward manner. The therapist’s aim is to help the patient to expand the sane attitudes and thoughts and diminish the psychotic functioning. A brief vignette may illustrate: A patient came to the session in a severe, hallucinated state of mind in which she walked around in the consultation room, restless and anxious and without making any eye contact. She came to the session saying (in Danish), “I feel blue,” “They step on me,” “They eat me,” “They walk away and walk on me.” The therapist listened in a calming way, saying softly, “It sounds awful. I will help you and protect you. In this room, you can feel safe.” After half an hour, the patient calmed down and sat in the chair, and the therapist asked the patient to tell what had happened to her. She told (although in fragments) how she had been driving her car (which was a small Morris Mascott) behind a huge truck. Suddenly, a fantasy overwhelmed her that the truck contained the bodies of hundreds dead pigs that fell out of the truck and buried her. She managed to park her car near the therapist’s consultation room but had to walk a few hundred meters. Walking on the street, she saw a man carrying a big, black plastic bag, and she immediately believed that this bag contained her two children chopped into small pieces. After this terrifying experience, she looked at the street sign and felt chaos inside herself and as if the world had broken down. In further exploration by the therapist of the event, it appeared that the name on the street sign she had seen had been perceived in a fragmented way. The sentences she had uttered all stemmed from the name of the street, and the patient was to a certain extent calmed down further by that information. The therapist did not in this session go further in his understanding of


Contemporary Psychodynamic Psychotherapy

the event, and he intentionally avoided following up with an interpretative association connecting the patient’s sentences to the fear the patient had shown in a previous session about the raising of her children, whom she often felt concretely invaded her body.

The vignette illustrates how it often may be important for the therapist to manage feelings associated with functioning primarily in a basic affect regulation capacity and to monitor the extent and depth of the interpretation that could be offered. (I am here tacitly assuming that the therapist always has at least some possible interpretations in mind when listening to sentences or narratives of the patient.) Understanding symptoms in the light of primitive defense mechanisms and implementing one’s understanding in subsequent interventions are challenging for the psychotherapist. Nevertheless, an important intervention that may reestablish equilibrium in phases of turmoil is letting the patient feel that defense mechanisms are there to protect and help the patient in the concrete situation. Patients may then recognize that their defensive attitudes have an adaptive and psychologically valuable function in preserving the integrity of the self. Later in the middle phase of the therapy, the therapist may convey to the patient that other attitudes, even giving up some defense patterns, will be a possibility in the future. The timing for these changes should be chosen with care and should be promoted without raising unnecessary anxiety and confusion. The positive and negative sides of defense mechanisms are something that the patient will slowly become aware of in the middle phase of therapy. This may go hand in hand with the therapist helping the patient to mobilize the healthy aspects of the patient’s personality. That includes helping the patient define his or her reality in different situations of social communications, enhancing perspectives for the patient’s life, and gradually supporting available mature defense mechanisms. In short, changes in the patient’s interpersonal attitudes—more openness, more trust, more personal ideas for a social future—are signs from the patient to the therapist that the time is ripe for talking about defense mechanisms in a more nuanced way. As was stated above, confrontations belong more to the middle phase than to the first phase. Confrontation addresses something the patient does not want to accept, or it identifies the patient’s avoidance or minimization (Gabbard, 2014). The latter is of importance in the psychotherapy of psychosis. By showing what the patient avoids or how the patient goes against his or her own decisions made in previous sessions, confrontations usually open and/or underlie disagreements between patient’s and therapist’s points of view on particular situations and their underlying dynamics, for example, by saying to a patient, “By not attending the funeral of your father, you may submit to the dominance of your fear rather than go against it and pursue your feelings of progress that you have obtained through your hard work in our therapy. You have several times uttered that the gazes from your family members shall not bother you anymore, and we have together explored the reasons behind this, so why go against your own promises?”

