Current treatment of the schizophrenic patient focuses on psychopharmacology, social skills training, vocational rehabilitation, and supportive family interventions. As a total treatment plan two elements are missing. There is no executive coordinator of the whole treatment with a long-term commitment to the patient, who phases in family work, social skills training, and vocational rehabilitation when clinically appropriate. Second, there is no role for dynamic psychotherapy.
The neglect of dynamic psychotherapy is not surprising. May(1) found that combined drug therapy and psychotherapy was not superior to drug alone. Grinspoon(2) showed a powerful drug-plus-psychotherapy effect, with unimpressive results for psychotherapy alone. Karon and Vandenbos(3) reported
significant effect for psychotherapy when delivered by experienced therapists, but this result has never been replicated.
Hogarty et al.(4-6) studied psychopharmacology and major-role therapy in 374 schizophrenic patients over a two-year period. Psychopharmacology was clearly effective; major role therapy was only effective during the 6th to 12th month of treatment.
The Stanton/Gunderson study(7,8) appears to have ended all dynamic psychotherapy for schizophrenic patients. Patients treated once weekly in a reality-oriented supportive therapy (RAS) did at least as well as patients treated three times per week in a primarily insight-oriented psychotherapy (EIO). In terms of time in hospital and role performance, RAS patients did better. The study does not examine the effectiveness of psychotherapy; it compares the effectiveness of two different psychotherapies. Furthermore, as Goldstein(9) notes, "....the results for realistic-adaptive therapy (once weekly) appear substantially better, in terms of symptomatic and social role functioning, then is typically found for schizophrenic patients on maintenance drug therapy alone" (p. 119).
Frank and Gunderson(10) examined the interaction between therapeutic alliance and clinical state. They showed: (1) the difficulty in maintaining a therapeutic alliance with schizophrenic patients; (2) the crucial role of the first six months in forming an alliance; (3) that good alliances are associated with decreased global psychopathology, decreased neuroleptic doses and increased compliance.
Drake and Sederer,(11,12) sensitive to overstimulation of the schizophrenic patient, argue that all therapeutic relationships must respect the patient's need for distance, allowing healing processes to proceed naturally. They focus on a trusting relationship as the crucial issue in treatment. Psychotherapy should focus on healthy, adaptive, and competent aspects of the patient, avoid regression, enhance self-esteem, and promote stabilization.
In a meta-analysis of studies of psychotic patients treated with drug therapy alone versus drug plus psychotherapy, Smith, Glass and Miller(13) found an effect size of 0.5 for drug versus 0.8 for combined drug therapy and psychotherapy. Similarly, in a meta-analysis by major drug type, antipsychotic alone produced an effect size of 0.44, antipsychotic plus psychotherapy an effect size of 0.83. These analyses suggest that psychotherapy is effective for psychotic patients.
Coursey(14) discusses the role of psychotherapy for schizophrenic patients in the context of the current biological revolution. The basic elements of his suggested psychotherapy include: (1) complementary roles for drug therapy and psychotherapy; (2) postponement of psychotherapy until patients are no longer acutely psychotic; (3) the crucial role of the therapeutic alliance; (4) interventions that make sense to the patients and are consistent with their internal experience; (5) a therapist who is eclectic and pragmatic; (6) education, crisis intervention, practical advice, insight, and the "normalization" of the patients' reactions given their biologically based dysfunction.
Over the past two decades, there have been significant advances in psychodynamic supportive psychotherapy. …