YRJO O .

A L A N E N

SCHIZOPHRENIA

Its Origins and Need-Adapted

Treatment

Foreword by Introduction by

STEPHEN FLECK MURRAY JACKSON

KARNAC BOOKS

SCHIZOPHRENIA

Yrjo O. Alanen
SCHIZOPHRENIA

Its Origins
and
Need-Adapted Treatment

Yrjo O. Alanen

Foreword Introduction
Stephen Fleck Murray Jackson

translated b y

Sirkka-Liisa Leinonen

London
KARNAC BOOKS
First published in English in 1997 by
H. Karnac (Books) Ltd,
118 Finchley Road,
London NW3 5HT

Copyright © 1997 Yrjo O. Alanen

The rights of Yrjo O. Alanen to be identified as the author of this work have
been asserted in accordance with §§ 77 and 78 of the Copyright Design and
Patents Act 1988.

All rights reserved. No part of this publication may be reproduced, stored in a

retrieval system, or transmitted in any form or by any means, electronic,
mechanical, photocopying, recording, or otherwise, without the prior written
permission of the publisher.

British Library Cataloguing in Publication Data

A C L P . record for this book is available from the British Library

ISBN 978 1 85575 156 9

Edited, designed, and produced by Communication Crafts

Printed in Great Britain by BPC Wheatons Ltd, Exeter

10987654321
my co-workers
CONTENTS

PREFACE AND ACKNOWLEDGEMENTS xi

FOREWORD by Stephen Fleck xv

INTRODUCTION by Murray Jackson xvii

CHAPTER ONE

T h r e e patients 1

Sarah, m y first patient 3

E r i c , significance of i n d i v i d u a l psychotherapy 8

P a u l a a n d family therapy 15

CHAPTER TWO

G e n e r a l notes o n schizophrenia 25

Symptoms 25

Subgroups 30

vii
Vlii CONTENTS

O n D S M diagnostics 32

Schizophrenia f r o m a public health perspective 33

Prognosis 36

Illness models 39

CHAPTER THREE

The origins of schizophrenia:

an attempt at synthesis 45
Starting-point: necessity of an integrative approach 45

Studies o n predisposition to schizophrenia:

role of biological factors 47

Studies o n predisposition to schizophrenia:

role of psychosocial factors 58

A n attempt at integration 73

Prepsychotic personality development 89

Factors precipitating the onset of psychosis 95

T h e onset of psychosis 101

Is schizophrenia a u n i f o r m illness? Integrating remarks 104

CHAPTER FOUR
Contemporary ways of treating schizophrenia

and psychotherapy research 111

Introductory remarks 111

Psychopharmacological treatment 114

I n d i v i d u a l psychotherapy 118

F a m i l y therapy 125

G r o u p s a n d communities 130

C o m m u n i t y psychiatric developments 134

 CONTENTS ix

C H A P T E R FIVE

Need-adapted treatment of schizophrenic psychoses:

development, principles, and results 139

T h e T u r k u Schizophrenia Project 140

T h e F i n n i s h N a t i o n a l Schizophrenia Project 159

T h e Inter-Scandinavian N I P S Project 167

C o n c e p t a n d principles of need-adapted treatment 170

Conclusions 187

C H A P T E R SIX .

Therapeutic experiences 191

Experiences of a p p l y i n g the different m o d e s of treatment 191

N e e d - a d a p t e d treatment:

case excerpts [with Irene Aalto and Jyrki Heikkila] 214

CHAPTER SEVEN

Treatment of schizophrenia and society 237

Political factors affecting the treatment of s c h i z o p h r e n i a 238

It is w o r t h w h i l e to develop treatment 239

D e v e l o p m e n t o f the treatment organization 241

Is it possible to prevent schizophrenia? 252

W h a t does the future look like? 254

REFERENCES AND BIBLIOGRAPHY 259

INDEX 297
PREFACE AND ACKNOWLEDGEMENTS

T
he starting-point of this book is to promote a concept a n d
therapy of schizophrenic psychoses based o n an integrated
p s y c h o d y n a m i c approach to this disorder. T h e theories of
schizophrenia are still quite contradictory, due to researchers' often
one-sided views of its causes. T h e progress of the treatment of schizo­
phrenic psychoses has also been greatly h a m p e r e d because of a lack
of integrative starting-points. I think that few schizophrenic patients
are currently receiving the k i n d of treatment that they need.
I b e g i n b y l o o k i n g back o n m y first experiences as a p s y c h o ­
therapist w i t h schizophrenic patients, an activity that I have n o w
been engaged i n for 40 years. T h e second chapter consists of general
theories of the nature of schizophrenia a n d its impact on p u b l i c
health. In chapter three, a short review of contemporary research of
the aetiology of schizophrenia is presented, followed b y a n attempt
at an integrative synthesis of the origins of schizophrenia based o n
research findings a n d m y o w n experiences a n d views. T h e chapter
m a y also function as a theoretical b a c k g r o u n d to the therapeutic
a p p r o a c h described i n the final chapters of the book.
C h a p t e r four is a brief discussion of the current state of the treat­
ment of schizophrenia. M a i n attention is given to the studies of

xi
Xii PREFACE AND ACKNOWLEDGEMENTS

psychological approaches. Chapter five focuses o n the development

a n d principles of the comprehensive psychotherapeutic approach
called " n e e d - a d a p t e d treatment of schizophrenic psychoses", w h i c h
was developed b y myself a n d m y colleagues w o r k i n g i n T u r k u ,
F i n l a n d , a n d w h i c h has stimulated a great deal of interest a n d
applications i n the Scandinavian countries. A c c o r d i n g to our experi­
ence, the success of the treatment is greatest w h e n it is based o n a n
integrative understanding of the i n d i v i d u a l l y determined a n d chang­
i n g therapeutic needs of each patient as well as those of the patient's
closest interpersonal network, generally h i s / h e r family. T h e follow­
u p results described i n this chapter suggest that o u r approach is
effective i n r e d u c i n g chronicity and disability arising f r o m schizo­
phrenia.
C h a p t e r six complements the description of our approach clini­
cally. I first summarize m y experiences i n family a n d i n d i v i d u a l
therapy w i t h schizophrenic patients as well as i n the psychothera­
peutic hospital community suited for their treatment. The application
of the need-adapted approach i n practice is then illustrated b y three
concise case reports, one written i n collaboration w i t h m y colleague,
specialist nurse Irene A a l t o , and one w i t h psychiatrist Jyrki H e i k k i l a .
In chapter seven, I discuss the effects of predominant social policies
o n treatment a n d rehabilitation, a n d I present m y views o n the
development of treatment activities w i t h i n the c o m m u n i t y p s y c h i ­
atric context.
This book was first published i n Finnish 1993. T h e E n g l i s h edition
has been revised b y leaving out a more comprehensive review of
schizophrenia investigation, a d d i n g information based o n later re­
search, a n d enlarging the clinical material. I w i s h to express m y
cordial thanks to m y friends, Stephen Fleck, M . D . , a n d D r . M u r r a y
Jackson, for their collaboration. Both of them read patiently through
the manuscript a n d , based o n their abundant experience, gave m e
invaluable advice w i t h regard both to subject matter a n d to language.
I a m also very grateful to Brian Martindale, M . D . , for his constructive
criticism and advice.
I dedicate this book to m y co-workers, both at the T u r k u clinic a n d
elsewhere. T h e T u r k u Schizophrenia Project was a team project d e ­
v e l o p e d actively over the years b y m a n y researchers and clinicians, of
w h o m I w i s h to mention the psychiatrists Jukka A a l t o n e n , Ritva Jarvi,
A n n e l i L a r m o , K l a u s Lehtinen, V i l l e Lehtinen, V i l h o Mattila, Viljo
 PREFACE A N D A C K N O W L E D G E M E N T S Xlii

R a k k o l a i n e n , R a i m o Salokangas, Simo Salonen, a n d H i l k k a V i r t a n e n ,

the psychologists Juhani Laakso a n d A i r a L a i n e , the A D P operator
A n n e Kaljonen, a n d , last b u t not least, w a r d nurse Riitta R a s i m u s
a n d the staff of W a r d 81, w h o took the m a i n responsibility for the
inpatient treatment of psychotic patients, e x p a n d i n g to therapeutic
relationships e v e n outside of the hospital. M y special thanks are d u e
to Irene A a l t o a n d Jyrki H e i k k i l a for their valuable contribution to
chapter six, as w e l l as to art therapist M a r j a K a r l s s o n , w h o p r o v i d e d
m e w i t h the cover picture of this b o o k — a painting b y a y o u n g schizo­
p h r e n i c patient.
In a d d i t i o n to m y T u r k u colleagues, I a m indebted to the co­
workers w h o participated i n the activities of the F i n n i s h N a t i o n a l
Schizophrenia Project as w e l l as i n the Inter-Scandinavian N I P S
Project. A m o n g the latter, I want especially to h o n o u r the m e m o r y of
the late D r . E n d r e U g e l s t a d , f r o m N o r w a y . E n d r e ' s contribution to
the p l a n n i n g a n d realization of the N I P S Project was crucially i m p o r ­
tant.
T h e original translation of m y manuscript into E n g l i s h w a s m a d e
b y S i r k k a - L i i s a L e i n o n e n . I thank her, as w e l l as the A c a d e m y of
F i n l a n d a n d the T u r k u U n i v e r s i t y F o u n d a t i o n for the economic s u p ­
port that m a d e the translation possible.
F i n a l l y , I w i l l express m y greatest gratitude to m y l o v i n g a n d
loveable wife, H a n n i , for her understanding support throughout the
u n c o u n t e d w o r k i n g hours i n v o l v e d .

Turku, Finland
August 1997
FOREWORD

Stephen Fleck
Professor o f Psychiatry a n d Public Health (Emeritus)
Department of Psychiatry, Yale University School of Medicine

P
rofessor A l a n e n ' s w o r k m a y be the most comprehensive
treatise o n schizophrenia i n 25 years—that is, since M a n f r e d
Bleuler's Die Schizophrenen Geistesstdrungen (Bleuler, 1972).
A l a n e n ' s v o l u m e begins a n d ends w i t h accounts of patients a n d their
treatments, illustrating first the benefits a n d constraints of d y a d i c
psychotherapy w i t h schizophrenics a n d the b e g i n n i n g realization of
the significance of familial disturbances. T h e case reports at the e n d
of the book illustrate " n e e d - a d a p t e d treatment" d e v e l o p e d i n T u r k u
u n d e r the author's auspices a n d guidance d o c u m e n t i n g the need for
and implementation of flexibility i n approaches adapted to each
patient a n d adapted further to the patient's particular situation or
h u m a n context, as w e l l as to the course of the illness. Psycho-active
drugs are used sparingly, usually at l o w dosage, a n d never as T H E
treatment.
The four chapters between these case reports reflect our travels
and travails over the last four a n d one-half decades i n particular, a n d
they d o so w i t h considerable erudition. T h e evolution of the seren­
d i p i t o u s l y discovered psychopharmacological treatments a n d the
e n s u i n g exploration of the biological substrate of psychoses that
dominates the research field today have been paralleled b y the devel-

XV
XVi FOREWOR D

opment of c o m m u n i t y psychiatry a n d rehabilitative treatments.

H o w e v e r , w i t h regard to research funds, the latter has remained a
step-child.
Dr. Alanen covers these developments a n d investigations,
as w e l l as psychoanalytic theories a n d approaches, i n great detail
a n d eventually he offers a n integrated v i e w of the development of
s c h i z o p h r e n i a — a systems-oriented approach encompassing the b i o ­
psychosocial gambit f r o m genetics to environmental factors. It is a
well-reasoned m o d e l a n d a constructive contrast to what Uttal (1997)
has called " n e u r o - r e d u c t i o n i s m " . Necessary reductionistic research­
based practices have become a major i m p e d i m e n t to comprehensive
treatment, let alone to continuity of care i n m a n y places. Research
necessarily involves narrow diagnostic a n d rigid treatment proce­
dures, w h i c h unfortunately have contaminated non-research clinical
practice (Fleck, 1995).
A l a n e n ' s comprehensive, painstaking, a n d balanced account of
relevant findings re schizophrenia, however fragmentary they m i g h t
be, are c o m b i n e d w i t h the aura of a truly caring physician. T h u s
" n e e d - a d a p t e d treatment" e v o l v e d — e a c h patient a n d context being
treated a n d h e l p e d according to her or his particular i n d i v i d u a l a n d
familial needs. T h i s m o d e l has spread throughout F i n l a n d a n d to
some of the n e i g h b o u r i n g countries, a n d w e can only hope that these
attitudes a n d programs w i l l m o v e west a n d serve as a n antidote to
the current U . S . practice of profit-oriented managed care. It is alleg­
e d l y m o r e economic to fit a patient into a service—even "speciality
clinics" (as briefly as possible)—than it is to shape services to each
patient's needs a n d to those of the significant others. In the final
chapter A l a n e n points out the socio-political aspects of schizophre­
n i a , indicating that short-term a n d limited treatments m a y not be
" e c o n o m i c " i n the l o n g r u n , aside from the humanitarian minuses of
short treatments. T h e knowledge to render comprehensive a n d i n d i ­
v i d u a l l y tailored treatment a n d services is here, even as o u r u n d e r ­
standing of schizophrenia remains incomplete. A s for the future,
patients, healers, a n d investigators alike might heed Faust's observa­
tion: " F o r t u n a t e he w h o c a n yet hope to emerge f r o m this sea of
errors" (Goethe, 1808; transl. S.F.).
INTRODUCTION

Murray Jackson
Psychiatrist and psychoanalyst

M a u d s l e y Hospital and King's College Hospital (Emeritus)

F
irst published in Finnish in 1993 and now in a new English
version, this book offers a comprehensive account of the work
of Professor Yrjo Alanen, a distinguished psychiatrist and psy­
choanalyst who, together with his colleagues, has been active both in
clinical practice and in psychiatric research in the field of schizophre­
nia in Finland for the last 45 years.
This work has been very successful; it has received wholesale
support from the Finnish government and has generated a sophisti­
cated level of psychobiological and psychoanalytical understanding
and a comprehensive nation-wide approach to treatment that is both
rational and humane. Although the influence of this "need-adapted"
approach has spread to many centres throughout Scandinavia, it is
relatively unknown in the United Kingdom. Despite the fact that the
author has in recent years addressed the British Psychoanalytic Soci­
ety and published in the British Journal of Psychiatry, it has produced
little sign of serious interest in the work, let alone recognition of its
profound implications.
"Schizophrenia" is the psychiatric classification of a group of
severe and persistent mental disturbances characterized by the dis­
ruption of the processes of rational thinking and perceiving, which

xvii
XViii INTRODUCTIO N

usually leads to delusional beliefs a n d hallucinatory perceptions i n

the auditory a n d v i s u a l field. T h e author's v i e w of schizophrenia is
that although it is a h i g h l y complex a n d insufficiently understood
p h e n o m e n o n , it is essentially a reaction to life crises b y i n d i v i d u a l s
w h o are psychologically a n d biologically less w e l l e q u i p p e d to meet
expectable developmental challenges, deprivations, a n d adversities
than are non-psychotics. Study of the life history of s u c h i n d i v i d u a l s
p r o v i d e s evidence for the v i e w that the root causes of this v u l n e r a ­
bility are to be f o u n d i n the psychological a n d social experiences of
infancy a n d c h i l d h o o d . Whilst recognizing that everyone emerges
into the w o r l d w i t h differing biological equipment, the author makes
clear his v i e w that although the biological aspects are of undeniable
relevance i n research a n d treatment of schizophrenia, they are fre­
quently g i v e n disproportionate emphasis, often at the expense of
p s y c h o d y n a m i c understanding.
T h e F i n n i s h a p p r o a c h was originally centred o n treatment w i t h
i n d i v i d u a l psychotherapy, but subsequent understanding of the
theory a n d practice of family therapy methods came to take priority.
A t first the obvious benefits of this a p p r o a c h seemed impressive;
gradually the limitations of its exclusive use also became clear. T h i s
l e d to the " n e e d - s p e c i f i c " approach, whereby the needs a n d capaci­
ties of the i n d i v i d u a l patient are evaluated f r o m the m o m e n t of first
contact, a n d treatment modalities of family therapy, both systemic
a n d p s y c h o d y n a m i c , i n d i v i d u a l psychoanalytically oriented psy­
chotherapy, other psychological treatments, a n d psychoactive m e d i ­
cation are offered as a n d w h e n believed to be appropriate to the
patient's condition at any particular time. This is a far cry f r o m most
current psychiatric practice, a n d it is continuing to evolve.
M e n t a l health professionals i n particular w i l l f i n d the text
applicable to their o w n interest a n d expertise. T h e detailed accounts
of epidemiological a n d other research findings include that of other
workers, and attempts to measure and quantify those factors
amenable to such a n approach receive an e v e n - h a n d e d critique.
T h o s e w i t h psychoanalytic or cognitive-behavioural interests w i l l
f i n d m u c h food for thought, and the " n e e d - a d a p t e d " a p p r o a c h can be
recognized as p r o v i d i n g the necessary support for further exploration
a n d development of their o w n particular skills. A l l w i l l be interested
i n the account of w o r k currently being p u r s u e d i n T u r k u , where
evidence is accumulating that the implementation of psychothera­
 INTRODUCTION xix

peutic a n d family methods f r o m the first m o m e n t of contact w i t h

first-episode patients can greatly reduce a n d i n m a n y cases totally
obviate the n e e d for neuroleptic medication. T h o s e interested i n d e ­
v e l o p i n g methods of early intervention b y the use of s m a l l psychosis
teams w i l l be interested to learn of their w i d e s p r e a d use throughout
F i n l a n d , a n d m o r e recently i n Sweden. Supporters of collaborative
international interdisciplinary research w i l l find an admirable m o d e l
described i n the account of the N I P S ( N o r d i c Investigation of the
P s y c h o t h e r a p y of Schizophrenia) Project, a n d of l o n g - t e r m care a n d
rehabilitation of the chronically i l l i n the w o r k of the S o p i m u s v u o r i
Project.
T h i s n e w a n d detailed account of the F i n n i s h contribution w i l l
n o w be available to a w i d e r audience, a n d the author's u n a s s u m i n g
a n d n o n - p a r t i s a n a p p r o a c h to the claims of various perspectives a n d
treatment methods w i l l allow the reader to come to his o w n c o n c l u ­
sions about their merits a n d limitations. T h e appearance of this b o o k
is especially w e l c o m e because it arrives at a time w h e n the pressures
of the market e c o n o m y are generating potentially destructive inter­
disciplinary competition a n d p o l a r i z e d " a n t i - p s y c h i a t r i c " a n d " a n t i ­
a n a l y t i c " stereotyped attitudes. A l t h o u g h the search for brief a n d
effective methods of treatment i n psychosis is i n itself praiseworthy,
it opens the door to a " f a s t - f o o d " psychiatric a p p r o a c h that does great
disservice to the practice of g o o d clinical psychiatry, ultimately a d d s
to the b u r d e n of w o r k of over-stressed psychiatrists, a n d u n d e r m i n e s
the recognition of the fact that the majority of schizophrenic patients
n e e d expert help for l o n g periods of time. It also introduces the d a n ­
ger that l o w standards of clinical practice m a y g r a d u a l l y become
accepted as the n o r m .
T h e appearance of this important book w i l l be w e l c o m e d b y all
those struggling to deepen their u n d e r s t a n d i n g of psychotic mental
illness a n d to alleviate the suffering of those unfortunate victims of
psychosocial a n d biological deficiencies a n d deprivations w h o s e fate
has l e d them into the confusing a n d often terrifying w o r l d of major
psychosis, a n d into the alienating diagnosis of " s c h i z o p h r e n i a " .
SCHIZOPHRENIA

CHAPTER ONE

Three patients

T
he attitude towards schizophrenia a n d schizophrenic patients
is always a notably personal matter. I have repeatedly noticed
this a m o n g researchers a n d psychiatrists: n o matter h o w
scientific a n d objective w e w i s h to be, o u r theories of the nature a n d
treatment of schizophrenia, shaped, as they are, b y o u r psychiatric
training a n d experience, are also influenced b y o u r personalities a n d
life histories. T h e attitude towards schizophrenia is often influenced
b y ideological considerations.
I begin this book b y relating m y o w n experiences with schizophrenic
patients. I hope this will also introduce the reader into the w o r l d of
schizophrenics—through the gate I used myself.
The first schizophrenic I k n o w of having met was a y o u n g w o m a n
w h o was kept i n confinement i n the mental department of the K u r i k k a
local authority home, waiting for a bed to be vacated i n the district
mental hospital. That was i n the late 1940s, w h e n I h a d started medical
studies a n d went to see the local authority home with m y father, the
m u n i c i p a l officer of health for this rural community i n Finland. K n o w ­
ing m y interest i n psychiatry, he indicated the patient to me as a schizo­
phrenic a n d encouraged me to get acquainted with her.

1
2 SCHIZOPHRENIA

The cell was gloomy, its only " f u r n i t u r e " being a ragged sleeping
bag w i t h straw squeezing out of the tears. There was a small shuttered
w i n d o w near the ceiling. I was probably brought a chair, but whether
the patient was, I do not remember. I only remember that she was sitting
on her bag, her hair tousled, making strange faces from time to time. But
she was interested i n meeting me and spoke volubly, though i n a way
that was difficult to understand. H e r speech revealed glimpses of p r o b ­
lems related to her family, strange references to homosexuality, a n d
m a n y other things.
A t that time, I was myself struggling with identity problems, though
m u c h less momentous than hers. Conflicts of family relationships and
the personal pressures caused b y them were of topical significance for
me, too. The things this y o u n g w o m a n was saying interested but also
horrified me. It seemed obvious to me that what she said was not ran­
d o m l y incoherent, but reflected her problems, though in an uncanny and
shocking way.
M y father took a more objective attitude. H e said he considered the
illness hereditary, referring to the abnormality of the whole family. I do
not remember whether he said that some other members of the family
were also mentally ill, but I knew myself that the patient's brother was
considered o d d and was called "Smarty Santanen". The girl's fate
aroused pity i n me: w o u l d she have to spend the rest of her life isolated
in a hospital?
Another factor that influenced m y preliminary conceptions of
schizophrenia was more theoretical. T h o u g h a medical student, I also
studied psychology at the university and was interested i n art. In his
book on developmental psychology, H e i n z Werner (1948) compared the
artistic productions of children, primitive people, and mental patients.
H e concluded that the art of the mentally ill is produced at a level that is
lower than the " u p s t a i r s " logic of an adult in a high-culture community
but which, nevertheless, exists in his dreams and subconscious m i n d .
Picasso and other twentieth-century pioneers of m o d e r n art h a d been
seeking stimuli on that more primitive level of expression to which we
all have internal access, p r o v i d e d we have not been blocked b y external
and internal constraints implicit i n our culture. I believe that the emer­
gence of modern art and the psychological understanding of schizophre­
nia are not coincident by chance alone (even if the appreciation of art
seems to have progressed more rapidly).
A s I advanced in m y studies, I found myself to be naturally oriented
towards psychiatry, which also signified a permanent solution for a
 THREE PATIENTS 3

central part of m y identity problem. While a student at the University

Clinic i n the Lapinlahti Hospital i n Helsinki, I began, encouraged by m y
teacher Martti Kaila, to work on a doctoral thesis o n the mothers of
schizophrenic patients (Alanen, 1958) and simultaneously to learn about
h o w to understand and treat these interesting patients. Never since that
time have I lost this interest.
The first experiences of psychotherapeutic work are especially
important for the professional development and orientation of a psy­
chiatrist. I shall describe three patients who taught me much. (Their
names have been changed.)

Sarah, my first patient

Sarah, a 25-year-old seriously schizophrenic language student, w a s

m y first long-term patient belonging to the schizophrenia g r o u p .
W h e n I first met her (in 1953), I was just beginning m y psychiatric
training a n d was o n l y pne year her senior.
Sarah h a d suddenly.become delirious while studying at a university
summer school away from home. H e r parents told me that w h e n they
h a d been informed of their daughter's illness and h a d gone to see her,
she h a d told them she was a m e d i u m and tried to hypnotize them,
m a k i n g rebuffing gestures with her hands. In the hospital Sarah told
me that she h a d been used for experiments for the psychology courses
simultaneously going on i n the summer school. They h a d begun to h y p ­
notize and train her i n a group of ten people. She said she was n o w a
clairvoyant, a m e d i u m able to converse with both spirits and many
people far away, w h o were taking turns to speak through her brain.
Later o n these voices coalesced into one, w h i c h she called her " G u i d e " .
The G u i d e lived inside Sarah but was a separate person from her. She
was able to hear the Guide's voice within herself and to talk to it. The
G u i d e was also able to write, using Sarah's hand.
A l t h o u g h the illness manifested itself suddenly, it was the end-point
of a long process of development. Sarah had always been withdrawn:
she preferred to live i n a fantasy w o r l d of her o w n and tended to cut
herself off from her companions. Over the preceding couple of years she
h a d developed a m o r b i d fear of examinations and lecturers. She made
no progress i n her studies. She h a d also begun to isolate herself at home,
studying at night and getting u p i n the afternoon, avoiding her parents.
4 SCHIZOPHRENIA

The summer school had been her last attempt to resume her studies i n a
new environment, but eventually it led to a break i n her precarious
psychic integration.
I met Sarah and her G u i d e about three months after her admission.
By that time she h a d been given both insulin and electroshock therapy,
and her psychosis appeared notably alleviated. Even so, she continued
to be seriously ill, preferring to isolate herself, talking to herself and
laughing with her voices. I interviewed her for m y research, inquiring
about her childhood memories and her relationship with her parents.
She gave matter-of-fact and calm answers but kept looking out of the
w i n d o w and partly covering her face with her hand. H e r narration was
colourless and conventional. She showed some bitterness at her mother,
but as soon as she expressed such bitterness, she began to defend her
again. She emphasized having been a conciliatory, good girl at home,
and she said that her homelife h a d actually been "quite o r d i n a r y " .
H a v i n g conversed with the patient for an hour, I asked her whether
she still h a d the other person, the Guide, within her. What happened was
quite astonishing. Sarah said: " L e t your G u i d e speak n o w " , and then
began to recite i n a deep, monotonous, theatrical tone: " M i s s K — S a r a h
herself—is not ill, she is a unique creature, she is a m e d i u m . There is
another person i n her, but Miss K does not know who this other person
is; she is not quite certain whether she is a m e d i u m or a schizophrenic.
The G u i d e thinks this is idle speculation." The G u i d e continued, saying
that it had long been dissatisfied with Miss K's "smooth words", and that
it was annoying to watch such different personalities as M r and M r s K —
Sarah's parents—having to live together. Sarah now began, i n her o w n
voice, to blame the Guide for ridding her from her responsibility towards
her parents, and there followed an animated dialogue between her and
the G u i d e . In the role of the Guide, Sarah walked about in the room,
gestured theatrically, laughed, and even began to sing.
Sarah's mother belonged to the series I was collecting for m y
doctoral thesis, and I met her soon after this. I described her as follows
(Alanen, 1958, p. 175):

When I questioned this mother (M) about the patient's child­

hood, she willingly led the conversation to her own childhood
home, saying that "there, if anywhere, one would have found
complications". M ' s own father, to w h o m she was attached, was
an alcoholic and had shot himself when M was 16. Following
this, M had had to leave her school, against her own wishes, and
take a job in order to be able to help her mother, with w h o m she
 THREE PATIENTS 5

had strained relations, in supporting the younger children. Since

that time M ' s attitude towards life was dominated by powerful,
martyr-like resentment. " W h e n life runs evenly, I always think
that some blow is soon coming from somewhere." ... She
married a businessman of labile temperament, nervously hasty,
with hypomanic traits, who at times used a great deal of alcohol.
The patient (P) described her father saying that there is always
some k i n d of air " o f an inuninent catastrophe" about h i m . M had
felt frustrated as she h a d to be alone great deal. The first child
came after a year's marriage; it was a girl, and the mother re­
garded her as beautiful; her attitude towards her has always
contained more attachment than her attitude towards P, a second
girl. P was born 4 years after her sister; but this time the parents
had wished for a boy. Meanwhile M h a d taken a job with which
she felt satisfied, but she relinquished it after the birth of her
second child. M d i d not say so herself, but both the father (F) and
P herself knew that P's birth had been a very unpleasant event
for M . She had often felt very sick during the pregnancy—"very
i l l " , as she later used to tell P — a n d felt bitterness towards F.
After P's birth she remained at home. She says that from that
time on she h a d sacrificed herself to her family. She h a d taken
care of the children all alone and had also sewn their clothes. H e r
conversation revealed resentment against this role, which, h o w ­
ever, she assumed with a martyr-like eagerness; it appeared as if
M w o u l d be repeating masochistically the situation after her
father's death, when she had also " h a d to sacrifice herself". There
was, for instance, something quite typical in that M related, with
great self-pity, how her sisters h a d wondered and felt pity for the
fact that her hands, which had been admired as beautiful, were
spoiled by constant laundering. . . . M ' s attitude towards P has
always been covertly hostile, with an admixture of contempt,
and M ' s attitude towards P's illness was surprisingly cold.