Psychosis and individual psychodynamic psychotherapy


Sometimes when the therapist intervenes with statements that are intended to support and help the patient, the patient may experience the therapist’s words as confusing and objectionable. The patient may even respond with anger toward the therapist for imposing on the patient statements that seem meaningless or feel harmful. Such situations demand that the therapist acknowledge that his or her words have caused an undesired state of mind in the patient, even though the words were uttered with the intention to help. SPP for psychosis follows the analytic principle of free association in that the patient’s associations are seen as paving the road for the themes and topics to be worked on in the session. In contrast to traditional psychoanalytic therapy, however, it is the therapist who structures the sessions in SPP. Thus the therapist assumes the responsibility for drawing into the sessions the disturbed dynamics that were revealed in the assessment and first phase of therapy. Further, it is the therapist’s responsibility to decide in the sessions how far and to what degree the problems can be worked through. Therapist statements such as “What we have talked about just now is of utmost importance, and I think we have come as far as we can today” may sometimes be uttered even in the middle of the session if the therapist feels that the patient has started repeating himself or herself or has become more anxious. Of course, seeking consensus about this structuring intervention is important, as is the therapist’s ability to create continuity: “Before we talked about this important topic, you introduced another topic that we should attend to . . ..” Again, the therapist’s sensitivity and listening capacity are at stake: Intervening at the right moment, with the right words, and with the appropriate, calming prosody, body movement, and facial mimicry is sine qua non in the psychotherapy with patients in psychotic states of mind.

Termination phase The termination phase of SPP involves a review and synthesis of the work accomplished during the treatment. Three to six months before ending therapy, the therapist should summarize what has been worked with in the treatment thus far. Differentiating and synthesizing the many elements of a long-lasting therapy are difficult for a person who is still influenced by the transference and reminiscences of psychotic experiences. Therefore the therapist may help in contrasting memories of the patient’s general appearance and mental condition from the beginning of therapy with how the patient appears now after his or her psychic development. Trajectories of the patient’s positive development should be emphasized. After the patient’s responses to this, the therapist may add that there are remaining problems that the patient may still have to deal with, think about, and encounter in different forms also after termination. Therapist and patient must allow for time to talk about how the patient might be able to handle remaining symptoms, considering which strategies may be used and why and what precautions might be taken and why.


Contemporary Psychodynamic Psychotherapy

The therapist should also give the patient the possibility of commenting on the therapist’s style and ways of being helpful and nonhelpful, ways of listening, and so on. The patient who has stayed in therapy to its end will obviously be hesitant to criticize the therapist. With a sense of warmth the therapist may highlight some blunders that may have affected the patient and as a result of which the therapist has learned something from the patient. I believe that the person who has lived through psychosis and stayed in therapy will experience the separation-individuation process as overwhelming and insupportable. The reasons for this are many. First, the states of schizophrenic psychosis reflect a life in symbiotic states of mind in which the function of the symbolic order fails to overwrite the imaginary order (Fink, 1997, pp. 87 90). The person’s thoughts and senses are caught in a projection of his or her inner world in which they mirror and identify themselves in persecutory and confusional ways (projective identification). The ways out of this symbiotic prison—or claustrum as Meltzer (1994) calls it—toward separation-individuation imply increasing functioning of volitional self-direction, volitional direction of thought and attention (Shapiro, 2000), and the dominance of the capacity of the autobiographical self to engage in the functions of the extended consciousness (Damasio, 1999).1 The work of separation-individuation can be helped immensely when future social circumstances in the patient’s life are drawn to the field of attention: finding work places with a good leadership, going into an educational course that is considered attractive, becoming part of circles with boyfriends and girlfriends who have normal-life social encounters, finding supportive spouses, experiencing positive changes in one’s own family, and so on.

