PSYCHOTHERAPY IN SCHIZOPHRENIA

The individual with schizophrenia, while completely disconnected with psychotic states, experiences immense anxiety while seeking the ways  of showing reality.

DR. Meral AYDIN

Grandiose delusions, paranoia, cognitive functions, and personality deterioration, first defined by ancient Greek doctors in history, even though they defined them, it was first expressed in the 19th century that schizophrenia is a medical condition that should be examined and treated. Emil Kraepelin and Eugen Bleuler researched this disorder in the fields of psychiatry and neurology. Kraepelin defined the expression démence précoce first proposed by Benedict Morel for schizophrenia as dementia praecox (early dementia), classifying it as a manic-depressive psychosis with periods of normal functioning and attacks (Kaplan & Saddock 2016).

Eugen Bleuler preferred to use the term schizophrenia to emphasize the existence of a split between thoughts, emotions, and behaviors in patients with this disorder. The symptoms he defined as the Four A’s are: disturbances in thought and associations, disturbances in affect, autism, and ambivalence. Secondary accompanying symptoms were hallucinations and delusions as defined by Kraepelin (Kaplan & Saddock 2016).

Freud stated that schizophrenia originates from important developmental functions that appear early in life. Developmental fixations cause disturbances in ego development, and this contributes to the formation of schizophrenia symptoms. The defective development of the ego disrupts the person’s control over drives such as sexuality and aggression and also distorts the evaluation of reality. Intrapsychic conflicts resulting from impaired ego functioning and ego deficits arising from insufficient early object relations cause psychotic symptoms (Kaplan & Saddock 2010).

Margaret Mahler noted that distortions in mother-child relationships, in processes of separation and rapprochement from the mother, lead to a type of dependency and inability to be autonomous, causing the person's self-identity fails to establish a secure foundation. Stack Sullivan emphasizes schizophrenia as a disorder of interpersonal relationships and points out that avoidance, due to anxiety toward closeness and relatedness, sometimes leads to persecutory distortion. According to Sullivan, he defines schizophrenia as a method of adaptation formed to escape panic, terror, and disintegration of the sense of self. He states that the source of pathological anxiety is the accumulation of traumatic experiences during development (Kaplan & Saddock 2016).

Psychoanalytic theory emphasizes that the various symptoms of schizophrenia have specific symbolic meaning for each patient. For example, fantasies that the end of the world has come may indicate that the person’s inner world has been disrupted. Hallucinations may have replaced the insufficiency in dealing with objective reality and may reflect internal fears and desires. Delusions are similarly regressive, may be an attempt to reconstruct reality, or a manifestation of hidden fear impulses. After the patient’s self-esteem is damaged, it can become grandiose (Kaplan & Saddock 2016).

The common expression of all theories is that human relationships can create internal horror and dissociative anxiety for people with schizophrenia.

Studies on the effectiveness of psychotherapy in schizophrenia show mixed results. On the other hand, we know that having someone to trust and rely on in the lives of individuals with schizophrenia is an indispensable main pillar of treatment, in terms of contact with reality and evaluation of psychotic states (including their own ability to evaluate). At this point, therapy with a therapist with whom a therapeutic alliance will be established and sustained over a long period will be effective in ensuring that the individual maintains a constant and sustainable ground in relation to themselves and the real world, and maximizes functionality in their relationships with themselves and the world.

At this point, I want to emphasize that therapy conducted without psychiatric monitoring and medication is not safe. The psychotherapy of individuals with schizophrenia is a type of work that is carried out integrated with the psychiatric and medical treatment process and through reciprocal communication. Because these individuals may not be willing to convey their psychotic states and may even be unable to distinguish this condition within themselves.

In therapy, the essential thing is that the individual can develop distinguishing mechanisms between the real reality related to the outer world and themselves, and the distorted reality they have created in their psychotic world. At the point where we discuss reality testing. We need to focus on ego capacity and ego functioning. The ego is the individual’s awareness of their own physical and psychological changes, both sensed and experienced, and in relation to the ego’s most important function, the capacity for integration, it needs to regulate the feelings (either calming or maintaining depending on the situation) and develop healthy, mediating defense mechanisms that the self can give to the outer world.

