The Primacy of Psychoanalytic Intervention inRecovery from the Psychoses and Schizophrenias
Patricia L. Gibbs
Abstract: Functional capacities, such as attachment and affect regulation, objectrelations capacity, symbolic function and language development, now docu-mented by neuroscientific research and epigenetics, are reviewed. Results fromthis research, together with other factors, are posited to have contributed to ef-fective contemporary psychoanalytic and psychotherapeutic treatments for thepsychoses and schizophrenias. Etiological factors involving the schizophreniasand other psychoses are considered both in terms of an epigenetic model, and interms of how etiology may, or may not, affect clinical treatment. The Lacanian388 program is reviewed in some detail, as are several psychoanalytic andpsychotherapeutic clinical approaches used with this population over the lastsix decades. All treatments focus on the primacy of psychotherapeutic interven-tion, and use medications minimally, not at all, or only as informed by an over-arching psychodynamic model of treatment. The author argues that there is nowsubstantial research and outcome data suggesting that the psychoses andschizophrenias are not chronic deteriorating conditions. Recovery is observed inmany psychotic and schizophrenic patients treated with approaches that focuson the primacy of psychotherapeutic intervention.
The functional capacities observed by early psychoanalysts, such asthe development of the defenses and the ego, language developmentand symbol formation, and affective and object relations capacities,have now been documented by contemporary findings in the areas ofneuroscience and epigenetics. Research in the areas of attachment, ob-ject relations capacity, affect regulation, language and cognitive devel-
Patricia L. Gibbs, Ph.D., Faculty Member and Lecturer, Michigan Psychoanalytic Insti-tute; Adjunct Faculty Member and Supervisor, University of Detroit Mercy – Ph.D. Clini-cal Psychology Program; Michigan Chapter Head, International Society for thePsychological Treatments of the Schizophrenias and Other Psychoses - United StatesChapter (ISPS–US); Private practice in adult psychoanalysis and psychotherapy.
The author would like to thank Channing Lipson, M.D., Ann–Louise Silver, M.D.,Charles Turk, M.D., and Wilfried Ver Eecke, Ph.D., for their generous support and reviewof this article.
opment, and trauma, will be reviewed. Referring to this research andclinical work, I posit several factors that have contributed to the develop-ment of effective contemporary psychoanalytic and psychotherapeutictreatments for the psychoses and schizophrenias. Etiological factors in-volved in the schizophrenias and other psychoses will be consideredboth in terms of an epigenetic model, and in terms of how etiology may,or may not, affect clinical treatment.
Worldwide, psychoanalytic psychotherapies, family therapy, andcommunity support are showing much greater recovery rates for boththe psychoses and schizophrenias than treatments in the United Statesthat focused on long–term medication–only treatment (Alanen, 1997;Apollon, Bergeron, and Cantin, 2002; Berke, Fagan, Mak-pearce, &Pieridoes-Müller, 2002; Davidson, 2003; Gottidiener & Haslam, 2002;Pepper, 2005; Ver Eecke, 2003). Programs of treatment that focus on psy-chological approaches as primary, sometimes also combined with medi-cation, have yielded outcomes superior to treatments focused onlong–term medication use. Especially in young people with a first timepsychotic break, medication is increasingly seen as a temporary and op-tional benefit, and not required life–long (Alanen, Lehtinen, Lehtinen,Aaltonen, & Räkköläinen, 2000; Mosher, 2004). I will provide evidencethat substantiates the following: The psychoses and schizophrenias areno longer universally seen as chronic deteriorating conditions; recoveryis observed in many patients receiving treatments that focus on theprimacy of psychotherapeutic intervention.
Before examining these various treatment approaches focused onpsychotherapeutic intervention and recovery, the confluence of factorsacross disciplines, research, and cultures that I believe laid the ground-work for these psychotherapeutic approaches will be outlined.
1. CONTEMPORARY ATTACHMENT RESEARCH, TRAUMATHEORY, AND POSTTRAUMATIC STRESS DISORDER (PTSD)RESEARCH
Attachment Theory and Affect
Research has demonstrated that the infant’s early interactions withprimary caregivers contribute greatly to the development of long–termemotional health. Peter Fonagy, and Allan Schore, both psychoanalystsand researchers, have been at the forefront of providing research thatdemonstrates the importance of a secure attachment in laying thegroundwork for later complex affective and cognitive abilities.Neuroscientific research has demonstrated that impaired attachment is
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associated with neurological and cognitive deficiencies and affectivedysregulation in childhood and adulthood (Fonagy, 2001; Schore, 2001).Early attachment experiences involving interpersonal interactions be-tween child and caregiver, then, molds the purely biological drives intocomplex cognitive and affective functions. The attachment sequelae areobservable both in terms of the neurological structures and neuro-chemical status, and the functional capacities of the developing childand later adult (Aron & Anderson, 1998; Decety & Chaminade, 2004;Gerhardt, 2004; Paquette et al., 2003; Schore, 2001), Secure attachmenthas been found to contribute to the development of personality charac-teristics such as the ability to trust, the capacity to empathize with others,the capacity to regulate affect and self–esteem, and the capacity to relateto others in a complex and mature manner.
Teixeira (1997) cites several studies demonstrating that children withattachment insecurity are less competent interpersonally, and have lowerself–confidence and ego resilence. Teixeira found that both mothers andfathers can contribute, though differently, to an insecure mother–childattachement. The importance of attachment is reflected in the findings of aNIMH study that analyzed the attachment of two– and three–year–oldsof mothers with bipolar, major, and minor unipolar depression, andnonpsychiatric control mothers. The study concluded that the mothers’expressed emotion predicted patterns of attachment independent of diag-nosis, and that the absence of the father increased the risk of insecuremother–child attachment for mothers with major affective disorder(Radke–Yarrow, Cummings, Kuczynski, & Chapman, 1985).
Separation, Loss, and Insecure Attachment
One of the primary frustrations of normal infancy and child-hood—and of life—is that of separation and loss. At these critical mo-ments of separation and loss, which can never be predicted, nor entirelyavoided, the child or later adult is always at risk. The vast majority ofpsychotic and schizophrenic individuals have had some experience of adisrupted attachment, evidenced by the schizophrenic’s pathologicalsymbiotic attachment style (Benedetti, 1987; Searles, 1965, 1979). Thispathological symbiotic attachment style is interesting to consider in lightof Lacan’s theory of psychosis. Lacan identifies the failure of the role ofthe father (“the Name of the Father”) to indoctrinate the child into theuse of symbols (“the Symbolic Order”), and break the early maternalsymbiotic attachment, as contributing to the child’s later psychoticallyorganized character (Lacan, 1993, pp. 193-213). With an inadequate at-
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tachment experience, these individuals are particularly vulnerable toloss and separation, and thus lack the ability to maintain emotionalstability and self–cohesion at these times.
Harold Searles is a psychoanalyst whose work is unparalleled in thepsychoanalytic treatment of schizophrenic patients. Searles spoke of theschizophrenic’s often constant experience of the “inevitability of death.”The terror involved in living with the emotional certainty of one’s owndeath is central to many other psychoanalytic conceptualizations of psy-chosis within the existential and object relations schools. These theories,unlike Freud’s theory of etiology for both the psychoses and neuroses,do not give libido theory and oedipal problems prominence. Instead, theterror of death in the schizophrenic, together with a pathological symbi-otic attachment pattern and experience of the self, makes the subjectiveaffective experience of the schizophrenic unbearable, resulting in theeventual retreat into psychosis.
Death is the ultimate experience of loss and separation. Persons devel-oping psychosis or schizophrenia have been found to be particularlyvulnerable to experiences of loss and separation, related to developmen-tal deficits that go back to the earliest experiences of attachment.Searles’s work has helped us understand the importance of dealing withthe schizophrenic’s constant experience of terror. Psychoanalysts holdthat only by working through these unconscious intense affects, such asterror and rage, can the individual integrate the split–off unbearable af-fective experiences, instead of being trapped in repeating and livingthrough them (Bion, 1957, 1959; Coltart, 2000; Daniel, 2004; Eigen, 1986,2002; Gibbs, 2004, 2007; Kavanaugh, 2003; Klein, 1946; Pick, 1985;Searles, 1979; Steiner, 1993). Contemporary psychoanalysts have notedthat poor early attachment and affective development is correlated witha later vulnerability to loss and separation, in persons described as fall-ing in the range of borderline and psychotic adolescent or adultfunctioning (Blos, 1967; Fonagy, 1998; Kernberg, 1984; Krystal, 1988).
