Special Report: Psychotherapy for Patients With Schizophrenia—A Specialized Practice

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More surprised than physically hurt, I found myself sitting on the cold floor of a patient interview room at St. Elizabeths Hospital in Washington, D.C. Without benefit of a desk between us, I had begun to interview Mr. Arnold, a new patient who turned out to be a talented boxer and who jumped up and decked me with a right uppercut, proclaiming that I was his enemy.

This was a rare incident, and it should not be assumed that people with schizophrenia are excessively dangerous or violent. That worry applies to antisocial criminals and, sad to say, acutely intoxicated people in bars or cars. But it did teach me to use a desk and have a safe interviewing situation when seeing new patients. Not many weeks later, in the outpatient clinic, Mr. Arnold and I had a mutual chuckle after his apology for the punch amid his thanking me for taking him out of “that bad place”—by that, I think he was referring both to his delusional state as well as the inpatient unit at St E’s.

In this article, I provide some practical advice about psychotherapy for people diagnosed with schizophrenia. My goal is to help psychiatrists at all stages of their careers to provide effective care; I will also indicate reasonable expectations of people with schizophrenia and their families during treatment.

If, as I did, you began your experience with schizophrenia by seeing seriously ill patients in the hospital, be aware that you were seeing the most severe manifestation of those illnesses, and the greatly troubled and unwell people you see in the hospital may be radically better when you see them later with their psychosis/blood glucose/cholesterol under control. As I discovered with Mr. Arnold, a distrustful, paranoid therapist-patient relationship may turn into a trusting and collaborative one in time with mutual investment.

Understanding the international knowledge base regarding what we call “schizophrenia” will influence what you consider to be appropriate therapeutic interventions, especially the way medications and psychotherapy interact. Therapy/medication interactions are powerful, and how clinicians talk to patients about their concerns or their objections can make all the difference. APA Publishing has a good resource on this subject by Michelle Riba, M.D., et al. called “Competency in Combining Psychotherapy and Pharmacotherapy, Second Edition.”

In any training program, you will have learned the basic types of psychotherapy that have proved useful for most mental illnesses such as schizophrenia. You should also have learned about the many adjunctive treatments such as psychoeducation, social skills training, cognitive remediation, family therapies, peer group support, positive psychology, mindfulness, metacognitive training, and newer attitudes regarding normalization of hallucinations and the recovery-oriented perspective on treatment. A quick introduction can be found in “The APA Publishing Textbook of Schizophrenia, Second Edition” by Jeffrey Lieberman, M.D., et al. If it takes a village to raise a child, then it takes an interdisciplinary team to effectively address all the issues experienced by patients with schizophrenia.

A History of Pessimism About Therapy

Perhaps this begs the question of whether you think it is worthwhile to engage patients with schizophrenia in psychotherapy, which takes a much greater commitment than simply providing medications or so-called simple medication-related psychotherapy. Pessimism about psychotherapy for people diagnosed with schizophrenia dates from the time of Sigmund Freud’s case study of Daniel Schreber. However, Freud never treated Judge Schreber, who did have some periods of long-term therapy from Professor Paul Flechsig. There are many monographs such as those by Frieda Fromm-Reichmann, Gaetano Benedetti, Gerard Hogarty, and Andrew Lotterman. While dated in many respects, they still provide helpful insights into how to work with and relate to people with schizophrenia.

It is probably true that there was an overriding pessimism about the value of psychotherapy for patients with schizophrenia until the encouraging work on the application of cognitive therapies by David Kingdon, Douglas Turkington, and colleagues. A review by Faith Dickerson, Ph.D., and Anthony Lehman, M.D., M.S.P.H., in the August 2011 Journal of Nervous and Mental Disease also presents evidence for personal therapy, acceptance and commitment therapy, compliance therapy, narrative therapy, and (my favorite) supportive psychotherapy. I favor it because it emphasizes “here-and-now” interventions rather than historical interpretations and can have immediate effects in improving self-esteem and skills to cope with illness.

The therapies mentioned cover a lot of ground, so in Table 1 I describe some of their defining characteristics and how they would typically help people with schizophrenia experiencing hallucinations.

Goals of Psychotherapy

The authors mentioned above indicate that the goals of psychotherapy include providing emotional support, enhancing functional recovery, and altering the disease process. While these goals may be the same as the goals of patients with other disorders or problems, such as resolving family conflicts and achieving one’s maximum potential in life, a strong motivator for people with schizophrenia to engage in psychotherapy—and one that you can emphasize when there is any uncertainty—is their distress at the often frightening or bizarre and confusing symptoms of their condition.