I h a d read i n the psychoanalytic literature—for example i n Otto

Fenichel's The Psychoanalytic Theory of Neurosis (1945), that schizo­
phrenic s y m p t o m s can be d i v i d e d into two categories, the first per­
taining to the b r e a k d o w n a n d regression of the patient's n o r m a l
psychic functions (regressive symptoms) a n d the second to the effort
to regain the e q u i l i b r i u m that h a d been lost, but w i t h i n the illness a n d
i n a pathologic manner (restitutional symptoms). Sarah's G u i d e w a s
a most i l l u m i n a t i n g example of the latter category: it was her s u p ­
porter a n d g u i d e , a n d simultaneously a k i n d of ideal ego, w h i c h also
h e l p e d Sarah to express her emotions better than she w o u l d other­
6 SCHIZOPHRENIA

wise have been able to d o — t h o u g h i n a w a y that was separate f r o m

her o w n personality. In retrospect, I also w o u l d stress the significance
of the G u i d e i n serving Sarah's symbiotic needs: this hallucinatory
figure followed her like a helping parent.
M y research on the mothers convinced me that disorders i n the intra­
familial relationships were significant for the pathogenesis of schizo­
phrenia, but it also made me realize that neither the mothers nor the
fathers should be blamed for their child's illness; rather, they needed to
be understood. We are actually dealing with the—mostly unconscious—
consequences of the parents' problems that they have been helpless to
face, problems that have been inherited by them from their o w n homes
a n d have usually been aggravated by their marital relationship. I found
it easy to agree with Sarah's Guide, who criticized her mother for sup­
pressing her normal feelings of anger ("Mrs. K thinks a good child is a
child whose behaviour is three times more controlled than that of an
adult"), but I could also visualize this mother as a y o u n g girl w h o h a d
herself been forced to support the mother she secretly hated after her
father's suicide.
After her discharge, Sarah continued i n psychotherapy with me for
more than a year. H e r condition seemed to develop favourably. But
there came a setback: the examinations and teachers continued to seem
as frightening as before, her anxiety increased, she d i d not sleep well,
she was unable to concentrate, and the accusing and frightening ele­
ments began to dominate her hallucinations. I soon concluded that a
rehospitalization was approaching.
Then, i n his perplexity, the young and inexperienced psychiatrist-to­
be made an inappropriate move. D u r i n g one session, Sarah leaned her
head against the table in desperation. Feeling sympathy, I began softly to
stroke her hair. I h a d not permitted myself to approach her thus before.
The outcome was astonishing. Sarah lifted up her head and said she n o w
heard m y voice i n herself: " Y r j d A l a n e n is speaking, he has become m y
Guide."
Transference psychosis, with which I was now faced, was a new and
embarrassing experience for me. I denied talking to Sarah i n any way
other than I h a d been talking to her previously—that is, through our
conversation. This was confusing to Sarah, because she kept hearing m y
voice in her head instead of her previous Guide. Sudden as the shift was,
I realized that there had been predictive signs of it: the G u i d e h a d
already acquired features reminiscent of me prior to this occasion,
w h i c h was shown by, for example, its increasing medical knowledge.
 THREE PATIENTS 7

The inclusion of the therapist as part of the patient's psychotic

w o r l d — w h e t h e r i n a good or a bad sense—is relatively c o m m o n i n the
psychotherapy of schizophrenia, and I have subsequently h a d several
experiences of it, though not as dramatic as i n Sarah's case. Several
therapists—for example, Searles (1965) and Benedetti (1975)—consider
transference psychosis a regular and even a necessary part of the course
of psychosis therapy.
I have subsequently considered it a mistake that I denied Sarah's
delusion pertaining to myself. It w o u l d not have been necessary for me
to confirm this internalization verbally; it w o u l d have been enough not
to contradict it, but to understand it as one stage of the therapeutic
process. I also consider it a mistake—due to m y o w n insufficiently con­
trolled countertransference feelings—that I stroked Sarah's hair, a n d
ever since that time I have avoided an approach of this k i n d . Frieda
F r o m m - R e i c h m a n n (1952) has written that the therapist should try
to maintain his or her empathically listening attitude unchanged i n
different situations, a n d this seems to me optimally to guarantee the
therapeutic relationship a n d the continuity of the therapeutic process.
The interaction between Sarah and myself might have developed more
peacefully and i n better accord with our internal resources if I h a d ab­
stained from showing her m y empathy i n the form of physical contact.
Sarah's fate was ultimately sad. After the transference psychosis, she
became increasingly restless and was rehospitalized, which w o u l d prob­
ably have been unavoidable anyway. I continued to meet her there, but
our therapeutic relationship was never again the same as it h a d been
originally. She continued to hear m y voice inside her head, a n d this
" Y r j o A l a n e n " probably grew more a n d more different from the one
w h o came to see her o n the w a r d . Another psychiatrist even applied
electroshock treatment to try to remove h i m from Sarah's head.
H a v i n g been discharged from hospital, Sarah continued psycho­
therapy with another therapist, w h o was as inexperienced as I
was—there were hardly any others available i n Finland at that time. A
few years later she was hospitalized as a chronic patient. I tried to con­
tact her while I was writing the manuscript for this book, but I was told
that she h a d died of cancer, having been i n the hospital almost without
interruption for more than 20 years. She h a d been living i n her o w n
w o r l d , her personality seriously disintegrated, talking to her hallucina­
tions. The G u i d e and the psychiatrists h a d been replaced b y a number
of good a n d b a d spirits, including Jesus Christ, Gautama B u d d h a , a n d
Lucifer.
8 SCHIZOPHRENIA

Eric, significance of individual psychotherapy

O v e r the f o l l o w i n g few years I h a d several psychotherapeutic p a ­

tients suffering f r o m psychoses classifiable as schizophrenic. I met
most of them first i n the Lapinlahti H o s p i t a l , as I d i d Sarah, but some
consulted m e privately. These therapies were supportive i n that I
intended to help the patients face their actual problems, b u t I also
u s e d the psychoanalytic approach to help them to have better insight
into the b a c k g r o u n d of their difficulties a n d to g r o w as h u m a n per­
sonalities. S u c h a combination of approaches is c o m m o n i n the p s y ­
chotherapy of psychotic disorders.
M y personal psychoanalysis, w h i c h I started in 1955, was of crucial
significance for m y development as a psychotherapist. It helped me to
clear u p a great many of m y o w n problems and made it possible for me
to approach the problems of m y patients i n an empathic way, yet retain­
ing sufficient internal distance and not allowing m y o w n anxiety to
interfere with the development of the interactive process. A l t h o u g h the
personality of the therapist is more important i n the psychotherapy of
psychotic patients than in the more technical therapy of neuroses, I agree
with V a m i k V o l k a n (1987) and others, w h o have emphasized the impor­
tance of the therapist's o w n psychoanalytic treatment as a prerequisite
for successful long-term therapy of psychotic patients. There are some
exceptions to this rule, some rare natural talents who are better able than
most of us to understand the problems of psychotic patients, mostly
through personal experience. O n e of these talents i n Finland was A l l a n
Johansson, w h o , in the 1980s, compiled his lifetime experience i n a book
(Johansson, 1985) illustrated with cases of catamnestic periods of u p to
30 years. H e , too, considered psychoanalytic training and the associated
personal therapy important, although he h a d been able to carry out
exceptionally successful therapeutic relationships even before such
training.
In 1962 I published a description of m y o w n experiences i n Nordisk
Psykiatrisk Tidskrift (Alanen, 1962). I also included an informal follow-up
account of 26 of m y patients. I excluded the sudden, clearly reactive
cases a n d only included patients with more persistent symptoms—
a few of them, however, could best be described as "borderline schizo­
p h r e n i c s " , a n d some were still in therapy. I considered the findings
encouraging: 17 of the 26 patients were i n good condition. N o t all were
completely free from psychotic symptoms, but i n their normal environ­
 THREE PATIENTS 9

ment they were able to cope i n a satisfactory manner corresponding to

their previous social level.
Discussing the prognosis, I emphasized the importance of the p a ­
tient's contact ability. Some patients were dominated by autistic
isolatory features, including a fear even of the interactional relationship
with the therapist and a desire to withdraw from it, while some others
were more trustful, transferring needs for support and dependence to
their therapist even at early stages of our relationships. Therapy was
considerably more successful i n the latter group than i n the former. The
duration of psychotherapy was also clearly significant: a therapeutic
contact that was possibly less intensive, but of long duration, resulted i n
better outcomes than d i d intensive short therapy.
Eric was one of the patients w h o responded most favourably to
therapy. H e consulted me, at first three times and then twice a week, for
18 months. W h e n I left to study i n the United States, he took u p therapy
with another psychiatrist, but he returned to me w h e n this colleague left
for further education. M y work with Eric lasted for several more years.
W h e n I first met Eric, he was just over 30 years o l d , and his personal­
ity was quite different from the rigid stereotype generally presented in
textbooks of schizophrenic patients. H e was exceptionally flexible—in a
compliant w a y — a n d h a d good contact ability, i n addition to w h i c h he
was also one of the most talented of m y patients. These factors were
certainly part of a personality structure favouring good prognosis. A l ­
though Eric's disorder clearly included schizophrenic features, they d i d
not—probably because of his skilful adjustment and our therapeutic
cooperation—result i n serious disintegration. H e never needed to be
hospitalized. Neuroleptic drugs were prescribed for h i m , i n small dos­
ages a n d for a shorter time, beginning with the nursing-home period
described later. I a m not convinced that they were necessary even then.
D u r i n g his first session, Eric sat i n his chair, pensive and hesitant,
with an occasional friendly but slightly mechanical smile, telling me of
his life situation generally, yet keeping back his most personal thoughts.
D u r i n g the second session he began to speak more openly of his experi­
ences and beliefs. H e told me that his previous superior at work h a d
become " s c h i z o p h r e n i c " three years previously: "I received messages
through ambiguous speech." Eric's wife also "became schizophrenic";
she began to enjoy confessing infidelities in a similar "second-degree
language", thus causing p a i n to her husband. The psychiatrist w h o m
Eric h a d consulted one year previously on the advice of a friend h a d
behaved similarly: 75% of his speech h a d been "sheer nonsense", and
10 SCHIZOPHRENIA

Eric had not been able to say much himself, as he was immediately
silenced with coughs and mutterings. Some kind of "therapy" had, how­
ever, been going on ever since he stopped thoscvisits. Eric was "fed"
experiences, and his "internal pressure" was regulated; there were pos­
sibly also hearing devices that his wife could control and turn on at will.
Eric felt himself to be a "robot" whose life was being controlled by
others. He asked whether I had now been appointed in charge of this
"therapy", whose strings, he thought, were being held by an American.
I told Eric that I was now his therapist, and that we should together
find out what this was all about.
Eric's psychotic experiences had begun when he projectively placed
the onset of "schizophrenia" in his boss. This man had criticized Eric for
negligence in his job, apparently without any reason. Eric had liked this
boss, but felt he was becoming increasingly hostile towards him. This
was shown by the boss's expressions and behaviour and gradually by
this "second-degree" speech, which Eric felt to cause unbearable "pres­
sure variations" in himself. There was either excess pressure or a "hole"
through which all pressure was depleted, leaving him quite weak and
his will controlled by others.
Using classical psychiatric terminology, we might say that Eric
had begun to live increasingly in a world of delusions of reference. By
"second-degree language" he meant meanings pertaining to himself
that were implicit in the speech of significant others. The others did not
themselves recognize these meanings—but they may often have been
close to subconscious attitudes expressed by them unintentionally. For
example, a man in the company had looked out of a window and said,
"It's getting overcast", which was considered by Eric to express his in­
creasing hostility towards himself. The "second-degree language" thus
came about in Eric's own mind, and he used its expressions also to
concretize the anxiety he felt to be overpowering.
Delusions of reference were also associated with physical delusions
of influence. Eric believed, for example, that his wife was able to use
certain digital movements connected with her needlework to give—
often at a certain time—her husband a "sleeping shock", which gave Eric
"a cap on his head".
Despite his delusions, Eric continued to cope astonishingly well in his
social environment. He had got a new job, but he told me during the
therapeutic sessions that even there he had almost daily experiences of
"pressure regulation" by fellow workers. He did not tell them about his
experiences, but he confided in a superior he felt to be protective. The
 THREE PATIENTS 11

latter cautioned Eric to keep such things strictly secret, mentioning three
members of the w o r k i n g community w h o w o u l d certainly not under­
stand h i m . They were precisely the "hole-makers", said Eric. I considered
this a good example of the " d o u b l e book-keeping" already described b y
E u g e n Bleuler (1911), w h i c h is frequently encountered especially in m i l d
forms of schizophrenia: although the patient feels his delusions to be real,
he simultaneously has a latent feeling of illness, w h i c h makes h i m hide
his symptoms from non-understanding neighbours.
M a n y of Eric's psychotic delusions c o u l d be understood s y m b o l i ­
cally, b u t he experienced them at the concrete level. It was not always
clear to w h a t extent h e understood the symbolic nature of his experi­
ences a n d expressions. A t one time, for example, he described himself
as a " c a r " , m e a n i n g that other people were able to control h i m as they
were able to steer a car. H e once asked me to steer h i m . I said I w o u l d
rather be a d r i v i n g instructor, w h o w o u l d teach h i m to steer himself.
I a s s u m e d E r i c c o u l d understand this s y m b o l i s m , a n d he certainly
d i d . Nevertheless, he called m e i n a n extremely w o r r i e d state one
m o r n i n g , s a y i n g that he h a d received a w r o n g - n u m b e r telephone call
asking whether he h a d a car to sell.
Problems of self-esteem both i n the working community and espe­
cially i n relation to his wife were clearly at the core of the difficulties that
h a d resulted i n Eric's illness. This was reflected i n his psychotic fantasies
of his wife's infidelity with more and more men. Eric's jealousy of her
affection towards their two small children m a y also have influenced
these dynamics. The quarrels over these imaginary incidents ultimately
led to a situation where divorce began to seem inevitable. A t that point
Eric came to spend a summer in the countryside i n a nursing home
where I was working as a psychiatrist. That summer was very important
for the development of our therapeutic relationship. Eric felt the atmos­
phere of the nursing home to be extremely beneficial, helping to balance
his condition. While i n the nursing home, he developed a n e w term,
" t e n t " , to describe a satisfactory condition of interpersonal solidarity,
where a pressure balance prevailed, because people freely p r o v i d e d
each other with pressure whenever necessary. " C o u l d n ' t we set u p a
tent", Eric occasionally said to me even later, when he felt that our
mutual pressure variations threatened his o w n well-being.
Empathic understanding of the concrete language of psychotic expe­
riences—of w h i c h the Finnish psychoanalyst Eero Rechardt (1971) has
written an illuminating article—is one of the things I learnt while being
Eric's therapist. In the nursing home, our m u t u a l interaction developed
12 SCHIZOPHRENIA

to a stage that has been called "complete symbiosis" by Harold F. Searles

(1961). During the sessions we had at that time I occasionally found
myself using psychotic expressions I had borrowed from Eric. If an out­
sider had been present to listen to our discussions, he would probably
have been quite baffled by what he heard. But I naturally also realized
that the therapist's task is not merely to understand such expressions,
but also to reveal their symbolic nature and thereby endeavour to in­
crease the patient's sense of reality.
This may be called "interpretation upwards" (Rechardt), and it can­
not succeed without mutual understanding of the patient's problems
even more widely than is suggested by his figures of speech. "Interpreta­
tions downwards", to probe and disclose the unconscious, which are
frequently used in the psychotherapy of neurotic disorders, may often be
unnecessary or even harmful in the therapy of schizophrenics. I once
went so far as to suggest to Eric that in his fantasies of his wife's esca­
pades he seemed to imagine himself in her position: was he possibly
able to imagine in his wife the feelings he himself had towards these
men? Eric burst out laughing heartily, whereby he—to the benefit of our
therapeutic process—seemed to discard for good this misjudged, or at
least badly timed, attempt at interpretation. Even the interpretation of
his aggressive feelings, evidently influencing his projective delusions,
did not have much effect early in the therapy.
Understanding Eric's problems, which we achieved by analysing
together his family and developmental background during the course of
the therapy, was of crucial significance, however. His mother appeared
to have been an exceptionally quick-tempered and domineering per­
son—which characteristics Eric at first depicted with almost tearful
idealism. Later on he described his childhood as hell: he had, for in­
stance, been forced to kneel down before his mother to apologize for his
small tricks, while the mother pulled at his hair so hard that tufts of hair
tore out. Eric had felt his younger brother to be his mother's favourite,
who was fed and pampered differently from himself; this gave us access
to the foundations of his jealousy. He spoke less about his father, who
seems to have been the more passive of the parents, subordinate to his
wife. It was no wonder, therefore, that Eric found himself struggling
with similar problems in adult life, and that new father figures, such as
superiors in work and the therapist, were important for him.
Eric's therapy thus gradually concentrated on pointing out and inter­
preting the connections between his childhood family background and
 THREE PATIENTS 13

his current problems. W e discussed, for example, his childhood experi­

ence of love requiring submission, which left no space for one's o w n
w i l l . We also realized that the mother who demanded submission was
thereby " r e l i e v i n g her pressure". The "sleeping shocks" found their
counterpart i n the necessity to go to bed at a certain regular time in
childhood. Eric soon developed an ability to perceive such connections
himself. "If y o u are just told to obey throughout y o u r childhood, it's no
wonder y o u grow u p a robot." A s we proceeded i n our exploration of
the influences of childhood, the questions of sexuality and the problems
of closeness and distance i n h u m a n relations became increasingly i m ­
portant. These questions also became topical w h e n Eric found a new
female friend after his subsequent divorce.
There is n o need to describe i n detail the later course of Eric's
therapy after m y return from the United States. H e h a d practically no
psychotic delusions, though they sometimes still peeped out as " w h i t e
rabbits". This term, w h i c h Eric himself used humorously, aware of its
symbolic significance, was derived from an A m e r i c a n film Harvey, i n
which James Stewart, in the role of the main character, sometimes sees i n
company a friendly creature of this kind, which is invisible to the others.
Eric realized that he was having similar experiences—milder forms of
recurrent "second-degree" ideas—especially w h e n he was unable to u n ­
derstand the aggression of other people and the reactions they caused
i n h i m . If one was rationally aware of them, one d i d not need "white
rabbits". H e was also sometimes helped i n anxiety-provoking situations
b y his speculation of h o w the therapist w o u l d cope—this was called
"permissible projection" b y Eric.
It was not, however, easy to give u p the "white rabbits" completely.
"It's sort of nostalgic to leave them and be always healthy", Eric once
said, showing increasing insight into himself. Nevertheless, the "rabbits"
gradually left the stage for good.
I often marvelled at the insight Eric developed u p o n growing out of
his psychotic experiences as to the unconscious motives of both himself
a n d other p e o p l e — a feature not altogether rare i n patients of this k i n d .
Thus Eric wondered, w h e n his boss occasionally gave " m i l i t a r y " c o m ­
mands, whether he should "oppose h i m for his o w n good—but, then,
I'm not his n u r s e m a i d " . This also implied the psychotic theme of "ex­
changing pressure", but now at a non-psychotic level. A n d w h e n we
once, later on, mentioned the "sleeping shocks" given b y his first wife,
he pointed out: "It was just a need for contact." This obvious interpreta­
14 SCHIZOPHRENIA

tion h a d not occurred to me, while I was trying to understand the d y ­

namics of the mutual aggressive feelings between the spouses.
Eric h a d remarried while undergoing therapy with m y colleague,
and his new marriage turned out moderately happy, as far as I could
judge. After the termination of our therapy he published a doctoral
dissertation a n d worked i n an intellectually demanding office for more
than 20 years. I met h i m again recently, asking for his permission to
publish m y experiences of his therapy. H e gave me permission, h o p i n g
that this book might increase the understanding of interpersonal prob­
lems a n d modify attitudes i n , for example, working communities. H e
was i n good condition both physically and psychically, and he h a d not
been i n need of psychiatric help or medication since his therapy.
The experience with Eric and other patients led me to believe that at
least part of psychoses of the schizophrenia group are understandable
psychologically, and that the patients suffering from such psychoses can
recover their mental integrity through psychotherapy. The recovery is
part of a process of personality development, which, as it advances,
makes psychotic symptom solutions unnecessary. It is also true that
setbacks occur, b u t — i f the continuity of the therapy is guaranteed—the
recurring psychotic stages or the aggravation of the symptoms of p a ­
tients undergoing psychotherapy are milder than previous episodes,
unlike i n patients who have not h a d a psychotherapeutic relationship.
A s far as I can see, there is hardly any consistent difference observ­
able i n the course and outcome of the psychotherapy of schizophrenic
patients with a good prognosis and that of long-term neurotic patients.
In both cases the symptoms usually subside gradually, and not always
completely: even after successful psychotherapeutic treatment, the ten­
dency to symptoms m a y persist (indicating the express of unresolved
areas of conflict) and be manifested in problematic situations, though
they are less conspicuous and under better control than before therapy.
Because psychotic symptoms involve a more profound disturbance of
the sense of reality, with m u c h greater social handicaps—including the
reactions of the people close to the patient—this analogy between them
and neurotic symptoms is often ignored.
H o w e v e r , I also treated psychotic patients whose therapy was not
successful.
 THREE PATIENTS 15

Paula and family therapy

T h e research o n families, w h i c h I continued to p u r s u e , increased m y

u n d e r s t a n d i n g of schizophrenia. It also s h o w e d m e the need to give
increased attention to matters pertaining to the family e n v i r o n m e n t
i n m y therapies. It took l o n g , however, before I began to practise
family therapy a l o n g w i t h i n d i v i d u a l therapy. T h i s f o r m of therapy
w a s u n k n o w n i n F i n l a n d at that time, a n d r e m a i n e d so for some time
after the year (1959-1960) I spent i n the U n i t e d States, w h e r e the
pioneers of family therapy h a d b e g u n their w o r k . T h e Department of
Psychiatry at Yale U n i v e r s i t y , where I spent a useful year as a m e m ­
ber of T h e o d o r e L i d z ' team, w a s not the best possible place w i t h
respect to integrating family a n d i n d i v i d u a l t h e r a p y — a l t h o u g h the
team w a s considered, w i t h reason, the central pioneer i n schizophre­
nia-oriented family research. T h e y were u s i n g family therapy at Yale,
b u t the therapeutic focus w a s o n i n d i v i d u a l therapies a n d c o m m u ­
nity therapies, w h i c h were s u p p l e m e n t e d b y separate meetings w i t h
the patients' parents to study the family d y n a m i c s a n d s u p p o r t the
patients' therapy.

However, I was able to observe, behind the one-way mirror, conjoint

family therapy conducted b y Stephen Fleck, where I thought the thera­
pist indicated b y his o w n behaviour to the patient h o w the latter could
get along with his father. W h e n I visited the National Institute of Mental
Health, I saw a family therapy session conducted jointly b y L y m a n C ,
W y n n e a n d H a r o l d F. Searles, w h i c h impressed m e considerably. It
seemed to me that the therapists h a d divided up their roles: Searles acted
as "stimulator", who asked quite bold questions or interpretations, while
W y n n e remained a safe father figure, w h o held the reins and helped to
perceive the situation i n an integrated manner.
I have subsequently realized that there also were some more per­
sonal matters, w h i c h were part of m y o w n family background a n d
w h i c h I only later became aware of, that caused me to resist becoming a
family therapist. These included a fear of emerging anxiety and aggres­
sion towards the patients' parents, w h i c h was due to m y empathic
understanding of the patient and consequent projective identification.
O n the other h a n d , I was not sure whether I could remain sufficiently
loyal to the patient i n a situation where we w o u l d be attacked b y his or
her domineering parents. I started family therapies at a stage where m y
o w n anxieties h a d been alleviated enough b y m y psychoanalysis a n d I
16 SCHIZOPHRENIA

was better able, i n a therapy situation, to conceive of myself as a thera­

pist of both the patient's parents (or spouse) and the patient.
A s these personal feelings of mine illustrated, family therapy is more
diversified and more difficult to control than individual therapy. This is
one reason w h y family therapy is currently considered a task of a thera­
peutic team or at least of two therapists, not one therapist working alone.
In the mid-1960s, when I started family therapy of schizophrenic
patients in the Lapinlahti Hospital, which h a d become the Clinic of
Psychiatry of the University Central Hospital of Helsinki, I met the fami­
lies alone. I found support i n a family therapy seminar I had started at
the same time, where we listened to the audiotaped family therapy
sessions and discussed them with m y colleagues. M y initial experiences
of this new mode of treatment were mainly favourable a n d soon con­
vinced me that family therapy may be significantly helpful i n the
therapy of many schizophrenic patients.
O n e of m y first family therapy patients was Paula, a 24-year-old
female student. She had been hospitalized four times over the preceding
couple of years. H e r psychotic state, which was dominated b y restless­
ness, disorganization, occasional thought disorders, a n d delusions, was
always alleviated in the hospital, but soon deteriorated w h e n she was
discharged, necessitating rehospitalization.
A s I became acquainted with Paula's family environment, I found
the parental relationship to be strained and conflict-ridden. H e r father
was a rigid m a n with obsessive and distrustful features, who tended to
dominate his family. The therapy also revealed his strong feelings of
inferiority and fear of being ignored. The mother was outwardly calmer,
but she was frustrated and tended to cling to her children, trying to
isolate the father from the rest of the family—as she h a d felt that he
isolated her from the outer world. Their three daughters were " d i v i d e d "
between the parents, as is typical of schismatic families (Lidz,
C o r n e l i s o n , Fleck, & Terry, 1957b). Paula was considered the most sub­
missive of the children, and she was attached to her mother.
W h e n Paula was i n the hospital for the third time, one of m y col­
leagues made a serious attempt at i n d i v i d u a l therapy w i t h her, while I
met her parents. This arrangement, however, aroused strong suspicions
in Paula. E v e n her individual therapy h a d to be discontinued w h e n her
condition at home again deteriorated and she gave u p her visits to the
therapist.
W h e n Paula was admitted for the fourth time, I began joint sessions
with her, her parents, and the sister who lived at home. I h a d hesitated to
 THREE PATIENTS 17

undertake this task, because I h a d been afraid that Paula w o u l d be

crushed under the continuous, often quite serious quarrelling between
her parents. It d i d not occur to me at the time that Paula was quite used
to it. A l t h o u g h she sometimes drew her head back during the stormiest
altercations and retreated into her own world, she generally coped quite
well, beginning, w h e n supported by the therapist, to express her o w n
views. She was well motivated to family therapy for the very reason that
she considered her illness to be originally due to family conflicts.
O n e of the most favourable effects of this family therapy was that
Paula's aggressiveness, which h a d at first found expression, in an uncon­
trolled and incoherent manner, during the psychosis, gradually began to
acquire more organized a n d balanced forms, becoming integrated into
her personality. A parallel development took place i n the whole family,
supporting Paula's integration: the atmosphere of the therapy sessions,
which was initially dominated by chaotic quarrelling, soon became more
peaceful, and the family began, stimulated by Paula's statements, to
discuss seriously the problems of their mutual relationships.
I illustrate this with the following audiotaped extracts. A t this point
the joint sessions h a d been going on weekly for three months.
The first extract begins with the family discussing whether M a r y ,
Paula's younger sister, should continue to be present at the therapy
sessions. M a r y h a d been attending up to that time but was absent from
this session.

THERAPIST: W h a t d o y o u think, w o u l d it be g o o d if she continued

to attend? She came because she lives i n the family, is a member
of the family, a n d it seems that it w o u l d be especially important
for P a u l a that M a r y w o u l d also attend, as there has been a k i n d
of tens...

M O T H E R : Yes ...

THERAPIST: ...ion between them, too.

M O T H E R : It w o u l d certainly be good, a n d I w o u l d say that M a r y

could continue to come.

F A T H E R : Let's try to make her come. [Emphatically] W e can make

M a r y come even if she doesn't want to. [Laughing] She doesn't
suffer if I say: Y o u come now, g i r l . . .

M O T H E R : It w o u l d certainly be good if M a r y also came here, that she

w o u l d n ' t be left out altogether.
18 SCHIZOPHRENIA

THERAPIST: What do y o u think about this, Paula?

P A U L A : W e l l , I don't really . . . [pauses]

THERAPIST: Y O U don't really . . .

P A U L A [stammering]: Well, I've had a d i f f e r e n t . . . like I've . . . ever

since the beginning I've had a different position in our family from
M a r y , I mean in the sense t h a t . . . er . . . I mean M a r y has always
had a different position from me in our family . . . I m e a n . . . er . . .
it's like . . . like, I mean it, doesn't really make any difference. She
could be here, all right, but then again I don't really know, but is it
sort of late now . . . I mean, to put right the relationships, b u t . . .

THERAPIST: D O y o u still feel that this different position has some effect
on you?

P A U L A : It doesn't affect me i n any way any longer.

[Pause]

F A T H E R : W h a t d o y o u m e a n b y this different position?

P A U L A : W e l l , y o u k n o w . . . y o u s h o u l d k n o w it, more or less, what

k i n d of position M a r y has i n our family. M a r y is a v e r y d o m i ­
neering personality a n d . . . I m e a n . . . er . . . v e r y d o m i n e e r i n g
p e r s o n a l i t y . . . a n d [speaking in a louder voice] I'm sure y o u
k n o w w h a t I'm trying to say, what the difference is between
M a r y a n d me i n our family, a n d y o u must k n o w it!

M O T H E R : P a u l a probably means that M a r y always gets w h a t she

wants, a n d P a u l a doesn't—is that w h a t y o u mean?

P A U L A : That's about i t . . . I m e a n like w h e n M a r y . . .

M O T H E R : If there's something she doesn't w a n t to d o , she doesn't

d o it, a n d if there's something she wants, so it's d o n e as she
wants it. I think this is w h a t y o u mean?

P A U L A : Yes, something like that.

F A T H E R [sighs]

MOTHER: So ...

FATHER: I was just...

M O T H E R : But M a r y is a bit like, I m e a n she wants to . . .

F A T H E R : What I w o u l d say is that it may be s o m e . . . but has it

occurred to y o u , Paula, that it's your reaction to M a r y ?
 THREE PATIENTS 19

P A U L A : It i s n ' t . . . it isn't originally, it came w h e n I . . . it i s n ' t . . . I

mean it doesn't depend o n that, but I sort of know it, because I get
along just fine w i t h M a r y , m u c h better than Cathy does, for i n ­
stance. [Cathy is the eldest sister, who has moved away from home.]
M a r y a n d C a t h y don't get along at all.

M O T H E R : T h e y certainly don't.

P A U L A : I get along with M a r y just fine, but there're the conditions . . .

er . . . [stammering]... the conditions . . . the conditions I sort of
have i n our family.

FATHER: What are these conditions?

P A U L A : I mean, I always have to admit everything, a n d M a r y just

never gives i n i n anything, I mean i n a n y t h i n g . . . like there's
still...

FATHER: S O y o u and M a r y . . .

PAULA: Yes.

FATHER: . . . I mean the relationship between y o u two.

P A U L A : Yes, it reflects our relationships from the point of view of the

whole family.

[Pause. Father sighs.]

M O T H E R : I see quite w e l l w h a t P a u l a means, I see it quite w e l l
now.

FATHER: Yes, w e l l , I...

M O T H E R : I w o u l d like to give one example, can I?

FATHER: Y e s , sure.

THERAPIST: Yes.

M O T H E R : I just give this one example. W e were s a y i n g at one time

that P a u l a w o u l d get this r o o m that M a r y has. T h i s is a bigger
r o o m , a n d as it w o u l d sort of be for P a u l a , w h o ' s i l l , like it u s e d
to be . . . I m e a n she w a s sort of u s e d to it a n d always w e n t to
b e d there w h e n she was not w e l l . A n d n o w w e were s a y i n g that
P a u l a w o u l d get that r o o m . . . a n d it w a s d e c i d e d that P a u l a
w o u l d h a v e it, b u t w h e n w e began to talk to M a r y about it,
w h a t w e s h o u l d d o about it, so it turned out i n the e n d that
P a u l a d i d not get that r o o m , but h a d to take the other one, a n d
20 SCHIZOPHRENIA

M a r y h a d that r o o m . T h i s shows what k i n d of position . . . that

it's like this. Wasn't this so?

P A U L A : I m e a n if y o u think t h a t . . . I m e a n I'm the one w h o ' s i l l i n

the family, a n d y o u w o u l d ' v e thought that the one w h o ' s i l l
w o u l d ' v e got the better r o o m a n d the one w h o ' s healthy
w o u l d ' v e m o v e d out. If y o u think that the illness has really sort
of d e v e l o p e d inside the family, that it's not m y private p r o p ­
erty, this illness of mine, but that it's really something that
comes out of the family. So y o u c o u l d ' v e expected m e to get
that r o o m .

MOTHER [sighing]: Yes.

P A U L A : I m e a n I sort of gave i n just like t h a t . . .

MOTHER: Yes.

P A U L A : I knew it for sure that M a r y will get the better room, that she
can keep i t , so I didn't even try to make any claims o n it. I just
accepted the other room, and I also lived i n that other room.

FATHER: W e l l now, about this r o o m s t i l l . . . er . . . I mean I've got the

impression from what M u m has said that Paula is really satisfied,
and that's precisely because there's that curtain and y o u always
see the movement there and y o u . . .

PAULA: I've never . . .

FATHER: . . . you've . . . y o u have y o u r s e l f . . .

MOTHER: A t first she . . .

FATHER: Y o u have even said so yourself, that and . . . er . . . wouldn't

it be so, Paula, that y o u could feel some satisfaction that you've
been able . . . er . . . and that y o u have a good room, too . . . that
you've been able i n this way to build harmony in the family, that
it doesn't matter if y o u have that room. M a r y , maybe . . .

PAULA [angry]: What do y o u mean when y o u say that I don't matter,

when I'm at home. Do y o u mean that. . .

FATHER: N O . . . I don't, but what I mean is that it hasn't been i n any

way inconvenient for y o u to live i n that room. Y o u ' v e been quite
h a p p y about it. Haven't you?