Developmental Sequelae—Language and Self Fragmentation
Related to this attachment research are theorists, such as GregoryBateson (1972), R. D. Laing and Esterson (1964), and Virginia Satir(1967), who identified particular communication patterns in schizo-phrenic patients and their families, based on what is called “the doublebind.” Essentially, communications involving double bind processescan be summarized as those in which the communicating person comesaway with a profound feeling of: “I can’t win—no matter what I say.”
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This experience is, over time, deeply embedded in the emotional experi-ence of the self, with the self being riddled with a sense of wrongness,alienation, and fragmentation. In the schizophrenic person, the frag-mentation often observed in typical cognitive processes, especially inco-herent and fragmented speech, was gradually understood to be based,in part, on the developmental deficits related to insecure attachment.
It is my observation, as well as that of others (Aderhold & Gottwalz,2004; Fromm Reichmann, 1959; Karon & VandenBos, 1996; Read, Good-man, Morrison, Ross, & Aberhold, 2004a; Read, Seymour, & Mosher,2004b, Sullivan, 1962) that the schizophrenic person, having an insecureattachment experience, and ongoing difficulties with normal separa-tion–individuation developmental tasks, is particularly sensitive tointrafamily conflict. The ongoing developmental sequelae of insecureattachment, and sensitivity to family dynamics, then, in combinationwith other factors is associated with fragmented speech patterns of theschizophrenic, and the schizophrenic family.
These splitting and fragmentation tendencies had been identified byWilfred Bion as early as 1953, and intensely studied by Silvano Arieti(1974) in his seminal work, Interpretation of Schizophrenia. Language andfamily dysfunction have long been observed by clinicians in psychoticand schizophrenic patients and their families, and is now being vali-dated by neuroscientific and epigenetic research, which will bereviewed shortly.
Trauma Theory, Dissociation, and PTSD Research
Experiences of overwhelming trauma, such as exposure to war, rape,or violence, often have a specific aftermath. The symptoms associatedwith Posttraumatic Stress Disorder, or PTSD, such as flashbacks, affec-tive blunting or volatility, nightmares and sleep disturbance, and disso-ciation of the traumatic event, have all been observed to be similar to thebehavioral manifestations of a psychotic episode. Contemporarytrauma work and PSTD research has added to our understanding of theimportance of talking about terrifying experiences, and in the case of psy-chotic or dissociative patients, talking about hallucinations and delu-sions within the safety of a transference relationship. The occurrences ofaffective blunting, fragmentation, dissociation, and projection, sharedby PTSD and psychotic patients, have been found to be quite responsiveto psychotherapeutic and psychoanalytic interventions based on an un-derstanding of affective containment, splitting, and projective identifi-cation, now long used by contemporary psychoanalysts (Boyer &
Psychoanalysts and psychotherapists working with dissociative pa-tients, including Dissociative Identity Disorder (DID), have contributedto treatment approaches that have overlapped with the effective treat-ment of psychotic individuals. Research in this area shows that traumaand abuse are highly correlated with the dissociative disorders(Putnam, 1989). In severely dissociative or DID patients, dissociativelybased hallucinations, delusions, and disorders of thinking are observed.Braun (1988) in his BASK model of dissociation, says patients utilize, to alesser or greater extent, dissociation as a protective defense against un-bearable behavior (self–mutilation), affect (rage, for example), bodily sen-sations (bodily “memories” of abuse, often psychosomatic symptoms),or knowledge (fugue states or amnesia). Interestingly, some researchersare now reporting the occurrence of trauma is a necessary, but not suffi-cient condition for the occurrence of PTSD. Rather, PTSD is thought to berelated to impairment of the attachment–based cognitive functions thatwould allow trauma to be processed symbolically, or verbally(Verhaeghe & Vanheule, 2005).
Trauma Theory and the Reality of Abuse
There is an extremely high incidence of childhood abuse or trauma as-sociated with the dissociative disorders. Empirical studies have estab-lished that 97 to 98% of cases diagnosed as DID or dissociative involveabuse (Putnam, 1989). Read, van Os, Morrison, and Ross (2005) re-viewed 218 studies and concluded that “symptoms considered indica-tive of psychosis and schizophrenia, particularly hallucinations, are atleast as strongly related to childhood abuse and neglect as many othermental health problems. Recent large–scale general population studiesindicate the relationship is a causal one" (p. 330). The researchers claimuntil recently this causal relationship has been “minimized, ignored ordenied” due to a “rigid adherence to a rather simplistic biological para-digm, inappropriate fear of being accused of family–blaming, avoidanceof vicarious traumatization on the part of clinicians and researchers, andrediagnosing from psychosis to PTSD, dissociative disorders and othernon–specific diagnoses once abuse is discovered” (p. 331). In a review ofthe Read et al. study, Oliver James (2005), in the United Kingdom news-paper The Guardian, wrote: “Not since the publication of R.D. Laing’sbook Sanity, Madness and the Family, in 1964, has there been such a signifi-cant challenge to [the psychiatric establishment’s] contention that genes
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are the main cause of schizophrenia and that drugs should be theautomatic treatment of choice” (p. xx).
It should be noted that our contemporary research in attachment andepigenetics will provide clinicians with more scientific evidence for thefolly of blaming anyone for psychosis or schizophrenia. In terms ofblame, successful psychoanalytic and psychotherapeutic approachesrecognize and avoid the untherapeutic nature of blaming either the pa-tient or the family (Alanen, 1997; Karon & VandenBos, 1996). Searles(1979) was the first to point out specifically that pathological symbioticattachment, or the hostile dependent relationship patterns found inschizophrenia and psychosis, contain both the seeds of rage and hatred,AND love.
Psychoanalytic Interventions and Trauma
Though Freud (1895/1955) started with theories that acknowledgedthe reality of abuse which accommodated the psychodynamic role ofabuse in shaping the personality, he soon changed his focus to the rolethat unconscious fantasies had in shaping character. Freud never, ofcourse, completely dismissed the role of actual trauma or the environ-ment in shaping character, however, emphasis for several decades wason the role of the drives in shaping the ego. Classical analysis becameprogressively more focused on working with patients’ verbal associa-tions interpretatively. Abreaction, or the expression of emotion, due toeither conscious or unconscious trauma, receded as a psychoanalytictechnique. Exclusive use of verbal association and interpretation hasbeen shown by research in the areas of PTSD, trauma, psychosis, andschizophrenia, to have limited, and sometimes contraindicated thera-peutic benefit. Because such patients can have difficulty trusting anotherperson sufficiently to establish a therapeutic alliance, techniques thatreach to the patient’s unconscious affective experience, such as utiliza-tion of the countertransference, abreaction, and the use of projectiveidentification, are most helpful. Research in attachment, trauma, andneuroscience now confirms that psychotic patients constantly monitorinterpersonal interactions, both consciously and unconsciously, forevidence of danger (Baker & Kim, 2004; Schore, 2003).
Trauma that is repressed, dissociated, or split off in psychotic, abused,and PTSD patients can be described as overwhelming affect associatedwith a truth we feel we cannot face. The truth of trauma cannot be faced, inmy opinion, because the affective nature of being overwhelmed by thedrives, or the bodily, sensation–based experience associated with
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trauma, cannot be adequately modulated by utilizing techniques rely-ing solely on verbal or symbolic functions. It has been my observationthat the psychotic, schizophrenic, or traumatized person is consumedpsychically and somatically with the reality of death, hatred, and evil(Gibbs, 2004, 2007).
