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VOLUME 3, ISSUE 3 PSYCHNEWS INTERNATIONAL Sept/Oct 1998
-- AN ONLINE PUBLICATION --
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SECTION D: THE FIFTH COLUMN
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Note: The Fifth Column is a regular, independent column
written by Jeffrey A. Schaler, Ph.D.
For this issue, Dr. Schaler has invited his colleague,
Louis B. Fierman, M.D., to contribute to the Psychnews as
a guest columnist.
Opinions and comments are invited. Please send them to
the PsychNews Int'l mailbox: psychnews@psychologie.de
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1
YOU'D BE PARANOID TOO IF EVERYONE WERE AGAINST YOU
Louis B. Fierman, M.D.
Cure in psychotherapy can be conceptualized as a
clinical triad: relief of symptoms, optimum social
adjustment, and enhanced creativity. The relief of
symptoms and improvement in social adjustment do not
necessarily require a basic transformation of the
patient's character. The release or enhancement of
the patient's creativity usually does require such a
transformation.
What is meant by "cure" in psychotherapy?
Neither more nor less than the meaning of the word
"cure" as it is used in general medical therapeutics:
The patient has become free of signs and symptoms of
illness even though he remains always partially or
totally vulnerable to recurrence of the same, similar,
or related illness. The use of the word or concept of
"cure" usually relates to the statistical probability
of recurrence. Thus, symptom-free addicts or cancer
patients are usually regarded as "arrested" rather
than "cured" until several years have elapsed, whereas
symptom-free patients treated for fractures or
bacterial infections are regarded as cured because of
the low probability of relapse.
Every illness represents a complex resultant
phenomenon, reflecting the interaction between the
forces of external or internal stresses impinging on
the patient's homeostasis versus the forces of the
patient's resistance/vulnerability factors. Some
illnesses reflect maximum external stress versus
minimum internal resistance; for example: traumatic
injuries, gunshot wounds, poisoning, and so forth.
Other illnesses reflect relatively minimal stress
versus maximum resistance/vulnerability factors; for
example: allergies, genetic diatheses, diabetes,
congenital disorders, and the like. Most illnesses
fall somewhere in between these extremes. So-called
mental illnesses reflect symptomatic and maladaptive
reactions to varieties of psychological stress. These
are conditioned by faulty social learning during and
beyond childhood interacting with inherited and
acquired vulnerabilities and susceptibilities at the
biochemical and neurophysiological level of
functioning, including aberrations of neurotransmitter
biochemical mechanisms at the synaptic cleft.
"Cure" as used here means relieving, changing, or
removing the signs and symptoms of mental illness,
restoring or establishing norms of psychic
functioning, reducing the probabilities of future
recurrence and relapse, and, finally, promoting
previously unrealized potentialities for optimum
psychosocial and creative functioning. Effective
psychotherapy can, and does, achieve "cures" with
mental illness; there is no scientific basis for the
persistent myth that mental disorders are incurable.
Recurrence, relapse, or new mental disorders may occur
with any individual patient, and future stresses may
not be prevented or eliminated, but, hopefully, stress
tolerance will be increased and recuperative powers
enhanced.
The goal of effective psychotherapy is to achieve
the clinical cure-triad of (1) relief of signs and
symptoms, (2) optimum social adjustment, and (3)
enhanced creativity. The relief of neurotic symptoms
such as anxiety, depression, dissociation, obsessions,
compulsions, phobias, and addictive states is the most
easily achievable component of the clinical triad of
cure. This is because neurotic symptoms are readily
influenced by the status of the transference-
countertransference relationship between therapist and
patient. Neurotic symptoms are manifestations of
underlying character neuroses and are by their nature
labile, interchangeable, and negotiable. Patients
frequently appear willing to give up their symptoms in
exchange for what they experience as nurturance and
dependency gratification from the therapist. Symptoms
may be reduced or removed by a wide variety of
therapist interventions including
psychopharmacotherapy, either directive or
nondirective psychotherapy, suggestion, hypnotherapy,
behavior modification therapy, authoritarian
relationships, and chance experiences. Unfortunately,
relapse and recidivism usually characterize the
outcome of therapies that do not address or affect the
patient's basic personality and character pathology.