P A U L A : Well, yes, but I w o u l d be even happier i f . . . I mean, I

was h a p p y not to have to share a room with M a r y , but [louder]
I w o u l d ' v e been even happier if I h a d h a d the better room,
 THREE PATIENTS 21

but I'm perfectly h a p p y about that (current) room, too, perfectly

happy.

P a u l a , w h o is supported b y her m o t h e r — i n opposition to the father—

brings forth her v i e w s w i t h increasing force, though u s i n g her illness
as a w e a p o n . T h e father's remark o n h o w Paula has been able to b r i n g
about h a r m o n y i n the family through her submissiveness is a g o o d
example of a desire to maintain the k i n d of family homeostasis de­
scribed b y D o n D . Jackson (1957), a state of e q u i l i b r i u m that is often
quite difficult to change i n these families, a n d w h i c h is regulated b y
unwritten rules based o n the m u t u a l emotional a n d p o w e r relation­
ships between the family members.
P a u l a w a s not content w i t h the assumption that her bitterness
was essentially d u e to her necessity to submit. A s the session c o n ­
t i n u e d , she p o i n t e d out that she was actually referring to intrafam­
ilial relationships w h e r e i n she was n o t — u n l i k e her sister M a r y —
" a c c e p t e d just as I a m " . W i t h regard to school performance, for ex­
a m p l e , she was set greater d e m a n d s than were her sisters.
Paula's appeals touched especially the father, w h o was actually
also Paula's m a i n target. T h e father was, at that time, m a k i n g a n
attempt to make contact w i t h P a u l a , asking about her c o n d i t i o n a n d
personal matters too frequently a n d i n a w a y that P a u l a f o u n d irritat­
ing. D u r i n g one of the following therapy sessions the father described
w i t h obvious pertinence the w a y i n w h i c h his relationship w i t h P a u l a
had been less adequate from the b e g i n n i n g than his relationships
w i t h the other daughters:

F A T H E R : T h i s is n o w , I guess, the matter . . . a n d the reasons lie

deeper, a n d . . . a n d . . . y o u cannot i n this w a y . . . w e l l , it is
obviously impossible to rectify them. I only remember that last
time P a u l a revealed that she hasn't received recognition, a n d
this p o i n t has p r e o c c u p i e d m e a lot, a n d I guess that it was also
meant for the father. W e l l , n o w , the mother has perhaps been
c l o s e . . . v e r y close to P a u l a , a n d even as a b i g g i r l . . . a year
ago, a n d e v e n this year, w h e n I a m away f r o m h o m e , P a u l a
comes to sleep w i t h the mother, a n d [coughs], w e l l . . .

M O T H E R : N O , not any longer, of course . . .

P A U L A [simultaneously]: It was w h e n I . . . w h e n I was i l l . . .

F A T H E R : N O . . . also while she's w e l l . . .

22 SCHIZOPHRENIA

[All of them speak excitedly and simultaneously]

P A U L A : I ' l l tell y o u , I preferred to sleep i n that bed because it was so

cool there as there was that w i n d o w . . .

F A T H E R : W e l l , yes. Let it be so . . . b u t . . . but, w e l l . . . I guess that it's

so that y o u have once longed for your father a n d y o u r father
hasn't understood y o u a n d has w a r d e d y o u off, or has not
that is to say, hasn't come to meet y o u somehow, a n d y o u again
are so sensitive and shy that y o u haven't been able to come, even
though your father w o u l d have been . . . w o u l d have been able to
receive y o u t h e n . . . that this has n o w happened w i t h y o u ,
whereas it isn't so with your sisters, w h o have been more
active, they themselves have made the initiative, and so forth, that
there is such a reason deeper here, somehow and, w e l l . . . I believe
that y o u also understand it yourself n o w , and that after this c o n ­
versation perhaps . . . it w i l l begin to clear u p better, y o u ' l l under­
stand y o u r father t o o . . . we must all understand, all of u s . . .
[entreatingly] also y o u have to understand me, that is to say y o u
have...

P A U L A : I tell y o u frankly I cannot stand y o u r a s k i n g . . . [general

laughter]... I tell y o u frankly that I don't stand . . .

P a u l a was naturally unable to c o m p l y w i t h her father's attempt to

alter their relationship so r a p i d l y , because this inevitably also i n ­
v o l v e d a n x i e t y - p r o v o k i n g elements. D u r i n g the f o l l o w i n g session she
a n d her mother attacked the father, taking their turn i n d e f e n d i n g the
p r e v i o u s psychological homeostasis of the family. O v e r the next few
weeks the therapist also got the i m p r e s s i o n that P a u l a w a n t e d r e ­
v e n g e for her father's rejection w h i c h she h a d experienced, b y n o w
rejecting h i m herself. E v e n so, their dialogue also suggested obvious
m u t u a l satisfaction, a n d P a u l a g r a d u a l l y grew closer to her father.
The weekly family therapy sessions were continued altogether for
18 months, d u r i n g w h i c h period the family atmosphere and the
intrafamilial relationships clearly developed favourably. Paula showed,
probably because of her father's new understanding of her, alleviation
of her previous pent-up bitterness and appeared to be liberated from
the bonds it h a d caused. The mutual relationship between the parents
also i m p r o v e d , which h a d a further liberating effect o n Paula. She partly
got r i d of her symbiotic reliance on her mother. She took a job and
was finally also able to resume her studies. She continued to have
 THREE PATIENTS 23

some paranoid-psychotic features, though clearly less obvious than be­

fore.
This family therapy was, however, discontinued too soon, as the
therapist m o v e d to another locality. The family were not motivated to
see another therapist, nor was I able to persuade Paula to return to
i n d i v i d u a l therapy, w h i c h seemed to me the optimal solution i n that
situation. Paula continued to develop favourably for some time after the
discontinuation of family therapy. She even completed her studies a n d
was married. But these life changes also brought with them new p r o b ­
lems, w h i c h resulted i n setbacks and even occasional aggravation of the
p a r a n o i d symptoms. H o w e v e r , Paula has managed to avoid new cycles
of hospital treatment.
A p a r t from the family therapy of patients, often seriously i l l , w h o
lived with their parents, I also h a d some experience w i t h couple therapy
of schizophrenic patients and their spouses. Problems of the marital
relationships often featured quite notably i n these cases, and the out­
come of therapy varied a great deal, depending, for example, o n the
attitudes of the spouses.
A s I reviewed our experiences with family therapy (Alanen, 1976;
A l a n e n & K i n n u n e n , 1975), I perceived—as i n the case of i n d i v i d u a l
therapies—the importance of the duration of the therapy for the devel­
opment of changes that take place i n intrafamilial relationships. M y
orientation as a family therapist was psychodynamic, being based o n the
psychoanalytic frame of reference that was familiar to me, though it h a d
naturally been complemented a n d widened b y family-dynamic f i n d ­
ings. T h e motivation of the different family m e m b e r s — i n c l u d i n g the
patient—to discuss shared problems p r o v e d an important prognostic
factor. In optimal cases the families themselves contained wholesome
resources for change and for an alliance with the therapist. In some other
cases, however, m y efforts met with resistance, w h i c h often caused the
therapy to be discontinued at an early stage.
T h e m a i n p r o b l e m i n the further development of the psychothera­
peutic treatment of schizophrenia appeared to be the question of
indications: w h e n was it useful to choose individual therapy, w h e n fam­
ily therapy, and w h e n were the two to be combined? A s far as I c o u l d
see, these two modes of therapy were not mutually exclusive but, rather,
complementary methods, a n d the choice between them was best made
independently i n each case.
In 19681 was nominated Professor of Psychiatry at the University of
T u r k u a n d M e d i c a l Director of the psychiatric university hospital that
24 SCHIZOPHRENIA

h a d been founded the previous year as part of the public health care
system of the City of T u r k u . In the T u r k u Clinic of Psychiatry I met with
a stimulating and constantly renewed group of colleagues and students.
Research on the development of the treatment of schizophrenia became
one of the main goals we shared.
CHAPTER TWO

General notes
on schizophrenia

S
c h i z o p h r e n i a is a serious mental illness that u s u a l l y becomes
manifest i n adolescence or i n early a d u l t h o o d . It is character­
i z e d b y partial disorganization of personality functions, d e ­
v e l o p m e n t a l regression, a n d a tendency to w i t h d r a w f r o m interper­
sonal contacts into a subjective internal w o r l d of ideas, often c o l o u r e d
b y hallucinations or delusions. T h e illness m a y b e g i n s u d d e n l y or
g r a d u a l l y , a n d its s y m p t o m s either i m p r o v e or become chronic to
different degrees. M a n y patients have better periods w i t h only m i n o r
s y m p t o m s a n d worse periods w h e n the s y m p t o m s are re-aggravated.
S c h i z o p h r e n i a differs f r o m the mental illnesses of definite organic
o r i g i n i n that it does not i n v o l v e dementia or disorders of m e m o r y ,
orientation, or intelligence comparable to the latter.

Symptoms

O n e central aspect of the disorganization of personality is the loss of

reality testing, w h i c h is usually considered a s y m p t o m p a t h o g n o m i c
of all psychotic disorders. It means that the ability to differentiate
u n a m b i g u o u s l y between internal experiences a n d sensations (per­

25
26 SCHIZOPHRENIA

ceptions) of the external w o r l d has been lost, w h i c h results i n the

emergence of hallucinations. A u d i t o r y hallucinations are particularly
c o m m o n i n schizophrenia, although all the sensory functions m a y be
i n v o l v e d . T h e loss of reality testing, i n a m i l d e r form, is also typical of
delusions, w h i c h are d u e to subjective misinterpretation of observa­
tions of the s u r r o u n d i n g w o r l d .
It is further typical that the psychological boundary separating the self
from others tends to be blurred i n schizophrenia. The patient may, for
example, feel himself to be simultaneously himself and an actor he has
seen o n television, or he m a y interpret the sensations he feels i n his
lower abdomen to be the sensations of someone else. T o an even greater
extent, this problem affects the patient's ability to draw a line between
internal ideas of oneself and of others (self- and object-representations).
U s i n g psychoanalytic language, we might therefore say that the dis­
integration of personality functions in schizophrenia pertains primarily to
the ego—that is, the part of psychic functions responsible for their logi­
cal integration, the control of the internal balance, and the adjustment to
the external w o r l d .
Eugen Bleuler (1911), father of the term "schizophrenia", considered
it particularly typical of this illness that the patient suffers disorders,
gaps, and shifts of associations, which impair his train of thought, inter­
fering w i t h the maintenance of intention or attention. D a v i d Shakow
(1962), an experimental psychologist, has stated that schizophrenic p a ­
tients find it difficult, i n their thinking and other functions, to follow the
holistic major sets, but cling to minor or segmented sets. In other words,
they d o not see the forest for the trees.
A closer look at these thought disorders may reveal their connections
to the patient's personal associations: unlike healthy people, the schizo­
phrenic patient is at the mercy of these associations, w h i c h tend to
interfere w i t h his thinking. M a n y schizophrenics have also described
experiences of having h a d thoughts extracted from their brain or alien
ideas forced into their m i n d .
Regression of ego functions refers to deterioration of the modes of
thought and conception governed by organized and realistic-level logic,
and their consequent substitution b y a more archaic logical system com­
patible with the ideational modes of the " p r i m a r y process" of dreams
and the unconscious. This process has been described in different ways,
emphasizing different aspects. E . v o n Domarus (1944) and Silvano Arieti
(1955) spoke of "paleologic t h i n k i n g " , while N o r m a n C a m e r o n (1938)
preferred the term "overinclusion", implying that a given shared feature
 GENERAL NOTES O N SCHIZOPHRENIA 27

m a y lead to different but inclusive associations. For example, a patient

calls herself " V i r g i n M a r y " because she is a virgin a n d M a r y was also a
virgin (Arieti, 1955). I w o u l d especially like to emphasize, following K .
Goldstein (1948), concretization—a pointedly concrete interpretation of
symbolic expressions. W e are able to interpret the symbols as symbols,
but o u r patients interpret them as part of the reality they take to be
concrete. G o o d examples of this were given b y Eric, as described i n
chapter one.
Concreteness of this k i n d is also apparent i n physical delusions: the
psychological influence of another person m a y be experienced as a con­
crete-level touch i n d u c e d b y h i m or her from a distance. In auditory
hallucinations, the concretization m a y appear as blame directed at the
patient, w h o deals with his or her inner thoughts as if they were fact; the
patient is blamed for being a whore if she has sexual thoughts i n her
m i n d . A l s o , characteristically, regression i n schizophrenics' ego relates
external events to one's self. O n e female patient, for instance, took a
w o r n - o u t car tyre i n the y a r d to be a malicious hint at her " w o r n " sex
organ. In its most extreme form, such egocentricity develops into o m ­
nipotent thinking. But even a meaning interpreted as global reveals a n d
reflects the personal meaning underlying it.
O n e of the patients i n our hospital claimed that wars and u n e m p l o y ­
ment w o u l d have been eliminated from the w o r l d if his relationship
with his former female friend h a d continued. If this h a d been so, it might
have prevented the onset of his illness—at least t e m p o r a r i l y — a n d his
later violent tendencies a n d unemployment. W e can thus see that even
this ostensibly senseless association has a k i n d of sense i n it, w h e n w e
recognize the regression of the patient's experiential w o r l d to a n o m ­
nipotent level.
The verbal expressions of deeply regressed schizophrenic patients
are frequently very scant and blocked, or so full of extremely subjective
phrases a n d neologisms, or at least semantically idiosyncratic words,
that they are difficult or almost impossible to understand. In some cases,
however, the patient's life course and developmental history m a y p r o ­
vide unexpected illumination o n h i s / h e r cryptic speech, as shown b y the
following examples.
I interviewed for educational purposes an extremely lonely y o u n g
m a n . A s I inquired about the onset of his illness, he told me that he h a d
lost part of his bones. W h e n I further asked what he thought the possible
cause of this to be, he replied: " P r o b a b l y d y i n g . " The patient also said
that he h a d been living i n the sea m u d under the water, a n d that it h a d
28 SCHIZOPHRENIA

been difficult to move " i n any sector" because the " m e r i d i a n s " were so
narrow that they hardly allowed h i m to turn around. W h e n asked about
hearing voices, he at first denied this, but he then said that he heard
telephone conversations at a distance of 50 metres even w h e n he was
indoors.
W e can well understand what the patient means by his " d y i n g " : he
describes an experience of psychological death. This became apparent i n
a rather upsetting way when the patient later said to me: "I w o u l d like to
be a h u m a n being again someday—now I a m not a h u m a n being any
m o r e . " The meridians turned out to be air spaces i n w h i c h the patient
could move, routes that he found safe and was able to use; when outside
them, he felt a disturbing p o p p i n g i n his head.
The patient's claim to be living under the surface of the sea might
also be understood symbolically. A member of the w a r d staff present at
the interview was, however, able to provide some illuminating informa­
tion: after the divorce of his mother and stepfather, the patient h a d been
living i n a small hut whose floor, at least according to his o w n report,
was below sea level, which is w h y it was always flooded i n the spring.
A t a distance of 50 metres from his hut there was a telephone booth,
w h i c h used to be the main location of his auditory hallucinations.
Another patient said he was suffering from diabetes, w h i c h was not
true. The significance of this delusion became comprehensible, however,
when the patient told his therapist that when he had temper tantrums as
a child, his parents often said: " N o w your liver is secreting too m u c h
sugar i n your b l o o d . "
Similar disintegration as i n thought functions also takes place i n
affective expressions. M a n y psychoanalytic researchers, especially, tend
to consider affective disorders of even greater importance i n schizo­
phrenia than are thought disorders. Particularly acute manifestations of
schizophrenia are often dominated by panicky anxiety a n d / o r agitation.
This reflects the horror brought about by the fatal change i n the experi­
ential w o r l d (disintegration anxiety) and is generally also related to the
hallucinations or delusions penetrating into consciousness. This m a y
later result i n a sense of losing one's o w n personality or a death of all
feeling. The y o u n g male patient i n the above example described such
experiences in a startling manner. "Affective extinction" of this k i n d is
particularly c o m m o n i n the hebephrenic forms of schizophrenia.
But milder forms of affective torpor can also be regarded as a conse­
quence of autistic development, a tendency to withdraw into oneself,
which is often—though not always—associated with schizophrenia. This
 GENERAL NOTES O N SCHIZOPHRENIA 29

tendency frequently also involves a loss of energy and a passive indiffer­

ence both towards the outer w o r l d and towards one's o w n condition.
V a r y i n g opinions have been expressed concerning the nature of
autistic and affective symptoms, such as isolation and passivity. Biologi­
cally oriented researchers often differentiate between productive or
positive symptoms—anxiety, thought disorders, delusions, and hallucina­
tions—and negative symptoms such as passivity, isolation tendencies, and
impoverishment of speech (Andreasen & Olsen, 1982). A n important
criterion for this differentiation is that neuroleptic drugs predominantly
affect the positive symptoms. M a n y of these researchers assume that
negative symptoms are due to an organic disease process (Barnes, 1989).
F r o m the viewpoint of a psychotherapist or w a r d community,
autism often turns out to be a secondary or relative phenomenon: a n
empathic approach may help the patient to give u p h i s / h e r autism quite
quickly. D o n a l d L . B u r n h a m a n d his co-workers (Burnham, Gladstone,
& Gibson, 1969) described the basic problem of the schizophrenic patient
as a "need-fear d i l e m m a " : o n the one h a n d , the patient feels the need to
have more contact with people, while o n the other h a n d h e / s h e is afraid
of such contact for fear of being misunderstood or rejected, or being
" s w a l l o w e d b y the other" and thereby deprived of h i s / h e r o w n person­
ality. Therefore the patient withdraws.
Affective disorders also include weakening of impulse control, w h i c h is
seen both i n acute schizophrenia and i n chronic patients. It may result i n
p o o r l y controlled violent outbursts of rage or—especially i n the case of
chronic patients—be combined with regressive behaviour indifferent to
the moral principles a n d reactions of the environment, such as mastur­
bation i n public.
Despite this, the homicide rate of schizophrenics is only slightly
higher than the population average, although the crimes that they d o
commit tend to attract m u c h publicity. H o m i c i d a l acts occur generally i n
a paranoid panic state. Suicides are more common: 3-13% of the schizo­
phrenic patients commit suicide, usually during the first two years of
their illness (Caldwell & Gottesman, 1990; Miles, 1977).
The predisposition to schizophrenia does not correlate with intelli­
gence, but i n many cases it is related to a sensitivity towards other
people. It m a y also stimulate artistic talents. M o s t schizophrenic artists,
however, have lost their creative power after the manifestation of their
illness (e.g. the poets Friedrich H o l d e r l i n and J. J. Wecksell, w h o lived
the final decades of their lives as mentally extinguished hospital p a ­
tients), or else their symptoms have made their art more difficult for the
30 SCHIZOPHRENIA

outsiders to appreciate (e.g. the painters C F. H i l l and Ernst Josephson).

But there have also been different courses of development: August
Strindberg, h a v i n g recovered from his inferno phase, was able to utilize
his psychotic " d i v e " to the psychic level governed b y the primary p r o ­
cess to heighten his artistically expressive talent (e.g. " T h e Road to
D a m a s c u s " and " T h e D r e a m Play").

Subgroups

Schizophrenia is not a single unified illness. E u g e n Bleuler (1911) h a d

already s p o k e n of " n u c l e a r a n d marginal g r o u p s " , w h i c h differed
notably f r o m each other both i n the intensity of s y m p t o m s a n d the
prognosis, a n d the same dichotomy, though differently formulated,
has persisted until the present time.
The nuclear group of schizophrenia is considered to consist of three
essential subcategories: hebephrenic, catatonic, and paranoid. Disorganiza­
tion a n d regression of the ego are most profound i n hebephrenic (or,
according to the D S M system, disorganized) schizophrenia, w h i c h also
has the earliest onset, being usually manifested before the age of 25
and often gradually. A u d i t o r y hallucinations are particularly dominant
in this type of schizophrenia (though they are also found i n milder
disorders, sometimes even as the only psychotic symptom). Catatonic
schizophrenia, w h i c h usually has an acute onset, also includes psycho­
motor disturbances i n addition to the other symptoms; these take the
form of either stuporous standstill or panicky, sometimes violent agita­
tion. Paranoid schizophrenia is dominated b y delusions and associated
hallucinations; apart from auditory hallucinations, somatic sensations of
being influenced by others are especially common, while disintegration
of ego functions is less conspicuous.
In the case of chronic patients it is more difficult to discriminate
between these subcategories. M a n y of them tend to show the conse­
quences of institutionalization, such as apathetic hopelessness, adapta­
tion to passive inactivity and loss of everyday social contacts and skills.
In the D S M system established by the American Psychiatric Association
(newest version, D S M - I V : American Psychiatric Association, 1994), the
term undifferentiated schizophrenia is used of patients showing features
typical of more than one subtype.
 GENERAL NOTES O N SCHIZOPHRENIA 31

A p a r t from these nuclear forms, there are schizophreniform psychoses,

w h i c h are less serious and often precipitated b y current conflict situa­
tions.
The use of this name, originally introduced b y Langfeldt (1939), has
varied. In the Scandinavian countries, it has meant acute psychoses with
confusion or perplexity at the height of the psychotic episode, absence of
symptoms typical of severe schizophrenia (including negative s y m p ­
toms), good premorbid functioning, and, almost invariably, a good
prognosis. In the D S M system, it is used of psychoses i n which the
symptomatological criteria of schizophrenia are met but the length of
them (including prodromal, active, and residual phases) is restricted. In
D S M - I V , the length of a psychotic episode is defined to be at least one
month but less than six months, and a further specifier is used to indicate
the presence or absence of features that may be associated with a better
prognosis (see above). If the length of the psychotic episode is less than
one month, the diagnostic category of brief psychotic disorder is used
(American Psychiatric Association, 1994).
M o r e prolonged a n d / o r recurrent milder psychotic disorders have
also been called borderline schizophrenias.
The symptoms of schizophrenia and bipolar affective psychosis m a y
occasionally be combined i n such a w a y that the patient shows, s i m u l ­
taneously, both schizophreniform symptoms a n d a typical manic or
depressive change of mood. These psychoses are called schizoaffective
psychoses (originally named b y Kasanin, 1933), and their prognosis tends
to be better than that of typical schizophrenia, even if often characterized
by recurrent episodes.
The boundary between schizophrenia and psychoses due to alcohol
a n d / o r d r u g abuse m a y occasionally also be obscure. In the O s l o
subproject of the Scandinavian Multicentre Psychotherapy Project deal­
ing with first-admitted patients (Alanen, Ugelstad, Armelius, Lehtinen,
Rosenbaum, & Sjostrom, 1994), for example, there was a notable group
of y o u n g patients with a dual diagnosis of d r u g abuse and a psychosis of
the schizophrenia group (Hjort & Ugelstad, 1994). Such patients are
probably increasing i n number in metropolitan environments (Allebeck,
Adamsson, E n g s t r o m , & R y d b e r g , 1993; Linszen, Dingemans, &
L e n i o r , 1994.)
The age limits for the risk of developing schizophrenia are usually
set at 15 and 45 years. Cases of childhood schizophrenia are also
seen, though rarely, and they are not to be confused with early infantile
32 SCHIZOPHRENIA

autism (even if the separating line may be difficult to d r a w ) . There are

also patients aged over 45 w h o become ill with psychoses whose s y m p ­
toms are similar to those of paranoid schizophrenia.
Paranoid psychoses with delusions limited systematically to a cer­
tain problem area, but without other disorders of ego functions or
hallucinations, are not classified as schizophrenias. E v e n this diagnostic
boundary m a y be difficult to define exactly.
A l t h o u g h the clinical characteristics of typical schizophrenia are gen­
erally easy for psychiatrists to recognize, we m a y conclude that patients
included i n marginal or atypical psychoses of the schizophrenia group
are not distinctly different from patients with other psychotic disorders,
such as affective, paranoid, and reactive psychoses. It is for this reason
that the theory of general psychosis—an umbrella term for all psychotic
disorders—still has its proponents (see, for example, Einar Kringlen's
1994 paper dealing with this topic).

On DSM diagnostics

E v e n if other diagnostic systems are also used, especially b y research­

ers, the currently official system of diagnosing schizophrenia is
largely parallel to the latest version ( D S M - I V ) of the Diagnostic and
Statistical Manual of Mental Disorders, p u b l i s h e d b y the A m e r i c a n P s y ­
chiatric Association (1994).
This classification illustrates the contractual nature of the diagnostic
boundaries defined for schizophrenia. A s referred to above, " s c h i z o ­
phrenic disorders" are separated from "schizophreniform disorders"
mainly o n the basis that certain distinct psychotic symptoms, together
with separately defined preliminary or residual symptoms, have per­
sisted for a m i n i m u m of six months i n the former category and for more
than one month, but less than six months, i n the latter. In the earlier
D S M - I I I version, the lower boundary line was defined as two weeks. It
is further proposed that there is some deterioration of social functioning
present i n the schizophrenic disorder.
A generally applicable diagnostic system is important for compara­
tive epidemiological research, as well as otherwise facilitating c o m m u n i ­
cation about schizophrenia. O n e of the motivating factors behind the
development of the D S M classification—published as DSM-III (Ameri­
can Psychiatric Association, 1980)—was the observation made i n a
 GENERAL NOTES ON SCHIZOPHRENIA 33

B r i t i s h - A m e r i c a n collaborative research project (Cooper et a l , 1972): it

turned out that schizophrenia i n L o n d o n was something quite different
from schizophrenia i n N e w York, where the diagnostic boundaries were
set wider and included some cases now called "schizotypal" or "border­
l i n e " personality disorder.
F r o m the epidemiological viewpoint, it is also advantageous that the
diagnostic labels of the D S M classification are not related to aetiologic
concepts, as was often the case with earlier diagnostic systems, but are
based on symptomatic definitions (in accordance with the old Kraepelin­
ian principles). This minimizes the effects that conceptual differences
among psychiatrists and schools of psychiatry may have o n comparative
findings. F r o m the viewpoint of developing psychiatric treatment, h o w ­
ever, the classification involves the great risk of concentrating o n
symptoms and their categorization at the cost of understanding patients
and their life situations.
O n e should realize that the planning of treatment has not been the
basis for developing D S M classification. The treatment of patients also
requires other approaches: an effort to understand h o w the illness is
related to the patient's personality development, h i s / h e r life course, and
h i s / h e r interpersonal relationships.
There is the further risk that the D S M criteria for discriminating
between schizophrenic and schizophreniform disorders are ascribed a
significance that is used to predict the patient's prognosis to too great an
extent a n d often also influences i t — a phenomenon that certainly does
not lack historical precedent.

Schizophrenia
from a public health perspective

T h e difficulty of defining the limits of schizophrenia is also reflected

i n the incidence a n d prevalence rates reported i n the literature. If the
relatively comprehensive set of criteria first suggested b y E u g e n
Bleuler (1911) is a p p l i e d , it turns out that 0.7-1% of the p o p u l a t i o n
reaching the age of 45 has suffered f r o m schizophrenic psychosis.
T h e " p o i n t p r e v a l e n c e " — t h a t is, the p r o p o r t i o n of adult p o p u l a t i o n
w i t h schizophrenic syndromes at a given t i m e — i s lower than this,
b e i n g 0.1-0.8% (Eaton, 1985). H o w e v e r , i n a n A m e r i c a n multicentre
s t u d y ( E C A ) the six-month p e r i o d prevalence of s c h i z o p h r e n i c /
34 SCHIZOPHRENIA

s c h i z o p h r e n i f o r m disorders w a s f o u n d to be 0.6-1.2% (Myers et al.,

1984), e v e n according to D S M - I I I criteria, whereas the lifetime p r e v a ­
lence w a s 1.1-2.0% (Robins et al., 1984).
If the diagnosis is delimited strictly, as was done i n two British
investigations (Shepherd, Watt, Falloon, & Smeeton, 1989; W i n g & F r y ­
ers, 1976), the annual incidence—that is, the number of n e w schizo­
phrenic patients admitted into psychiatric treatment units each y e a r —
appears to be only 7-14 cases per 100,000 inhabitants. A survey carried
out i n six different areas in Finland i n the 1980s revealed an average of
11-14 n e w DSM-III-diagnosed "schizophrenic disorders" per 100,000
inhabitants; w h e n the "schizophreniform disorders" were included, the
incidence went up to 16-20 (Salokangas et al., 1987). In the other N o r d i c
countries the incidence figures tend to be somewhat lower (see A l a n e n et
al., 1994).
It was interesting to note that although there were n o significant
differences i n the annual incidence between the districts located i n dif­
ferent parts of Finland, the number of schizophrenic inpatients was
three- or even fourfold i n some areas (mainly i n eastern Finland), c o m ­
pared with the "best districts" (the southwestern and southern parts of
the country). The project team of the national programme for developing
the treatment and rehabilitation of schizophrenia, w h o carried out these
comparative surveys, postulated the difference to be mainly due to the
social conditions, including the effects of migration, o n the one h a n d ,
and o n the other to the fact that a hospital-centred orientation tended to
increase along with the increasing number of hospital beds available i n
the district (Alanen, Salokangas, Ojanen, Rakkolainen, & P y l k k a n e n ,
1990b; State M e d i c a l Board in Finland, 1988). A similar difference i n the
prevalence of schizophrenia between the different parts of Finland was
also seen i n the psychiatric part of the M i n i - F i n l a n d Project supervised
by Ville Lehtinen, where the estimates were made o n a large population
sample aged over 30 years. In this study, the prevalence of schizophrenia
varied from 0.9-2.1% (Lehtinen & Joukamaa, 1987).
A c c o r d i n g to epidemiological data, schizophrenia morbidity is
roughly the same throughout the world, although there are numerous
regions for w h i c h there are no reliable data available. Higher-than-aver­
age morbidity rates have been reported, for example, for Ireland (Torrey
et aL, 1984), for the Catholic population of Canada, for northern Croatia,
and for the T a m i l population of southern India and Sri Lanka ( M u r p h y ,
1973). Referring to findings presented above, eastern Finland m a y be
 GENERAL NOTES O N SCHIZOPHRENIA 35

a d d e d to the list. There are also interesting observations recently re­

ported i n some industrialized countries w h i c h suggest that there has
been a m i n o r decline i n the incidence of schizophrenia i n the past few
decades (Der, G u p t a , & M u r r a y , 1990; Munk-Jorgensen & Mortensen,
1992). These observations have not been sufficiently corroborated so far.
The International Pilot Study conducted b y the W H O i n the late
1960s a n d the early 1970s also showed that the forms of schizophrenia
are, i n principle, similar o n the different continents and i n different
cultures (World Health Organization, 1979). T h e findings obtained b y
L a m b o (1955) i n Nigeria as early as the 1950s suggested, however, that
the members of the Yoruba tribe living in their traditional village culture
generally h a d psychoses that consisted of twilight and confusion states,
while the tribesmen w h o h a d m o v e d to towns often suffered from para­
n o i d states reminiscent of the psychoses of the white population. In a
report recently published b y the W H O o n ten countries (Jablensky et aL,
1992), broadly defined schizophrenia was shown to be more c o m m o n i n
developing countries, whereas narrowly defined schizophrenia was
equally c o m m o n i n both industrialized and developing countries.
F r o m the v i e w p o i n t of both national e c o n o m y a n d p u b l i c health,
schizophrenia is the greatest psychiatric p r o b l e m , although many
other psychiatric disorders, particularly the neuroses, are m o r e c o m ­
m o n . E p i d e m i o l o g i c a l studies carried out i n F i n l a n d have s h o w n the
overall incidence of notable psychiatric problems to affect about 2 0 %
of the p o p u l a t i o n . A p p r o x i m a t e l y 400 people per 100,000 p o p u l a t i o n
a n n u a l l y make their first contact w i t h units p r o v i d i n g psychiatric
health care services, b u t only one out of every 20 s u c h people has a
psychosis of the schizophrenia g r o u p . Despite this l o w figure, at the
e n d of the 1980s 10% of all the disability pensions granted o n the basis
of various illnesses were for schizophrenia; i n the 16-45-year age
g r o u p the p r o p o r t i o n of schizophrenics o n p e n s i o n w a s m o r e than
20%, according to the N a t i o n a l Pensions Institute i n 1989. In N o r w a y
a n d S w e d e n , the p r o p o r t i o n of schizophrenia is lower, probably
partly d e p e n d i n g o n the use of more restrictive diagnostic criteria.
These figures reflect the relative severity of schizophrenia, its
early onset, a n d the consequent long duration of the illness. T h e y also
underline the need to invest the resources allotted to the treat­
ment of schizophrenia as effectively as possible at the early stages of
the illness, w h e n the chances of ensuring a favourable outcome are the
best
36 SCHIZOPHRENIA