Karon and VandenBos (1996) have provided detailed research thatprovides evidence that a modified psychoanalytic approach is effectivewhen used with schizophrenics, though only when the therapists pro-viding the treatment are highly trained in working with the population,and have an average of a minimum of ten years of such work. Karon andVandenBos (1996) emphasize a nonclassical psychoanalytic approachthat recognizes the symbiotic attachment pattern already discussed, yetseeks to avoid the development of an unproductive maternal transfer-ence by utilizing both supportive and interpretative techniques. Not allanalysts agree with Karon’s and Vandenbos’s modified approach,though analysts and psychotherapists working with psychotic patientshave long realized the necessity of modifying techniques in some way(Jacobson, 1971; Silver, 1989). Transference work, as we will see whenwe review the Lacanian 388’s treatment of schizophrenia, is alsotypically modified.
The work done in the areas of attachment, trauma, abuse, dissociation,and PTSD has not gone unnoticed by clinicians across a range of disci-plines and orientations. We will see the influence of this diverse re-search across disciplines and theoretical orientations when we reviewthe contemporary successful treatments of psychosis and schizophre-nia. Interestingly, the experience of immigration has also been identifiedas sharing many of the long–term behavioral features seen in PSTD (Ja-cobson, 1971; Krystal & Petty, 1963). Noting the similarity between reac-tions to extreme stress and psychotic behavior, clinicians have usedthese observations to develop treatment approaches to psychotic andschizophrenic individuals. Further, as long–term effects of extremetrauma, such as war and torture, are seen to be passed down from gener-ation to generation (Davoine & Gaudilliere, 2004; Kane, 2005), in termsof familiar vulnerabilities to anxiety or depression, for example, the oncebiological model of genetic transmission of these psychologicalconditions began to develop into what is today called theBio–Psycho–Social Model, or Epigenetics.
2. ETIOLOGY AND THE EPIGENETIC MODEL:CONTEMPORARY NEUROSCIENCE AND EPIGENETICS
Two questions immediately arise from the above overlap of treatmentand behavioral similarities of the psychoses with the trauma, abuse, and
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PTSD research. First, we are vexed by the question of differential diag-nostic accuracy and etiology. I would like to ask a second question: interms of the efficacy of the treatment—is treatment efficacy related toetiology?
Diagnostic accuracy does matter of course, in terms of identifyingcausal relationships, or etiology. Not all causal relationships, however,can be demonstrated by our methods utilizing observable, measurable,and replicable empirical methods. In terms of my question above—doesthe efficacy of the treatment matter in terms of the etiology of the condi-tion, the answer is—yes, BUT, only within an epigenetic model. I willfirst briefly explain the area of epigenetics, before moving on to the re-search that is providing the basis for the successful psychotherapeuticand psychoanalytic treatments of the psychoses and schizophrenias.
In epigenetics, the relationships between biological, psychological,and social influences represents a matrix, wherein all of these factors areequally weighted, and organized as feedback loops (or epigenetic inher-itance systems; Jablonka & Lamb, 2005) of fluid and complex influencewithin all human beings. For any particular condition, one of these feed-back loops may be primary in terms of etiology, though the other twofeedback loops can never be dismissed. Further, the total feedback sys-tem is fluid, and may affect any manifest biological, psychological, or so-cial condition over time. Conditions we once thought to be heavilycaused by biological or genetic factors, for example, after treatmentfocused in the psychological and social realms, may improve.
An example of the fluidity of the causal and treatment relationships inthe epigenetic model are the studies documenting that the environmenthas an effect on the remediation of genetic deficiencies. Stephen Suomi(1997), Chief of the Laboratory of Comparative Etiology at the NationalInstitute of Child Health and Human Development, of the National In-stitutes of Health, studied two groups of rhesus monkeys. The first sub-group manifested high anxiety and depressive–like symptoms from in-fancy, and high ACTH levels from infancy, which spiked wheneverthese monkeys were in new situations. The monkeys in the secondgroup were hyper–aggressive, and made poor and impulsive socialjudgments. These monkeys had low 5–HIAA levels found throughoutlife. Genes have been identified that seem responsible for modulating5–HIAA levels, which might support the choice of medication in an ef-fort to modulate a neurophysiological condition. Suomi’s ongoing re-search, however, exemplifies how these conditions thought to be geneti-cally determined, are influenced by psycho–social factors. Suomi’sgroup identified a group of “super–mom” monkeys who had nursedmonkeys initially showing an anxious pattern, back to health. His grouptook monkeys from both the anxious–depressive and aggressive sub-
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groups, and had them foster–mothered by these super–mom older fe-males. All of these young rhesus monkeys, in both the subgroups, devel-oped into troupe leaders. Silver (2003), in reviewing the research ofSuomi and others, says: “Good home situations mitigate bad genes.Biology is not destiny; pathology is not immutable” (p. 327).
Research based on a Multi–Causal Epigenetic Model of theSchizophrenias and Psychoses
Etiology and Treatment. The issue of how the etiology of theschizophrenias and psychoses may, or may not be, related to the treat-ment of these conditions is important to clarify. As we have seen above, acomprehensive multicausal epigenetic model allows for multiple causalagents, and successful interventions that may or may not directly de-scend from the etiology of a condition. Thus, anxious and aggressivetemperament may be largely caused by neurophysiological abnormali-ties, and be best remedied by environmental reparenting and socializa-tion (Suomi, 1997). Many contemporary psychoanalytic approaches tothe schizophrenias are based on the disordered thought, language de-velopment, and speech associated with this condition. Psychoanalytictherapies, in spite of the evidence that a genetic vulnerability is opera-tive in some cases of the schizophrenias, have found that techniquesbased on language development are successful in undoing the disorga-nized cognitive and language process, sometimes to the point of full re-covery. Techniques such as the therapist avoiding the use personal pro-nouns, not asking questions, specifically wording interventions to helpthe patient develop the capacity to be self-reflective and use symbolicidentification, and a modified understanding and interpretation of thetransference, have been found by analysts from differing backgroundsto be among the most effective in the treatment of schizophrenic patients(Karon & Van den Blos, 1996; Renee, 1994; Segel, 1950; Ver Eecke, 2001;Villemoes, 2002).
The research of Denise Fort (1990) illuminates some of the languageand communication deviances found in schizophrenic patients andtheir families, as well as illustrates the therapeutic benefits of verbalcommunication. Fort took normal sons and their parents, and schizo-phrenic sons and their parents, and studied proverb identification inthese two groups. (The parents of the schizophrenic boys were not nec-essarily identified as schizophrenic.) The results found were:
parents performed less well after listening to a schizophrenic boy and sons
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performed less well after listening to parents of a schizophrenic son. Fortconcluded that there is a communication deviance in both directions.Schizophrenic sons were more impaired in their performance when re-sponding to parents of schizophrenics than normal sons. Most striking, itwas found that schizophrenic sons responding to parents of a normal sonincreased their performance on proverb identification to be equal to that ofthe normal sons.
Ver Eecke (2001) concludes that Fort’s research provides empirical ev-idence for refuting the claim that there is unidirectional impairment in-volved in schizophrenia, that is, that only parents’ communicationdeviance impairs children. Rather, there is reciprocal impairment of theparent and child. Fort recommends that this reciprocal impairment benoted in an effort to support families, and counter parental blame.
Genetics—Analyzing the Adoption Studies
There are many well done twin–adoption studies now available re-searching the etiology of the schizophrenias and psychoses. A few stud-ies most relevant to the article’s thesis that the schizophrenias andpsychoses are no longer seen as chronic deteriorating conditions, andthat recovery is often observed with appropriate psychologically ori-ented intervention, will be briefly reviewed.
Tienari (1992) directed a Finnish adoption study finding that childrenof biological mothers with functional psychosis, given up for adoption,were more psychiatrically disturbed (10.3%) compared to children ofcontrol parents given up for adoption (1.1%). The study also found, how-ever, that no adopted child of a functionally psychotic biological mother ac-quired a functional psychosis if the adoptive family was deemed psychologicallyhealthy. The families were studied over two days (14 to 16 hours each),with each family receiving family, individual, and couple interviews(tape recorded for blind ratings, reliability, and reclassification by otherresearchers), the Consensus Rorschach, the Interpersonal PerceptionMethod, and the MMPI. The OPAS, a 33-item family rating scale, wasalso done on the adoptive families. Using the 12 items with the highestreliability (between .0068 and 0.84), there were significant correlationsbetween these independent ratings of the adoptive families and the indi-vidual diagnoses of the offspring (p. 164). The highest correlation wasfor empathy, disrupted communication, and conflict between parentsand offspring (pp.164–66).
