T, an elderly patient, was becoming very infirm and believed that people were breaking in through cracks in her floorboards to steal her (minimal) possessions. She went to complain, not to the police station, but to her doctor.
The extent to which the mind resorts to psychotic ways of coping varies from person to person and from moment to moment. An individual may be using reality-oriented integrating processes in some areas of their functioning and interactions, and psychotic solutions in others, even within the same conversation ( Reference LucasLucas 2009 ).
Transference and countertransference
Transference is the human tendency to distort current relationships in line with unconscious internal models of either a wished-for relationship (positive transference) or a feared relationship (negative transference), these internal models having themselves been shaped by the person’s earlier relationships. These distortions have conscious and unconscious aspects. In psychosis, there may be three dimensions to an interaction, often present at the same time:
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1 a rational part of the individual who understands the role of the other person and recognises their personal qualities reasonably accurately;
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2 a ‘neurotic’ transference, where the distortion has an ‘as if’ rather than a concrete quality;
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3 a psychotic transference where distortions of the other are experienced concretely.
U believed that people were spying on him and he carried a knife for self-defence. A nurse saw him at home regularly in a supportive capacity. He seemed to appreciate the visits and to accept that he needed his fortnightly depot injection and noticed some benefit (probable rational relationship). In their discussions there would be some hesitancies which he could overcome and could readily see were related to worries about what the nurse was thinking about him. He could understand that these linked with his self-esteem and with his experience that his parents favoured him less than his sisters (neurotic transference). He then suddenly disengaged and refused his depot medication. It became clear that in parallel to the above two dimensions he had, out of the nurse’s awareness also developed an increasing conviction that she was in league with the pharmaceutical company arranging for his injection to be replaced with poison (psychotic transference).
Transference happens in all relationships, with individuals, groups and organisations. Countertransference, which is similarly ubiquitous, refers to the feelings and relationships evoked in response to transference (Reference Bateman and HolmesBateman 1995; Reference Hughes and KerrHughes 2000). Consequently, transference and countertransference partially shape the relationships that patients have with the professionals working with them (Reference Kanter, Harru and BachrachKanter 1988; Reference Hughes and KerrHughes 2000) and that these practitioners have with their patients and colleagues. Although often unnoticed, these phenomena are highly relevant to outcomes, whatever the practitioner’s theoretical framework and whatever the treatment, whether medication, cognitive–behavioural therapy or in-patient care. Recognising them can also provide insights into the patient’s inner world and their relationships with friends and family.
Attending to transference and countertransference may elucidate meaningful understanding of important clinical challenges. For example, large numbers of patients with psychosis do not readily maintain contact with mental health professionals (Reference Nosé, Barbue and TansellaNosé 2003), and it is easy to dismiss this as the patient being unmotivated or not prepared to take responsibility. However, if one takes seriously the frequency of projection of unbearable feelings in psychosis, then this implies an alternative way of thinking about the non-engagement. The non-engagement could be understood as a ‘sane’ response to the patient experiencing the professional as disturbed or disturbing, as in the case of U. Developing a capacity to be open to these possibilities and to tolerate psychotic transference projections will allow staff to avoid a vicious cycle of forcing these projections back on patients who cannot yet tolerate the idea that they themselves are disturbed or lack motivation. It is then important that staff can tolerate this as an ‘idea’.
Another common example is for practitioners to reduce the frequency of contact with a patient because they do not feel the patient is identifying any particular problems to work on. In some cases, careful exploration may lead to the understanding that this withdrawal has resulted from countertransference responses, where practitioners have become identified with the patient’s withdrawal from disturbing aspects of what change would involve and the dangers of closeness to another person.
In contrast to withdrawal, other kinds of countertransference feelings may also provoke excessive and counterproductive interventions.
V emerged from a psychosis developing a progressively less abrasive relationship with his occupational therapist as his bricklaying apprenticeship proceeded and he could see himself becoming employed in some months’ time. He completed his course, but then found there were no jobs. He became increasingly contemptuous of his occupational therapist, accusing her in an arrogant manner of being useless and doing nothing for him. In trying to avoid her own feelings of uselessness, which she had not recognised as countertransference, the occupational therapist tried harder and harder but the patient’s disparagement only increased. The occupational therapist was helped by a psychodynamically trained colleague to bear the patient’s contempt for the uselessness that he had projected onto her. She then had less need of her own ‘manic’ overactivity with V, which was aimed at avoiding the painful feelings of uselessness. The occupational therapist’s feeling of uselessness was a combination of a massive projection from the patient as well as a piece of external reality that she ‘was’ useless in not being able to find the patient a job. The situation became particularly problematic because of the occupational therapist’s own difficulty tolerating the ‘useless’ feelings that affected her professional and personal self-esteem.