In Table 2, I have given a fairly comprehensive list of potential goals in the psychotherapy of people with schizophrenia.

Addressing Roadblocks in Therapy

Despite the intrinsic motivations and recent interest in psychotherapy for people with schizophrenia, not all of these patients are interested in therapy. The reasons for this may vary: Some patients simply may not be able to derive benefit from significant talk therapy sessions due to the current symptoms of illness or their inherent inability to engage in therapy. Others, however, may be able to benefit from psychotherapy but experience obstacles to proceeding with the therapy. For example, the patient may be paranoid, distrusting, or dismissive of the therapeutic relationship. Consider another of my experiences.

A patient I had been seeing for a few months in the clinic told me that he went fishing every week. I did know something about saltwater fishing, but I was less familiar with lake fishing so I asked him about some of the lures he used. After I had asked a few questions, he bristled at me: “Please, doctor, I know you don’t care about what I use for my fishing. It is just a waste of time. Just give me my medicine, and let me out of here!” Which I did.

In this case, as with all situations in which I found a negative relationship issue, I needed to determine whether the patient was basically right—that is, that I really wasn’t interested in his fishing lures—or, conversely, that he perceived an interest that was “too close” and created some unacceptable feeling. In addition, perhaps he was developing some paranoid attitudes toward me. I have often pointed out to students that people with schizophrenia are frequently more skilled than we think in reading the emotions on our faces and pick up on our end-of-day boredom and the like. When patients are right, we should be gracious enough to admit it. However, my well-intended but failed attempt was to engage discussion in the nondelusional or nonconflicted sphere of my patient’s life at a time when a discussion of his delusions would be too conflictual.

A Recent Approach

A synthesis of cognitive-behavioral methods with more traditional psychodynamic techniques is presented by Michael Garrett, M.D., in Psychotherapy for Psychosis: Integrating Cognitive-Behavioral Treatment and Psychodynamic Treatment (Guilford Press, 2019). He advocates the initial use of cognitive therapy to reduce delusions followed by the gradual introduction of psychodynamic therapy, which enables patients to find symbolic if not literal truth in the delusions they experience. Dr. Garrett sees much value in recognizing the origin of psychotic beliefs in previous traumatic experiences. The preponderance of trauma in the histories of our patients is, of course, a given. Trauma needs to be assessed and addressed from the start of psychotherapy, but it is not always true that it explains the development of psychosis. More recent research is turning to specific theories of neurological structures.

Although you probably took a statistics course sometime in your training, I suggest you receive as much training as possible in understanding the advanced statistics involved in current psychotherapy research studies running the gamut from small studies, retrospective analyses, randomized controlled trials, to complex meta-analyses. Otherwise (1) you will probably avoid looking at the current research and (2) you won’t be able to use evidence-based data to make treatment decisions. I recommend taking a look at the reports of the Cochrane Collaboration, which is rather conservative in recommending therapeutic interventions that are not strongly supported by adequate trials. For example, review Cochrane’s reports on schizophrenia and delusional disorder.

Addressing Psychosocial Issues

Learn to work without resentment with health care professionals in disciplines other than your own. As a team, you must address the full range of your patients’ psychosocial issues—for example, estrangement from family, nonadherence with treatment recommendations, homelessness, and criminal justice involvement. The relationship of mental illness to criminality is still a subject of much argument among advocates for better treatment of people with mental illness and opponents of incarceration.

In learning about all these connections, know that you are building the basis for a lifelong practice. However, the “lifelong” part of it also applies to getting to know the life course of people with schizophrenia; the good news is that they generally improve as they get older, although they have to deal with the social isolation and financial problems that come about with aging. So, even if you see yourself primarily as a medication manager, think about taking on a few long-term psychotherapy patients with diagnoses of schizophrenia. If you can’t, then at least try to do psychotherapy with people with schizophrenia of different ages, degrees of severity, or specific stages of illness.