Tienari concludes that the findings are “consistent with the hypothe-
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sis that healthy rearing families have possibly protected the vulnerablechild” (p. 162–163). Portin and Alanen (1997) analyzed twin-adoptionstudies, environmental studies, and brain imaging research and con-cluded: “. . . it seems that the present day conclusion is that genes are nei-ther sufficient nor a necessary cause of schizophrenia . . .” (p. 3). Kendlerand Diehl (1993) also conclude:
Schizophrenia is clearly a complex disorder in that gene carriers need notmanifest the illness (incomplete penetration), affected individuals need nothave the gene (environmental forms or phenocopies), diagnostic uncertain-ties cannot be avoided, and different families may carry different suscepti-bility genes (genetic heterogeneity). (p. 261)
Wahlberg et al. (1997) analyzed the interaction of high genetic risk (be-ing the biological child of a schizophrenic mother) with the communica-tion deviance of adoptive parents, as measured by the Index of PrimitiveThought. Wahlberg’s results have significance in terms of etiology,treatment, and prevention of the schizophrenias. First, the increasingcommunication deviance scores of the adoptive parents were associatedwith sharp increases of positive scores on the Index of Primitive Thoughtfor high risk adoptees (scores rise from 40% to 90%). This increase incommunication deviance of adoptive parents, however, does not in-crease the positive scores for control adoptees. Secondly, it was foundthat when high risk adoptees were exposed to adoptive parents with lowlevels of communication deviance, these high risk adoptees have a lowerproportion of postive scores that did the control adoptees (p. 361).Wahlberg’s research is related to Fort’s, both showing the protective role of theenvironment in ameloriating communication deviance. Teixeira (1997) alsofound that families with high communication deviance and negative af-fective style were most likely to have children who developed schizo-phrenia spectrum disorders. Ver Eecke (2001), in reviewing thisresearch, concludes: “. . . It is as if the comparison adoptees developmore according to their own scheme whereas high genetic risk adopteeseither drown or flourish depending on the environment . . .” (p. 55).
Other Neuroscientific Research
After receiving psychotherapy, structural (sMRI) and functionalchanges (fMRI, PET) have been observed in persons with severe mentalillness. Regarding this research, Brian Koehler, at New York Universitystates: “We have within our grasp a potentially fruitful neural basis for
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the psychotic structure, and its amelioration within psychotherapy . . . itis possible to study neural regions mediating empathy andintersubjectivity utilizing fMRI imagining” (Koehler, 2005). Ciompi(1980, 1984) also reports significant improvements in neurocognitivefunctioning, such as in memory, reasoning, and judgment, in schizo-phrenics receiving intensive psychotherapy; with up to 30% ofdiagnosed schizophrenics recovering.
The volume of the brain, seen through MRI imaging, is often reportedto be reduced in people suffering from schizophrenia. Schröder,Bottmer, and Pantel (2002) have presented evidence that cortical volumechanges are dynamic and reversible. Schröder et al. concluded: “Thepresently available neuroimaging studies do not convincingly supportthat schizophrenia is generally associated with a global cerebral tissueloss” (p. 93). Ventriculomegaly, one of the most prevalent neurologicalchanges seen in schizophrenia, is nonspecific. In other words, thesebrain changes, many of which are reversible, are observed in schizo-phrenia, PTSD, bipolar and other depressions, as well as in the normaland aging brain. These neurological changes, then, nonspecific toschizophrenia and psychosis, are also responsive to functional andstructural remediation through psychotherapeutic treatments (Schore,2003). In related research, Waterland and Jirtle (2003) reported in Molec-ular and Cellular Biology that an enriched environment can overridegenetic mutations in mice.
Research in neuroscience is providing evidence that the therapeuticalliance in psychoanalytic treatments has a crucial, ameliorative role inrepairing neurological and neural structural damage associated with in-sufficient attachment, psychotic symptomatology, and trauma (Aronand Anderson, 1998; Schore, 2003; van der Kolk, 1996). Havens andGhaemi (2005) have shown that the therapeutic alliance, in appropri-ately conducted psychotherapy, functions as a mood stabilizer in pa-tients diagnosed with bipolar disorder. Koehler is a major developer andadvocate of the epigenetic model within psychoanalysis, and believes itwill increasingly inform psychoanalytic and psychotherapeutic work.Koehler (2005) states:
The pharmaceutical companies are already researching how theirpsychopharmacological agents impact on the epigenetics of psychiatric ill-nesses. However, since the role of the social environment looms muchlarger within psychiatric epigenetics, psychosocial interventions, includingmost importantly psychotherapy, will be increasingly recognized asameliorative.
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The research of Eva Jablonka and Marion Lamb (2005) is related toKoehler’s emphasis of epigenetic models in psychotherapeutic treat-ments. Jablonka and Lamb have identified four pathways of influence intheir Epigenetic Inheritance System: genetic, epigenetic, behavioral, andsymbolic influence. Their behavioral and symbolic systems are relevantto social scientists trying to identify, and develop treatment for, allmental health disorders.
3. RESEARCH ON THE EFFICACY AND RELAPSE RATESASSOCIATED WITH PSYCHOTROPIC USE
The last fifty years have slowly yielded many well-designed, con-trolled research studies that indicated, time and again, that long term useof neuroleptics worsens long term outcome, and greatly reduces the possibilityof recovery from the psychoses and schizophrenias. Scooler, Goldberg,Boothe, and Cole (1967) looked at one-year outcomes for 299 patients inthe first long–term study conducted by the NIMH. Patients were treatedeither with placebo or neuroleptics upon admission to a hospital. Thosereceiving placebo were less likely to be rehospitalized than those who re-ceived any of the three active phenothiazines: thioridazine (Mellaril),fluphenazine (Prolixin), and chlorpromazine (Thorazine). Epstein, Mor-gan, and Reynolds (1962) conducted the first large-scale study of hospi-tal release rates in the 1950s for schizophrenic patients treated with andwithout neuroleptics, and concluded that “drug–treated patients tend tohave longer periods of hospitalization” (p. 44). Prien, Cole, and Belkin(1968), in another NIMH study, identified what would later be called“re–bound psychosis,” or a increase of symptoms upon withdrawalfrom neuroleptics. They found that relapse rates rose in direct relation todosage. Sixty–five patients were on 300 mg of chlorpromazine at thestart of the study, and 54% of these patients worsened after drug with-drawal. One hundred thirteen patients were on more than 300 mg ofchlorpromazine at the start of the study, 66% of whom worsened afterdrug withdrawal (p. 684). Prien, Levine, and Switalski (1971) in anotherNIMH study, confirmed the earlier finding that relapse rates rose incorrelation with neuroleptic dosage.
Bockoven and Solomon (1975) compared relapse rates in thepre–medication era to those in the medication era, and found that pa-tients in the pre–medication era had done better. Forty–five percent ofthe patients treated at Boston Psychiatric Hospital in 1947 (pre–medica-tion era) had not relapsed in the five years following discharge, and 76%were successfully living in the community at the end of that follow–upperiod. These results are in sharp contrast with those of the medicationera. Only 31% of patients treated with drugs in 1967 at a Boston commu-
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nity health center remained relapse–free for the next five years. As agroup these 1967 medication–era patients were much more “socially de-pendent” on public aid, such as welfare, than the 1947 cohort. Lehrman(1960) reported similar findings when reviewing relapse rates for pa-tients in New York psychiatric hospitals. Lehrman (1982) found that in-dividual psychotherapy, without an overreliance on neuroleptics, wasthe most helpful approach to assist chronic schizophrenics in returningto the community, and, in some cases, recovering from schizophrenia.