Learning Objectives
- Describe how various psychological perspectives view and explain schizophrenia
Psychodynamic Perspectives on Psychosis
Early psychoanalytic conceptions of psychosis explained psychotic symptoms as a manifestation of the conscious mind being invaded by the unconscious and by dreams (Federn, 1928/1952). More contemporary approaches underline the importance of early relationship patterns (e.g., Bion, 1962; Winnicott, 1991). Internal representations of experiences with significant others and current relationships are assumed to result in tension and psychotic symptoms are considered to be a constructive way of dealing with this tension (von Haebler & Freyberger, 2013). Psychodynamic therapy focuses on these processes and helps the patient to gain self-awareness and understanding of the influence of the past on present behavior, and it fosters new positive relationship experiences. An empathic, respectful, and supportive attitude allows re-enactment of internalized relational patterns in the therapist–patient interaction (Lempa, Montag, & von Haebler, 2013). Some early theories of psychoanalytic thought argued that psychosis could result from poor parenting behaviors (e.g., the schizophrenogenic mother stereotype) and the concept of double-bind communication, which refers to parental communication that is contradictory (rejecting while demanding affection), have not been supported in later research. Additionally, studies have generally shown that insight-oriented forms of psychotherapy do not typically work well with most persons with schizophrenia because of their difficulty in self-reflection and abstract thinking due to thought disorder.
Humanistic Perspectives on Psychosis
In client-centered or humanistic therapy, unconditional positive regard, accurate empathy, and genuineness are assumed to help a patient to increase the congruence between the real self and the ideal self (Rogers, Gendlin, Kiesler, & Truax, 1967). Rogers and colleagues’ concept of actualizing tendency points to an inherent tendency to achieve personal growth and reach one’s full potential. In this framework, psychotic symptoms are understood as a distortion of this actualizing tendency. Client-centered therapy focuses on personal experiences whereas relieving specific symptoms is secondary. Thus, no specific therapeutic strategies have been established for psychosis. However, this perspective recommends therapists pay particular attention to understanding the client’s perspective, ensuring that the patient is being heard and emphasizing the personal relationship (Gendlin, 1962).
The Cognitive Perspective of Schizophrenia
When we think of the core symptoms of psychotic disorders such as schizophrenia, we think of an individual who may hear voices, see visions, and have false beliefs about reality (i.e., delusions). However, problems in cognitive function are also a critical aspect of psychotic disorders and of schizophrenia in particular. This emphasis on cognition in schizophrenia is in part due to the growing body of research suggesting that cognitive problems in schizophrenia are a major source of disability and loss of functional capacity (Green, 2006; Nuechterlein et al., 2011). The cognitive deficits that are present in schizophrenia are widespread and can include problems with episodic memory (the ability to learn and retrieve new information or episodes in one’s life), working memory (the ability to maintain information over a short period of time, such as 30 seconds), and other tasks that require one to control or regulate one’s behavior (Barch & Ceaser, 2012; Bora, Yucel, & Pantelis, 2009a; Fioravanti, Carlone, Vitale, Cinti, & Clare, 2005; Forbes, Carrick, McIntosh, & Lawrie, 2009; Mesholam-Gately, Giuliano, Goff, Faraone, & Seidman, 2009). Individuals with schizophrenia also have difficulty with what is referred to as processing speed and are frequently slower than healthy individuals on almost all tasks. Importantly, these cognitive deficits are present prior to the onset of the illness (Fusar-Poli et al., 2007) and are also present, albeit in a milder form, in the first-degree relatives of people with schizophrenia (Snitz, Macdonald, & Carter, 2006).
These findings suggest that cognitive impairments in schizophrenia reflect part of the risk for the development of psychosis, rather than only being an outcome of developing psychosis. Further, people with schizophrenia who have more severe cognitive problems also tend to have more severe negative symptoms and more disorganized speech and behavior (Barch, Carter, & Cohen, 2003; Barch et al., 1999; Dominguez Mde, Viechtbauer, Simons, van Os, & Krabbendam, 2009; Ventura, Hellemann, Thames, Koellner, & Nuechterlein, 2009; Ventura, Thames, Wood, Guzik, & Hellemann, 2010). In addition, people with more cognitive problems have worse functioning in everyday life (Bowie et al., 2008; Bowie, Reichenberg, Patterson, Heaton, & Harvey, 2006; Fett et al., 2011).
The Cognitive-Behavioral Perspective
Cognitive-behavioral interventions for psychosis (CBTp) build on the assumption that psychotic symptoms lie on a continuum with normal experiences. They are also informed by research suggesting that psychotic experiences result from normal, though exaggerated, mechanisms of perception and reasoning. This understanding has formed the basis for cognitive models of psychosis. As one of the most influential of these models, Garety, Kuipers, Fowler, Freeman, & Bebbington (2001) postulate that psychotic symptoms develop when stressors overload a person, causing them to have unusual experiences. According to this model, the unusual experience itself is not crucial, but its appraisal—how it is understood or evaluated by the person—is. Most descriptions within the cognitive-behavioral interventions for psychosis (CBTp) framework converge in stressing the importance of building a stable therapeutic relationship through the process of listening and validating, of taking a collaborative approach, and of working with an individual case formulation. The use of cognitive and behavioral interventions for working with psychotic symptoms as well as for changing dysfunctional beliefs and interventions to prevent relapse are also essential elements.