Prognosis

Despite the arbitrary nature of diagnostic boundaries, the findings o n

the long-term prognosis of schizophrenia have s h o w n relatively g o o d
agreement.
O n e of the most widely k n o w n follow-up studies was M a n f r e d
Bleuler's i n 1972. H i s series consisted of 208 patients admitted succes­
sively d u r i n g the years 1942-1943. O f these patients, 152 h a d reached a
stable state lasting five years or more prior to their death or the follow­
u p examination carried out 23 years later. O f the patients, 20% h a d
recovered completely, 33% were slightly i l l , 24% moderately i l l , a n d
another 24% seriously ill; w h e n only the first admissions were consid­
ered, the corresponding percentages were 23, 43, 19 and 15%. Bleuler
noticed that the psychological status of a schizophrenic patient does not,
on average, deteriorate once five years have elapsed since the outbreak
of the psychosis; more often there is a tendency towards further i m ­
provement (Bleuler, 1972).
The Swiss series of C i o m p i a n d M u l l e r (1976), the West G e r m a n
series of H u b e r , Gross, Schuttler, & L i n z (1980), and the series collected
in America b y Tsuang and his co-workers from Iowa (Tsuang, W o o l s o n ,
& F l e m i n g , 1979), similarly showed about half of the patients to be i n a
relatively good condition after a long follow-up period, while the other
half were i n poor condition. A l l of these findings were based o n very
long follow-up periods, a n d most of the patients h a d been admitted
before the beginning of the neuroleptic era. A five-year follow-up study
b y Harris, Linker, and Norris (1956) i n Britain following insulin shock
treatment showed that 45% of patients had recovered socially. In a fol­
l o w - u p study of similar duration ten years later, the team of G . B r o w n
and J. K . W i n g (Brown, Bone, Dalison, & W i n g , 1966) obtained a corre­
sponding recovery percentage of 56% i n a group treated with neuro­
leptics; i n addition to this, 34% of the patients lived in their communities
as "social invalids". Harris had reported 21% for "social invalidity". The
improvement of the prognosis was probably due both to the introduc­
tion of neuroleptic drugs and to the progress made i n outpatient care. In
a series collected more recently by Shepherd et al. (1989) comprising
only first-admission schizophrenic patients, the prognosis was g o o d —
with " n o or only slight deterioration"—in 58% of the cases, and the same
result was obtained by Bland, Parker, and O r n (1976) i n Canada in a ten­
year follow-up of new schizophrenic patients.
 GENERAL NOTES O N SCHIZOPHRENIA 37

Exceptionally good prognostic findings were reported b y H a r d i n g et

al. (1987), w h o analysed the 20- to 25-year outcome of patients w h o h a d
participated i n an extensive rehabilitation programme i n Vermont, i n
the 1950s. O f the schizophrenic patients, most of w h o m h a d been i n
hospital for l o n g p e r i o d s — a n d w h o were retrospectively f o u n d to meet
the D S M - I I I diagnostic criteria—68% h a d n o psychotic symptoms at the
time of the follow-up (some of these were supported b y neuroleptic
medication), a n d most were coping moderately well psychosocially.
In a recent meta-analysis of the twentieth-century outcome literature,
Hegarty et al. (1994) considered 40% of schizophrenic patients to
have i m p r o v e d after follow-ups averaging 5.6 years. T h e proportion of
patients w h o i m p r o v e d increased significantly after mid-century (for
1956-1985 vs. 1895-1955, 48.5% vs. 35.4%). H o w e v e r , d u r i n g the past
decade the average rate of favourable outcome h a d declined to 36.4%,
w h i c h , according to the authors, reflected the re-emergence of narrow
diagnostic concepts. O n e m a y ask whether this was the o n l y reason for
the decline.
In the W H O investigations mentioned above, the prognostic findings
were both interesting a n d unexpected. Both the clinical a n d the social
prognosis of schizophrenics was better i n the developing countries than
in the industrialized parts of the w o r l d . In the first investigation, the
best two of the five prognostic groups included 34-48% of the patients
i n the U n i t e d States, Great Britain, Denmark, Czechoslovakia, a n d the
Soviet U n i o n , whereas the corresponding figures for developing c o u n ­
tries were 86% i n Ibadan, N i g e r i a , 66% i n A g r a , India, a n d 53% i n C a l i ,
C o l o m b i a ( W H O , 1979). A parallel finding was also made i n the subse­
quent investigation carried out i n 10 different countries (Jablensky et al.,
1992). There has been disagreement as to the reasons for these findings.
The most plausible assumption m a y be that proposed b y M o s h e r a n d
Keith (1979)—namely, that the m a i n reason for the differences i n p r o g ­
nosis is influence of the social environment. T h e extensive family a n d
village networks of the more primitive communities support the sick
individuals better than d o Western people, w h o tend to isolate them­
selves i n their o w n living units (see, for example, the descriptions of
Tanzania b y the Finnish child psychiatrist Forssen, 1979). It is also easier
to resume w o r k and other activities i n less differentiated societies. T h e
relatively milder forms of the disease i n the developing countries p r o b ­
ably also influence this finding, but the causal relation m a y work both
ways.
38 SCHIZOPHRENIA

Some other studies (Hsia & C h a n g , 1978; R a m a n & M u r p h y , 1972;

Waxier, 1979), as well as the review b y L i n and K l e i n m a n (1988), have
confirmed the preliminary findings of the relatively good prognosis of
schizophrenia i n less developed areas. Waxier (1979), w h o worked i n Sri
Lanka, especially emphasized the significance of cultural beliefs and less
labelling.
The effect of employment conditions o n the social prognosis of
schizophrenia is obvious i n the series of prognostic studies carried out b y
K. A . Achte, J. L o n n q v i s t , O . Piirtola, a n d P. N i s k a n e n (1979) i n H e l ­
s i n k i . O f the 100 schizophrenia-group patients first admitted into
h o s p i t a l i n 1950, 5 9 % were socially recovered—that is, able to w o r k
despite their possible symptoms—after five years; the c o r r e s p o n d i n g
percentage w a s 68% for the 1960 admissions a n d 54% for the 1970
admissions. T h e authors postulated that the introduction of n e u r o ­
leptics h a d a beneficial effect o n the prognosis f r o m the 1950s to the
1960s, but the poorer e m p l o y m e n t situation worsened the social p r o g ­
nosis i n the 1970s. T h e latter postulation w a s c o n f i r m e d b y a report
p u b l i s h e d b y K . K u u s i (1986) o n patients admitted into hospital i n
H e l s i n k i i n 1975: only 38% of them met the criteria of social recovery
five years after their admission. In K u u s i ' s series the diagnostic c r i ­
teria for i n c l u s i o n were stricter than they h a d been p r e v i o u s l y . Still,
5 8 % of the p a t i e n t s — w h i c h is more than i n the older series—were
w i t h o u t obvious psychotic s y m p t o m s .
I return to f o l l o w - u p data of the psychotherapeutically oriented
T u r k u series a n d the F i n n i s h Multicentre S t u d y ( N S P Project) i n
chapter five.
It has b e e n observed i n various studies that the factors predictive
of a g o o d outcome i n c l u d e a lack of nuclear s y m p t o m s or their short
d u r a t i o n , a n acute onset as c o m p a r e d w i t h a g r a d u a l onset, manifes­
tation of schizophrenia at a n older age, a lesser tendency to isolation,
presence of affective expressions, a heterosexual couple relationship
established before the onset of the illness, a n d the " n o r m a l i t y " of
interpersonal relationships i n general, as w e l l as a job a n d a satisfac­
tory financial position p r i o r to the illness (e.g. G e l d e r , G a t h , &
M a y o u , 1984; S i m o n & W i r t , 1961).
In the F i n n i s h N S P Project, described i n chapter five, the p s y c h o ­
social factors were more significant prognostically than w a s clinical
symptomatology. O n e important factor predictive of the patient's
subsequent d e v e l o p m e n t turned out to be the prognostic variable
d e v e l o p e d b y us i n F i n l a n d : maintenance or loss of the " g r i p o n l i f e "
 GENERAL NOTES O N SCHIZOPHRENI A 39

(Salokangas, Rakkolainen, & Alanen, 1989)—that is, whether the pa­

tient had, by the time of the admission, maintained or abandoned
his/her aspirations towards age-appropriate goals pertaining to
other people and social life.
Men and women do not differ as to their schizophrenic morbidity,
but nearly all recent prognostic surveys (see, for example, Goldstein
& Tsuang, 1990; Salokangas, 1983;) have shown that the average long­
term prognosis is better for females than for males. The reason for the
sex-bound differences can be assumed to consist of either biological
factors or differences in the psychosocial roles. The former might
include the effect of progesterone, which possibly affords a relative
protection from the psychosis and comes to an end at the menopause
(Hafner et al., 1994).
But we must bear in mind that all that I have said above about the
factors influencing the prognosis is based on average findings; there
are exceptions in individual cases due to early and active treatment
as well as to environmental factors. In a follow-up study made in
Turku, the influence of such factors came out significantly even in the
statistical analysis (Alanen, Rakkolainen, Laakso, Rasimus, &
Kaljonen, 1986). Luc Ciompi writes:
For everyone who does not link the concept of schizophrenia
itself to an obligatory bad outcome, the enormous variety of pos­
sible evolutions show that there is no such thing as a specific course
of schizophrenia. [Ciompi, 1980, p. 420]

Illness models

The premises of researchers concerning the origins and nature of

schizophrenia continue to be highly contradictory. They are often
also extremely one-sided: the relatively narrow field of study
adopted in one's own work is regarded as the only correct approach,
and one's view is restricted by blinkers that effectively shield one
from seeing any other field.
The polarization of clinical practice may have diminished some­
what during the past few years. But it continues to exist and notably
hamper the development of the treatment of our patients. After all,
therapeutic approaches are determined by our theories of the nature
of the illness.
40 SCHIZOPHRENIA

In Exhibit 2.1,1 have c o m p i l e d the most important contemporary

approaches to the causes a n d the nature of s c h i z o p h r e n i a — t h e " i l l ­
ness m o d e l s of s c h i z o p h r e n i a " . T h e central c l a i m of each a p p r o a c h
has been expressed as a — p e r h a p s slightly exaggerated—catch­
phrase, a n d the most important m o d e s of therapy according to the
principles of each a p p r o a c h have been presented.
T h e names a n d catchphrases of the approaches reflect one central
cause for the divergence of the concepts: their scientific b a c k g r o u n d s ,
research methods, a n d frames of reference for the findings differ
notably f r o m each other. A n y investigator w i l l i n g to cast off his b l i n k ­
ers a n d acquaint himself w i t h another research a p p r o a c h must really
enter a different w o r l d a n d a b a n d o n for a m o m e n t his or her criteria
for scientific research.
T h e biomedical model is deeply e m b e d d e d i n the natural-scientific
research culture a n d the m e d i c a l tradition f o u n d e d u p o n it. It has
therefore always been g i v e n a p r o m i n e n t position b y investigators of
s c h i z o p h r e n i a w i t h m e d i c a l training. S u r v e y i n g recent schizophrenia
research, it is easy to see that the projects a n d publications w i t h a
b i o m e d i c a l orientation dominate quantitatively.
M e t h o d s similar to the b i o m e d i c a l o n e s — e m p i r i c a l experimenta­
tion a n d measurement, statistical analysis of results—are also a p p l i e d
i n s o m e psychologically a n d sociologically oriented psychiatric re­
search. T h e psychological models i n Exhibit 2.1 are, however, based
o n a different a p p r o a c h to case-specific understanding. T h e individual
psychological and interactional models are close to each other i n this
respect, although they are separated b y some radical differences that
h a v e also been a source of dispute a m o n g different schools. B o t h
differ f r o m the b i o m e d i c a l m o d e l i n that their findings are difficult to
verify w i t h methods acceptable i n the natural sciences, such as ex­
perimentation. T h e reproducibility of the therapeutic results is also
less c o n v i n c i n g , because they are always dependent o n the d e v e l o p ­
m e n t of the interactional relationship between therapist a n d patient.
A s early as the 1950s, W h i t e h o r n a n d Betz (1960) noted the consider­
able influence of the therapist's o w n personality o n the therapist­
patient relationship.
Despite all this, the research that applies psychological models is
empirical a n d experiential, a n d observations based o n p r o f o u n d case­
specific k n o w l e d g e , whenever they reveal a recurring pattern, can
also be generalized as c o m m o n knowledge. U s i n g the terminology of
the G e r m a n philosopher Jurgen Habermas (1968), we might say that
 GENERAL NOTES O N SCHIZOPHRENIA 41

EXHIBIT 2.1
Illness m o d e l s o f s c h i z o p h r e n i a

a n d treatment modes related t o t h e m

1. BIOMEDICAL
"The illness is based on an organic brain process"
• psychopharmacological treatment

• other somatically oriented treatments

2. INDIVIDUAL PSYCHOLOGICAL
"The illness is based on a deep-rooted disorder

of the personality development"

• individual psychotherapy
• application of individual psychological principles
in other modes of treatment (e.g. group therapy,
family therapy, art therapy)
3. INTERACTIONAL
"The illness is part of a disordered interactional network

and/or manifested as problems of interactional adaptation"

• systemic family therapy

• dynamically oriented group therapy
* therapeutic communities
4. SOCIAL AND ECOLOGICAL
"The patients should have support as members of community"
• environment-centred mental health activities
• rehabilitation
5. INTEGRATED
"All the approaches presented above are justified.

Their significance as well as their mutual relation are

weighed differently in different cases"

• treatment should be carried out comprehensively

and according to case-specific needs

these approaches differ from biomedical research in that their interest of

knowledge is hermeneutic-emancipatory (not natural-scientific or tech­
nical), aiming at a liberating developmental process made possible b y an
understanding of the phenomena at h a n d . In i n d i v i d u a l therapy, this
process takes place through a dyadic relationship between patient a n d
therapist, w h o tries, using this relationship, to discover the distortions i n
the patient's previous development and to promote new personality
growth. In the interactional m o d e l , the individual's symptoms are seen
as an indication of the interactional network or system, generally the
family, of w h i c h the patient is a member, and efforts are made to alter its
interactions.
42 SCHIZOPHRENIA

The fourth—social and ecological—approach is not based o n the k i n d

of aetiologic theory formation underlying the other approaches. I have
therefore formulated a more pragmatic catchphrase for it. Despite a lack
of aetiologic focus, the methods of this approach—that is, milieu-ori­
ented mental health work and rehabilitation—are just as important as
the other methods. Mental health work supports the healthy develop­
ment of individuals and communities and thus helps to prevent psychi­
atric illnesses. Rehabilitation helps especially chronic patients to cope
more satisfactorily i n society. Rehabilitative work, w h i c h is extremely
important for schizophrenic patients, can easily be combined with
any aetiologic approach. Rehabilitation is accepted generally and does
not evoke resistance among biomedically oriented researchers i n the
w a y that psychological methods more strictly committed to aetiologic
premises often do.
It m a y be asked whether we should also talk about an "antipsychi­
atric" model. T h e representatives of this orientation—such as Szasz
(1961) a n d Goffman (1961)—gave a beneficial airing to the excessive
hospital orientation of psychiatric work and its implicit violence a n d
violation of h u m a n rights. I do not consider their ideas to be as i m p o r ­
tant aetiologically as they are sociologically. It is true that labelling,
w h i c h they considered particularly detrimental, m a y have a notably
unfavourable influence o n the patient's prognosis, especially h i s / h e r
possibilities of coping in h i s / h e r social environment. It should be real­
ized, however, that labelling is almost always a secondary phenomenon
due to the individual's role as a patient, which comes about at or after
the onset of the illness.
Schizophrenia has also been described as a way of maintaining one's
individuality, a refusal to adjust to the conventional ways of life. It is
quite true that i n a psychotic condition, particularly a prolonged one, it
is possible to recognize desperate and distorted attempts at protecting
"one's self" i n an anxiety-provoking h u m a n environment that seems to
be destroying individuality. Theodore L i d z , m y A m e r i c a n teacher, once
said that unless schizophrenia existed, someone w o u l d soon invent it.
W h a t w o u l d be more natural—he meant—than that an individual w h o
has experienced contacts with fellow h u m a n beings to be overwhelm­
ingly frightening should isolate himself and begin to live i n a fantasy
w o r l d of his own. This is not, however, a matter of voluntary choice, but
something due to an inner impulsion.
It is m y opinion, that the first four separate models described i n
Exhibit 2.1 have their o w n research-based justification and therapeutic
 GENERAL NOTES O N SCHIZOPHRENIA 43

significance. A t the same time, each of them also has its limitations. W e
s h o u l d therefore try to create an integrated model of schizophrenia, w h i c h I
have also included i n Exhibit 2.1. In this m o d e l , the biomedical factors,
the aspects of i n d i v i d u a l development, and the factors implicit i n the
patient's closest interactional network as w e l l as his psychosocial situa­
tion are all considered. The same applies to the treatment, w h i c h should
utilize all the modes of therapy included i n the different models. The
selection of the modes of treatment should not, however, be done i n a
vaguely "eclectic" manner, but o n the basis of a case-specific evaluation
of the therapeutic needs.
CHAPTER THREE

The origins of schizophrenia:

an attempt at synthesis

Starting-point:
necessity of an integrative approach

S
c h i z o p h r e n i a studies based o n b i o m e d i c a l , genetic, i n d i v i d ­
ual psychological, interactional psychological, a n d social
approaches have all p r o v i d e d findings that s h o u l d be taken into
account w h e n trying to analyse the pathogenesis a n d nature of schizo­
p h r e n i a . T h e n e e d for comprehensive thinking seems obvious.
I d o n o t agree w i t h theories according to w h i c h schizophrenia is
r e g a r d e d as a clearly organic disorder, w i t h n o relation to p s y c h o ­
social e n v i r o n m e n t a l factors. Interactional relationships w i t h other
people are part of h u m a n biology. T h e y p l a y a crucial role i n h u m a n
psychosocial development a n d the u n d e r l y i n g cerebral functions. M y
experiences as a psychotherapist a n d family researcher convinced m e
that i n d i v i d u a l s fallen i l l w i t h schizophrenia s h o u l d not be p l a c e d
outside this general rule, w h i c h is the basis of all integrated p s y c h o ­
biological psychiatry.
The most dramatic evidence for the fundamental significance of
interactional relations for h u m a n personality development comes from
the observations o n children w h o have grown u p w i l d , without any

45
46 SCHIZOPHRENIA

h u m a n contact, surviving under animal care i n a w a r m climate. It is not

easy to find reliable information o n the development of these so-called
wolf children, but it appears that they do not learn to speak, their facial
expressions are undeveloped, a n d even their drive functions remain
rudimentary (Malson, 1972; Rang, 1987). Interactional relationships with
other people thus prove a necessary prerequisite for h u m a n develop­
ment.
The developmental significance of interaction is not restricted to
m a n , as demonstrated b y H a r r y F. a n d Margaret H a r l o w (1966), w h o
experimented with rhesus monkeys. Baby monkeys separated from their
mothers grew u p seriously disturbed both socially a n d sexually c o m ­
pared with infants brought u p b y their biological mothers. A u d i t o r y and
visual contact with other monkeys d i d not help if the babies were de­
p r i v e d of physical contact, and mother surrogates made of metal wire or
furry material were also useless. For h u m a n development, the effects of
interactional relations are even more significant than they are for ani­
mals, whose behaviour is based more o n instincts. H u m a n beings
therefore need a longer time to grow from infancy to adult maturity. The
stages of cerebral development are also longer i n man, and development
is most massive i n early infancy. Still, the developmental growth of the
h u m a n cortex (especially the frontal lobes) continues past the age of 20,
w h i c h is unparalleled i n other primates. The increasing dominance of the
newer centres (neocortex) i n m a n is also noticeable in the development of
transmitter activities, such as i n the form of a "developmental l a g " of
dopaminergic activities ( M . and A . Carlsson, 1990); apes have a denser
pattern of dopamine receptors in their cortex than d o adult humans.
The key to species-specific development is to be found i n the genetic
m a k e - u p of m a n . O n the other h a n d , the genetically determined long
period of development shows that the interactional experiences a n d the
chances for identification and learning related to them are increasingly
significant for the development of the h u m a n personality, compared
w i t h other species. A s L i d z (1964) has emphasized, h u m a n beings have
two endowments, one based o n our genes and a second sociocultural
one, based o n the effects of our developmental environment.
If schizophrenia is related to disturbances of h u m a n personality
development, as is suggested b y psychologically oriented research, it is
only natural to postulate that interactional relationships contribute to
this pathogenesis, not only on the psychological but also o n the biologi­
cal level.
 THE ORIGINS OF SCHIZOPHRENIA 47

Studies on predisposition to schizophrenia:

the role of biological factors

T h e factors i n v o l v e d i n the pathogenesis of schizophrenia have been

s h o w n to be b o t h m u l t i l e v e l a n d complex. I discriminate here b e ­
tween factors associated w i t h vulnerability to schizophrenia a n d
factors related to its onset, t h o u g h the t w o are closely connected.
D u r i n g recent decades, biologically oriented schizophrenia research
has become quite extensive and versatile (for reviews, see, for example,
Sedvall & Farde, 1995; Syvalahti, 1994; Weinberger, 1995). It w o u l d be
overwhelmingly difficult to give a comprehensive review of this field
of research. I shall concentrate o n a short description and discussion of
findings that n o w seem to be most significant aetiologically. I thus p u t
aside, for example, neurophysiological and biochemical studies, apart
from a short reference to the effects of and links to transmitter substances
i n schizophrenia, a topic about which new and more conclusive findings
w i l l probably be made i n the future.
W e can n o w discriminate between two groups of biological factors
obviously predisposing to schizophrenia: minor structural abnormalities of
the brain o n the one h a n d , and the effect of hereditaryfactors o n the other.
Both factors clearly increase the vulnerability for becoming schizo­
phrenic but are, at least i n the light of contemporary research findings,
not clearly specific to schizophrenia or influential i n all of the patients.

Structural abnormalities of the brain

T h i s is especially obvious for the abnormalities of the brain, suggested

as early as the 1960s b y pneumoencephalographic studies (Haug,
1962; H u b e r , 1961), first demonstrated w i t h computer tomography
(CT) b y Johnstone et al. (1976) a n d soon confirmed b y other investi­
gators (e.g. A n d r e a s e n et al., 1990; N a s r a l l a h , M c C a l l e y - W h i t t e r s , &
Jacoby, 1982; N y b a c k , Wiesel, Berggren, & H i n d m a r s h , 1982; S u d d a t h
et a l . , 1989; Weinberger, T o r r e y , N e o p h y t i d e s , & Wyatt, 1979) u s i n g
C T or magnetic resonance i m a g i n g (MRI). T h e prevalence of these
a b n o r m a l i t i e s — a n enlarged v e n t r i c l e / b r a i n ratio, a smaller v o l u m e of
certain structures, especially of those i n the m e d i a l temporal lobes,
a n d of the thalamus—has ranged between 6 a n d 4 0 % of schizophrenic
patients (for reviews, see C l e g h o r n , Z i p u r s k i , & List, 1991; L e w i s ,
48 SCHIZOPHRENIA

1990; Syvalahti, 1994). A c c o r d i n g to studies of m o n o z y g o t i c twins

discordant for schizophrenia, even affected t w i n s — i n c l u d i n g those
w h o s e ventricles were s m a l l — t e n d to have larger ventricles than their
healthy twins (Reveley, Reveley, C l i f f o r d , & M u r r a y , 1982; S u d d a t h ,
C h r i s t i s o n , & T o r r e y , 1990). H o w e v e r , findings similar to those m a d e
i n schizophrenia have also been obtained i n other conditions. Rieder
et a l . (1983), i n a C T study, f o u n d brain abnormalities i n schizo­
affective psychoses a n d i n bipolar affective illness almost as often
as i n schizophrenia; w i t h regard to manic psychoses, this w a s s h o w n
b y N a s r a l l a h et al. (1982). H a u s e r et al. (1989) m a d e a M R I study of
patients w i t h p r i m a r y affective illness, w i t h the same result.
The structural abnormalities are not directly related to either the
onset of the illness or its subsequent course: these findings remain u n ­
changed d u r i n g follow-up (Nasrallah et al., 1986; Dlowsky, Juliano,
B i g e l o w , & Weinberger, 1988). This is quite contrary to typical organic
brain disorders, such as Alzheimer's disease, i n w h i c h the deterioration
of the psychic condition is related to the progress of a massive illness
process i n brain tissue. N o r can the findings be explained away as conse­
quences of treatment—they are also detected i n recently diagnosed
unmedicated patients, particularly y o u n g men.
The origins of these structural abnormalities are u n k n o w n . They
may be heterogeneous i n nature. There are several aetiological possibili­
ties. Weinberger (1987) enumerates the following: a hereditary encephal­
opathy or a predisposition to environmental injury, an infectious or
postinfectious state, an immunological disorder, toxic or metabolic dis­
orders, perinatal trauma, or some other early factors affecting the devel­
opment of the nervous system. H e adds two factors that he considers
" h i g h l y u n l i k e l y " but remotely possible: early psychosocial (e.g. inter­
personal) factors might produce a structural brain lesion i n plastic n e u ­
ral systems, or schizophrenia might not be a discrete event or illness
process at all, but, rather, one end of the developmental spectrum that,
for genetic a n d / o r other reasons, w o u l d occur i n about 0.5% of the
population.
The theory that structural disorders result from early damages
caused b y physical environmental factors has been supported b y
many. However, the assumptions of the role of obstetric complica­
tions, originally based o n risk surveys of the children of psychotic
mothers (Cannon et aL, 1993; Mednick, Parnas, & Schulsinger, 1987),
have not been confirmed i n some extensive studies of unselected schizo­
phrenic populations (Davis, Breier, Buchanan, & Holstein, 1991; Done,
 THE ORIGINS OF SCHIZOPHRENIA 49

Johnstone, & Frith, 1991). T h e y are still included as a possible aetiologi­

cal factor i n a number of cases ( M c N e i l et a l 1994). The role of maternal
v

influenza d u r i n g the second trimester of pregnancy, o n the other h a n d ,

seems more plausible i n the light of recent investigations (Mednick,
M a c h o n , H u t t u n e n , & Bonett, 1988; Huttunen, M a c h o n , & M e d n i c k ,
1994). This is also supported b y the nature of brain findings: lesions
originating from a later period of time should have left traces i n the glial
tissue of the brain, and n o such traces have been found (Roberts, 1990).
H o w e v e r , i n a large British survey (Sham et al., 1992), the role of mater­
n a l influenza seemed relevant i n only a small fraction of the patients,
and other criticisms have also been expressed (e.g. C r o w , 1994).
A recent M R I study (Bremner et al., 1995) indicated that the volume
of the right hippocampus was statistically significantly smaller i n those
suffering from combat-related posttraumatic stress disorder (PTSD) than
i n carefully matched controls; n o such difference was found i n the v o l ­
u m e of other brain regions. T h e investigators present several potential
explanations for their findings, which resemble hippocampal findings i n
patients with schizophrenia, including glucocorticoid-mediated damage
to the hippocampus associated with stress. O n the other h a n d , altera­
tions i n hippocampal morphology may have preceded P T S D , presenting
a p r e m o r b i d risk factor for its development.
Still, I also find it difficult to believe that early interpersonal influ­
ences—or later stress related with panic anxiety—could bring about
clear morphological changes i n the brain. It is more probable that
somatogenic effects are more primary than are psychogenic ones, but,
w h e n present, c o u l d induce a restricting effect o n the range of develop­
mental possibilities i n psychological functions a n d their integration.
The aetiological interpretations of the relationship between these
findings a n d schizophrenia are not unanimous among the leading inves­
tigators. Weinberger and his co-workers (Weinberger, 1987; Weinberger,
B e r m a n , S u d d a t h , & Torrey, 1992) have repeatedly postulated that their
significance m a y be understood through the rich interconnected net­
work between different brain regions, whose overall functioning m a y be
affected b y local abnormalities. O n the other h a n d , Andreasen et al.
(1994), while presenting an image of an "average schizophrenic b r a i n " ,
proposed that the diverse symptoms of schizophrenia " c o u l d all result
from a defect i n filtering or gating sensory input, w h i c h is one of the
p r i m a r y functions of the thalamus i n the h u m a n b r a i n " . H o w e v e r , it
should not be forgotten that the findings, as revealed b y currently avail­
able imaging methods, cannot be regarded as specific to schizophrenia.
50 SCHIZOPHRENIA

They most probably constitute risk factors for this disorder, and possibly
also for other conditions.