Rappaport, Hopkins, Hall, Beleza, and Silverman (1978), in a study in-terestingly entitled “Are there schizophrenics for whom drugs may beunnecessary or contraindicated?” randomly assigned eighty youngmale schizophrenics admitted to Agnews State Hospital to medicationand nonmedication groups. Only 27% of the drug–free patients relapsedin the three years following discharge, compared to 62% of the medi-cated group. In a large multiple–study research project conducted underthe auspices of the World Health Organization, the WHO demonstratedthat in underdeveloped countries where use of neuroleptics was at aminimal rate, or nonexistent, persons diagnosed with schizophreniahad better outcomes (Harrison et al., 2001; Hopper et al., 2007; Jablenskyet al., 1992). Whitaker (2002), in Mad in America: Bad Science, Bad Medicine,and the Enduring Mistreatment of the Mentally Ill, discusses the findings ofthe WHO at length, and concludes that maintaining people onneuroleptics is a disservice, it worsens long–term outcomes, and makesrecovery more difficult. He also answers the charge of contemporary re-searchers that the newer atypicals and other psychotropic medicationsare more effective than early medications. Whitaker states that researchnow indicates that these newer medications are often no more effectivethan placebo, are not improvements over older psychotrophics in termsof efficacy, and are more often associated with serious side effects. Heconfirms the findings of the WHO study: outcome and recovery rates forthe psychoses and schizophrenias are better in undeveloped countriesthat do not use, or use minimally, neuroleptics, and focus onpsychotherapy, family therapy, psychosocial education and communitysupport.
4. THE HUMAN RIGHTS AND PSYCHIATRIC RIGHTSMOVEMENTS
Emerging from the research showing long–term use of neurolepticsworsens longterm outcome, and minimizes the possibility of recovery, isthe Psychiatric Rights movement. This movement has its basis in the Hu-man Rights movement. The basic tenets of the Psychiatric Rights move-ment are the primacy of individual choice when the individual is not a
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threat to self or others, informed consent, the right to privacy, and theprofessional ethic to do no harm. Grace Jackson (2005), a psychiatristand researcher, provides an exhaustive examination of the short andlong–term side effects, and the efficacy of psychotropic treatments. Jack-son also provides documentation of the massive influence pharmaceuti-cal industries have had on outcome research and medical schoolcurriculums and how this industry has increasingly monopolized stan-dards of care in the healthcare and legal systems, based on profit motivesinstead of scientific research. Jackson’s Informed Consent: Rethinking Psy-chiatric Drugs, is one of many works that now calls for a careful examina-tion of the use of all psychotropic medication in the United States(Glenmullen, 2001; Healy, 2004; Jackson, 2005; Whitaker, 2004). Jacksonand others seem to be making the point that there is now sufficientresearch available to alert us to taking a cautious approach to medicationuse.
Psychoanalytic Contributions to Recovery from the Psychosesand Schizophrenias—Contemporary Successful Treatments
Because of the unconscious repetition of trauma in both individualsand families, as well as particular attachment and object relations pat-terns that contribute to compromised language development andintrapsychic psychotic structures, I believe it is only a psychoanalyticapproach that can truly free a person having a “psychotic core” from adownward cycle into terror, alienation, and psychotic deterioration. TheLacanian “388” program will be reviewed in some detail, as its overalltreatment approach integrates much of the psychoanalytic, languagedevelopment, attachment, and epigenetic research already covered.Other effective treatments will also be briefly mentioned.
Quebec’s 388
The Treatment Program for Psychotic Young Adults, commonly re-ferred to by its street number in Quebec, 388, was founded by Drs. WillyApollon, Danielle Bergeron, and Lucie Cantin. They all obtained psy-choanalytic training, under the auspices of Jacques Lacan. Work donepreviously by both Freud and Lacan had not been promising in develop-ing a therapeutic transference with psychotic patients. While Freud(1915) hoped that the study of the ego would provide the means to even-tually treat psychosis, he could find no means to facilitate a therapeutic
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transference with such patients. Lacan (1993), in his treatment of a para-noid woman, also came to the conclusion that the psychotic could form atransference, but that it would inevitably become persecutory, or wouldproduce an erotomania, resulting in unsuccessful treatments.
Not to be deterred, Apollon, Bergeron, and Cantin drew upon theirLacanian training and went on to develop the analytic concepts andtechniques necessary to establish a successful transference with the psy-chotic person. Briefly, these concepts are based on an understandingthat a particular defect in language, that affected the psychotic’s rela-tions to symbolic order, interfered with accessing necessary cognitivefunctions within psychic structure. When a person experiences a psy-chotic “crisis,” the experience is one of being subjectively inside the de-struction of the world. The representational field that forms the templatefor object relations is shattered. This shattering crisis leads to what istermed a “ruptured social link” (Apollon, Bergeron, & Cantin, 2002).
The similarities of the observations made by Apollon, Bergeron, andCantin with those that have already been presented, in terms of attach-ment and psychic structure, language development, and the subjectiveexperience of terror associated with death and destruction, are apparent.These observations are all reported across various disciplines and orien-tations that work with psychotic and schizophrenic patients.
When a crisis inevitably arises, then, the analytic process is supportedby the structure of 388 and viewed as a therapeutic opportunity. Theminimum requirement to enter 388 is for the patient to make a request.This first manifestation of patient–as–agent is then sustained, first dur-ing the initial interview, and then throughout the patient’s contact with388. Each patient is worked with to identify a unique “project,” or a per-sonally meaningful activity that helps to rebuild the patient’s shatteredsocial link. Patients are expected to enter psychoanalytic treatment, andthis is kept entirely separate from the program at 388. The patient’s ana-lyst, importantly, has nothing to do with what goes on in the program at388.
There is no formal group therapy at 388, instead group process servesthe function of containing delusional efflorescence and offering ways torebuild the ruptured social link. Artistic studios occupy a special place at388. They provide a unique and protected space where each patient canlocate their own desire. This is done by employing various media in orderto capture and contain the otherwise inexpressible and ineffable experi-ence of one’s psychosis and unique history. Lacan’s work on desireinforms a complex theory of the structures that underlie the psychoticperson’s delusions and hallucinations. For our purposes, suffice it to saythat the treatment at 388 is organized around providing a “localization
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for desire,” in the sense that it reorganizes psychotic structuresunderlying delusions and hallucinations, using Lacanian analysis.
The four rooms of the third floor house seven beds, and are availableon a 24 hour/seven day a week basis. Any person involved in the 388program who is in “crisis” can voluntarily go to the third floor, and havean “intervenant” (388 staff) available, as much as is needed. Finding away to accept the ineffability of some things, especially of the psychoticexperience, is a central part of the work done at 388. Patients are calledUsager because they “make use of” the Intervenant to accompany themthrough the psychotic experience. This accompaniment is similar toProuty’s (2003) pre–therapy with schizophrenic patients, in which thetherapist may make very few verbal comments, ask no questions, andsimply be available. The usager agrees to involve himself or herself in ana-lytic treatment and is always free to come and go, leave 388, go to thethird floor for round the clock care when needed, stay at home, or go toschool. In this way the 388 program treats psychosis where it is mostadvantageous to do so, right in the community.
Charles Turk (2006), a psychiatrist in Chicago working with psychoticpatients for over 30 years, says:
In the United States after the second hospitalization a schizophrenic patientis usually considered to have become chronically ill. The average number ofhospitalizations prior to entering 388 is about 4.5 per patient. The experi-ence of having the availability of an intervenant, combined with their analy-sis, in some cases results in complete recovery from schizophrenia,eliminating the need for medication . . . the experience here is that people’slives are turned around.
Reverse Psychiatry in Falun, Sweden, and the TurkuSchizophrenia Project in Finland
Lars Martensson (2004) is a Swedish psychiatrist who recently spokein San Diego on the recovery from schizophrenia. Martensson spoke pri-marily of a program in Falun, Sweden, under the direction of psychia-trist Goran Andre.