A Key Variable

As I found out when talking with my fisherman patient, the therapist-patient relationship is a key variable in psychotherapy outcome, and you should be aware of this, cultivate it, and address possible deficiencies in it at every turn. You can say, “If you begin to suspect me of something, which might mean you’re getting paranoid again, it would be better to come in and tell me about it rather than stay away from your appointment.” Simply learning what is to be called paranoia—having a common language for talking about symptoms—is one of several factors that recovered patients believed enhanced their psychotherapy, according to a report by Jone Bjørnestad, Ph.D., and colleagues in the September 2018 Frontiers in Psychology.

Psychoeducation Is Aid to Therapy

Establishing the initial relationship can be a real off-putting challenge. Often delusional patients present a classic “lose/lose” dilemma. If you agree with their delusions, then you are eventually going to be mistrusted even if it facilitates the initial relationship, but if you argue against the delusions, they will say “Why don’t you believe me? What is the point of seeing you. Goodbye!” You can address this dilemma by telling patients that it is simply too early to give them an answer about their beliefs and that you are very much interested in learning about them and how they have come to believe what they do. Emphasize that it would be unfair for you to draw any conclusions about their beliefs until you know them considerably better, which will take several sessions at least.

As suggested above, some people with schizophrenia want to take medication occasionally or not at all. You need to ask yourself whether you are willing or able to continue to work with patients when they are not taking their medication. Despite the disadvantages, antipsychotics are still a mainstay of therapy for most people with psychotic illnesses. The benefits (and concomitant disadvantages) of living with voices and living without medications are of growing interest, but I am still uncomfortable with the wholesale rejection of medication for some patients; this often accompanies the belief that being psychotic is just another mode of being that causes no problems whatsoever in their lives.

People with schizophrenia often show ambivalence when making decisions, so it helps to explore that ambivalence and strengthen the side that concurs with appropriate nonpsychotic reality testing. Building on the therapist-patient relationship by sharing our own reasoning with them can help to improve their reasoning abilities.

Psychoeducation plays a vital role in the therapy of schizophrenia. There are many things that patients do not know and need to know about having schizophrenia, and part of your job is to teach them. This includes telling them that everybody is an individual. That is to say: Although they have been diagnosed with an illness called schizophrenia, there are still many differences between one person with schizophrenia and another. Some people are never hospitalized, and some are hospitalized 10 times a year. Many people struggle with suicidal thoughts, and some become dangerous to others (“and you don’t want to get that way, do you?”). There is an old joke about a person with schizophrenia that ends “I may be schizophrenic, but I’m not stupid,” and it reminds us that people with schizophrenia often have good memories and can usually be reminded of what they were thinking when they were at their most delusional and getting into trouble because of it. The time to remind them of that is when you are seeing them as an outpatient and they are beginning to get delusional again.

Working Toward Insight

Learn to avoid dogmatic positions—not just about medication—but about the “insights” that you consider important at various stages of psychotherapy. Spend more time than you think you should letting patients argue with you, even if you think they are doing so because they are delusional. In conjunction with this, develop an understanding of how to “stage” the fixation or treatability of delusions and save more aggressive interpretations for stages such as what is called the dual awareness phase of the illness, when there is greater cognizance by the patient of what is traditionally called “observing ego” or reality testing that their beliefs are not founded in reality. Learn to explore patients’ evidence both for and against their delusions, which can form the basis for challenging them at the appropriate stage. For example, on what basis does a paranoid person “decide” he needs to preemptively strike back at an imagined adversary because of a hallucination he has experienced? Does the hallucination make that person a genuine threat to him? Question it.

The same advice applies for addressing supposed connections between hallucinations and dangers to oneself. You can ask: “Why would you hurt yourself just because you hear a voice on TV telling you to do so?” When I posed that question to one of my patients, she said that the voice threatened to send her to hell if she did not comply. Thus, I knew there was a reason she would hurt herself. Such therapies as acceptance and commitment therapy can be used to help teach patients to accept their hallucinations without acting on them. Of course, if there is a definite plan to strike out, you must address the safety issues. In cases of suicidal thinking, various measures for bolstering self-esteem can counteract the esteem-lowering statements of hallucinated voices.