At this point, the ego of an individual with schizophrenia does not function properly, and the ego deficits we will discuss are: 1.) weak reality perception, 2.) impulse control, 3.) low tolerance of frustration, 4.) ego boundaries.

However, beyond ego deficits in individuals with schizophrenia, in psychotic states (under the influence of delusions and hallucinations), the ego is completely split and the individual’s connection with their own reality is broken. In psychotic states, the functional ego is entirely offline, and the person evaluates themselves and the worldly reality through their psychotic reality construction. Although psychotic states have an internal coherence, the connection with functional ego capacity is lacking.

At this point, what I want to emphasize: to reach a psychotic person and gain their trust, it is first necessary to communicate through the psychotic world they bring. Otherwise, the reality you propose may be perceived as threatening, or the anxiety brought by this reality may strengthen the psychotic state further. Therefore, distinguishing delusions is particularly difficult because a delusion is highly organized, continuous, and systematic in itself.

The first goal in therapy is to help the individual with schizophrenia develop understanding and comprehension of their psychotic side, but never become a part of that psychotic world. The therapist, aware that the individual’s psychotic world is a false reality interpreted by them, can only proceed by ensuring that communication occurs through that reality.

In psychotic states, especially, trying to make the person accept reality or taking a position that rejects the individual’s distorted reality creates anxiety. Anxiety always disrupts healthy ego functions, and the individual increasingly withdraws into their psychotic depths.

Character analysis is not done in therapy with individuals with schizophrenia. An attempt is made to build a bridge between the person’s psychotic aspects and reality. In this context, a psychoanalytic working model called mentalization can be applied (Bateman & Fonagy 2004).

Especially in borderline personality disorder, this method, which is very effective in working with the person’s reality distortions, evaluations, and self-centered aspects distant from intersubjective understanding, can serve as an important buffer in helping individuals with schizophrenia both in their inner world and in understanding the outer world. In therapies planned more toward improving social adaptation and daily functioning, healthy behavior development, development of social cognition skills, reduction of anxiety in interpersonal relationships, and addressing issues such as stigma or the ability to feel part of the community should be included. At this point, group therapies focused on social cognition and interaction, and especially individual therapies focusing on developing social cognitive capacities, may be more effective (Wang & Friends 2013).

It is extremely critical to address the effects of stigma due to the illnesses that individuals with schizophrenia face throughout their lifetime, and to prevent the individual’s tendency to self-stigmatize. Ultimately, while realizing the psychotic world in which the individual is stigmatized, developing and addressing their healthy and functional aspects represents the real and healthy world.

The individual’s ability to orient toward society and interpersonal relationships, and to establish as much stability and continuity as possible, will serve as an anchor connecting the patient to the real world. Because schizophrenia progresses more destructively when withdrawal and social isolation are not prevented. In short, for an individual with schizophrenia, who cannot establish a consistent, realistic, and reliable relationship with themselves and the outer world, continuous relational support for their pathological and psychotic internal aspects is necessary to establish a kind of healthy auxiliary ego function.

In therapy with individuals with schizophrenia, one must approach them very carefully. Imagine: even as healthy individuals, we struggle to manage our feelings between our own reality and outer reality, so searching for ways for a person with schizophrenia to navigate between completely disconnected psychotic states and reality creates immense anxiety. Despite all these difficult conditions, those who, at the onset of symptoms, quickly begin psychiatric and medication treatment, continue this treatment regularly with follow-ups, receive therapy, and have social and emotional support, can maintain a relatively functional life to a certain extent.

This article was published in Psikeart Journal, Issue 96, a special issue dedicated to the theme of Schizophrenia.

References:
Sadock, B. J., Sadock, V.A., Ruiz, P. (2016). Kaplan & Sadock Psychiatry Behavioral Sciences/Clinical Psychiatry.Ankara: Gunes Medical Bookstore (Eleventh Edition)

Bateman, A., Fonagy, P. (2004). Psychotherapy for Borderline Personality Disorder. Oxford University Press

Wang, Y., Roberts, D. L., Xu, B., Yan, M., & Jiang, Q. (2013). Social Cognition and Interaction Training for Patients with Stable Schizophrenia in Chinese Community Setting. Psychiatry Research, 210(3), 751-755. DOI: 10.1016/j.psychres.2013.08.038