Goran outlines the four cornerstones of the Falun method as:
1. Psychosis is seen as a crisis, a crisis to be overcome.2. A session with the whole family is arranged within 24 hours.3. Neuroleptic drugs are avoided and hardly ever used.4. Hospitalization is avoided and hardly ever necessary.
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The Falun method is based on relational theories of establishing anempathic mutual relationship with another person, and neuroscientificand attachment research already covered. It is also grounded in the neu-roscience of human consciousness, with Martensson explaining that thisprocess is similar to establishing this mutual relationship as with a baby.Martensson says:
Let us compare the relation between the doctor and the patient with the rela-tion between the mother and the baby at the moment the baby is mentallyborn by the leap to an outside viewpoint. The leap, we understand, is onlypossible because of the empathy, dedication, openness, total presence of themother. There are no ulterior thoughts, no manipulation. This is Love. Hu-man consciousness is born of Love. The task of the psychotic person, as wenoted, is similar to the task with the baby. The task is to activate the frontalbrain function that underlies all human consciousness. (p. 6)
Lars Martensson states: “It is an unbearable horrible tragedy when ayoung person, often a gifted, sensitive, creative young person, is drown-ing in psychosis . . . They can be saved. Therefore they must be saved” (p.6)
The Turku Schizophrenia Project in Finland
The Falun treatment approach is similar to that developed by YrjoAlanen and his team of researchers at the University of Turku, Finland.Alanen’s approach to the treatment of schizophrenia now has four de-cades of outcome research strongly pointing to the efficacy of the“need–adapted approach” (Aaltonen, Alanen, Keinänen, & Räkkö-läinen, 2002; Alanen, 1997; Alanen, 1991). A psychotherapeutic attitudedominates all aspects of treatment, including psychopharmacologicalregimes, family therapy, individual psychoanalytic therapy, and insti-tutional and interdisciplinary countertransference resolution. Such pro-cessing of institutional group dynamics, as well as individualcountertransference responses, is central to effective treatments of thepsychoses and schizophrenias. Hinshelwood (2004) in his book SufferingInsanity has written specifically on the conflicts seen in institutions, andbetween disciplines, in the psychoanalytic treatment of psychosis. TheTurku Schizophrenia Project also provides advanced training in treatingpsychotic patients for psychotherapists and psychoanalysts throughoutScandinavia and Europe. Case studies of work with psychotic patients
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through the Turku project can be found in Jackson’s (2001) Weatheringthe Storms: Psychotherapy for Psychosis.
SUMMARY AND CONCLUSIONS
The contemporary research in the areas of attachment, object relationscapacity, affect regulation, language and cognitive development, andtrauma were reviewed. The functional capacities observed by early psy-choanalysts, such as affect regulation, mature object relations capacity,and primitive defenses, have been documented by contemporary find-ings in the areas of neuroscience and epigeneitcs. Clinical observationshave noted similarities in the behavioral manifestations of psychotic,schizophrenic, and traumatized patients. Effective psychoanalytic andpsychotherapeutic treatments for the psychoses and schizophreniashave been developed by synthesizing the findings across the above dis-ciplines. Outcome data has substantiated the effectiveness of psychoan-alytically informed treatments of the psychoses and schizophrenias. Iposit that two other factors have laid the groundwork for the emergenceof effective psychotherapeutic and psychoanalytic treatments of thesepatients: poor long–term outcome and recovery rates formedication-only treatment of the psychoses and schizophrenias, and theemergence of the Psychiatric Rights Movement.
The Lacanian 388 Progam was examined in some detail. Other effec-tive treatments for the psychoses and schizophrenias were also brieflyreviewd. All programs reviewed focused on psychotherapeutic inter-ventions as primary, and used medications minimally, not at all, or onlyas informed by an overarching psychoanalytic or psychotherapeuticmodel of treatment. All these treatments aimed to be available to thefamilies and the communities of the patients, and were flexible in mak-ing any modifications necessary in terms of technique and transferencework. In all treatment approaches recovery from schizophrenia was as-sumed to be possible, and probable in many patients. The individualand group treatments reviewed are based on clinical work now span-ning over seven decades, and on contemporary research in trauma,neuroscience, and epigentics.
Madness is frightening, and cannot be observed from a so–called “ob-jective” professional stance. The madness of our patients will inevitablyaffect us deeply in terms of countertransference responses because themadness of the external Other resonates with our own internal madness.The terror and chaos that is involved in these treatments is difficult tobear. Countertransference reactions can and should be ultimately usedto further the therapy or analysis (Bollas, 1999; Gibbs, 2004, 2007). A will-ingness to be flexible in terms of accommodating technique to the needs
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of the psychotic patient, without compromising the gains possible fromalways working as analytically as possible, is required. The successfulindividual practitioners and larger treatment programs reviewed hereinall utilizes some mechanism for ongoing training, the effective utiliza-tion of the countertransference, and the processing of dynamicsamongst team members. In conclusion, based upon this research andclinical work: The psychoses and schizophrenias can no longer be seen aschronic deteriorating conditions; recovery is observed in many patients treatedwith approaches that focus on the primacy of psychoanalytically–orientedpsychotherapeutic intervention.
REFERENCES
Aaltonen, J., Alanen, Y., Keinänen, M., & Räkköläinen, V. (2002). An advanced special-ist–level training programme in psychodynamic individual psychotherapy of psy-chotic and borderline patients: The Finnish approach. European Journal ofPsychotherapy, Counseling and Health, 5(1), 13–30.
Aderhold, V. and Gottwalz, E. (2004). Family therapy and schizophrenia: Replacing ideol-ogy with openness. In Models of madness: Psychological, social, and biological approachesto schizophrenia. New York: Brunner–Routledge.
Alanen, Y. O. (1991). Psychotherapy of schizophrenia in community psychiatry. Paper pre-sented at the Xth International Symposium for the Psychotherapy of Schizophrenia,Stockholm, Sweden.
Alanen, Y. O. (1997). Schizophrenia: Its origins and need–adapted treatment. Karnac: London.Alanen, Y., Lehtinen, V., Lehtinen, K., Aaltonen, J., Räkköläinen, V. (2000). The Finnish in-
tegrated model for early treatment of schizophrenia and related psychoses. In B.Martindale, A. Bateman, M. Crowe, and F. Margison (Eds.), Psychosis: Psychologicalapproaches and their effectiveness. London: Gaskell.
Apollon, W., Bergeron, D., & Cantin, L. (2002). After Lacan: Clinical practice and the subject ofthe unconscious. New York: SUNY Press.
Arieti, S. (1974). Interpretation of schizophrenia. New York: Basic Books.Aron, L., & Anderson, F. S. (1998). Relational perspectives on the body, Hillsdale, NJ: Analytic.Baker, K. B., & Kim, J. J. (2004). Amygdalar lateralization in fear conditioning: Evidence for
greater involvement of the right amygdale. Behavioral Neuroscience, 118, 15–23.Bateson, R. D. (1972). Steps to an ecology of mind. Ballentine Books, New York.Benedetti, G. (1987). Psychotherapy of Schizophrenia. New York: New York University Press.Berke, J. H. Fagan, M., Mak–pearce, G., & Pieridoes–Müller, S., (2002), Beyond Madness:
Psychosocial Interventions in Psychosis. London: Jessica Kingsley Publishers, Ltd..Bion, W. (1957). Differentiation of the psychotic from the non–psychotic personalities. In-
ternational Journal of Psycho–Analysis, 38, 266–275.Bion, W. (1959). Attacks on linking. International Journal of Psycho–Analysis, 40, 308–315.Bion, W. (1967). Notes on the theory of schizophrenia In Second Thoughts: Selected papers on
psycho–analysis. London: Karnac. (Original work published 1953)Blos, P. (1967). The second individuation process of adolescence. Psychoanalytic Study of the
Child, 22, 162–186.Bockoven, J. S., & Solomon, H. C. (1975). Comparison of two five year follow–up studies:
1948 to1952 and 1967 to 1972. American Journal of Psychiatry, 132 (8), 796–801.
PSYCHOANALYTIC CONTRIBUTIONS TO RECOVERY 307
Bollas, C. (1999). Occasional madness of the psychoanalyst. In The mystery of things (pp.140–148). London: Routledge.