Hereditary factors
T h e role of p r e d i s p o s i n g hereditary factors i n the aetiology of schizo­
p h r e n i a has b e e n clearly verified b y research, but it has p r o v e d to b e
relative.
In most series of schizophrenic patients, the parents turn out to have
schizophrenia i n 4-6% of the cases, the siblings i n 8-12%, and the chil­
dren i n 10-15%. C o m p a r e d with these figures, those presented b y early
twin researchers for the morbidity of identical twins spoke strongly i n
favour of the importance of hereditary factors, particularly as the m o r ­
bidity of non-identical twins with schizophrenia d i d not differ notably
from the corresponding value of ordinary siblings.
Table 3.1 shows the results of twin studies of schizophrenia. They
indicate that the findings published since 1960 differ from the older
findings i n that the co-morbidity rates of identical twins are clearly
lower i n the more recent studies—30 to 50% at the m o s t — a n d even then
a rather wide scope of diagnostics is needed. Nevertheless, even the
recent studies show that the co-morbidity of identical twins is consist­
ently higher than that of non-identical twins.
The authors of the early twin studies collected their material
f r o m hospitals o n the basis of clinical records and personal inquiries,
while most of the subsequent investigations are based o n either census
registers of twins (the Northern European studies) or at least successive
hospital admissions. Identity diagnoses of identical twins are n o w con­
firmed w i t h serological tests. Furthermore, many of the earlier investi­
gators, for example K a l l m a n n (1946), reached their conclusions b y
following a proband-wise (not pair-wise) calculation, i n w h i c h every
concordant twin pair was counted twice. W h e n K a l l m a n n further a p ­
p l i e d a "shorter" method designed to take into account the relation of
the subject's age to the risk of morbidity, he was able calculate a n 86%
schizophrenia risk for an identical twin whose twin partner h a d become
schizophrenic.
Studies of discordant monozygotic co-twins of schizophrenic p a ­
tients a n d of the children of two schizophrenic parents have yielded
particularly conclusive evidence to contradict the monogenetic theories
of schizophrenia. Both groups display a widely variable spectrum of
 0 - ra w>
to
t

CN
C
^ ! 00 fN i n i n o *c
i 4 <i
b

LA 00
i * "
C "O

I
<L>
<L> — c c
v O u
-Fi >- ­
3
to
C CN KD 00 V* > "to
* - <N rn ^ ^ rt «? £ £
4-* o °-
4—" -£ c c
c
CD CD 4J E
£ - vp
Q3
S= DC ~
S?S §
O CX>
4-" 00 r\ 00
DO TO
C
TJ
LO CO CN t— CN
C cz:
00 a
-E J b
o
aj

i_
O
U o
u 3TO Si
nj .H
o ^=
_c £ -cu
CO

>
C
r -
* •g
I— r o t o r - cNLocorsirsi
ro
§:S -g
UJ c
Si ™ 2
tfi
—1
CO
•5 0)
< *c S
.E ~
p
<u
CD
_C
Q_ Q_ _Q _D
O &
N c -a £ 03 "O
§ o
In C

51 i5 Z D Q
o
D Z 3 Q_ —
u at a;
c
o
D i
to
LL
O _0 cy
c ^
<D c o
(J TRI TO op
c TO
> ifl Qj
03
"D
i—
O
(J H3 TO 3 c
w

c
0
> TO
V 'E

CD

CO

32 *-!0) 8­
U
N
c
TO
ain

CD
E
"a
In
o
o
°8 2^
c 03
c
E
£ 5 a>
S> « 5 U 5b
S "5b^.E <_c
Z "2 r\ ir O Q_
~ ^ n £ £ .E =_ wy C
^ L O - E H - U ^ C X L I I I - ^ O
£ «
^ c JC N

U
B o

51
52 SCHIZOPHRENIA

disorders, i n addition to which a great many co-twins as well as children

of psychotic couples grow u p psychically quite normal (Kringlen, 1967,
1978; Onstad, Skre, Torgersen, & K r i n g l e n , 1991). These findings seem
to disprove theories of a specific schizophrenic genotype, which, apart
from the cases developing into a schizophrenic phenotype, should be
manifested as schizophrenia-spectrum personality disorders.
W e might here also refer to the fact underlined already b y many
early schizophrenia researchers: that since the fertility of schizophrenic
subjects is lower b y about 50% than that of the normal population,
the incidence of schizophrenia—if it were an exclusively monogenous
hereditary disease—should decrease markedly from generation to gen­
eration through "natural selection". N o such decrease has occurred,
however. This fact seems to contradict both dominant a n d recessive
modes of heredity.
T h e significance of non-manifested genotypes can be approached
also b y analysing the incidence of schizophrenia a m o n g the off-spring
of identical twins discordant for schizophrenia. T w o such surveys
have been p u b l i s h e d . T h e first was that of Gottesman a n d Bertelsen
(1989), w h o m a d e a follow-up study until 1985 of the offspring of the
t w i n series gathered b y Fischer (1973). T h e second w a s conducted b y
K r i n g l e n a n d C r a m e r (1989), w h o followed the series collected b y
K r i n g l e n (1967) i n the same w a y . Gottesman a n d Bertelsen reported
practically n o difference i n the incidence of schizophrenia a n d related
disorders between the children of schizophrenic a n d their n o n - c o n ­
cordant identical twins: 16.8% of the children of schizophrenic co­
twins a n d 17.4% of the healthy co-twins s h o w e d disorders. K r i n g l e n
a n d C r a m e r , i n turn, f o u n d a clear (though not statistically significant)
difference, 17.9% a n d 4.4%. Gottesman a n d Bertelsen regard their
f i n d i n g as a definite indication of the significance of genetic factors,
whereas K r i n g l e n a n d C r a m e r emphasize the importance of e n v i r o n ­
mental factors. T h i s contradiction between the two reports is a further
example of the problems inherent i n this field of research.
Identical twins have not only the same genes but almost invariably
also the same growing environment. It was hoped that studies of adoptive
children w o u l d differentiate better than twin studies the hereditary
pathogenetic factors from those originating in the environment.
The best-known of the adoption studies dealing with schizophrenia
is the series of studies designed b y two American researchers, S. S. Kety
and D a v i d Rosenthal, the central part of w h i c h was conducted o n
D a n i s h populations. T h e results of this D a n i s h - A m e r i c a n adoption
 THE ORIGINS OF SCHIZOPHRENIA 53

study demonstrated: (1) that children b o r n to psychotic mothers a n d

placed i n adoptive families h a d a greater disposition to schizophrenia or
disorders close to it than d i d adoptive children whose biological parents
h a d not suffered from psychoses (Rosenthal et al., 1968,1971); (2) that the
biological relatives of adopted children w h o h a d become schizophrenic
often h a d more serious mental disorders than their " a d o p t i v e relatives"
(Kety et al., 1968, 1994); a n d (3) that, according to a rank ordering, a
group of adoptive parents of adopted children w h o h a d become schizo­
phrenic were less disturbed than a group of biological parents of the
schizophrenic children reared i n their homes (Wender, Rosenthal, &
K e t y , 1968). D u r i n g the course of these investigations, Rosenthal a n d
Kety developed the concept of the schizophrenia spectrum, b y w h i c h they
meant that the schizophrenia group also includes genetically a number
of less severe disorders (especially non-affective functional psychoses
and schizoid a n d paranoid character disorders), these disorders being
notably more numerous than actual schizophrenias.

The results of these studies have been interpreted as speaking

strongly i n favour of genetic factors associated with schizophrenia a n d
against the effect of environmental factors. However, their methodology
a n d the interpretation of their results has also been strongly criticized,
especially b y psychodynamically oriented family investigators ( L i d z &
Blatt, 1983; W y n n e , Singer, & T o o h e y , 1976).
The extensive Finnish adoptive family study conducted b y Pekka
Tienari a n d his co-workers (Tienari, 1992; Tienari et al., 1987,1993,1994)
is less well k n o w n but is, i n m y opinion, the most important study
clarifying the roles of hereditary a n d environmental factors i n schizo­
phrenia. It is based o n almost 200 children given u p for adoption b y
w o m e n w h o h a d been inpatients i n Finnish mental hospitals from
1960-1979, because of psychoses of the schizophrenia group, and is c o m ­
p a r e d w i t h matched controls. T h e investigation also included the
assessment of the global mental health of the rearing environment, based
on interviews as well as o n a battery of psychological tests. The Tienari
study is the only adoptive study planned a n d carried out with a c o m ­
b i n e d genetic a n d psychodynamic expertise.
The m a i n findings of this study are presented i n Tables 3.2 a n d 3.3.
E v e n though still considered preliminary b y the team, the results can be
regarded as conclusive. T h e y confirm clearly the importance of both
genetic and psychological environmental factors for the vulnerability for
schizophrenia as well as the interaction between them a n d genetic fac­
tors. O f the adopted-out children of psychotic mothers 14 (9%) have
 <0 J5
•5 > s
O
Q_

3
15 w O <D
a. , -o
CN r-1
£ u LO ro •—" o
c J5 > " u
o x
CM CN cL-Q <u
LO CM
« i£ cB
nj a
o Q--= O
rn c «
(%0* = •§..«
-5 5 5 E.§ J

.O ii
00

o
O
ro o^
oq a> ro
LO
—
'r —^ r —

0-
ro
s
U
> . ^*>
Q
to
/ Q_
2 -c 1/1u u

—».— —*" *CN

—'
<N

_2
TJ­ —-

^ .,CN
s—^
CD ro a.
ro ro

& "D =s t3
E

CL C o 9

t
o c "o 8.
g
X CL ?
u
V rn O
c X
LO m
t- o o 5
i o O
2 C

§
O •8 S II 2
u> O o
-> <S> IS>
c — <u
u -c­

m cu
03 N d N
(N fN TM- N (N fM (N "So 8.2 »
o S
.2 Z
s"g t/i . o
CO
2 ^ to
CU
_D U! ^
to O
CU to H = .«

it
CO

o u
c
C
T> c V 9­
cu o E ro Oc
c

E .a 55 J_
D
o "O CL U . Q_ g E
V CU
£ O
CL

3
O
to
i
§ £ -m "O
C "J
18.
o
c C

11 E2 S
DO • ­
o u c o
c
to
o3
to
to JZ
1_
CU
CU
•— o— c

aj O
CU CU

E "S y ^
Q_ to
O
to
O
Q_
o
^
LO Q_ 'DO 13 ^
c E * u u N
.2 a
>- c ^ v
£ a> — >
rt
D | XI >
LO

"g u
w

to
.2 CL CL C£ i= 05 io o ca
cu s « ^ c a . _ oi t« c o
<L> — .
u x
LU
CU ON ^ ^ T3 Q .
o o o
CL .12 3
- r c a> *s>
to
i o E *
ii £ §
-° s %
O a; LO
LO U
Q_
CO
r-- U
</O
>
<^ IZ "
LO
Z Z
o 00
_OULO
11 11
O C O
CN LO < 0 < C D it (N LO
03 _D U J ' O t o
O <D O
—
t*
* ro 3 X O <N

54
 THE ORIGINS OF SCHIZOPHRENIA 55

TABLE 3.3
Outcome diagnoses of the adoptees in relation to
global mental health ratings of the adoptive families

Adoptive Family Ratings

4-5
1-2 3 severely
Adoptee rating healthy "neurotic" disturbed Total

Index 1-2
healthy 47 17 5 69
3
"neurotic" 9 11 13 33
4-5
personality disorders 2 7 20 29
6
functional psychoses 0 4 9 13

total 58 39 47 114

Control 1-2
healthy 51 27 12 90

3
"neurotic" 20 22 17 59
4-5
personality disorders 3 9 13 25
6
functional psychoses 0 0 2 2

total 74 58 44 176

Source: Tienari, 1 9 9 2 .

become ill with schizophrenia or a closely related psychosis, while the

corresponding number among the matched control group was 2 (1.1%).
H o w e v e r , it was also found that the disorders of the adopted children
clustered strongly i n the rearing environments whose global mental
health was assessed as disturbed. This was true of both index and c o n ­
trol adoptees. A logistic regression analysis, which included the genetic
difference between the series, showed that the most powerful factor
preceding mental disorder i n the adoptee was disturbed intrafamilial
communication. After exclusion of this variable came conflicts between
56 SCHIZOPHRENIA

parents a n d children, combined with the genetic variable, a n d as a

third factor lack of empathy, also combined with the genetic variable.
Especially noteworthy is the conclusion that a wholesome family envi­
ronment seems to protect from disturbance even those children whose
biological mothers have been ill with schizophrenia.
In the late 1980s, molecular genetic studies based o n the possibility
of locating genetic markers i n chromosome charting studies became pos­
sible. Since then, there has been very intensive study to find the evidence
that w o u l d connect schizophrenia to a specific gene. However, thus far
the results of these linkage studies have yielded almost exclusively nega­
tive a n d / o r contradictory results (e.g. Barr et a l , 1994; C o o n et al., 1994;
for a critical review, see Portin & A l a n e n , 1997). The postulates of spe­
cific genetic factors located in different genes i n different cases still seem
possible, and the same can be said of the hypothesis according to w h i c h
two or three genes together could lead to a predisposition for schizo­
phrenia. Results of a large international (families from eight countries)
two-stage genome-wide search for schizophrenia susceptibility genes
(Moises et a l , 1995) suggested that a more complex oligogenic or
polygenic model is most likely to be correct. In this study, based o n
families from eight countries and a narrow diagnosis of schizophrenia,
five different loci, i n chromosomes 6p, 8p, 9, 20, a n d 22, were found,
w h i c h , acting i n concert, could cause susceptibility for this disease. In
another recent international multicentre study, Williams et al. (1996)
found that a polymorphism of the 5 - H T 2-A receptor gene, located i n the
long a r m of chromosome 13, was 1.3 times more general i n schizophre­
nia than i n the general population (p = 0.003).
Both the overall quality of the variably based genetic a n d family­
dynamic findings and the postulated clinical continuum of schizophre­
nia and the personality disorders within and outside the schizophrenia
spectrum rather suggest a collective effect of several genes acting less
specifically but i n interaction with causative factors of another k i n d . It
is most probable that the genetic predisposition to schizophrenia is
polygenic, a n d the effects are dependent o n interaction with physical
and psychosocial environmental factors. E v e n the possibility that the
genetic susceptibility to schizophrenic psychoses generally represents
one extreme of normal h u m a n genetic variation cannot be excluded. In
that case, an individual's genetic vulnerability to schizophrenia could be
characterized as merely one extreme of normal h u m a n genetic variabil­
ity (Portin & A l a n e n , 1997).
 THE ORIGINS OF SCHIZOPHRENIA 57

Some researchers have postulated that a part of schizophrenia w o u l d

be caused b y genetic factors, a n d another group w o u l d be related to
brain damage. Efforts to confirm this have, however, led to contradictory
findings, giving only limited support to this hypothesis.
This k i n d of theory has been presented b y Reveley et al. (1982) as
well as b y Suddath et al. (1990), based o n their findings of enlarged
cerebral ventricles i n discordant identical twins. Because the schizo­
phrenic twins regularly h a d larger ventricles than their healthier
co-twins, the brain abnormalities appeared to be independent of genetic
factors. Reveley, Reveley, and M u r r a y (1984) supported their findings b y
pointing out that i n their series there was a " f a m i l y taint" only among
patients w i t h no enlargement of the cerebral ventricles. However, D e L i s i
et al. (1986), while studying the ventricle/brain ratio of schizophrenic
patients w h o came from sibships more than one member of w h i c h h a d
schizophrenia, found that the ventricular enlargement was not likely to
be restricted to those without the " t a i n t " . Furthermore, according to
other studies (Cannon et al., 1993; Torrey et al., 1994), a positive correla­
tion between ventricular enlargement and genetic risk for schizophrenia
was found.
Other attempts to discover a difference between hereditary a n d
" s p o r a d i c " schizophrenia—the latter group of patients having no schizo­
phrenia i n their families—have not yielded conclusive findings. Sedvall
a n d W o d e - H e l g o d t (1980), for example, noted differences i n the meta­
bolic products of spinal fluid transmitter substances between two
patient groups, one with other cases of schizophrenia i n the family, the
other w i t h none. O ' C a l l a g h a n et al. (1991) found evidence for the occur­
rence i n connection with winter births—with a possible connection with
increased maternal influenza—to be confined to patients without a fam­
ily history of mental disorders. These findings have remained disputable
a n d / o r not sufficiently confirmed.
The influence of the two groups of biological predisposing factors o n
the prognosis of the patients seems to differ. Structural brain abnormali­
ties d o have some correlations with outcome—chronic patients a n d
those with negative symptoms exhibit such changes more often than d o
patients with a better outcome—even if there is n o obvious connection
with the different subtypes of schizophrenia. The genetic factors, o n the
other h a n d — a s defined b y the appearance of other cases of schizophre­
nia i n the family h i s t o r y — d o not have a similar correlation with
outcome (Ciompi, 1980).
58 SCHIZOPHRENIA

Studies on predisposition to schizophrenia:

the role of psychosocial factors

In Exhibit 2.1,1 separated the p s y c h o d y n a m i c a l l y oriented studies of

the nature a n d causative factors of schizophrenia into two sections.
T h e a i m of the i n d i v i d u a l - p s y c h o l o g i c a l a p p r o a c h , represented b y
psychoanalytically oriented studies, is to discover, i n a d y a d i c rela­
tionship w i t h the patient, h o w the illness is l i n k e d to the internal
g r o w t h of the personality, shaped b y constitutional factors a n d
early interactional relationships. T h e interactional a p p r o a c h , i n turn,
focuses o n the study of interpersonal relationships a n d n e t w o r k s —
mostly families—wherein the i n d i v i d u a l ' s development a n d life
events take place. In b o t h cases, psychotherapeutic treatment is
closely connected w i t h research.
Psychoanalytic research and family-dynamic research, while close to
each other, approach schizophrenia from mutually complementary
viewpoints. T h e differences i n their basic premises result i n a different
weighing of pathogenic factors. I shall briefly review the development of
both approaches.

Psychoanalytic studies

Sigmund Freud's experience w i t h psychotic p a t i e n t s — w h o are not

v e r y suitable for treatment b y the classical psychoanalytic method
he i n v e n t e d — w a s not extensive. E v e n so, h e p r o m o t e d a h i g h l y sig­
nificantly psychological understanding of schizophrenia, b o t h theo­
retically a n d t h r o u g h the famous analysis of the autobiographical
m e m o i r s of D r . D a n i e l P a u l Schreber, a lawyer w h o suffered f r o m
p a r a n o i d schizophrenia (Freud, 1911c). F r e u d postulated that schizo­
p h r e n i c psychosis i n v o l v e d a conversion of l i b i d o (i.e. pleasure-seek­
i n g drives) a w a y f r o m external objects a n d directed towards oneself.
T h e p s y c h o d y n a m i c s of psychosis consisted of two stages: the first
stage of the abandonment of object relations was of basic significance
a n d w a s often followed b y s y m p t o m formation that c o u l d be inter­
preted as an effort to revive the lost object relations, yet i n a m a n n e r
that w a s egocentric a n d megalomanic a n d isolated f r o m real objects.
In a paper o n narcissism published three years later, F r e u d (1914c)
further specified his views o n the early development of the libido and its
 THE ORIGINS OF SCHIZOPHRENIA 59

relation to schizophrenia. The first postnatal stage is objectless, charac­

terized b y " p u r e autoeroticism". This is followed b y primary narcissism,
where the object of libido is oneself. It is only after this that the libido
begins to be directed increasingly towards other people, while the " e g o
l i b i d o " is retained at the same time, and constant partial and reciprocal
shifts take place between it and the "object l i b i d o " . Schizophrenic p s y ­
chosis involves a return to the stage of p r i m a r y narcissism a n d at the
same time—as was particularly underlined b y A b r a h a m (1916)—a p s y ­
chological regression to the early levels of the first year of life. This
meant that the early mother relationship a n d frustrations connected
w i t h it became of central importance i n psychoanalytic theories of
schizophrenia. However, F r e u d a n d his co-workers also considered
hereditary-structural factors significant i n the origins of traumatic fixa­
tions of libidinal development.
The theory of primary narcissism was connected with a therapeutic
pessimism. In his essay " T h e Unconscious", F r e u d (1915e) emphasizes
the therapeutic inaccessibility of schizophrenic patients, as opposed to
"transference neuroses", resulting from the abandonment of libidinal
object cathexes, preventing the transference necessary for any therapeu­
tic relationship.
In a couple of later papers, published i n 1924 after the creation of his
theory of the structure of psychological functions (id, ego, superego),
F r e u d (1924b, 1924e) proposed a definition of the difference i n develop­
ment between neurosis and psychosis i n a more parallel way: neurosis is
a consequence of conflicts between ego and i d , while psychosis is an
analogous outcome of conflicts between ego and outer w o r l d . In neuro­
sis, the ego represses the anxiety-provoking drives, whereas in psychosis
the ego is overrun b y the i d a n d loses its commitment to external re­
alities.
H o w e v e r , the views expressed b y Freud about the therapeutic i n ­
accessibility of schizophrenic patients overshadowed these later papers
and were weighty enough to keep the interest of most psychoanalysts to
these patients largely theoretical. A notable exception to this rule was
Freud's faithful p u p i l and fellow worker Paul Federn, w h o successfully
treated schizophrenic patients with psychoanalytically oriented psycho­
therapy (including supportive parameters) in Vienna, beginning as early
as 1906. H o w e v e r , he only published the major reports of his abundant
experience w i t h psychotic patients during the 1940s, having m o v e d to
the U n i t e d States (Federn, 1943,1952).
60 SCHIZOPHRENIA

In A m e r i c a , A d o l f Meyer (1906, 1910), at the beginning of the cen­

tury, presented psychodynamic views o n the causes a n d nature of
schizophrenia, based o n a pragmatic psychobiological approach. Psy­
chotherapy with these patients became more common than i n Europe
and was greatly influenced b y the pioneering work of Harry Stack
Sullivan (see Sullivan, 1962). Keeping a certain distance from Freud's
theories, Sullivan regarded schizophrenia as the result of a process that
proceeded through several stages. H e especially emphasized the signifi­
cance of the disorders of self-esteem as well as that of an overpowering,
" u n c a n n y " anxiety about the development that ultimately resulted i n
schizophrenia. The individuals susceptible to schizophrenia are those
with m a n y dissociated—in psychoanalytic terms, repressed—life fields,
drives, a n d other emotional needs of this k i n d . However, the dynamics
of the personality may also undergo changes that affect the dissociated
experiences both favourably a n d unfavourably, especially during
school-age and early adolescence. Schizophrenia m a y become manifest
at that time, but the personality may also be reinforced.
The therapists of the "Washington School"—including Frieda F r o m m -
Reichmann (1950, 1952) , Otto A . W i l l , Jr. (1961), a n d H a r o l d Searles
(1965)—further developed the psychotherapy of schizophrenic patients,
combining psychoanalytic starting-points with those derived from
Sullivan's views. Searles especially published illuminating descriptions
of the intensive but ambivalent symbiotic needs for dependence typical
of schizophrenic patients that undermine their psychic stability. These
are needs that " h e cannot allow to recognize in himself, or if recognized
in h i m he dare not express to anyone, or which are expressed b y h i m
in a fashion that, more often than not, brings an uncomprehending
or relatively rejecting response from the other p e r s o n " (Searles, 1961).
H o w e v e r , it became clear that Freud's view of the therapeutic inaccessi­
bility of schizophrenic patients was not correct, even if the establishment
of therapeutic relationships, especially with chronic patients, was an
arduous and time-consuming task.
A significant step towards understanding the psychology of schizo­
phrenia and other serious disorders derived from the theories presented
by the psychoanalysts of the British Object Relations School, especially
Melanie Klein (1946, 1975; see also Segal, 1973). A c c o r d i n g to Klein, i n ­
fants have primitive object relationships from birth, initially w i t h " p a r t
objects", the most significant of them being the mother's breast. In order
to be able to understand Klein, one has to realize that a majority of the
infantile psychic functions consist of unconscious fantasies, which, h o w ­
 THE ORIGINS OF SCHIZOPHRENIA 61

ever, are i n constant interplay with the w a y the infant experiences re­
ality. A central part of these fantasies pertains to satisfactory, " g o o d " ,
or frustrating, " b a d " , experiences of one's o w n a n d of the w o r l d . If an
infant w h o is h u n g r y , and w h o has an omnipotenf hallucinatory
idea of a good and nourishing breast (as is shown b y the movements of
its m o u t h a n d fingers), is promptly nourished even in reality, it feels its
o w n goodness and the goodness of its objects to be powerful a n d reli­
able. If not nourished, the infant develops an idea of the badness a n d
persecutory character of the object, and the ensuing hatred becomes
more powerful than h i s / h e r love.
The early, primitive defence mechanisms of the infant are denial,
splitting, projection, a n d introjection. K l e i n (1946) introduced projective
identification as a new and important defence mechanism: it is based o n
an omnipotent phantasy that it is possible to split parts of the self a n d
the internalized objects away from the self and place them i n an external
object, where they are preserved a n d controlled, while it simultaneously
is possible to continue to identify w i t h them. Projective identification is
mostly applied to parts of self that are felt to be dangerous or that—at
later stages—cannot be accepted as part of one's ego image. Projective
identification is also a useful concept i n understanding family p s y c h o l ­
ogy, a n d I shall return to it later.
A c c o r d i n g to K l e i n , the first year of the infant's life already involves
two developmental stages or positions, w h i c h are of fundamental sig­
nificance for the subsequent development of personality. The first of
them, the paranoid-schizoid position, is dominated b y splitting and p r o ­
jective and introjective processes, w h i c h are used to defend against
threatening " b a d " objects as well as a hateful ego a n d the persecutory
anxiety aroused by these mental images. Fixation to this stage confers a
vulnerability to subsequent regression into a paranoid or schizophrenic
state. W i t h regard to schizophrenia vulnerability, constitutional fac­
tors—for example, the strength of the death instinct (assumed b y F r e u d
i n the 1920s to be the reverse of life-sustaining libido)—are crucially
important. The second stage, the depressive position, beginning soon
after the age of six months, coincides with the development whereby the
baby is able to perceive the mother as a whole object and begins to
realize that good a n d b a d experiences can be associated with one object
and one ego, instead of there being separate " g o o d " and " b a d " part­
object representations. The infant also recognizes its helplessness and
dependence o n its mother as well as its jealousy towards other people.
This recognition mobilizes concern for the object (mother) who has pre­
62 SCHIZOPHRENIA

viously been attacked when b a d (frustrating), and a desire to make good

the damage felt to have been done. These "reparative" feelings, based o n
concern for the other (the object), form the basis for normal healthy guilt
and morality later i n life and a decreased susceptibility to subsequent
psychosis. The depressive states in later life are due to internalization of
the feelings of anger towards the object a n d their application to one's
o w n ego, as F r e u d (1917e) originally described.
W . R. Bion, a psychoanalyst of the Kleinian school, postulated that
the fear felt b y the psychotic patient, w h i c h reaches back to the
paranoid-psychotic position, results i n projective identification charac­
terized b y an attempt to destroy all observations a n d intrapsychic
representations of one's self and the object—an attempt, as it were, to
obliterate completely the psychic w o r l d filled with representations that
provoke anxiety (Bion, 1967). This w o u l d result i n serious distortion i n
early ego development. This is frequently observable as a prepsychotic
deficiency i n ego functions i n an i n d i v i d u a l w h o later becomes schizo­
phrenic as well as a disorganization of thought functions u p o n the onset
of psychosis. There is a simultaneous attempt to break the links between
the objects a n d the self as well as between different objects. Bion also
postulated that early processes of this k i n d may, through internal split­
ting, result i n a situation where a separate "schizophrenic" core of
personality is established, w h i c h is excluded from consciousness and is
not integrated in the partly hollow growth and development of the rest
of personality, but m a y emerge during subsequent regression triggered
b y anxiety. This could explain w h y certain individuals tend to regress to
the schizophrenic level rather than the neurotic one.
T h e A m e r i c a n psychoanalyst Otto F. Kernberg (1975, 1984) d e m o n ­
strated that the primitive defence mechanisms—splitting, early forms of
projection including projective identification, denial, omnipotence,
primitive idealization and its counter-pole, devaluation—are of central
importance i n the psychic function of the borderline personalities i n
particular. Kernberg regarded the "borderline personality organization"
as a relatively stable structure. However, there are also psychosis-prone
patients with various defensive mechanisms. Thus, i n a Finnish study of
first-admitted schizophrenics, a group of regressed patients with under­
lying borderline personality was found (Rakkolainen et a l . , 1994).
Kernberg criticized the more speculative parts of Kleinian theories a n d
especially her timing of the early developmental phases: whereas Klein
placed even the oedipal stage i n the first year life immediately after the
depressive position, Kernberg locates even the early positions defined
 THE ORIGINS OF SCHIZOPHRENIA 63

b y K l e i n at later stages. Together with his followers—one of them being

V a m i k D . V o l k a n , k n o w n for his contribution to psychotherapy of psy­
chotic or nearly psychotic patients (1987,1990,1995)—Kernberg created
a theoretical frame of reference capable of combining the propositions of
K l e i n and the child psychoanalyst and investigator Margaret S. M a h l e r
(1968; Mahler, Pine, & Bergman, 1975)—positions that were originally
quite far apart. Figure 3.1 shows the early phases of personality develop­
ment, as depicted i n a paper b y V o l k a n (1981).
J. S. Grotstein (1977) also combined the ideas of the A m e r i c a n a n d
British psychoanalytic schools. The development begins with an autistic
phase, w h i c h , according to h i m , involves a preliminary orientation to­
wards objects through "adhesive identification". This is followed b y a
symbiotic phase, w h i c h is parallel to Klein's paranoid-schizoid position.
After this, more developed defence mechanisms are gradually adopted.
U n l i k e Kernberg, Grotstein presents differentiation a n d integration as
temporally parallel phenomena; they make u p a d u a l track along w h i c h
personality development proceeds towards more holistic experiences.
The effects of constitutional factors and early interactional relation­
ships are intermingled i n many ways, and they cannot be discriminated
b y means of psychoanalytic research. It is also disputable h o w m u c h
the k i n d of development that predisposes to schizophrenia should
be ascribed to p r i m a r y deficiencies of personality formation, and h o w
m u c h to internal personality conflicts. Federn (1952), emphasizing defi­
cient ego boundaries, supported the former alternative, the deficiency
theory. Other proponents of it include, for example, H a r t m a n n (1953)—
w h o pointed to the inability of the schizophrenic ego to neutralize
aggressions—London (1973), and Salonen (1979), whereas Kleinian pos­
tulates o n the early conflicts and defence mechanisms can be classified as
conflict theory. It was also supported b y A r l o w and Brenner (1969), start­
i n g from different premises, Grotstein (1977) a n d Pao (1979)—who
categorized the schizophrenic illness i n different subtypes based o n a
combined psychodynamic and family dynamic assessment of the grade
of the patient's disturbance—assume an intermediary position at this
point, w h i c h also seems justifiable to me.
The influence of recent advances i n neurobiological research o n
psychoanalytic theory has not been rapid. However, some efforts to­
wards the integration of these two disciplines have been published.
M o s t noteworthy is Michael Robbins' book Experiences of Schizophrenia:
An Integration of the Personal, Scientific, and Therapeutic (1993), based o n
long-term psychotherapeutic work with these patients. For Robbins, it
STAGES "ALL GOOD" "ALL BAD"
, = = = = = V////X ,

1st
1 month Memory traces which Memory traces which
of life contain "pleasurable ­ contain "painful ­
good" stimuli bad" stimuli

2
2nd

to

6th - 8th Undifferentiated self-

N T3 Undifferentiated self­
month object representation +-*
a> object representation
(Nucleus of the self w
% c
system of the ego) >.
c

0 0
* >* r

CTJ
C

6th - 8th ID
S>

month

Io
J5
cn

3 to
18th­
36th Differentiated self and Differentiated self and
month object representations object representations

from

3rd

year

4 through Integrated self and object representations

oedipal (Ego, superego, and id, as definite intrapsychic structures,
period are consolidated)
(Repression replaces primitive splitting as
the main defensive operation)

5 Further consolidation of superego and further

integration of ego identity

Q Object representation @ Self representation

FIGURE 3.1. The development of internalized object relations (Volkan,

1981).