Command Hallucinations

A major piece of knowledge concerns what to say and do about command hallucinations, especially when to take them seriously. Over the years, the consensus on this has evolved from advice to respond strongly (often with hospitalization) when hearing about dangerous commands to generally becoming tolerant of many of them. The declining number of available psychiatric hospital beds has certainly lessened the ability to hospitalize dangerous patients and has led researchers to attempt to quantify the risks created by command hallucinations. Fortunately, the growing body of research gives more tailored advice about when and when not to hospitalize a patient with command hallucinations. Simply hearing some commands is not an absolute reason to hospitalize a patient, and if you do, you will soon learn that the patient will be discharged while still having some elements of psychosis and possibly even hearing the same commands. Thus, it is important to apply judgment based on the current research about command hallucinations, for example, whether commands are chronic or there has been an acute change. For example, one of my patients had unremitting commands to drive his car through the White House gates. Of course, the response to this would have been fatal for him, but he sold his car so the command could not be obeyed. (We checked to make sure that he did not rent or borrow a car.) In contrast, we hospitalized many people who had traveled to Washington to “see the President.” It is more useful to challenge dangerous delusions—which in the case of schizophrenia are usually inferences from hallucinations—rather than the perceptual reality of the hallucinations themselves.

Updating and Developing Your Skills

As you follow any research on the understanding or treatment of schizophrenia, it is important to ask yourself this: “Have I learned to be wrong (as rare as that may be!) and update my knowledge base with new practices?”

I recommend that you consider yourself to be eclectic; nearly all psychotherapists do. Learn to combine various tried-and-true or mix-and-match methods (even if they seem to rest on incompatible theories) perhaps in creative ways, to reach difficult-to-treat people. The existence and efficacy of what are called the common factors in psychotherapy such as a strong and positive therapeutic alliance are now well known, even if this fact seems to grate against the egos of some of the more idiosyncratic psychotherapists who think that their approaches are uniquely theirs. But don’t think that your value as an individual is degraded by the efficacy of common factors. Your ability to relate individually to your patients is one of the common factors that you create personally through your caring and effortful behaviors and investments in your patients.

Consider what you have to do to reach your patients. Maybe they are not an open book; maybe they are like a locked diary. Regardless, there is a key or keys, or perhaps it is more like a safe that requires a diligent search for the combination (or convincing patients to give you the combination). Develop a repertoire for dealing with what many therapists (but not the motivational interviewers) call “resistance” such as objections to medication or reasons that an individual avoids coming into appointments.

Having Reasonable Expectations

Don’t get overly confident or even arrogant that your personal but unduplicated methods work in all cases. There is a tendency called apophenia in psychotic people to find connections between events that are not connected. Don’t fall prey to believing that you have found some remarkable technique that cured your patient. However, in general you should review your practice and seek genuine outcome measures if you have enough cases to make it worthwhile, and avoid the biases you teach your patients during cognitive therapy to avoid, for example, attributional bias and neglect of negative evidence.

Learn to be satisfied with only modest gains and even to live with a lack of success in your psychotherapy. If there is a failure, be prepared to do your own “root cause” analysis even if it is not required for other reasons. And there will be other reasons: you should be prepared to deal with first-episode post-psychotic depressions and suicidal behaviors because the illness can be devastating in some people. Document for yourself or others your recommendations or reasons for recommendations.

Career Improvement Recommendations

Be cognizant of what are called “burnout” issues, that is, the loss of efficacy in treatment and satisfaction in your work, so you can continue to be effective and continue to find satisfaction in your work. And if you have time, I suggest you do some teaching, writing, and mentoring and put together some case studies of your successes (and failures) in psychotherapy for people with schizophrenia. This should also include a look at the ethical and policy issues of giving people the time they need for psychotherapy. How much time can be made available in private versus public mental health practices? Since there are so few inpatient units, any cost savings must be made in the various levels of outpatient programs, for example, in moving an individual from an intensive supported housing arrangement into independent living. In the criminal justice field, in which I have had much experience, I recommend more psychotherapy (in addition to any appropriate medication management) for both short-term and long-term residents with mental illness, which has cost and quality-of-life implications by addressing the personal and social dysfunctions of criminal behavior and preventing recidivism. ■

In Closing

I did not find it possible to say everything I wanted to say about psychotherapy for schizophrenia in the text of this article, but I thought it would help to re-emphasize and elaborate on some points in Table 3. ■

^{Author Disclosure Statement}

^{Peter Novalis, M.D., receives royalties from APA Publishing.}

Peter N. Novalis, M.D., Ph.D., has more than 30 years’ experience treating people with serious mental illness, mostly in the public sector. He has primarily been a clinician with a long-term interest in supportive psychotherapy. He is the author of Clinical Manual of Supportive Psychotherapy, Second Edition, from APA Publishing. APA members may purchase the book at a discount.