Boyer, L. B., & Giovacchini, P. L. (1980). Psychoanalytic treatment of schizophrenic, borderlineand characterological disorders. New York: Aronson.
Braun, B. G. (1988). The BASK (behavior, affect, sensation, knowledge) model of dissocia-tion. Dissociation, 1, 4–23.
Ciompri, L. (1980). The natural history of schizophrenia in the long term. British Journal ofPsychiatry, 36, 413–420.
Ciompri, L. (1984). Is there really a schizophrenia? British Journal of Psychiatry, 145, 636–640.Coltart, N. (2000). Slouching towards Bethlehem . . . New York: The Other Press.Daniel, P. (2004). A phantasy of murder and its consequences. In E. Hargreaves and A.
Varchevker (Eds.), In Pursuit of psychic change: The Betty Joseph workshop. Hove, Eng-land: Brunner–Routledge.
Davidson, L. (2003). Living outside mental illness: Qualitative studies of recovery in schizophre-nia, New York: New York University Press.
Davoine, F., & Gaudilliere, J–M. (2004). History beyond trauma: Whereof one cannot speak,thereof one cannot stay silent. New York: Other Press.
Decety, J., & Chaminade, T. (2004). When the self represents the other: A new cognitiveneuroscience view on psychological identification. Consciousness and Cognition, 12,577–596.
Eigen, M. (1986). The Psychotic Core. Northvale, NJ: Aronson.Eigen, M. (2002) Rage. Middletown, CT: Wesleyan University Press.Epstein, L. J., Morgan, R. D., & Reynolds, L. (1962). An approach to the effect of ataraxic
drugs on hospital release rates. American Journal of Psychiatry, 119, 36–47.Fonagy, P. (1998). An attachment theory approach to treatment of the difficult patient. Bul-
letin of the Menniger Clinic, 62, 147–169.Fonagy, P. (2001). Attachment theory and psychoanalysis. New York: Other Press.Fort, D. (1990). Parent–child effects on performance, thinking, and communication in fami-
lies of normal and schizophrenic sons. In A. S. Silver and M. B. Cantor (Eds.), Psycho-analysis and Severe Emotional Illness. New York: Guilford Press.
Freud, S. (1955). Studies in hysteria. In J. Strachey (Ed. and Trans.), The standard edition of thecomplete psychological works of Sigmund Freud (Vol. 2). London: Hogarth Press. (Origi-nal work published 1895)
Freud, S. (1915). Instincts and their vicissitudes. In J. Strachey (Ed. and Trans.), The standardedition of the complete psychological works of Sigmund Freud (Vol. 14, pp. 117–140, 1957).London: Hogarth Press. (Original work published 1915)
Fromm–Reichman, F. (1959). Psychoanalysis and psychotherapy. Chicago: University of Chi-cago Press.
Gerhardt, S. (2004). Why love matters: how affection shapes a baby’s brain. New York: Brun-ner–Routledge.
Gibbs, P. L. (2004). The struggle to know what is real. Psychoanalytic Review, 91(5), 615–641.Gibbs, P. L. (2007). Analysands’ use of the internet and ordinary everyday psychosis. Psy-
choanalytic Review, 94(1), 11–38.Glenmullen, J. (2001). Prozac backlash: Overcoming the dangers of Prozac, Zoloft, Paxil and other
anti–depressants with safe effective alternatives. New York: Simon and Schuster.Gottdiener,W.H., & Haslam, N. (2002). The benefits of individual psychotherapy for peo-
ple diagnosed with schizophrenia: A meta–analytic review. Ethical Human Scienceand Services, 4(3), 163–187.
Harrison, G., Hopper, K., Craig, T. Laska, E., Siegel, C., Wanderling, J. et al. (2001). Recov-ery from psychotic illness: A 15 and 25 year international follow–up study. BritishJournal of Psychiatry, 178, 506–517.
308 GIBBS
Havens, L., & Ghaemi, S. N. (2005). Existential despair and bipolar disorder: The therapeu-tic alliance as a mood stabilizer. American Journal of Psychotherapy, 59(2), 137–147.
Healy, D. (2004). Let them eat Prozac: The unhealthy relationship between the pharmaceutical in-dustry and depression. New York: New York University Press.
Hinshelwood, R. D. (2004). suffering insanity, psychoanalytic essays on psychosis.. Hove, Eng-land: Brunner–Routledge.
Hopper, K., Harrison, G, Aleksander, J., & Sartiorius, N. (2007). Recovery from Schizophrenia:An International Perspective. Oxford University Press.
Jablensky, A., Sartorius, N., Ernberg, G., Anker, M., Korten, A., Cooper, J. E., Day, R., &Bertelsen, A. (1992). Schizophrenia: Manifestations, incidence and course in differ-ent cultures: A World Health Organization ten country study. Psychological Medicine(Monograph Supplement 20), 1–95.
Jablonka, E., & Lamb, M. (2005). Evolution in four dimensions: Genetic, epigenetic, behavioral,and symbolic variation in the history of life. Cambridge, MA: MIT Press.
Jackson, G. (2005).Rethinking psychiatric drugs: a guide for informed consent. Bloomington, IN:Authorhouse.
Jackson, M. (2001). Weathering the storms: Psychotherapy for psychosis. London: Karnac.Jacobson, E. (1971). Depression: Comparison studies of normal, neurotic, and psychotic condi-
tions. Madison, CT: International Universities Press.James, O. ( 2005). Review: International researchers conclude that child abuse is causal fac-
tor for psychosis and schizophrenia. The Guardian, October 22.Joseph, B. (1988). Projective identification—some clinical aspects. In E. B. Spillius (Ed.),
Melanie Klein today: Developments in theory and practice (Vol. 1). London: Routledge.Kane, B. S. (2005). Transforming trauma into tragedy: Oedipus/Israel and the psychoana-
lyst as messenger. Psychoanalytic Review, (92)6, 929– 956.Karon, B., & VandenBos, G. R. (1996). Psychotherapy of schizophrenia: The treatment of choice.
Aronson: New York.Kavanaugh, P. (2003). The dead poets society ventures into a radioactive analytic space.
Psychoanalytic Review, 90(3), 431–361.Kendler, K. S., & Diehl, S. R. (1993). The genetics of schizophrenia: A current ge-
netic–epidemiologic perspective. Schizophrenia Bullentin, 19(2), 261–285.Kernberg, O. (1976). Object relations theory and clinical psychoanalysis. New York: Aronson.Kernberg, O. (1984). Severe personality disorders: Psychotherapeutic strategies, New Haven,
CT: Yale University Press.Klein, M. (1946). Notes on some schizoid mechanisms. International Journal of Psychoanaly-
sis, 27, 99-110.Koehler, B. (2005). Personal Communication and Posting on the International Society for
the Psychological Treatments of the Schizophrenias and other Psychoses.(ISPS–US). Professional Listserv, March–May, 2005.
Krystal, H. (1988). Integration and self–healing: Affect, trauma, alexithymia. Hillsdale, NJ: TheAnalytic Press.
Krystal, H., & Petty, T. (1963). The dynamics of the adjustment to migration. PsychiatricQuarterly (supplement), 37(1), 118–133.
Lacan, J. (1993). The seminar of Jacques Lacan, book III: The psychoses (1955–1956), New York:Norton.
Laing, R. D., & Esterson, A. (1964). Sanity, madness and the family: The families of schizophren-ics. London: Tavistock.
Lehrman, N. S. (1960). A state hospital population five years after admission: A yardstickfor evaluative comparison of follow–up studies. Psychiatric Quarterly, 34, 658–681.
Lehrman, N. S. (1982) Effective psychotherapy of chronic schizophrenia, American Journalof Psychoanalysis, 42(2), 121–131.
Mitrani, J. (2001). Ordinary people and extra–ordinary projections: A post–Kleinian approach tothe treatment of primitive mental states. Hove, England: Brunner–Routledge.
Mosher, L. (2004). Non–hospital, non–drug intervention with first episode psychosis. InModels of madness: Psychological, social and biological approaches to schizophrenia. NewYork: Brunner–Routledge.