64
 THE ORIGINS O F SCHIZOPHRENIA 65

seems likely that schizophrenia " i s the expression of a cerebral variant, a

differently functioning brain than a n o r m a l one with some discrete de­
fect". A constitutional vulnerability a n d deficits a n d abnormalities of
p r i m a r y parenting have, from the beginning, a combined effect o n the
development of a person predisposed to schizophrenia.
A c c o r d i n g to Robbins, there are two m a i n areas of p r i m a r y disor­
ders. The first of these is a vulnerability in the area of organization and
affinity, manifested as the schizophrenic's aversion to contact with other
h u m a n beings and—related to this—a deficiency i n psychological differ­
entiation and integration. T h e second handicap is formed b y problems
w i t h intensity a n d regulation of stimulation, both external and internal,
especially m a r k e d w i t h regard to rage and its management. Because of
this, a n d referring to his o w n experiences, Robbins emphasizes that the
schizophrenic's early development, including the symbiotic situation, is
not comparable to the n o r m a l development of the symbiotic phase as
described b y M a h l e r a n d her co-workers (1975) a n d also reflected i n
Searles' (1955,1965) writings. Robbins calls the symbiotic situation of a
schizophrenic " p r o t o t y p i c " , characterized b y a passive, global, a n d i n ­
discriminate adaptation to others. In psychotherapy with schizophren­
ics, the goal of the therapist is—after the initial phase of engagement i n
the pathologic, prototypic symbiosis—to stimulate development to­
wards a more n o r m a l , growth-promoting symbiosis and i n this w a y to
adequate psychological differentiation a n d integration. Despite his con­
sideration of the constitutional handicaps, Robbins views' of the possi­
bilities of psychotherapy in schizophrenia are relatively optimistic.
Heinz Kohut, the developer of self psychology (1971, 1977), d i d not
focus o n schizophrenia. However, his theories, w h i c h form an antithesis
to the drive-based psychoanalytic theories, are interesting from the
viewpoint of schizophrenia research. A c c o r d i n g to Kohut, the represen­
tational developments pertaining to the self o n the one hand and objects
o n the other—which correspond to Freud's division into narcissistic and
object-oriented l i b i d o — c a n be examined as parallel but separate phe­
nomena not b o u n d to each other i n the w a y suggested b y Freud.
Nevertheless, K o h u t considers some of the most intensive narcissistic
experiences to be related to object representations. K o h u t calls these
narcissistically cathected objects self-objects. For the children, parents are
always both objects of an emotional relationship and self-objects, w h i c h
are used i n the service of the growth of self and i n the maintenance of its
investments.
66 SCHIZOPHRENIA

A c c o r d i n g to Kohut, the sensations and experiences associated with

drive gratification i n infantile development are consistently subordi­
nated to the child's experience of the relation between the self a n d
self-objects. The mother and the other adult caregivers are at first self­
objects for the infant, and the infant's view of itself and others—that is,
its personality—grows primarily from this foundation through identify­
ing interaction. Kohut points out that this is of crucial importance o n two
counts, and he continues:

It changes our evaluation of the significance of the libido theory

on all levels of psychological development i n childhood; a n d ,
consequently, it changes our evaluation of some forms of psycho­
pathology which classical theory viewed as being caused b y the
personality's fixation or regression to this or that stage of instinct
development. [Kohut, 1977, p. 80]

Kohut's views of aggression are typical. Aggression is, admittedly,

part of the individual's personality, and it has its biological foundation.
Nevertheless, Kohut postulates that destructive aggression (so important
in the schizophrenic psychodynamics!) originally comes about because
of the inability of the infant's early self-object environment—that is,
primarily its mother—to respond to the infant's needs with o p t i m a l —
not maximal—empathy. It is not primarily drive-based but, rather, a
result of developmental disintegration, which is due, above all, to narcis­
sistic fury aroused b y damaged self-esteem (Kohut, 1977).
I shall later o n examine the usefulness of the self-object concept for
both the theory and treatment of schizophrenia.

Psychodynamic family studies

T h e first systematic investigation of the family b a c k g r o u n d of schizo­

p h r e n i a w a s p u b l i s h e d b y K a s a n i n , K n i g h t , a n d Sage i n 1934, w h o
n o t e d that 60% of the parents of 45 schizophrenic patients s h o w e d
the characteristic feature of over-protection, w h i l e only a few of the
p a r e n t - c h i l d relationships c o u l d be described as rejecting—certainly
a f i n d i n g that w a s not i n v e r y g o o d accordance w i t h p r e v a i l i n g p s y ­
choanalytic theories. T h e e n d of the 1950s a n d the early 1960s became
the g r o u n d b r e a k i n g p e r i o d of p s y c h o d y n a m i c family studies. T h e
simultaneous b u t largely independent w o r k s of some A m e r i c a n
teams were of central significance.
 THE ORIGINS O F SCHIZOPHRENIA 67

Theodore Lidz a n d Ruth W . L i d z published i n 1949 a study of the

childhood family environments of 50 schizophrenic patients, noting that
90% of the childhood homes of these patients were seriously disturbed
(Lidz & L i d z , 1949). W o r k i n g with his team at Yale U n i v e r s i t y — w i t h
Stephen Fleck and A l i c e R. Cornelison as his closest c o - w o r k e r s — L i d z
then specified his findings b y analysing i n close detail the families of 17
schizophrenic patients. T h e findings were published i n several papers
after the mid-1950s and were later compiled i n a book, Schizophrenia and
the Family (Lidz, Fleck, & C o r n e l i s o n , 1965). The m a i n findings can be
d i v i d e d as follows:

1. In 6 0 % of the cases, one or b o t h parents h a d serious personality

disorders; three of the parents s h o w e d clearly psychotic features.
Fathers were as b a d l y disturbed as mothers ( L i d z , C o r n e l i s o n ,
Fleck, & T e r r y , 1957a). T h e team speaks of a transmission of irration­
ality i n this context, b y w h i c h they m e a n that f r o m their parents
c h i l d r e n learn disturbed w a y s of thinking, w h i c h are thus trans­
mitted f r o m one generation to another ( L i d z , C o r n e l i s o n , Fleck, &
T e r r y , 1958).

2. T w o types of disturbed parental marriages were differentiated:

schismatic, where the relationship between the spouses w a s char­
acterized b y persistent, continuous, hostile d i s c o r d , l e a d i n g to
chronic " u n d e r c u t t i n g " of the w o r t h of one partner to the c h i l d r e n
b y the other; a n d skewed, where the family atmosphere w a s d i c ­
tated b y a d i s t u r b e d d o m i n a n t parent, the spouse b e i n g , i n most
cases, more healthy i n his or her t h i n k i n g b u t dependent, if n o t
submissive, o n the other a n d thus unable to counteract the d o m i ­
nant parent's pathogenic influence ( L i d z et al., 1957b).

3. O w i n g to their m u t u a l dissatisfaction, the parents m a d e emotional

d e m a n d s of their c h i l d r e n w h i c h s h o u l d have been satisfied b y
their m u t u a l relationship. T h i s " v i o l a t i o n of the generation
b o u n d a r i e s " , reflected b y the emotional symbiosis between a p a r ­
ent a n d a c h i l d , often arouses p a n i c k y anxiety, b e i n g coloured b y
incestual a n d / o r h o m o s e x u a l proclivities, w h i c h cause notable
p r o b l e m s i n the d e v e l o p i n g sexual identity of the c h i l d r e n .

4. T h e fathers of psychotic male patients are often passive, offering a

p o o r m o d e l of masculinity for sons to identify w i t h , w h i l e the
mothers are d o m i n a n t a n d dependent u p o n their sons for their
o w n emotional satisfaction a n d completion. T h e g r o u p of female
68 SCHIZOPHRENIA

patients, o n the other h a n d , i n c l u d e d m a n y fathers w h o turned

to their daughters i n a seductive manner a n d emotionally cold
mothers w i t h p o o r l y developed femininity.

In the concluding part of their book (Lidz et aL, 1965) L i d z and Fleck
consider that schizophrenia is a k i n d of emotional and cognitive defi­
ciency disease, involving serious defects or distortion of the parental
nurturance a n d guidance as well as of the transmission of adaptive
abilities i n these families to their children. L i d z and his team founded
their theory firmly on the psychoanalytic theory of personality develop­
ment, but the findings also suggested new theories of the pathogenesis
of schizophrenia that were notably more comprehensive and covered a
longer developmental span than the earlier views.
Another pioneering group for family research w o r k e d at Palo A l t o ,
California, around the well-known anthropologist Gregory Bateson. H i s
starting-points lay in cybernetics and communications theory. Based o n
family therapy and other encounters with family members, Bateson,
together with D o n D . Jackson, Jay Haley, and John Weakland, developed
the concept of the of the double bind (Bateson et al., 1965), which became
widely k n o w n and referred to the phenomenon that they assumed to be
the essential cause of the communication disorders resulting i n schizo­
phrenia.
The starting-point for the double b i n d is a situation where one i n d i ­
v i d u a l (e.g. a parent) sends another individual (e.g. a child) messages at
two different levels that are mutually incompatible. The incompatibility
usually prevails between the verbal a n d the non-verbal, emotional
communication. A s an example, we can take a mother w h o calls the
child to h u g her, but as the child approaches, stiffens with an unrespon­
sive expression, causing the child to stop, whereupon the mother
says: " W e l l , w h y didn't y o u come?" The double b i n d further implies
that the " v i c t i m " is unable to escape the situation, as he is dependent on
the individual who makes the double bind. This is the situation between
a small child and his or her parent.
The communications involving a double b i n d are quite confusing to
the child, for w h o m it becomes impossible to respond to them i n a
satisfactory manner. A s a consequence, he learns contradictory and ob­
scure forms of communication (which m a y be adequate from his
viewpoint i n his relationship with the parent), and, even more signifi­
cantly, he learns to avoid interpersonal situations because of the anxiety
that they arouse and develops a tendency to withdraw into his o w n
 THE ORIGINS OF SCHIZOPHRENIA 69

w o r l d . The concept of double b i n d also has psychodynamic dimensions

a n d is easy to apply to relations between three i n d i v i d u a l s — s u c h as the
father, the mother, a n d the child i n schismatic families.
In schizophrenia research, this concept has been criticized b y demon­
strating that the phenomena i m p l i e d b y it are b y n o means restricted to
the families of schizophrenic patients. H o w e v e r , what m a y matter is the
extent to w h i c h behaviour of the double-bind type dominates the grow­
i n g - u p atmosphere or whether it occurs as a marginal feature. Bateson
himself later endeavoured to separate this concept from its original
aetiological emphasis. H e also pointed out that communicative conflict
situations of this k i n d m a y — i n addition to their negative effects—also
stimulate i n d i v i d u a l creativity (Bateson, 1973).
T w o teams w o r k i n g at the N I M H near Washington also based their
w o r k o n conjoint family therapy with schizophrenic patients. B o w e n
(1960; Bowen, Dysinger, Brodey, & Basamania, 1961) defined the forma­
tion of an undifferentiated ego mass as being characteristic of these
families. A n y efforts at differentiation aroused exceptionally intense anx­
iety i n these families. Bowen and co-workers also became k n o w n for their
three-generation hypothesis, which suggested that the schizophrenic dis­
order develops as a consequence of progressive psychic immaturity. The
team lead b y Lyman C. Wynne developed the concepts of " p s e u d o - m u t u ­
ality" (Wynne, Ryckoff, D a y , & H i r s c h , 1958) a n d " p s e u d o - h o s t i l i t y " ,
describing family atmospheres that completely deny a n d isolate certain
emotions (dissociation i n Sullivan's sense). In p s e u d o - m u t u a l families
the parents tend to show both each other a n d their children a pretence
of an eternally harmonious family; the expression of hostility is not
accepted, a n d the children therefore feel an immense fear of hostile
emotions arising i n themselves a n d tend to repress a n d deny them. In
pseudohostile families constant bickering holds the family enmeshed
while emotions of endearment a n d affection have to be repressed or
suppressed.
In collaboration w i t h the psychologist Margaret T. Singer, W y n n e
analysed communication deviances (CDs) of the parents of schizophrenics.
Great attention was aroused b y these studies, where Singer, w o r k i n g o n
large patient population, was able to pick out with 90% accuracy the
Rorschach test protocols of parents w h o h a d a schizophrenic child a n d
those whose children were less seriously disturbed (Singer & W y n n e ,
1963, 1965; W y n n e & Singer, 1963). T h e findings were based o n family
communication patterns, later codified into 33 or 41 categories of C D s i n
the parents. T h e findings were largely confirmed b y the team's later
70 SCHIZOPHRENIA

w o r k (Singer, W y n n e , & T o o h e y , 1978); however, they c o u l d not be

considered fully specific for schizophrenia. A l o n g the axis of schizo­
phrenia-borderline-neurosis-normal a certain continuum of c o m m u n i ­
cation disorders for all groups of family members was found. In 1978
W y n n e defined the communication studies as a research strategy ori­
ented to one dimension of the interpersonal relationships—communica­
tion skills being a prerequisite for enduring relatedness—that c o u l d be
described as a n intermediate variable between genetic endowment a n d
the eventual symptomatic breakdown i n adolescence a n d adulthood,
" p e r h a p s formative a n d contributory to acquired vulnerability", rather
than a separate aetiological factor. H e also emphasized that the C D
scores were not directly related to the degree of clinical disturbance—
for instance, they p r o v e d higher among the parents of schizophrenic
patients than among their clearly psychotic children (Wynne et aL, 1977).
N o r d i d W y n n e agree with the suggestions of some authors attributing
the disorders of intrafamilial communication as secondary to the child's
illness a n d his influence on the family (Wynne, 1978). Several authors
(see Doane, 1978; R u n d , 1986) at least partly confirmed the C D findings,
a notable exception being the work published b y S. R. H i r s c h a n d Julian
Leff (1971) i n L o n d o n .

M o r e or less similar findings on the disturbances of the parents of

schizophrenics a n d their growing atmosphere were also made i n some
European studies (Alanen, 1958; A l a n e n , Rekola, Stewen, T a k a l a , &
T u o v i n e n , 1966; Delay, Deniker, & Green, 1957,1962; Ernst, 1956; L a i n g
& Esterson, 1964; M c G h i e , 1961). The investigations we made i n Finland
were complementary to the American studies (esp. those of L i d z et al.,
1965) i n that series were larger and control groups were also studied.
The atmosphere i n the families could be d i v i d e d into two groups:
" c h a o t i c " a n d " r i g i d " . The chaotic families included parents suffering
from psychosis or borderline disorders and were characterized b y n o n ­
predictability of communication. The rigid families showed extremely
formal a n d confining attitudes; the children were tightly b o u n d b y
hopes and fears transmitted to them by their parents. Symbiotic relations
were common, especially between schizophrenic sons and their mothers.
The families of typical neurotic patients, serving as a control material,
showed clearly less serious disturbances; some families with rigid fea­
tures were seen, but these features were generally less serious a n d less
dominated b y parental projective identifications (Alanen et al., 1966).
The starting-points of family researchers led them to view the family
situations holistically, as a system, rather than analysing separately the
 THE ORIGINS O F SCHIZOPHRENIA 71

relations between certain family members. This was especially true of

Bateson's team as well as of W y n n e a n d Bowen, with their interest i n
communication theories a n d family therapy. The influence of children
o n their parents was also taken into account. W y n n e , for example, a p ­
proaches the schizophrenic child as both a disturbed a n d a disturbing
family member. T h e originator of systems theory a n d its relevance to
biological a n d psychological processes was v o n Bertalanffy (1956).
A s the forms of family research a n d family therapy have become
more advanced, the system-oriented approach has gained more a n d
more prominence. It sees the family as a psychological whole, where all
the members are continually influencing each other. Like other func­
tional systems, the family is an open system, whose members are also
i n contact w i t h the extrafamilial environment, i n jobs, schools, friend­
ship circles, a n d so o n . A n important family dynamic perception was
reported b y D . Jackson (1957), w h o realized that a certain overall p s y ­
chological e q u i l i b r i u m prevailed i n families, w h i c h was determined b y
the mutual psychological needs of the family members and their mutual
p o w e r relations, a n d w h i c h also tended to resist change. H e called this
p h e n o m e n o n family homeostasis. Family studies have regularly revealed
an exceptionally rigid homeostasis i n a notable portion of families of
schizophrenic patients—although there also are forces aiming at change,
w h i c h s h o u l d be stimulated d u r i n g the family therapy.
T h e works of m a n y psychodynamically a n d systemically oriented
family researchers a n d family therapists—for example, of H e l m Stierlin
(1972,1974,1976,1983; Stierlin, R i i c k e r - E m b d e n , Wetzel, & W i r s c h i n g ,
1977), Ivan Boszormenyi-Nagy and J. L . Framo (1965), R. D . Scott a n d his
co-workers (Scott & A l w y n , 1978; Scott & A s h w o r t h , 1967,1969), as well
as M a r a Selvini Palazzoli with her M i l a n group (Selvini P a l a z z o l i ,
Boscolo, C e c c h i n , & Prata, 1978,1980)—have been important with re­
gard both to the theory a n d to the treatment of schizophrenia, a n d I
return to some of their findings later.
M a n y psychodynamic family studies have been criticized because of
their methodological or conceptual weaknesses (e.g. Hirsch & Leff, 1975;
Jacob, 1975; Riskin & Faunce, 1972). The question touches o n the theory
of science: what value should be attributed to hermeneutic research
based o n clinical a n d understanding observation as compared with the
scientific-behaviouristic approach? In m y opinion, case-specific psycho­
dynamic family studies (no more than individual psychological studies)
cannot be disregarded. T h e E E (expressed emotion) measurements—
based o n the number of critical comments and of signs of emotional
72 SCHIZOPHRENIA

involvement noted d u r i n g the parent's interview (Brown, Birley, &

W i n g , 1972; V a u g h n and Leff, 1976; and see the reviews b y Kavanagh,
1992, and Jenkins & Karno, 1992)—tell us something of the climate i n the
families, but not what underlies the remarks made b y patients' parents
nor the psychological history of these remarks.
Some interesting empirically oriented family studies, i n addition to
those of W y n n e a n d Singer, were also made. D a v i d Reiss (1971) gave
complicated tasks requiring mutual communication to the families. H e
demonstrated that the work of "schizophrenic families" was character­
ized b y particular sensitivity to intrafamilial consensus (consensus
sensitivity), while behaviour of an opposite kind was typical of the
group w i t h character disorders (distance sensitivity).
A t the University of California i n L o s Angeles ( U C L A ) , M i c h a e l
Goldstein a n d Jerry Doane conducted a study including 65 families,
each w i t h a child aged 14-15 years, w h o sought outpatient therapy for
non-psychotic disorders (Doane, Goldstein, M i k l o w i t z , & Falloon, 1986;
Goldstein, 1985,1987). The methods used were C D , E E , and A S ("affec­
tive style" based o n the remarks made b y the parent to the patient
d u r i n g a conjoint meeting). Fifteen-year follow-up of the youths was
feasible i n 45 cases. Four of the subjects were diagnosed with schizo­
phrenia d u r i n g this follow-up. A l l of them came from families where
both parents showed " h i g h " baseline E E and negative interactive behav­
iour (AS). If the families h a d a better-than-average initial AS-profile as
w e l l as low C D , the offspring developed n o schizophrenia-spectrum
disorders. T h e results thus indicate that families with A S a n d E E dis­
orders have a greater risk of having an offspring with schizophrenia­
spectrum disorders than do other families, a n d that the disordered
intrafamilial patterns of behaviour antedates the onset of the disorder
and is not a reaction to the psychotic behaviour of a schizophrenic child.
Attitudes towards psychodynamic family studies of schizophrenia
have been influenced b y their interpretation—even b y some profession­
als, such as Torrey (1983)—as an accusation aimed at the parents for
causing their children's illnesses. Such an interpretation of the findings
of family studies is a misunderstanding. It is not implied b y these stud­
ies that a parent w i t h a distorted attitude towards his or her child is
consciously causing h i m harm. Rather, the parents are seen as victims of
their o w n problems, w h i c h they have been powerless to face. W e can
understand them just as well as their children a n d also find the roots
of their problems i n their o w n childhoods and later life. The mother of
Sarah, w h o m I described i n chapter one, is an example of this.
 THE ORIGINS O F SCHIZOPHRENIA 73

The systemic approach has h a d a balancing effect. It is n o w generally

understood that all interactions among different members i n the family,
as i n any group, are two-way processes or triangular ones. Parents influ­
ence their children, a n d children influence their parents. W e also know
that the question of the causes of schizophrenia is always a complex one
and s h o u l d not be restricted to factors pertaining to p a r e n t - c h i l d rela­
tionships.
M i s h l e r and Waxier (1968) proposed four alternative explanations
for the relationship between parental disorders a n d the children's i l l ­
ness. T h e y are, i n a slightly simplified form, as follows:

1. Aetiologic: Parental disorders cause the children's schizophrenia.

2. Reactive: Parental disorders are a consequence of the c h i l d r e n ' s

schizophrenia. (This explanation also covers the parents' reactions
to the early manifestations of the children's vulnerability: for ex­
a m p l e , special sensitivity or tendency to isolation.)

3. Situational: Families w i t h a c h i l d d i a g n o s e d as schizophrenic

behave i n a d i s t u r b e d m a n n e r at the time of examination.

4. Interactional: T h e r e is a complex sequence of feedbacks w i t h i n

the intrafamilial system of pathogenic interactions.

D e l l (1980) evaluated these explanations, considering the last one the

most p r o m i s i n g , b u t at the same time nearly impossible to test. T h i s
formulation is i n accordance w i t h the systems-oriented approach. T h e
factors suggested b y the first three explanations also h a v e m u t u a l
interactional relations, but none of them suffices to exclude the others.

An attempt at integration

In the f o l l o w i n g account, m y p u r p o s e is to achieve a m o r e holistic

interpretation of the factors that affect p r e d i s p o s i t i o n to schizo­
phrenia. I especially a i m to integrate the psychoanalytic a n d
f a m i l y - d y n a m i c findings a n d theories that are closest to m y o w n
experience.
W e n e e d to b e c o m e aware of the d u a l quality of p a r e n t - c h i l d
relationships i n the personality development of c h i l d r e n . O n the one
h a n d , parents are the first important emotional objects for their c h i l ­
d r e n , a n d , o n the other, both parents a n d c h i l d r e n learn f r o m each
other d u r i n g this m u t u a l g r o w t h process. T h e crucial factor i n the
74 SCHIZOPHRENIA

latter d i m e n s i o n is children's identification w i t h their parents—first

unconsciously, as w h e n learning the first expressions of e m o t i o n or
the first w o r d s , a n d later also consciously. These interactional rela­
tionships m a k e u p the earliest a n d the most fundamental part of our
sociocultural e n d o w m e n t . Both components s h o u l d be considered
w h e n a n a l y s i n g psychological predisposition to schizophrenia.
O f these t w o dimensions, the emotional relationships are of p r i ­
m a r y significance, because their emergence is closely related to the
gratification of the infant's biological needs. T h e first sensations of
emotional gratification are inseparable f r o m mother's responses to
the infant's h u n g e r or thirst a n d the ensuing feelings of w e l l - b e i n g . It
is t h r o u g h these gratifications that the feelings of attachment a n d
affection towards the mother develop, p r o m o t i n g the infant's ability
to have similar feelings for other significant people. These processes
of attachment p r o b a b l y also have a biological f o u n d a t i o n based o n
genetic instincts, as has been e m p h a s i z e d b y B o w l b y (1969) a m o n g
psychoanalytic researchers, referring to the b o n d i n g described b y
L o r e n z a n d other ethologists for animals. T h e ability of a b a b y at the
age of o n l y 3 days to identify a p a d moistened w i t h the m i l k of its o w n
mother (MacFarlane, 1975) is probably based o n undifferentiated p s y ­
chobiological b o n d i n g of this k i n d (Stern, 1985).
The emergence of primitive emotional bonds is also a prerequisite
for learning through identification. C h i l d r e n suffering from early infan­
tile autism, w h o remain unable to establish an emotional relationship
w i t h their care-givers, are also not able to learn to use their language.
The dyadic relationship, w h i c h is the cornerstone of psychoanalyti­
cally oriented individual therapy, uses transference and countertransfer­
ence processes to stimulate the patient to express his or her emotional
needs and the mental images associated with them. The psychoanalytic
approach is therefore well suited to study the emotional dimension of
the parent-child relationship and its effects o n the patient's intrapsychic
development, which determines the evolution of h i s / h e r object relation­
ships. A s these effects are re-created and worked through i n the patient­
therapist relationship, the growth process induced b y the therapy is also
significantly promoted b y experiences of a re-creative identification with
the therapist, so important i n the psychotherapy of schizophrenic p a ­
tients (Benedetti, 1979; V o l k a n , 1994).
Family therapy, on the other hand, pays less attention to intrapsychic
development but provides a direct view of a patient's developmental
environment. It permits observation of the parents' personalities as well
 THE ORIGINS OF SCHIZOPHRENIA 75

as of the current intrafamilial relationships, even i n situations d o m i ­

nated b y schizophrenic patients' developmental needs. The parents'
style of responding to them provides important insight, thus comple­
menting psychoanalytic research b y shedding light o n the reciprocal
nature of family factors influencing both n o r m a l and dysfunctional
personality development. It furnishes a wider perspective o n the oppor­
tunities extant i n the patient's family environment for identifications
that m a y promote or hinder personality development and change.
F r o m the psychological view, schizophrenia is essentially a disorder
of ego functions. Research o n the interactional family dynamics of
. schizophrenics has contributed to our knowledge of the preconditions
for ego development and its disorders but has not yet been adequately
integrated with psychoanalytic theories of schizophrenia. Another i m ­
portant d o m a i n of knowledge that has not been adequately applied to
the psychodynamics of schizophrenia is the self psychology developed
b y K o h u t , w h i c h touches u p o n family-dynamic research i n several
respects.

Five psychoclynamic propositions

O n this basis, I formulated five integrative propositions (Alanen,

1994):

1. P s y c h o d y n a m i c factors related to vulnerability to s c h i z o p h r e n i a

are not restricted to the early m o t h e r - c h i l d relationship; family
research emphasizes the continuity of intrafamilial disturbances.

2. Parental personalities a n d their effects o n p a r e n t - c h i l d relation­

ships are critically important.

3. P r i m i t i v e psychological defence m e c h a n i s m s — p a r t i c u l a r l y p r o ­
jective identification—occur c o m m o n l y i n the p s y c h o d y n a m i c s
of these f a m i l y networks a n d tend to h i n d e r i n d i v i d u a l d e v e l o p ­
ment.

4. T h e persistence of symbiotic needs is typical of s c h i z o p h r e n i a

vulnerability. These needs are also characteristic of their transfer­
ence relationships; self psychological v i e w p o i n t s m a y assist u n ­
d e r s t a n d i n g w h a t they are like: d e l a y e d needs to retain p r i m i t i v e
self-object relationships but also ambivalent needs to obtain n e w
self-objects that w o u l d m a k e further personality development
possible.
76 SCHIZOPHRENIA

5. T h e overall pattern of intrafamilial r e l a t i o n s — i n c l u d i n g the i n f l u ­

ences of the children, w i t h their different innate inclinations, o n
their parents—is crucially important.

Early frustrations alone are not crucial

A c c o r d i n g to the libido theory proposed b y F r e u d a n d A b r a h a m , the

core of the schizophrenic disorder consists of a n abandonment of
object relations a n d a regression to p r i m a r y n a r c i s s i s m — a p s y c h o ­
logical state where interpersonal relations d o not yet exist. T h e causes
of schizophrenia s h o u l d therefore also be f o u n d at this stage of devel­
opment, m a i n l y i n the frustrations that have caused libidinal
development to be arrested at a stage where the libido w a s p r i m a r i l y
directed towards one's self.
A s already pointed out, this notion caused the widespread therapeu­
tic pessimism of psychoanalysts towards schizophrenia. T h e very
possibility of establishing a therapeutic relationship with such severely
regressed patients has been doubted, or it has been postulated that it is
possible to approach such a regressed patient only b y p r o v i d i n g n o n ­
verbal experiences of gratification, i n indirect or symbolic forms (e.g.
Tahka, 1984). Psychotherapeutic experiences, however, have shown that
such pessimism was exaggerated, while empirical studies of small
babies (Stern, 1985) have revealed the infant's primary object orientation
and thereby disproved the idea of a primary lack of objects.
The significance of indirect oral drive gratification was obvious for
Sechehaye (1955), whose classic work, Symbolic Realization, promoted
significantly the b l o o m of psychosis therapy that began i n Central
Europe i n the mid-twentieth century. She offered to Renee—a seriously
regressed schizophrenic patient, who subsequently wrote about her re­
covery—a slice of apple across her breast, saying: " 'It's time to drink the
good m i l k from the apples of maman. M a m a n (the name used b y the
patient of her therapist) will give it to y o u . ' . . . Renee then leant herself
against m y shoulder, put the apple o n m y breast a n d ate it with her
eyes shut, solemnly and full of immeasurable bliss" (p. 43). But should
we not, i n this event described b y Sechehaye, emphasize the patient's
experience of being understood holistically and empathically b y the
therapist rather than the oral gratification in itself? M y o w n therapeutic
experience seems to speak in favour of this interpretation.
 THE ORIGINS O F SCHIZOPHRENIA 77

A c c o r d i n g to psychodynamic family research (Alanen, 1958; A l a n e n

et al., 1966; Bowen, 1960; B o w e n et al., 1960,1961; L i d z et a l , 1965; Scott
& A l w y n , 1978; Scott & A s h w o r t h , 1969; Stierlin, 1972,1976; W y n n e et a l ,
1958), one of the most frequent findings i n the families of schizophrenic
patients was the presence of excessively binding or over-involved paren­
tal attitudes towards children, rather than rejection or indifference. It
was also revealed that the disordered interactional relationships were
continuous, as they were still apparent w h e n the grown-up child came to
treatment.
W h e n investigating the mother-child relationships of schizophrenics
i n the 1950s (Alanen, 1958), I frequently encountered signs that the
m u t u a l relationship h a d h a d a p o o r beginning. It often happened that a
mother spontaneously began to vent her bitterness, telling me that she
h a d been anxious or depressed at that time, due to marital difficulties
or other serious problems. The most extreme subgroup consisted of psy­
chotically disturbed or emotionally inhibited mothers whose manifest
disturbance h a d probably made it very problematic for their infants to
establish their first relationship. But I also met several mothers w h o said
that caring for the baby h a d been a particularly gratifying experience for
them right from the beginning. It was easy to believe them, because even
at the time of the study these mothers tended to have a conspicuously
possessive relationship towards their n o w fully-grown child. T h e
m o t h e r - c h i l d relationship thus involved psychological features that
were probably related to the child's disturbed development, but i n a w a y
that the influence became obvious only w h e n the child grew out of
infancy to the phase i n w h i c h h e / s h e should have become more inde­
pendent. It thus appeared that both maternal attitudes and other charac­
teristics of family dynamics were long-acting factors that affected the
patient throughout the most important years of his or her development.
It is also appropriate here to note that studies of external, measurable
criteria have repeatedly revealed that children w h o have spent their
infancy i n conditions that appear particularly inadequate—not only so­
cially, but also as regards the continuity of interpersonal relations—do
not usually develop schizophrenia or other psychoses (though they m a y
occur more c o m m o n l y than normal) but develop asocial or sociopathic
disorders involving lack of object constancy a n d inability to adjust to the
s u r r o u n d i n g community a n d its rules. Findings of this k i n d have been
obtained from both adult-age follow-ups of children w h o have spent
their infancy i n such inadequate conditions (e.g. Beres & Obers, 1950;
78 SCHIZOPHRENIA

Heston, 1966) a n d comparative retrospective surveys of the early en­

vironments of adults or children suffering from psychoses, neuroses
and personality disorders (Malmivaara, K e i n a n e n , & Saarelma, 1975;
Stabenau, T u p i n , Werner, & Pollin, 1965).
M y observations of the "faithfulness" of m a n y schizophrenic p a ­
tients to their therapist (in contrast to sociopathic patients) demonstrates
their ability to establish a long-term object relationship. It m a y have to
begin at a symbiotic level, but it reflects the satisfactory aspects of the
early m o t h e r - c h i l d relationship, w h i c h were also stressed b y Searles
(1958). Robbins (1993) also refers to an initially unintegrated part of
the patient's personality, "based o n loving a n d c a r i n g " , w h i c h emerges
d u r i n g the psychotherapeutic process a n d provides fuel for h i s / h e r
development.
L i d z and his co-workers (Lidz, 1992; L i d z et a l , 1965) especially have
criticized the schizophrenia theory of Freud and A b r a h a m , w h o postu­
lated that the level of regression categorically indicated the origin
of the disorder. According to developmental psychological research also,
the continuity of the environment generally seems to be more predictive
for behavioural outcome than is any particular form of early infant expe­
rience (Emde, 1988).