Social Cognition
Some people with schizophrenia also show deficits in what is referred to as social cognition, though it is not clear whether such problems are separate from the cognitive problems described above or the result of them (Hoe, Nakagami, Green, & Brekke, 2012; Kerr & Neale, 1993; van Hooren et al., 2008). This deficit of social cognition includes problems with the recognition of emotional expressions on the faces of other individuals (Kohler, Walker, Martin, Healey, & Moberg, 2010) and problems inferring the intentions of other people (theory of mind) (Bora, Yucel, & Pantelis, 2009b). Individuals with schizophrenia who have more problems with social cognition also tend to have more negative and disorganized symptoms (Ventura, Wood, & Hellemann, 2011) as well as worse community function (Fett et al., 2011).
Diathesis-Stress Model
The diathesis-stress model helps to settle the debate of nature versus nurture; it explains how the two have a bidirectional relationship and a dual influence on the development of many mental health illnesses, especially schizophrenia. The diathesis refers to the genetic predisposition or risk an individual has of developing a certain disorder. This predisposition comes from the individual’s unique genetic makeup as well as the increased risk if a first-degree blood relative such as parent or sibling has been diagnosed with a disorder. The diathesis is the nature component of the model, reflecting the biological vulnerability an individual possesses. An environmental stressor can trigger the onset of a disorder, especially in those genetically vulnerable to developing the disorder. If an individual is greatly susceptible to developing a disorder, only a small level of stress is needed to catalyze the onset of the disorder. Extreme trauma or the use of a drug such as cannabis can serve as environmental stressors and aspects of nurture that influence the onset of schizophrenia and related disorders.
Childhood trauma has specifically been shown to be a predictor of adolescent and adult psychosis. Approximately 65% of individuals with psychotic symptoms have experienced childhood trauma (e.g., physical or sexual abuse and physical or emotional neglect). Increased individual vulnerability toward psychosis may interact with traumatic experiences promoting an onset of future psychotic symptoms, particularly during sensitive developmental periods. Importantly, the relationship between traumatic life events and psychotic symptoms appears to be dose-dependent, in which multiple traumatic life events accumulate, compounding symptom expression and severity. This relationship suggest trauma prevention and early intervention may be an important target for decreasing the incidence of psychotic disorders and ameliorating its effects.
Sociocultural Perspective
There are also a number of environmental factors that are associated with an increased risk of developing schizophrenia. For example, problems during pregnancy such as increased stress, infection, malnutrition, and/or diabetes have been associated with increased risk of schizophrenia. In addition, complications that occur at the time of birth and cause hypoxia (lack of oxygen) are also associated with an increased risk for developing schizophrenia in the child (M. Cannon, Jones, & Murray, 2002; Miller et al., 2011). Children born to older fathers are also at a somewhat increased risk of developing schizophrenia. Further, using cannabis increases risk for developing psychosis, especially if when other risk factors are present (Casadio, Fernandes, Murray, & Di Forti, 2011; Luzi, Morrison, Powell, di Forti, & Murray, 2008). The likelihood of developing schizophrenia is also higher for kids who grow up in urban settings (March et al., 2008) and for some marginalized ethnic groups (Bourque, van der Ven, & Malla, 2011). Both of these factors may reflect higher social and environmental stress in these settings. Unfortunately, none of these risk factors is specific enough to be particularly useful in a clinical setting, and most people with these risk factors do not develop schizophrenia. However, together they are beginning to give us clues as the neurodevelopmental factors that may lead someone to be at an increased risk for developing this disorder.
Cross-Cultural Perspectives and Cultural Influences
Culture plays a role in the way we view mental health disorders and their corresponding features. There are cultures around the world, such as in Peru, who do not perceive features of schizophrenia like hearing voices (hallucinations) as abnormal. Rather, they may even be seen as special abilities and connections to the spirit realm, where the individual who hears voices could be the community Shaman, or medicine man. These individuals actually help to provide insight and healing to themselves and to others.
In Western societies, the same feature of hearing voices would be considered to be abnormal and a symptom of an underlying disease such as schizophrenia. An individual experiencing these symptoms would not be placed in a position of reverence or admiration, but would most likely be placed in a treatment facility or hospital for further care and treatment to manage and reduce the experienced symptoms. Even in Western society, however, there have been advocates, like Dorothea Dix and Philippe, who emphasized respecting and admiring those with mental disorders.
Cross-Cultural Studies
The International Pilot Study of Schizophrenia revealed some interesting data about how schizophrenia differs across cultures. Among all cultures, paranoid schizophrenia was the most common subtype (40% of persons diagnosed). The content and themes of delusions vary between the background experiences and beliefs of individuals with schizophrenia—religious delusions are more common in Christian societies, while magical religious delusions are more common in rural areas. In Islamic Pakistan, there were lower rates of religious delusions, grandiose delusions, and delusions of guilt, while these were more common in African countries.
Visual hallucinations are more common in African countries and non-European patients. Auditory hallucinations are common everywhere. Negative symptoms are also more common than positive symptoms, though there are differences between countries as to which types of negative symptoms are most distressing.
Watch It
Watch this video (starting at the 3:35 mark) to learn about various explanations for the etiology of schizophrenia.
You can view the transcript for “Tricky Topics: Causes of Schizophrenia” here (opens in new window).
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