Odgen, T. (1989). The primitive edge of experience. New York: Aronson.O’ Shaughnessy, E. (1992). Psychosis: Not thinking in a bizarre world. In R. Anderson (Ed.).
Clinical lectures on Klein and Bion (pp. 89-101). London: Brunner–Routledge.Paquette, V., Levesque, J., Mensour, B., Leroux, J.–M., Beaudoin, G., Bourgouin, P., &
Beauregard, M. (2003). Change the mind and you change the brain: Effects of cogni-tive–behavioral therapy on the neural correlates of spider phobia. NeuroImage, 18,401–409.
Pepper, T. (2005). Talking to the demons: Schizophrenia is no longer seen as a geneticallypredetermined disease. Newsweek International (December 12, 2005), 52. GeneralReference Center Gold. Thomson Gale.
Pick, I. (1985). Working through in the countertransference, International Journal of Psycho-analysis, 66, 157–166.
Portin, P., & Alanen, Y. (1997). A critical review of genetic studies of schizophrenia. I: Epi-demiological and brain studies. Acta Psychiatrica Scandinavica, 95, 1–5.
Prien, R. F., Cole, J. O., & Belkin, N. F. (1968). Relapse in chronic schizophrenics followingabrupt withdrawal of tranquillizing medication. British Journal of Psychiatry, 115,679–686.
Prien, R.F., Levine, J., & Switalski, R. W. (1971). Discontinuation of chemotherapy forchronic schizophrenics. Hospital and Community Psychiatry, 22, 20–23.
Prouty, G. (2003). Pre–therapy, A newer development of schizophrenia. Journal of the Amer-ican Academy of Psychoanalysis and Dynamic Psychiatry, 31(1), 57–75.
Putnam, F. W. (1989). Diagnosis and treatment of multiple personality disorder. NewYork: Guilford Press.
Radke–Yarrow, M., Cummings, E., Kuczynski, L., & Chapman, M. (1985). Patterns of at-tachment in two–and–three–year olds in normal families and families with parentaldepression. Child Development, 56, 884–893.
Rappaport, M., Hopkins, H. K., Hall, K., Belleza, T., & Silverman, J. (1978). Are thereschizophrenics for whom drugs may be unnecessary or contraindicated? Interna-tional Pharmacopyschiatry, 13, 100–111.
Read, J., Goodman, L., Morrison, A. P., Ross, C. A., & Aberhold, V. (2004a). Childhoodtrauma, loss and stress. In Models of madness: Psychological, social and biological ap-proaches to schizophrenia. New York: Brunner Routledge.
Read, J. Seymour, F., & Mosher, L. R. (2004b). Unhappy families. In Models of madness: Psy-chological, social and biological approaches to schizophrenia. New York: Brun-ner–Routledge.
Read, J., van Os, J., Morrison, T., & Ross, C., (2005). Childhood trauma, psychosis andschizophrenia: A literature review with theoretical and clinical implications. ActaPsychiatrica Scandinavica, 112(5), 330–50.
Renee. (1994). Autobiography of a schizophrenic girl: The true story of “Renee” (with an analyticinterpretation by Marguerite Sechehaye). New York: Meridian.
Satir, V. (1967). Conjoint family therapy. Palo Alto, CA: Science and Behavioral Books, Inc.Schore, A. N. (2001). Effects of a secure attachment relationship on right brain develop-
310 GIBBS
ment, affect regulation, and infant mental health. Infant Mental Health Journal, 22,7–66
Schore, A. N. (2003). Affect Regulation and the repair of the self. New York: Norton.Scooler, N. R., Goldberg, S. C., Boothe, H., & Cole, J. O. (1967). One year after discharge
community adjustment of schizophrenic patients. American Journal of Psychiatry,123(8), 986–995.
Schröder, J., Bottmer, C., & Pantel, J. (2002). Are structural cerebral changes progressive inschizophrenia? In H. Hafner (Ed.) Risk and protective factors in schizophrenia: Towardsa conceptual model of the disease process. Darmstadt, Germany: Steinkopff Verlag.
Searles, H. (1965). Collected papers on schizophrenia and related subjects. New York: Interna-tional Universities Press.
Searles, H. (1979). Countertransference and related subjects. New York: International Univer-sities Press.
Segel, H. (1950). Some aspects of the analysis of a schizophrenic. In E. Bott Spillius, Ed.,Melanie Klein Today: Developments in Theory and Practice, Vol. 2. New York: Brun-ner–Routledge, 2001.
Silver, A. S. (1989). (Ed.). Psychoanalysis and psychosis. Madison, CT: International Universi-ties Press, Inc.
Silver, A. (2003). The psychotherapy of schizophrenia: Its place in the modern world, Jour-nal of the American Academy of Psychoanalysis and Dynamic Psychiatry, 31(2), 325–341.
Steiner, J. (1993). Psychic Retreats: Pathological organizations in psychotic, neurotic and border-line patients. London: Routledge.
Sullivan, H. S. (1962). Schizophrenia as a Human Process. New York: Norton.Suomi, S. (1997). Aggression, serotonin, and gene–environment interactions in rhesus
monkeys. In J. T. Cacioppo and G. G. Bernston (Eds.), Essays in neuroscience. Cam-bridge, MA: MIT Press.
Teixeira, M. A. (1997). Problematics of specificity and assessment of psychosocial risk factors in thepathogenesis, course, and treatment of schizophrenia (and affective disorders). Paper pre-sented at the 12th International Symposium for the Psychotherapy of Schizophre-nia. London, October 12–16.
Tienari, P. (1992). Interaction between vulnerability and rearing environment. In A.Werbart, and J. Cullberg (Eds.), Psychotherapy of schizophrenia: Facilitating andobstuctive factors (pp. 154–178). Olso: Scandinavian University Press.
Turk, C. (2006). Personal Communication.van der Kolk, B. A. (1996). The body keeps the score: Approach to the psychobiology of
posttraumatic stress disorder. In B. A. van der Kolk, A.C. McFarlance, and L.Weisaeth (Eds.), Traumatic stress: The effects of overwhelming experience on the mind,body and society (pp. 214–241). New York: Guilford Press.
Ver Eecke, W. (2001). The usefulness of the theory of DeWaelhens/Lacan as an effective ap-proach to schizophrenia, after the decade of the brain. (Chapter One.) In A.DeWaelhens, and W. Ver Eecke Phenomenology and Lacan on schizophrenia, after thedecade of the brain (pp. 37–123). Leuven, Belgium: Leuven University Press.
Ver Eecke, W. (2003). The role of psychoanalytic theory and practice in understanding andtreating schizophrenia: A rejoinder to the PORT report’s condemnation of psycho-analysis. Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry,31(1), 11–29.
Verhaeghe, P., & Vanheule, S. (2005). Actual neurosis and PTSD. Psychoanalytic Psychology,22(4), 493–507.
PSYCHOANALYTIC CONTRIBUTIONS TO RECOVERY 311
Villemoes, P. (2002). Ego–structuring psychotherapy. Journal of the American Academy ofPsychoanalysis, 30(4), 645–656.
Volkan, V., & Akhtar, S. (1997). The seed of madness: Constitution, environment, and fantasy inthe organization of the psychotic core. Madison, CT: International Universities Press.
Wahlberg, K., Wynne, L. C., Oja, H., Keskitalo, P., Pykäläinen, L., Lahti, I., Moring, J.,Naarala, M., Sorri, A., Seitamaa, M., Läksy, K., Kolassa, J., & Tienari, P. (1997).Gene–environment interaction in vulnerability to schizophrenia: Findings from theFinnish adoptive family study of schizophrenia. American Journal of Psychiatry,154(3), 355–362.
Waterland, R. A., & Jirtle, R. L (2003). Transposable elements: Targets for early nutritionaleffects on epigenetic gene regulation. Molecular and Cellular Biology, 15, 5293–5300.
Whitaker, R (2002). Mad in America: Bad science, bad medicine, and the enduring mistreatment ofthe mentally ill. Cambridge, MA: Perseus.