Significance of the quality of parental personality

A l t h o u g h transference i n i n d i v i d u a l therapy informs the therapist

about patients' early relationships w i t h parents a n d other significant
p e o p l e , the effect of these relationships o n the patient's d e v e l o p m e n t
is always reflected i n the m i r r o r of his or her o w n psychic processes.
It has n o t been possible to study the other parties of the early inter­
actional processes or the interactional system as a w h o l e until the
m o r e recent family research.
The pioneers of ego-psychological psychoanalytic "research,
H a r t m a n n , Kris, a n d Loewenstein, were well aware of their limited
viewpoint, when, at the end of the first part of a series of papers o n the
formation of psychic structures, they said: " T h e systematic study of large
numbers of life histories from birth on, based o n an integration of m a n y
skills of observation, permits the greatest chance for verification or falsi­
fication of hypotheses" (1946). Hartmann (1958), w h e n discussing his
theories of early psychic development, also made it clear that his theo­
ries are applicable to the growth of an infant in an "average expectable
 THE ORIGINS OF SCHIZOPHRENIA 79

environment". A c c o r d i n g to family studies, a child prone to schizophre­

n i a has not g r o w n u p i n such an environment.
T h o u g h psychotic or near-psychotic disorders were only diagnosed
i n about 10% of the parents of schizophrenic patients, personality disor­
ders graver than neurosis are m u c h more c o m m o n among them. In a
p o p u l a t i o n collected b y our team i n H e l s i n k i in the 1960s a n d analysed
w i t h both psychiatric and psychological methods, disorders that h a d an
obvious adverse effect o n ego functioning were seen i n almost two thirds
of the parents of typical schizophrenics—equally frequently i n mothers
a n d i n fathers—whereas the corresponding figure for the parents of
typically neurotic patients was about 20% (Alanen et al., 1966). In two
subsequent studies conducted at T u r k u , w h i c h covered a more extensive
a n d unselected population of patients first diagnosed for schizophrenia­
group psychosis, similar disorders were seen i n about half of the parents
(Alanen et al., 1986; Rakkolainen, 1977). In the psychoanalytic frame of
reference, most of these parental disorders correspond to narcissistic and
borderline-level personality disorders. A certain relationship between
narcissistic personalities and disposition to psychoses was also f o u n d i n
Mattila's (1984) study, i n w h i c h these kinds of personalities were f o u n d
to be more c o m m o n a m o n g those w h o fell ill with psychoses i n inter­
m i d d l e age.

Serious parental personality disorders were also found i n the e m p i r i ­

cal communication deviance studies b y W y n n e and Singer (Singer et al.,
1978; W y n n e & Singer, J963; W y n n e , Singer, Bartko, & T o o h e y , 1977).
A p a r t f r o m genetic factors, these disorders are significant i n both the
children's object relation development a n d i n their identification p r o ­
cesses. Concerning the latter, the effects of the distorted sense of reality of
m a n y of these parents should be emphasized. T h e y m a y not be psychotic
but show paranoid or other w e i r d ways of thinking, w h i c h interfere w i t h
the development of the sense of reality i n the children, w h o identify with
them a n d become predisposed to thought disorders ("transmission of
irrationality": L i d z et al., 1958).
Especially illuminating examples of partial or occasional " c o n t a ­
g i o n " with parental psychotic delusions were shown i n Anthony's (1968,
1969) field-work. H e a n d his co-workers found out that m a n y of the
children i n the families of schizophrenic parents believed i n their p a r ­
ent's psychotic ideas occasionally, or they m a y have believed i n them
w h i l e they were at home, but not outside the home. Some school-age
children were found to have personal delusional reactions, which resem­
b l e d those of their parents. T h e disorders were communicated most
80 SCHIZOPHRENIA

effectively w h e n the parent h a d paranoid psychosis or "reactive" p s y ­

chosis, frequently dominated b y chaotic affective attitudes. The children
of autistic parents with catatonic or hebephrenic psychosis, i n turn,
made a more definite distinction between themselves a n d their p s y ­
chotic parents—but often lacked adequate care. It is obvious that the
transmission of disturbed modes of thinking from one generation to the
next is the more effective, the fewer opportunities the children have for
establishing significant interpersonal relationships outside the home.

Involvement of ego defences

with interactional relations

A p a r t f r o m the problems of identification, the qualitative personality

disorders of the parents have other, possibly e v e n m o r e p r i m a r y
effects o n the c h i l d r e n . These arise f r o m the fact that the p s y c h o l o g i ­
cal b o u n d a r y between one's self a n d others—here the c h i l d r e n — i s
often b l u r r e d i n disorders i n v o l v i n g ego pathology. A l t h o u g h few of
these parents are a m o n g the seriously disturbed b o r d e r l i n e patients
w e often encounter i n our clinical p r a c t i c e — a n d m a n y of t h e m regard
their d i s o r d e r e d features as ego-syntonic—that is, they a p p r o v e of
t h e m a n d d o not regard t h e m as signs of d i s t u r b a n c e — t h e y often
d i s p l a y the k i n d of p r i m i t i v e defence mechanisms described as t y p i ­
cal of borderline a n d narcissistic personalities (Kernberg, 1975). It is
characteristic for m a n y of these parents that the defectiveness of ego
b o u n d a r i e s drives them to d o m i n a n t a n d exploitative attitudes to­
w a r d s their c h i l d r e n .
A s has been emphasized b y Viljo Rakkolainen and myself (Alanen,
1980; Rakkolainen & A l a n e n , 1982), these " l o w e r - l e v e l " psychological
defence mechanisms, though intrapsychic, also function interpersonally
and influence object relations. I called this part of their defensive func­
tions transactional defence mechanisms (Alanen, 1980). B y relying o n other
people or fantasies about them, these defensive functions serve to p r o ­
tect the person from anxiety caused by internal or external threats—most
typically, separation anxiety. W a r d i n g off anxiety successfully depends
o n whether the other person behaves i n the manner expected of h i m or
her, or whether such fantasies can be sustained. In such a dyadic rela­
tionship defensive mechanisms easily become complementary, arresting
the processes of development and growth. Such parental defence mecha­
nisms often contribute significantly to the disturbance of the child's
 THE ORIGINS O F SCHIZOPHRENIA 81

separation-individuation development, both i n early c h i l d h o o d a n d

d u r i n g adolescence (Rakkolainen & A l a n e n , 1982).
Projective identification (described above i n discussing Melanie
Klein's school) occupies a central position i n these transactional defence
mechanisms. It externalizes and transfers unconsciously both self-repre­
sentations a n d object representations into another person, with w h o m
one has a close relationship, a n d re-lives these representations through
the other. O f the terms coined i n family-dynamic research, projective
identification is closely associated to delegating, as defined b y Stierlin
(1972, 1974), though delegating m a y take place o n a more conscious
level.
A s emphasized b y O g d e n (1979), the interactional relationships char­
acterized b y projective identification are often connected with direct
pressure put on the "recipient" that he or she should behave in a manner
congruent with the projection.
I treated i n family therapy a y o u n g m a n w h o developed a schizo­
affective psychosis while i n the armed service. E v e r since his son's
infancy, this man's father h a d entertained an image of h i m as weak a n d
delicate a n d needing special protection i n order to get along i n life. T h e
father himself—a highly narcissistic p e r s o n — h a d been successful, but
h a d h a d to fight continually, particularly i n his youth, against his o w n
h i d d e n " w e a k n e s s " , w h i c h he d i d not accept a n d w h i c h he also associ­
ated with his image of his o w n father. W h e n the son went into the army,
the father kept w a r n i n g h i m that he might become a target of ridicule
f r o m other youths: "I d i d not, I managed to get along well, but what
about y o u , as y o u are so unable to defend yourself?" he asked. A n o t h e r
feature of the dynamic picture of the family was that the mother's atti­
tude towards the son was one of close a n d anxious attachment. This
aroused envy a n d aggressiveness i n the father, for w h i c h his projective
defence mechanism p r o v i d e d an unconscious outlet.
A n n e l i L a r m o (1992), a psychoanalyst a n d family therapist, studied
the impact of parental psychosis o n the family a n d the children a n d
concluded that the processes based o n projective identification are
crucial i n the dynamics of interactional relations transmitted from
generation to generation i n these families—both with regard to the
parents' relationships with their o w n parents, their spousal relation­
ships, a n d their relationships with their children.
Similar interactional dynamics can be observed i n other borderline­
level defences. Splitting frequently serves projective identification a n d
other projective processes. The use of omnipotence and idealization or
82 SCHIZOPHRENIA

devaluation as defences also requires the presence of another person. It

is often a matter of extending oneself narcissistically at the expense of
others, or of achieving the same goal b y identifying w i t h the idealized
person and attributing omnipotence to h i m or her.
These defences engender the b i n d i n g a n d possessive interactional
relationships that have been described i n the families of schizophrenic
patients b y L i d z a n d co-workers, the present writer, Stierlin, and others.
T h e y also explain the tenacity with w h i c h m a n y parents of schizo­
phrenic patients stick to the gratifications and notions they have devel­
o p e d d u r i n g earlier developmental stages of their children. The parents
are not conscious of the narcissistic quality of these attributes a n d expec­
tations a n d of their importance for their o w n mental balance.
Transactional defence mechanisms often serve to maintain resistance
in the family against the patient's development towards individuation. It
w o u l d , however, be an error to view these primitive defence mecha­
nisms i n an exclusively negative light. In an empathic family therapeutic
relationship they may transform into positive resources i n support of the
patient's development.
A s has been pointed out b y V o l k a n (1987), recent psychoanalytic
literature has increasingly implied that Freud's structural theory, w h i c h
focuses o n the intrapsychic conflicts among ego, superego, a n d i d ,
though useful for the understanding of neurotic disorders, is insufficient
i n the d o m a i n of serious disorders deriving from preoedipal p r o b l e m s —
or, to use Mahler's (1968) terms, symbiotic problems or problems dating
back to the separation-individuation stage. A psychoanalytic approach
to the study of internalized a n d externalized object relations has c r u ­
cially enhanced o u r understanding of borderline personalities a n d ,
according to Volkan, is necessary for the understanding and treatment of
schizophrenia. It is also important to realize that preoedipal psychopa­
thology is not restricted to the schizophrenic patient, but operates i n
other family members as well.

The need for self-objects

as the basis of symbiotic dependency

Psychotherapeutic experiences have demonstrated that the tendency

towards symbiotic d e p e n d e n c y is a characteristic feature of schizo­
p h r e n i c patients. It evolves even i n autistically w i t h d r a w n patients as
s o o n as contact w i t h them has been successfully established. D u r i n g
 T H E ORIGINS O F SCHIZOPHRENIA 83

the psychotherapeutic process, it is easy to observe that the symbiotic

needs h a v e their o r i g i n i n these patients' prepsychotic personality
development. H o w e v e r , o p i n i o n s of the nature of these needs are not
u n a n i m o u s a m o n g psychoanalysts.
The term symbiosis, i n the sense used b y M a h l e r (1968; M a h l e r et a l ,
1975), has recently been challenged b y developmental psychologists and
some psychoanalytic theorists. Tahka, among others, questions the c o n ­
cept, stating that " o n l y b y assuming the presence of a primary self i n the
baby's w o r l d of experience w i l l it be possible to think that somebody has
a delusion of his oneness w i t h the mother" (Tahka, 1993). It is more
probable, however, that there m a y be a desire for a fully gratifying
object—a "perfect" mother. A l t h o u g h the elementary foundation of the
infant's self begins earlier than it h a d been assumed (Stern, 1985), I tend
to agree w i t h Tahka. T h e goal of the transference relationship w e have
called symbiotic is to acquire an idealized and understanding mother (or
parental) figure rather than desiring to merge with the mother a n d lose
one's o w n personality (which is a significant fear among our autistic
schizophrenic patients, hampering them i n relating to their therapists).
In The Analysis of the Self, K o h u t defined self-objects as "objects . . .
w h i c h are either used i n the service of the self a n d of the maintenance of
its instinctual investments, or objects w h i c h are themselves experienced
as part of the self" (Kohut, 1971, p. xiv). It follows from this definition that
the relations of children to their parents are, to a significant degree, self­
object relations. This is especially true of the processes whereby children
b u i l d u p their personalities both through the love their parents show
towards them and through identification w i t h them. The need for self­
objects is not restricted to childhood, however. The mother as a self-object
is followed b y the father and parental substitutes (grandparents, teach­
ers, etc.), d u r i n g adolescence b y peer groups and later by spouse, friends,
a n d — w h e n it comes to therapeutic relationships—by the therapist. " W e
never outgrow our need for confirmation, support, idealization a n d the
experience of kinship, without them we wither" (Pines, 1992).
In the family, it is not only the children w h o use their parents as self
objects. The parents also feel their children to be both individuals sepa­
rate from themselves a n d complements to themselves, perpetuators of
their lives. In this way, children are self-objects to them. It is the patho­
genic intensity of this phenomenon that earmarks m a n y families of
schizophrenic patients. What we observe is an exaggerated form of nor­
m a l interpersonal relationships. T h e narcissistic aspect of the p a r e n t ­
child relationship becomes pathological only if it remains disproportion­
84 SCHIZOPHRENIA

ately strong, foreclosing a more mature and age-appropriate relation­

ship appreciating the child as a personality separate from oneself. This
m a y be the core of the tragedy experienced b y m a n y parents of schizo­
phrenic children: they typically show a tendency to live too m u c h
through their children, or an excessive need to keep the relationship
unchanged, due to unconscious difficulty giving u p the gratifications
that children as self-objects have given them.
This emerges most cogently i n many mothers of schizophrenics w h o
have felt the early infancy of their children to be "the happiest time of
their l i v e s " . Motherhood has evoked i n them—as i n other mothers—a
new attitude towards life, and their empathic attempt to understand the
representational w o r l d of a baby brings about a strongly interactional
regression into a w o r l d of infantile, orally and symbiotically coloured
gratifications. For the mother, satisfaction of her o w n frustrated needs
for empathic love and care can be achieved through projective identifica­
tion with the child she is caring for. But problems arise when it becomes
necessary to give u p these regressive gratifications and return to those
more appropriate to the life of adult h u m a n beings. This h a d been dif­
ficult for m a n y possessive mothers of schizophrenic patients I have
met. M o u r n i n g of the loss of loved object, which w o u l d have been a pre­
requisite for a mature development, h a d been made difficult b y earlier
traumatic relationships and—often quite pointedly—the unsatisfactory
nature of the marital relationship.
O v e r time, these narcissistically coloured interactional relationships
become laden with increasing ambivalence attributable both to the
mother's previous development and to her contemporary life situation.
For example, if the marital relationship has not been satisfactory, she
m a y have felt reluctant about having the baby in the first place. The
desire to possess a n d control the child m a y thus gradually develop i n a
critical direction, even devaluing characteristics of the growing child.
A c c o r d i n g to m y studies, a dominance of this side of the ambivalence is
more usual i n the family background of female schizophrenic patients
(Alanen, 1958).
This defective development and its causative factors are not c o n ­
scious a n d are not under the mother's control. These problems are
traceable to the mother's o w n childhood. In the background of a d o m i ­
nating mother we m a y find a frustrated little girl seeking empathy and
understanding. A n d quite soon there enters the father, who has also
been a n d continues to be frustrated emotionally and has his o w n self­
object needs directed to his wife and child.
 THE ORIGINS O F SCHIZOPHRENIA 85

The ambivalent quality of the relationship is even more obvious if

we consider it from the child's viewpoint. It involves an increasing lack
of parental empathy towards the child's o w n aspirations, whenever they
are not accordant with the narcissistically based needs of the parent.
Schizophrenic patients often tell their therapists of their parents' lack of
understanding. But at the same time they also feel that they have been
significant for their parents, and that the parents love them i n their o w n
way. These feelings often result i n anxiety-provoking conflicts between
the child's attempts at separation and independence on the one h a n d
a n d the archaic feelings of love and demands for intrafamilial loyalty on
the other.
Like m a n y other pathogenic factors, the psychodynamic picture I
have outlined here cannot be considered specific for schizophrenia.
Similar relational configurations based on unconscious parental self­
object needs are also seen i n the background of less seriously disturbed
patients, though generally i n a less exaggerated form. A n d it should be
emphasized that we also encounter patients whose developmental e n v i ­
ronment has been characterized b y a lack of people affording sufficient
self-object relationships.
A s early as the 1960s, I used the term "dependency needs of the ego"
(Alanen, 1968; A l a n e n et al., 1966) to describe an important part of the
symbiotic needs directed b y schizophrenic patients to their therapist.
These needs could not be interpreted exclusively o n the basis of Freud's
libido theory. O n e essential component is the need of the patient's ego to
find new opportunities for identification within a permanent and under­
standing therapeutic relationship, w h i c h w o u l d help h i m or her to
control better the anxieties previously felt to be intolerable. Kohut's ana­
lytic account of the quality of the self and self-objects seems to provide a
solution to these problems: we are dealing with a need for an empathic
self-object and a holistic—if often ambivalent—need to interact with this
self-object i n a way that helps the disintegrated personality to generate
again its incomplete growth process through transmuting internaliza­
tion. This provision should not be confused with uncritical indulgence.

Significance of the overall system of intrafamilial relations

In c o n t e m p o r a r y family research a n d theory, attention is focused

o n systemic networks of interpersonal relationships i n w h i c h the i n d i ­
v i d u a l m e m b e r s are constantly influencing each other. T h i s insight
86 SCHIZOPHRENIA

was significantly pioneered b y studies dealing w i t h the intrafamilial

environments of schizophrenic patients. There emerged a w i d e u n a ­
n i m i t y a m o n g the researchers that the psychological factors associ­
ated w i t h the pathogenesis of schizophrenia extend far b e y o n d the
m o t h e r - c h i l d d y a d . T h i s d y a d is—despite its importance for the o r i ­
gins of i n d i v i d u a l d e v e l o p m e n t — n o t a closed system, but inseparable
f r o m a more extensive network of psychological relations. T h e label­
l i n g term " s c h i z o p h r e n o g e n i c m o t h e r " is, for this reason alone, i n a p ­
propriate.
The different dimensions of the overall family findings include the
schismatic a n d skewed marital relationships described b y L i d z et al.
(1957b), the atmosphere of " p s e u d o - m u t u a l i t y " described b y W y n n e et
al. (1958), and the "chaotic" and " r i g i d " families defined b y us (Alanen
et al., 1966). The significance of the family system as a whole for the v u l ­
nerability of children to psychotic disorders has also been confirmed
b y empirical studies. A c c o r d i n g to analysis of covariance executed b y
W y n n e et al. (1977), the communication deviance scores, for the parents
as a couple a n d for the mothers and fathers separately, all continued to
discriminate the severity of disorder i n index offspring even w h e n the
effects of major demographic variables and the parents o w n severity of 7

disorder were taken into account. However, the discriminations were

most striking for the parents as pairs. Similarly, according to Tienari et
al. (1994), the risk of an adopted child becoming psychotic or developing
other disorders graver than neurosis showed a higher correlation with
the overall rating of the family's mental health status than with separate
ratings of each of the adoptive parents.
W i t h family research, the significance of the father i n the patho­
genetic study of schizophrenia became apparent, i n contrast to the earlier
psychoanalytic conceptions. Families were found i n which the core of the
difficulties seemed to lie i n the personality of the father: both the family
study carried out b y our team (Alanen et al., 1966) as well as that by Scott
and A l w y n (1978) also included a noticeable number of symbiotically
b i n d i n g fathers. A s a matter of fact, a classic example of a pathogenic
father was already available from the family environment of Daniel P a u l
Schreber, the subject of Freud's (1911c) classical treatise o n paranoid
schizophrenia (see Niederland, 1984).
O n deeper levels, we regularly also find disturbances i n the parents'
o w n family backgrounds, most notably i n prolonged dependent re­
lations. In some cases this is directly observable i n the contemporary
configuration—the parents continue to maintain pathological inter­
 THE ORIGINS OF SCHIZOPHRENIA 87

dependent relationships w i t h their o w n parents—often revealed b y

psychological fixation to frustrations they have experienced i n their
c h i l d h o o d homes. The observations o n the families of patients w h o de­
veloped schizophrenia while married similarly demonstrate the signifi­
cance of the mental health status of the whole family system (Alanen &
K i n n u n e n , 1975). E v e n in these cases, predisposition to schizophrenia is
usually associated w i t h the persistence of strong symbiotic needs for
dependence—now generally transferred towards the spouse.
H o w e v e r , psychodynamic comprehension remains very defective
if it only proceeds backwards i n a linear w a y a n d fails to take into
account the child's innate characteristics a n d his or her o w n role i n
the development of intraf amilial psychodynamic patterns. C h i l d r e n are
an inseparable part of the systemic whole. Because of the linear
individual-psychological tradition, these patterns have not been consid­
ered sufficiently i n the psychoanalytically oriented investigation of
schizophrenia.
Theoretically, the role of the innate characteristics of children a n d
their vulnerability have been emphasized b y m a n y psychoanalysts, for
example, b y Freud a n d Hartmann. Margaret Mahler and her co-workers
(1975) illuminated this point b y commenting on the differences between
children i n their ability to "utilize the mothering object" d u r i n g their
early development. This ability is influenced both b y biological factors
controlling the development of each child a n d b y the evolving patterns
i n the interpersonal environments. H o w e v e r , clinically oriented investi­
gations of the connections between these factors have remained sparse.
Robbins (1993) emphasized this topic from the standpoint of a
schizophrenia psychotherapist also familiar with the findings of recent
biopsychiatric research. A s mentioned earlier, he describes two basic
vulnerability areas: those of "organization-affinity" leading to aversion
of contact with other h u m a n beings and passivity; and of problems with
intensity a n d regulation of stimulation. These vulnerabilities are consti­
tutional. Together with environmental influences, they lead early i n life
to pathological symbiotic development. Greenspan (1989) referred, o n
the basis of his studies of infants, to specific constitutional a u d i t o r y ­
verbal-affective vulnerabilities that w o u l d be associated with disor­
dered thought patterns, especially w h e n coupled with environments
that tend to confuse affective meanings at behavioural-gestural a n d
symbolic levels.
F r o m a n integrative point of view, these ideas are very interesting,
requiring further investigation. A c c o r d i n g to m y experiences, however,
88 SCHIZOPHRENIA

Robbins overemphasizes the passivity of schizophrenic patients: it fits

some patients but not others. M a n y schizophrenic patients appear, when
their therapy is progressing, to be quite active i n m a n y areas, such as
studying, writing, or painting; that is, i n developing their personalities
outside the therapy. This points to the restricting effects of the early
interpersonal environment. Other schizophrenic patients find such
activities more difficult, if not impossible. A r e these the patients w h o
w o u l d , i n biopsychiatric investigations, reveal deficiencies i n the struc­
ture of their brains?
It is highly probable that children with structural brain abnormalities
are handicapped i n developing their integrative ego functions. I have
suggested that they most probably also have greater than n o r m a l p r o b ­
lems i n establishing relationships with the people w h o act as their early
self-objects (Alanen, 1994, 1997). Such a hypothesis corresponds to the
viewpoint presented b y Robbins (1993) with regard to the p r i m a r y dis­
turbances of "organization-affinity" of schizophrenic patients, leading to
an aversion to contact with other h u m a n beings. Such infants m a y also
tend—as soon as they have managed to set u p an interactional relation­
ship*—to become intensely attached to their self-objects, rendering their
development at the separation-individuation phase more problematic
than usual.
The formation of early self-object relationships is an interactional
process that depends o n both participants. Thus the people acting as
self-objects (mainly the mother) are affected b y the interaction and m a y
tend to maintain or continue a symbiotic relationship with children w h o
seem to d e m a n d or seek it. F r o m a systemic point of view, it is an
interactional phenomenon that is influenced b y both the qualities of the
infant and the tendency of the mother—or of other self-objects—to de­
velop symbiotic relationships.
Findings of larger cerebral ventricles of the schizophrenic co-twins
among monozygotic twin pairs discordant for schizophrenia (Reveley et
al., 1982; Suddath et al., 1990) may be related to the prolonged symbiotic
needs of children. Tienari (1963), when studying discordant identical
male twins, found an increased predisposition to schizophrenia among
those w h o were more passive than their brothers a n d h a d therefore
remained more dependent o n their mothers. Onstad, Skre, Torgersen,
and K r i n g l e n (1994) found that schizophrenic probands were more
overprotected b y parents (especially fathers) than were their discordant
monozygotic or same-sexed dizygotic co-twins. A r e such findings re­
lated?
 THE ORIGINS O F SCHIZOPHRENIA 89

In the majority of schizophrenics with n o k n o w n structural b r a i n

abnormalities, the disturbed development seems to be rooted i n the i n ­
terpersonal realm, though the predisposing role of the children's genetic
factors s h o u l d not be overlooked. W e s h o u l d once again remember
the systemic cycle: not only d o the parents affect their children, but the
children also influence their parents, and adult schizophrenics impose
serious stress o n relatives as w e l l as the reverse.

Prepsychotic personality development

Descriptions of the prepsychotic personality

F i n d i n g s o n the prepsychotic personalities of schizophrenic i n d i v i d u ­

als h a v e revealed t w o opposite poles: a tendency to w i t h d r a w f r o m
contacts, w h i c h is often called schizoid, a n d a symbiotic need for reli­
ance. M o s t patients fit somewhere o n the continuum between these two
extremes. T h e schizoid tendency to avoid contacts a n d to turn i n w a r d
into one's o w n mental life is particularly notable i n the most typical
forms of schizophrenia. For example, 61% of the 142 schizophrenic p a ­
tients examined b y D e i n (1964) i n Denmark h a d this k i n d of personality.
In the family study conducted b y o u r team, w h i c h covered both
the patients a n d their parents a n d siblings (Alanen et al., 1966), 20 of
the 30 typical schizophrenic patients h a d shown autistic, w i t h d r a w i n g
tendencies prior to the psychosis. O n l y 12 of them h a d clearly s h o w n
such tendencies before school age, while the remaining 8 became more
clearly w i t h d r a w n at puberty. W e also noted that the patients, even
prepsychotically, were regularly more markedly dependent o n their
parents than were their healthier siblings.
Such findings are quite understandable i n the light of the need-fear
d i l e m m a proposed b y B u r n h a m et al. (1969). The autistic-schizoid ten­
dency m a y hence be seen as a consequence of the increasing anxiety felt
i n relation to other people, especially at puberty, and an attempt to solve
the need-fear dilemma b y avoiding social relationships. Underneath this
tendency m a y hide an ability to establish symbiotic relationships.
A c c o r d i n g to M e d n i c k a n d Schulsinger (1968), hypersensitive pre­
psychotic personalities, w h o are apt to withdraw from interpersonal
relationships into their inner psychological w o r l d , were typical particu­
larly of patients with milder schizophrenic disorders. T h e y emphasized
90 SCHIZOPHRENIA

that weak impulse control, impaired ability to concentrate, and incipient

thought disorders were typical prepsychotic features in those w h o later
developed serious schizophrenic psychoses.
A n especially interesting report of the personalities of later schizo­
phrenics is the follow-up based o n the prospective U . K . national birth
cohort comprised of a r a n d o m sample of 5,362 births i n E n g l a n d , Scot­
l a n d , a n d Wales d u r i n g the week of M a r c h 3-9, 1946 (Jones, Rodgers,
M u r r a y , & M a r m o t 1994); 43 years later, 30 cases of schizophrenia were
found, corresponding to a risk of 0.63%. T h e statistically significant
prepsychotic predictors of schizophrenia included later development of
w a l k i n g a n d more speech problems than controls, a n d the continuity
of an aloof, solitary habit, avoiding social interaction. H o w e v e r , there
was n o grossly abnormal speech or motor behaviour i n adolescence. A t
15 years, teachers rated these youngsters as being more anxious than the
others i n social situations (p = 0.003), unrelated to intelligence quotient.
O n the other h a n d , there was n o evidence of increased antisocial or
aggressive behaviour, nor of conspicuous differences between girls
a n d boys. N o significant sociodemographic predictors were found, but
health visitors' ratings indicated that more mothers of the future schizo­
phrenics showed worse than average general understanding a n d m a n ­
agement of their children w h e n the child was 4 years o l d (p = 0.02). The
British study thus confirms the theories of adult schizophrenia as a de­
velopmental disorder, the origins of w h i c h may be found i n early life.
The schizoid avoidance of social contacts dominates the picture of the
prepsychotic personality.
H o w e v e r , the presence of schizoid gestures does not mean that the
person i n question should necessary become schizophrenic. A c c o r d i n g
to a recent study ( M c G o r r y et al., 1995) so-called p r o d r o m a l features of
schizophrenia (much the same as the features typical of schizotypal per­
sonality according to D S M - I V ) are "extremely prevalent" among older
adolescents a n d unlikely to be specific for subsequent schizophrenia.

Early self-object relationships in schizophrenia

T h e experiences connected w i t h early self-objects crucially p r o ­

gramme the development of o u r p s y c h o l o g i c a l functions. This
process is not restricted w i t h i n the psychological sphere, b u t also
i n v o l v e s the biological level, influencing the functional d e v e l o p m e n t
a n d integration of n e u r a l networks.
 THE ORIGINS OF SCHIZOPHRENIA 91

In early infancy, the need for self-objects (mother or her substitutes)

is absolute, biologically and socially. But these needs are not restricted to
infancy: the self-object relationships continue throughout the develop­
mental cycle. C h i l d r e n b u i l d their personalities both through empathic
approval that parents provide for their emotions and actions, and identi­
fication with parents.
In the development of a schizophrenia-prone i n d i v i d u a l , these p r o ­
cesses have remained deficient. The disorders of self-object relationships
that contribute to the vulnerability to schizophrenia seem to have dis­
similar m u t u a l weighting i n different cases. O n one end of a continuum
are those patients w h o suffered from a poor beginning of their early
self-object relationships; on the other end are those patients w i t h a con­
fusingly b i n d i n g propensity of these relationships. The common d e n o m ­
inator is the lack of self-objects' sufficiently empathic responses to
support i n d i v i d u a l development.
It is of vital importance to understand that most of those falling
ill with schizophrenia have not been rejected children, even if we do
find such persons occasionally. M a n y have been too important for their
parents as self-objects. This is felt b y the child as a d e m a n d for compel­
l i n g — t h o u g h ambivalent—internal loyalty, w h i c h makes h i m comply to
the parents' needs, even w h e n h i s / h e r o w n developmental challenges
w o u l d require psychological separation from them. Conflicts i n w h i c h
they are caught w h e n the problems become critical m a y be very anxiety­
a n d guilt-laden and have a direct connection with the onset of psychosis.
In this respect, the situation of directly rejected children is often less
deleterious because it is possible for them to vent their anger on parental
figures more directly, with fewer guilt feelings.
The following example is an extreme one, but it serves to illustrate
the pattern of mutually disordered self-object relations between a
mother and a child.
The patient, a 17-ye^r-old schoolboy, w h o was admitted with s y m p ­
toms of severe hebephrenic schizophrenia, was the only child i n his
family. H i s appearance and behaviour were characterized b y helpless­
ness, disorganization, and child-like regression o n the one h a n d , and
extremely intense anxiety with catatonic, stereotypic praying and s u d ­
den outbursts of aggression on the other.
The family situation was skewed. The patient's father was a h a r d ­
w o r k i n g a n d relatively successful m a n , w h o was, however, passively
dependent on his wife. A few years before the onset of the son's illness,
the father h a d h a d a somatic attack of illness, w h i c h h a d impaired both
92 SCHIZOPHRENIA

his health and his family-dynamic role. The patient's mother was an
extremely possessive person, who viewed things strictly i n terms of
black or white. H e r overriding ideal was goodness a n d compliance; she
praised both of her " b o y s " (her husband and son) for being good. E x ­
pressions of anger were almost completely prohibited i n the family,
and an atmosphere of pseudomutuality prevailed. The patient h a d sub­
mitted to the mother's expectations: he h a d been a good boy a n d h a d
avoided everything evil. A t school he h a d been considered a w e l l ­
behaved boy w h o was more childlike than his age-mates. D u r i n g the
year preceding his illness, he h a d become " a b s e n t - m i n d e d " a n d re­
served, and his school performance had fallen off. H e was hospitalized
because of increasing anxiety, which h a d resulted i n bouts of violence
completely unexpected b y the family.
The patient was admitted at a time when the family-oriented ap­
proach was not yet a regular part of our therapeutic practice. The
possessive attitude shown b y the mother during her visits on the w a r d ,
however, led to an attempt at family therapy. The need for a family
approach was also apparent i n the light of the patient's problems during
leaves, where his behaviour was unpredictably aggressive. H e even
attacked his mother physically. In the joint family sessions the mother's
attitude was reserved; for her, the most important thing was to make the
son understand that he must not be angry. The father's attitude d u r i n g
the therapy sessions was passive and compliant with his wife, while the
patient remained quiet.
The mother h a d been 5 years old w h e n her father died, a n d she
h a d then been reared by her maternal aunt. She praised her foster­
mother as h a v i n g been an "extremely g o o d " and excellent person,
d e n y i n g all of her possible disappointments and frustrations. Religious
ideals h a d been important i n her upbringing, and she still held to
them. She indulged her son like a little baby and expected h i m to be
unquestioningly obedient to her o w n ideals. The idealization of her
foster-mother presumably helped the patient's mother to deny her dis­
appointment and resentment at being abandoned. H e r possessive
attitude reflected both the lack of boundaries between her and the other
family members and, quite probably, her extreme need to rely o n them
and keep them close to herself. She felt as if her s o n — a n d actually even
her husband—were part of herself, and the son's aggressive behaviour
therefore aroused both fear and intense internal anxiety in her. The son's
aggression towards his mother only became manifest during the psycho­
sis, simultaneously raising intense feelings of guilt in h i m .
 THE ORIGINS O F SCHIZOPHRENIA 93

In the therapy of a family of this k i n d , the most important thing is to

listen to a n d understand the mother. This is even more urgent than
supporting the son's attempt at separation—which can be postponed.
T h e therapist and his supervisor (myself) d i d not realize this well
enough at the time, and the therapy was terminated quite early, as the
mother claimed a need to go into the countryside to take care of her
foster mother.
Searles (1961) emphasized that the symbiotic relation between the
mother a n d the child persists w h e n the mother (or other self-object) is
unable to recognize consciously her need to use the child as a comple­
ment to herself a n d is therefore incapable of giving h i m u p . She remains
incapable of m o u r n i n g the abandonment she suffered a n d her early
frustrations reinvoked b y giving u p the care of the child, w h e n the child
begins to show needs for individuation.