Social adjustment is the second major index of
psychological health or disorder and, like neurotic
symptoms, it is also reflective of the patient's
underlying character pathology. It may be more
difficult to achieve, however, than symptom removal
via psychotherapy. Trouble with the law, delinquency,
antisocial behavior, crime, and poor interpersonal
relationships are all examples of social adjustment
pathology. As with neurotic symptoms, social
adjustment may be influenced by a wide variety of
therapist interventions, including both directive and
nondirective therapies. As with neurotic symptoms,
patients may improve their social adjustment in
exchange for perceived approval, indulgences, and
dependency gratification from their therapists. In
addition, as with neurotic symptoms, relapse and
recidivism are likely to occur unless the therapy
successfully addresses and affects basic personality
and character structure and releases human potential
for integrated autonomous functioning.
The third and most crucial component of the
clinical triad of cure relates to the patient's basic
character structure, namely, the enhancement of the
patient's creativity and the achievement of his
integrated autonomy. Effective psychotherapy frees
the human spirit and results in a person who is
creative, loving, independent and comfortably
interdependent with others, spontaneous and more fully
utilizing his innate talents and aptitudes, and
willing to take risks in pursuing personal,
gratifying, and socially-relevant interests. When
this quality of cure is achieved, relapse does not
occur unless the patient's threshold for stress is
subsequently overwhelmed by unusually intense and
adverse pressures of life.
In summary, effective psychotherapy can be
regarded as curative if it results in a patient free
of neurotic signs and symptoms, maintaining optimum
social adjustment, and manifesting enhanced autonomy
and creativity for at least one year following
termination of therapy.
CASE VIGNETTE
This is the story of a paranoid schizophrenic
patient whom I have been treating for the past eight
years. Gradually, over the years I heard less and
less from him about persecutory delusions, and now for
the past two years he seems completely free of any
delusions or other signs of thought disorder.
Throughout his psychotherapy with me he firmly refused
any psychotropic medication.
Jozeph Kerenski was a 60-year-old, married,
unemployed Polish immigrant, referred to me by his
chiropractor who had heard of me from other patients
of his. At our first meeting he proved to be a short,
wiry, casually dressed, intense, gray-haired man who
strode into my office, thrust out his hand for a
handshake and, in broken English with a heavy Polish
accent, said, "My name is Jozeph Kerenski and
somebody's trying to kill me!"
Jozeph went on to explain that for several years
he was being painfully "zapped" by laser beams aimed
at his back, stomach and genitals. He attributed
these beams as coming from a hostile witch. His
family doctor found no organic pathology to account
for the pains so Jozeph finally sought help from his
chiropractor who persuaded him to see me. I suggested
antipsychotic medication but he adamantly refused. "I
don't need pills. I need help to stop these beams
before they kill me."
"Look, Jozeph," I said, "I don't believe such a
thing as being tortured by laser beams is possible,
but since you are having pain that doctors seem unable
to explain or treat, I would agree with your
chiropractor that psychiatric treatment may be of
help." And so began a psychotherapy that has
continued over the past eight years. In therapy he
has always been actively communicative. He filled his
early hours with vivid accounts of laser beams aimed
at him from a distance and penetrating his body,
usually at night, causing pain in his back, chest,
abdomen and groin.
I listened passively and chose not to challenge
his delusional talk but, instead, conveyed my interest
in everything and anything he chose to bring to his
therapy hours. His life history gradually emerged
haphazardly over the weeks and months. He did not
know who his father was. He was born in a small
farming village near Warsaw. His teen-age mother
brought him to the village convent and he was raised
by the nuns there. He attended a local school but
left after the sixth grade and worked as the convent
gardener. As a teen-ager he became sexually active
with girls from the village. At age 18 he was drafted
into the Polish army and although he did not
experience combat he was kept in a military prisoner
camp for two years after the Nazis overran Poland.
When released he returned to the convent as its
gardener. A marriage broker sought him out to arrange
a marriage with an American-Polish woman who was
seeking a husband. She came by plane to Poland,
married him and they then returned to her home in New
Haven, Connecticut. They had three children, now
grown and living separately. But when they were small
he worked in a local garden nursery while his wife
worked as an office clerk in a local department store.