Empirical evidence for supportive psychodynamic psychotherapy: the Danish Schizophrenia Project Despite past pessimistic attitudes toward psychodynamic psychotherapy for psychosis, many clinicians and researchers have remained cognizant of the inconclusive empirical status of this issue. Efforts to explore the role of psychodynamic therapy for psychosis have thus persisted. One such effort is the Danish Schizophrenia Project (DNS-II) (Rosenbaum et al., 2012), which compared psychodynamic psychotherapy for psychosis with standard treatment in patients with a first-episode schizophrenia spectrum disorder. The study was designed as a prospective, 1

Damasio (1999, p. 230) nicely summarizes these functions: the abilities to create helpful artifacts, consider the mind of the other, sense the minds of the collective, suffer with pain rather than just feeling pain and reacting to it, sense the possibility of death in the self and in the other, value life, construct a sense of good and of evil distinct from pleasure and pain, take into account the interests of the other and of the collective, sense beauty as opposed to just feeling pleasure, sense a discord of feelings and later a discord of abstract ideas, which is the source of the sense of truth. These functions of the extended consciousness seem to parallel the functions of the lacanian symbolic order (Fink, 1997), the prominence of which may be a measure of the phase of termination.

Psychosis and individual psychodynamic psychotherapy


comparative, longitudinal, multisite investigation of nonselected, consecutively referred patients. Patients were treated either with SPP—a manualized form of individual psychodynamic treatment—in addition to treatment as usual or with treatment as usual alone (TaU). No preselection of patients to either of these modalities took place; the only selective factor was the home addresses of the patients. Both groups contained university/nonuniversity departments and rural/urban departments. Symptoms and functional outcomes were measured by using the Positive and Negative Syndrome Scale (PANSS) and the Global Assessment of Functioning (GAF) scale. The study included 269 admitted patients, ages 18 35 years, of whom 79% remained in the study after 2 years. The psychotherapy group (119 patients) improved significantly on measures of both PANSS and GAF scores, with large effect sizes at 2-year follow-up after inclusion. Furthermore, improvement on GAFfunction (P 5 .000) and GAFsymptom (P 5 .010) significantly favored SPP in combination with TaU over TaU alone. These differential effects remained; however, they were not sustained to a significant degree at 5-year follow-up (Harder et al. 2014). This is consistent with the findings of other comparative, 5-year follow-up investigations. While these findings indicate promise for SPP for psychosis, they provoke important questions for further inquiry: Is 2 years of active intervention too little? Are some patients helped considerably with only 2 years and others not at all, and thus, by assuming homogeneity of the group, do we lose a possible insight into the differentiated effects of the psychotherapy intervention?

Summary Given the serious nature of psychosis, the field needs as many potentially helpful interventions as possible. Psychosis attacks not only the functioning of thinking, feeling, and reasoning, but also, even more so, the person’s conception of self. In the psychodynamic approach, the collaboration of therapist and patient mainly work with the person’s conception, understanding, and feelings for the patient’s self as it appears in the transference, the intersubjective relation (internal object relationship), interpersonal relation (the socially communicating self), and the development of the self toward greater dominance of symbolic integration. In spite of limitations the DNS-II study speaks in favor of including psychodynamic psychotherapy in the treatment for patients with schizophrenic first-episode psychoses. The study also contradicts the repeated cliche´ about overall harmful effects of psychodynamic psychotherapy. As to scientific methodology, in the end we must ask ourselves what kind of measures we will use to evaluate a good therapy. What are the features of clinical improvement, and might this not necessarily correspond with improvement in the patient’s personal life? Moreover, we should continue to determine the main contributors to these life changes—what combination of therapist abilities, situation with family and/or friends, and/or other stable social conditions? The psychodynamic


Contemporary Psychodynamic Psychotherapy

approach also questions whether we should ignore the significance of life years from age 0 to 16 years for personality development that antecedes psychosis and the implications for the development of psychosis. These kinds of questions favor an individual and holistic approach, such as a psychodynamic approach that links past, present, and future into subjectively understandable narratives for the patient. In some European countries (Denmark, Norway, Germany), year-long courses in psychosis psychotherapy already exist, and initiatives are being taken to establish more empirical evidence for psychodynamic approaches that may help patients with psychosis in all its different phases and phenomenological appearances.

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