To help care for their children her widowed mother had
moved in with them.
"Doctor, she turned out to be the witch!" he
proclaimed several months into his therapy. He
reported that while his mother-in-law was living with
them she would entice him to come into her bedroom
when his wife was away and would have aggressive sex
with him. If he resisted or refused he noticed he
would suffer afterwards with sharp pains in his body.
"She would zap me with laser beams," he groaned,
"I finally insisted that my wife send her away to live
with one of her sisters. That was three years ago but
since then she has been zapping me every night."
The weeks and months went by and while his hours
always included reports of being "zapped," his
demeanor gradually changed. He became more relaxed,
more cheerful, more lighthearted and more willing to
discuss a wide range of topics and themes: his life
history, army experiences, his children and
grandchildren, his pet dog, his garden and his
marriage. Gradually there was less and less reporting
of torture by laser beams and finally all such
references ceased completely. Throughout this period
I elected to make no inquiries about his disappearing
paranoid delusion but remained interested in any and
all topics he brought to his hours.
Two years ago he suffered a heart attack while
working in his garden and underwent by-pass surgery.
His therapy was interrupted for about three months and
when he returned he requested monthly sessions instead
of weekly. The hours are lively and he seems happy to
come and reluctant to leave. There is no sign of
delusional paranoid thinking. I remain content to
meet with him as long as he wishes to continue his
friendly encounters with me and I regard his therapy
now as justified in that it is preventing his relapse
into his former paranoid state.
*******
In this age of psychopharmacotherapy and
electroconvulsive shock therapy clinicians may forget
that in previous years, when such therapies were not
available, psychotic patients in mental hospitals
received little more than staff-patient psychosocial
interactions. Nonetheless, the spontaneous remission
and discharge rate was about 60% within the first year
of hospitalization, usually followed by relapses in
subsequent years. There is also the occasional
phenomenon of chronic, paranoid, delusional psychotic
patients who experience without any therapy a gradual
spontaneous remission after several decades of mental
disability.
For a more detailed discussion of the
psychotherapy of schizophrenia, see my book "The
Therapist Is The Therapy" (Northvale, Jason Aronson,
1997). In regard to the frequency of therapy sessions
or the duration of therapy, there is no absolute rule.
The therapist must use judgment, not to foster
dependency by prolonging therapy unnecessarily but
also not to reject the patient because of some
arbitrary symptom alleviation. This man's blatant
paranoid comments gradually stopped as his therapy
progressed, and he finally requested less frequent
meetings, which currently seems appropriate. Other
patients might choose to terminate therapy and then
return periodically, every six months or every year
for brief visits. A therapist should remain flexible
and open to what is appropriate or "works" for each
person.
This patient's life experiences were heavily
weighted with controlling women, from his mother (no
known father) to convent nuns to a wife (plus her
mother) who brought him to a new and strange country.
For him to find a separate, non-controlling male
friend (therapist) was a factor in the remission of
his psychosis, and to avoid relapse the relationship
should not be terminated unilaterally by the
therapist.
FOOTNOTE (to title)
1. The case vignette presented here is reprinted with
permission from Fierman, L.B. (1998). "Freeing the
Human Spirit / A Psychiatrist's Journal", Northvale,
N.J.: Jason Aronson (in press). To maintain
confidentiality all identifying features of the
patient have been altered or removed. The first part
of this article is adapted from Fierman, L.B. (1997).
"The Therapist Is The Therapy", Northvale, N.J.:
Jason Aronson, pp. 18-22, with permission of the
author.
Louis B. Fierman, M.D. was appointed Chief Resident at
both the Yale Psychiatric Institute and the Yale-New
Haven Hospital Psychiatric Service and has remained on
the clinical faculty of the Yale School of Medicine.
He has been President of the Connecticut Psychiatric Society,
Chief of the Psychiatric Service at the West Haven Veterans
Administration Medical Center, Medical Director of Elmcrest
Psychiatric Institute, and is in private practice in
New Haven as Medical Director of Psychotherapy Associates.
He is a Life Fellow of the American Psychiatric Association.
Now semi-retired, Dr. Fierman has returned to his
childhood interest in classical music and plays the
French horn in local symphony orchestras.
His email address is bkst47@aol.com.
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