Importance of the period of adolescence

Despite the crucial significance of the early development, the process

of i n d i v i d u a t i o n must be seen as a l o n g - t e r m developmental process
that continues throughout c h i l d h o o d a n d adolescence, c u l m i n a t i n g i n
a d u l t h o o d . Successful g r o w t h into a d u l t h o o d requires that the self­
object relationships are g r a d u a l l y — n e v e r c o m p l e t e l y — r e p l a c e d b y
m o r e mature object relationships. It is characteristic of s u c h relation­
ships that one experiences others as i n d i v i d u a l s separate f r o m one­
self, w i t h goals of their o w n — t h a t is, there are clearly differentiated
internal self- a n d object-representations. F u r t h e r m o r e , the relation­
s h i p w i t h others is based o n e q u a l i t y — a t least i n a relative s e n s e —
a n d concern for each other's needs, a n d not o n self-centredness,
w h i c h is inherently typical of the needs a p p l i e d to self-objects seeking
s u p p o r t for one's o w n actions a n d emotional balance.
T h e problems often culminate when the i n d i v i d u a l approaches the
developmental challenges of adolescence. These include control of
awakened sexuality a n d finding a sexual partner, gaining independence
from one's parents, a n d finding one's place i n the community through
occupational competence. A l l this is difficult for an i n d i v i d u a l whose
personality is inadequately organized, w h o is excessively (and often
mutually) dependent o n h i s / h e r parents, a n d w h o finds it difficult to
establish relationships with age-mates because of delayed psychological
development a n d consequent liability to disappointments.
94 SCHIZOPHRENIA

The need for self-objects outside the home involving objects of iden­
tification a n d sources of approval is great at this stage, a n d the more
acute the need is, the weaker the existing basis for adult growth. A
successful, or unsuccessful, course of adolescent development is often
crucially significant for the individual's ability to a v o i d — o r not a v o i d —
the risk of schizophrenic psychosis. A s Sullivan (1956) pointed out,
issues of self-esteem are extremely significant during this developmental
process. Successful extrafamilial interpersonal experiences i n adoles­
cence m a y lead to a more balanced development and a diminished risk
of psychosis. O n the other hand, the development takes a more negative
turn w h e n frustrations i n interpersonal relationships lead to passivity
and withdrawal and the traumas to self-esteem are counteracted b y i n ­
ternal narcissistic fantasies.
Problems dating back to the oedipal situation often a d d to the pre­
psychotic conflicts of schizophrenic patients, sometimes quite concretely.
L i d z and his co-workers (1965) emphasized that the p a r e n t - c h i l d rela­
tionships i n these families—apart from the children being easily d r a w n
into the contradictory, often double-bind-like relationship between their
parents—frequently also show incestuous tendencies a n d / o r tensions,
w h i c h are enhanced b y the unsatisfactory quality of the parental marital
relationship. They m a y be either hetero- or homosexual, and they often
remain latent and unconscious. Even so, they give rise to intense anxiety
at puberty, interfering with normal age-appropriate development.
The difficulties of establishing heterosexual relationships with
age-mates are thus often aggravated b y both the double binds w i t h the
parents a n d — p a r t l y as a consequence—the adolescent's or y o u n g
adult's underdeveloped personality a n d the anxiety aroused b y the
recognition of sexual drives.
O n e female patient included i n m y family study was said to have
been attached to her father i n her childhood, often sitting willingly i n
his lap, being, however, afraid of his hot temper. W h e n she was 14, she
began to develop a powerful dislike for the father. The repulsion was
associated w i t h the fear that the father w o u l d be looking at her with
erotic interest. It was difficult for her to be i n the same r o o m with
h i m . G r a d u a l l y she became more and more reclusive also i n her social
relations. In fact, there must have been something exceptional i n the
father's attitude, of w h i c h the following event is an indication. Once,
w h e n the patient was 16, she h a d been berrying i n the forest. The father
heard voices of drunken m e n from the forest a n d was out of his senses
for fear that his daughter w o u l d be raped, and, when she came home, he
 THE ORIGINS OF SCHIZOPHRENIA 95

gave her a beating with a cane, even though the patient h a d not even
seen the men.
T h e marital relationship of the parents seemed to be quite u n h a p p y ,
w h i c h h a d increased the problems of both spouses. The father was m o r ­
b i d l y jealous, scolding his wife, for example, for "excessive cheerful­
ness" i n social situations. The mother was agonized a n d insecure a n d
felt guilt, trying h a r d to repress her aggressive feelings towards the
father. Sex life was repulsive for her.
T h e onset of the psychosis, at the age of 25, was sudden, accompa­
n i e d b y strong " h y p n o t i c " ideas of influence, w h i c h were associated
with a m a n w h o h a d been sitting next to her at concerts (both had season
tickets). T h e patient was beset by strong fears, h a d " s u r p r i s i n g experi­
ences of close ideational communications", and felt that the m a n took
sexual control of her through them. The acute phase was followed b y
a strongly autistic, disintegrated, outwardly inhibited psychotic state,
b e h i n d w h i c h there was h i d i n g a strong, painful, psychotic ideational
w o r l d , dominated b y " a p p r o a c h i n g " men and w o m e n , including the
father. T h e problems that h a d been troubling the patient ever since p u ­
berty a n d were traceable back to the oedipal situation, thus emerged i n a
new form w h e n she became psychotic.

Factors precipitating the onset of psychosis

A c c o r d i n g to the simple diathesis-stress theory, p r o p o u n d e d espe­

cially b y genetically oriented researchers (Rosenthal, 1970; Zubin &
S p r i n g , 1977), the factors precipitating schizophrenic psychosis are
nonspecific, consisting of both psychic a n d physical stress factors that
p r o v e intolerable to the patient. P s y c h o d y n a m i c d e v e l o p m e n t a l re­
search shows this notion to be superficial. E v e n the significance of
precipitating factors becomes understandable i n the light of patients'
life histories—both the e v o l u t i o n of their interpersonal relations a n d
their intrapsychic personality development.

Physical precipitating factors

W h e n the precipitating factors include p h y s i c a l stress, they can be

considered relatively nonspecific. T h i s is the case w h e n , for example,
the patient becomes psychotic d u r i n g a fever. But even i n these cases
96 SCHIZOPHRENIA

the patient seems to have been psychologically p r e d i s p o s e d to

schizophrenia, w i t h topically d i m i n i s h e d stress tolerance.
In some other cases physical and psychological precipitating factors
combine i n such a w a y that the nature of the physical stress is more
specifically related to a psychological vulnerability. This is frequently
the case i n schizophreniform puerperal psychoses. Psychodynamically
the birth of a baby has frequently been a problematic event, arousing
ambivalent feelings i n the mother because of her life situation or because
becoming a mother has involved a particular psychological strain due to
problems connected with the relationship to her o w n mother.
These problems are sometimes shown i n patients 7
delusions. A
patient of mine, w h o h a d previously repressed the problems of her diffi­
cult mother relationship, developed after her first delivery a puerperal
schizophreniform psychosis. She then believed that her o w n mother h a d
tried to strangle her as a baby. The patient h a d been an unwanted baby
for her then elderly mother, w h o was living i n exceptionally dire con­
ditions at the time. She was greatly helped b y psychotherapeutic w o r k ­
ing-through of the problems of her early mother relationship.
Similar specific psychodynamics m a y also be observable i n post­
operative psychoses, often related to the patient's unconscious fears of
castration or annihilation. The schizophreniform psychoses manifested
d u r i n g physical stress are frequently—though not always—benign and
subside relatively quickly, as the patient recovers strength.
Another group of patients' psychoses are related to the use oi drugs,
especially cannabis, and alcohol, though i n such a w a y that they cannot
be classified as toxic psychoses. The effect of drugs or alcohol i n these
cases is best understood as having brought into consciousness anxiety­
evoking psychic tendencies intolerable to the weak ego structure, such as
homosexual drives. A l s o , the use of drugs i n itself m a y be an indication
of anxiety or lability of the psychic balance. Recently, several reports
have described schizophrenic psychoses precipitated b y the use of can­
nabis (Allebeck et al., 1993; Hjort & Ugelstad, 1994; L i n s z e n et a l , 1994).
The number of such patients seems to be increasing i n urban environ­
ments.

Psychological precipitating factors

T h e onset of schizophrenic psychosis is typically associated w i t h

p r o b l e m s experienced i n adolescence or early a d u l t h o o d . A s p o i n t e d
out earlier, the precipitating factors are s e l d o m very conspicuous,
 THE ORIGINS OF SCHIZOPHRENIA 97

because they are related to problems or d e v e l o p m e n t a l tasks experi­

e n c e d b y all y o u n g people.
Psychoanalytic researchers have emphasized the increased drive pres­
sure at puberty. Maturation of genital sexuality strengthens the needs
emanating from the drive base of the personality i n a w a y that appears
uncontrollable to the weak ego, which therefore disintegrates, regressing
to the narcissistic level and abandoning aspirations towards external
objects. This is true of both sexual and aggressive impulses. W h e n F r e u d
(1924a) defined psychosis as a consequence of a conflict between the ego
and the outer w o r l d , he meant that the ego, attacked b y intolerable
anxiety due to frustrations of the drive-based aspirations towards the
outer w o r l d , gives i n , abandons reality, a n d creates a new, delusional
internal reality, w h i c h , i n a psychotic, projective form, is felt partly to
coincide w i t h a n d replace external reality.
Later, psychoanalytic research emphasized the most central early
anxiety, called annihilation anxiety or dedifferentiation anxiety (e.g. Tahka,
1993). It is the deepest fear of the h u m a n b e i n g — a threat of death or at
least psychological death. It finds its first expression i n the baby's vague
fear of being rejected, i n a state of helplessness from w h i c h there seems
to be no salvation. A t the oedipal stage it is associated with the emer­
gence of castration anxiety. A c c o r d i n g to K o h u t (1977), annihilation
anxiety becomes manifest later i n life, whenever the i n d i v i d u a l experi­
ences heavy narcissistic offences or losses of important self-object
relations. It is not the only reaction caused b y such experiences: d e p e n d ­
i n g o n the ego's resources, there m a y alternatively also develop an
" e m p t y depression", associated with a feeling that life lacks any p u r ­
pose, or a rage resulting i n violence.
Viljo Rakkolainen (1977), a colleague i n T u r k u , examined the factors
precipitating the onset of psychosis in 68 new patients. H e pointed out
that i n most cases the onset of psychosis was preceded b y the beginning
of an important transitional phase i n the patient's life. H e especially
emphasized two specific areas of affected psychodynamics: narcissistic
traumas, or offences to self-esteem—for example, feelings of failure or
rejection i n l o v e — a n d unsuccessful attempts to detach oneself from sup­
portive relations, usually with parents, but occasionally transferred to
other people. H i s conclusions combine the intrapsychic a n d interper­
sonal viewpoints. Individuals w h o develop schizophrenia-type psycho­
ses tolerate frustrations and life changes poorly, because they have
established or retained as their support concrete unions or bonds w i t h
people (serving as self-objects), w h o are vitally important for them as
98 SCHIZOPHRENIA

surrogates for the deficiency of their internal psychological structures.

The mental representations pertaining to these self-objects are often
of archaic, omnipotent quality, w h i c h i n itself tends to predispose to
frustrations and is particularly painful when the self-object relationship
is lost. Rakkolainen also talks about protective interpersonal structures,
w h i c h help to keep together the personalities of m a n y schizophrenia­
prone individuals b y p r o v i d i n g them w i t h the support they need a n d
confirmation for their psychological existence. Protective structures of
this k i n d were also found to be significant for the prognosis of psychotic
patients (Rakkolainen, Salokangas, & L e h t i n e n , 1979).
A n insight into this k i n d of psychodynamics m a y best help one to
understand w h y such " o r d i n a r y " psychosocial stressors as leaving home,
migration, a n d so forth m a y pave the w a y to psychotic breakdown. T h e
most obvious psychological precipitating factors consist of experiences of
loss, as u p o n the death of someone w h o has served as an important
supportive self-object, or other separation from such a person, or u p o n a
change of the quality of the self-object relations due to the latter's somatic
illness, for example. Hence the onset of serious schizophrenia i n patients
undergoing early adolescence has occasionally a clear—if not necessarily
immediate—connection with the death or divorce of a parent.
A girl included i n m y family study samples fell i l l with catatonic
schizophrenia at the age of 16. She h a d been very attached to her father,
w h o m , however, she h a d lost through death two years earlier. After that,
her relationship with the mother—always strained—became increas­
ingly aggressive, at times with violent outbursts. T h e outbreak of the
patient's psychosis was acute and confusional. She h a d religious experi­
ences, feelings of "emancipation and disappearance of inhibitions", but
also end-of w o r l d experiences a n d ideas of reference. She went i n a
psychotic condition to deliver a speech o n her father's a n d M a r s h a l
Mannerheim's graves. In the hospital she declared that all her m o v e ­
ments a n d feelings—like her hate towards the mother—are compelled
b y an outside force. It also became clear that she h a d h a d her first ideas
of reference soon after the father's death.
In some other cases the experience of separation m a y be due to the
patients' concrete attempts at leaving home, or situations where there is
a change i n the external conditions, such as the person m o v i n g away to
study or into military service.
A l t h o u g h precipitating factors of this k i n d m a y be easily discernible,
they are often psychodynamically complex a n d difficult to interpret,
 THE ORIGINS OF SCHIZOPHRENIA 99

owing, for example, to double-bind-type family attitudes. I experienced

this poignantly w h e n I was present as a consulting observer i n the fam­
ily therapy session of a first-admitted schizophrenic patient.
T h e patient was a 26-year-old w o m a n w h o h a d become psychotic
soon after she h a d left h o m e a n d m o v e d to live alone i n a flat. She was
uncontrollably aggressive towards her parents a n d vaguely accused
them of treachery. U n l i k e her younger brothers, w h o were still living
at home, she h a d even previously frequently vented her partly veiled
dissatisfaction w i t h her family, which h a d seemed disruptive i n the
prevailing " h a r m o n i o u s ' atmosphere of pseudomutuality. T h e patient
7

h a d , however, tried to control her aggressive feelings a n d h a d usually

apologized to her parents as soon as she h a d calmed d o w n .
W h e n her m o v i n g away from home was discussed w i t h the family, it
turned out that the initiative h a d been hers, a n d she h a d intended to
start a "life of her o w n " . The mother, w h o was the dominant figure i n
the family, h a d assumed practical responsibility i n the matter a n d h a d
arranged a small flat for her. It was not considered a particularly good
deal b y the daughter, but she accepted it because the flat was located
relatively close to her parents' home. T o the patient's surprise, however,
the family, without preparing her i n any way, m o v e d soon afterwards to
a remote suburban locality. It was after this incident that she became
psychotic.
T h e family therapist asked the patient whether she h a d felt dis­
appointed w h e n the family m o v e d away. "I guess s o " , she replied. A t
that, the mother burst out crying, saying that she visited her daughter
frequently and even stayed overnight i n her flat w h e n doing night shifts,
as she w o r k e d quite near. The patient also began to show signs of anxi­
ety a n d started consoling her mother. Yet it hardly escaped anybody that
the mother, while arranging for the daughter's flat, h a d also considered
the family's future m o v i n g plans. There ensued an oppressive silence,
w h i c h was broken b y the father, w h o remarked that the l a m p o n the
ceiling was hot.
Despite the patient's attempt at separation, her relationship w i t h
her mother was still dominated b y ambivalent dependence. She stated
emphatically that her mother was the person to w h o m she told every­
thing. T h e mother, i n turn, seemed to appeal to her daughter, exploiting
the guilt feelings caused b y her o w n anxiety. It also turned out that the
patient d i d not have m a n y contacts outside the family, a n d that her
chances for an independent life were therefore not very good.
100 SCHIZOPHRENIA

After several months of family therapy, the patient started i n d i ­

v i d u a l therapy. She stayed on in her flat, but, after recovering from the
acute stage of the psychosis, developed a reclusive personality, living i n
a partly psychotic w o r l d of her o w n imagination, w h i c h she abandoned
only gradually as her therapy proceeded.
O f the life changes taking place at a more internal level,falling in love
(usually i n a w a y characterized by strong symbiotic features) and the
consequent disappointments and injuries to self-esteem probably consti­
tute the most c o m m o n factor precipitating psychosis. There m a y be cases
of remote love at an imaginary level, but there are also instances of
actual dating with attempts to establish an interpersonal relationship
at a more adult level than previously. " S y m b i o t i c " reliance and adher­
e n c e — w i t h an underlying desire to find a self-object relation—and
vulnerability due to a developmental lag and childishness compared
w i t h the partner are factors that often precipitate failure. F r o m the view­
point of the patient's self-esteem, the investment is greater than usual
a n d the w o u n d thus inflicted all the more severe.
E v e n i n so-called homosexual panic—which refers to the severe anxi­
ety that m a y be released b y the recognition of intense and conflicting
emotions felt for a friend of one's o w n sex—the desire for a self-object
usually plays a central role. The idealized friend towards w h o m the
emotions are directed is felt to be a more developed i d o l or object for
identification, w h o w i l l help to consolidate one's o w n masculinity or
femininity. This is an important underlying factor i n an anxiety-evoking
attachment leading to intense feelings of jealousy, w h i c h ends u p i n a
panic, as the sexual components of the relationship threaten to become
conscious.
Precipitating factors of this k i n d are especially c o m m o n among
y o u n g people. But even among people living i n a couple relationship,
the contradictory feelings involved i n falling i n love m a y precipitate
psychosis. A n d the manifestation of psychosis is even more c o m m o n
u p o n rejection b y the partner (Alanen & K i n n u n e n , 1975).
But it is easy to understand that an irreconcilable conflict between
inner imagery and the external reality may lead to gradual isolation
from concrete h u m a n relationships and to omnipotent phantasies, which
are increasingly removed from reality. In such a regressive develop­
ment, the finding of external precipitating factors m a y prove to be very
difficult.
 THE ORIGINS OF SCHIZOPHRENIA 101

The onset of psychosis

T h e connections of schizophrenia w i t h both psychological a n d p h y s i ­

ological events is most obvious at the onset of the psychosis. E s p e ­
cially a n acute onset of a psychotic state involves intense p s y c h i c
anxiety a n d / o r agitation, w h i c h is also evident at the p h y s i o l o g i c a l
level. T h i s d e v e l o p m e n t reaches its culmination i n catatonic states,
w h i c h — w h e t h e r agitated or s t u p o r o u s — a p p e a r to d e n y the p o s s i b i l ­
ity of p s y c h o l o g i c a l contact even more than d o the other schizo­
p h r e n i c states, t h o u g h their ultimate prognosis is generally g o o d .
E v e n w h e n the psychosis develops gradually a n d the clinical status
is dominated b y negative symptoms and progressive isolation, the early
stages of the process m a y involve recurrent culminations or leaps, w i t h
symptoms of anxiety followed b y a deterioration of the patient's c o n d i ­
tion.
A l t h o u g h the disorganization of psychic functions manifested as
psychosis has been investigated from several viewpoints b y physiolo­
gists, pharmacologists, a n d biochemists, all that we actually know about
the associated biological processes is based on assumptions and postula­
tions.
The dopamine hyperactivity theory, based o n the observation that the
effect of neuroleptic drugs is related to an inhibition of the dopaminergic
(esp. D2) nerve paths i n the central nervous system (Carlsson &
Lindqvist, 1963; Snyder, 1981) is, at least i n its simple form, contradicted
b y the conflicting P E T (positrone emission tomography) findings of the
density of dopamine receptor sites i n the brains of drug-naive schizo­
phrenics (Farde et al., 1990; H i e t a l a et al., 1994, 1995; Martinot et al.,
1990; W o n g et al., 1986). Seeman (1993) tried to interpret the controver­
sies regarding the differences between the studies w i t h respect to their
inclusion of the D4-type dopamine receptor sites i n their findings, d e ­
p e n d i n g on the radioligand used.
The hypothesis proposed b y Marta and A r v i d Carlsson (1990) is one
example of more complex theories. The central idea is that schizophrenia
m a y primarily be a consequence of the inadequate functioning of glut­
aminergic pathways resulting i n an excessive or uncontrollable flood of
information i n the cortex. Summarizing their views, the Carlssons write:
"Schizophrenias may be looked u p o n as a syndrome induced b y neuro­
transmitter imbalance i n a feedback-regulated system, where dopamine
a n d glutamate play a crucial role i n controlling arousal and the process­
102 SCHIZOPHRENIA

ing of signals from the outer w o r l d to the cerebral cortex v i a the

thalamus." However, apart from dopamine hyperactivity or glutamate
hypoactivity, many other neurotransmitters may also contribute.
C i o m p i (1991, 1994), when striving for an integrative explanation,
refers more generally to a functional overload of the central nervous
system and a disturbed balance, which comes about through the " m u t u ­
ally escalating interaction between the constantly declining ability to
adapt and the increasing psychosocial or biologically based emotional­
cognitive stressors". These m a y correspond to normal developmental
tasks as well as to hormonal changes, or to the use of drugs. A t a critical
moment, the psychological-biological system is ultimately jolted out of
balance, becomes decompensated, and is forced into a new, structurally
disorganized functional constellation, which is psychotic. C i o m p i thinks
that this development can be understood b y means of chaos theory.
In itself, the notion of a disorder of the physiological regulatory
mechanism seems quite plausible, even to a psychologically oriented
researcher. It is of interest, then, h o w " t i e d u p " the disorders of the
integrative functions are in their biological base a n d / o r how easy it is to
influence them psychologically, b y means of a therapeutic relation­
s h i p — o r other h u m a n relationships—increasing the feeling of safety i n
the panic-ridden individual. A c c o r d i n g to m y experiences, schizo­
phrenic patients differ m u c h from each other even i n this respect.

Pao's five steps

P i n g - N i e P a o of the W a s h i n g t o n School, i n his book Schizophrenic
Disorders (1979), presented a n interesting classification of the d e v e l ­
o p m e n t a n d subsequent course of schizophrenic psychosis as five
successive stages or steps, w h i c h he v i e w e d f r o m a holistic p s y c h o ­
d y n a m i c viewpoint. Pao proposed the following five steps:

1. Certain events i n the life situation activate a p r e v i o u s l y repressed

conflict, where erotic or aggressive impulses p l a y a n important
role.
2. T h e conflict causes the i n d i v i d u a l to feel exceptionally intense
anxiety, w h i c h Pao calls " o r g a n i s m i c p a n i c " , referring to M a h l e r ' s
term " o r g a n i s m i c distress" (Mahler, 1968). T h e tension i n v o l v e d
i n the panic is uncontrollable for the ego and becomes manifest at
the physiological level; it is comparable to the uncontrollable ten­
 THE ORIGINS OF SCHIZOPHRENIA 1 03

s i o n o f a little infant that can only be relieved b y the presence of

another p e r s o n (the mother).

3. T h e p a n i c state, w h i c h is a relatively brief t h o u g h often recurrent

affective experience, results i n a temporary deactivation of a l l ego
functions, a n internal catastrophe or shock.

4. R e c o v e r y f r o m the shock involves regression of ego functions,

w i t h the internal goal of f i n d i n g a "best possible s o l u t i o n " at a
m o r e p r i m i t i v e level of p s y c h o l o g i c a l organization. T h i s leads to
activation of m o r e archaic defences as w e l l as s u c h p r i m i t i v e w a y s
of self preservation that i m p l y a loss of p r e v i o u s p s y c h i c v i a b i l i t y ,
d r i v e neutralization, a n d personality organization. A personality
change typical of s c h i z o p h r e n i a ensues.

5. Psychotic s y m p t o m formation serves the p u r p o s e of f i n d i n g the

" b e s t possible s o l u t i o n " .

V o l k a n (1990) agrees w i t h P a o to a considerable extent b u t points

o u t — q u i t e justifiably—that the latter gives inadequate attention to
the schizophrenic patient's internalized object relations. A c c o r d i n g to
V o l k a n , the p u r p o s e of p s y c h o t h e r a p y is to activate a recovery p r o ­
cess i n a n order that is the opposite of Pao's stages. A particularly
i m p o r t a n t a n d critical stage of the therapy is the n e w , n o w victorious,
r e t u r n to the representational contents that originally b r o u g h t about
the psychotic p a n i c .
It is interesting to ask to what extent the onset of a psychosis can be
seen as h a v i n g meaningful developmental goals aiming at better adjust­
ment. This possibility has been suggested b y some psychotherapeutic
researchers of schizophrenia, such as Sullivan (1924).
L a r m o discussed this question from a systemic point of view i n her
m o n o g r a p h o n parents' psychosis (1992). She pointed out that a goal
orientation of this k i n d , the " d y n a m i c s of r e - b i r t h " , c o u l d be seen i n
cases where the illness was d u e to a conflicting triadic relationship. In
these cases, the psychosis is a n indication of the family's developmental
crisis at a certain stage of life—the stage w h e n the children grow u p —
s h o w i n g that the intrafamilial relations h a d become stuck at a critical
juncture. T h e psychosis and its influence o n the family members c o u l d
be conceived of as a n attempt to re-activate development. The other
group analysed b y L a r m o , w h i c h typically suffered from symbiotic
dyadic relationships, showed n o signs of such meaningfulness but was
exclusively dominated b y the " d y n a m i c s of regression".
104 SCHIZOPHRENIA

The psychosis of an adolescent attempting to separate from his or her

family or to establish an age-appropriate heterosexual relationship can
certainly also be interpreted as a developmental effort that fails, result­
ing i n the onset of the psychosis. Relatively few y o u n g people, however,
have sufficient personal resources—as d i d Sullivan (1924), w h o is said
to have experienced his o w n crisis at adolescence as a developmental
victory. It is more often the case that problem solution at a psychotic
level leads to a regressive representational world. E v e n w h e n the p s y ­
chosis is over, it is still felt to be a loss that further impairs self-esteem.
Things m a y , however, turn out differently if the patient at this stage
receives psychotherapeutic support for his or her development.

Is schizophrenia a uniform illness?

Integrating remarks

I h a v e n o t been able to identify any one single causative factor that

w o u l d be specific for schizophrenia—that is, w o u l d always b e
present i n its b a c k g r o u n d a n d w o u l d also be restricted to it. Instead,
I h a v e presented several factors contributing to the emergence of
schizophrenia.
M y conclusion is that the causes of schizophrenia are multifactorial,
both multi-faceted a n d multi-layered. These factors are differently
weighted i n different cases. Clinically, schizophrenic conditions can be
described as a heterogeneous continuum, w i t h severe psychoses due to
extensive and deep-rooted developmental disorders at one extreme a n d
prognostically benign, reversible psychotic states at the other.
Since even the aetiologic subfactors are differently weighted i n dif­
ferent cases, some researchers have been ready to postulate that schizo­
phrenia is actually a group of diseases consisting of t w o — o r even
several—disorders with different aetiologies. Is it possible, for example,
to separate cases of schizophrenia that involve structural brain abnor­
malities from others as a sub-group with definite organic causes? There
are also clinical reasons for such assumptions because negative s y m p ­
toms are more frequent i n this type of patients than i n the others, a n d
their prognosis is also poorer than the average. But even here the
boundaries are blurred rather than clear, a n d not even the s y m p t o m ­
atological differences are sufficient to permit a precise clinical discrimi­
nation a m o n g patient groups. This becomes even more obvious w h e n
 THE ORIGINS OF SCHIZOPHRENIA 1 05

we recall that corresponding brain abnormalities are found i n some

schizoaffective a n d bipolar affective disorders (Hauser et al., 1989;
Rieder et al., 1983).
The theory that schizophrenia w o u l d comprise two or more different
disorders is not new. E v e n Sullivan (1954) proposed, based o n his p s y ­
chotherapeutic experiences, that "schizophrenia s i m p l e x " — a clinical
condition totally restricted to negative s y m p t o m s — s h o u l d be separated
from the psychologically based "essential" schizophrenia as an organic
illness process appropriately called dementia praecox.
A m o n g the newer conceptions, the hypothesis of two types of
schizophrenia b y C r o w (1985) may be mentioned. T y p e I is characterized
b y the predominance of positive symptoms a n d w o u l d , according to
h i m , be d u e to an overactivity of the dopaminergic system. T y p e II is
based o n cellular loss i n the brain structures a n d shows predominantly
negative symptoms. Still, C r o w does not regard these types of disorder
as totally separate entities, but, rather, as different manifestations of the
same disease, w h i c h might overlap.
Furthermore, even if the predisposition to negative symptoms is
probably influenced b y biopsychiatric factors—to variable degrees i n
different patients—psychological factors contribute to their appearance.
Strauss, Rakfeldt, H a r d i n g , a n d L i e b e r m a n (1989) enumerated as m a n y
as ten different factors that m a y cause the patient to withdraw into
isolation dominated b y negative symptoms, some of them being the
psychic suffering due to the recurrence of positive symptoms, the loss of
hope a n d self-esteem, the presence of guilt feelings for previous p s y ­
chotic behaviour, the threat evoked b y social situations, and the effects of
institutionalization, including the stigma of being diagnosed as schizo­
phrenic.
A s far as I can see, it is more appropriate to speak of a heterogeneity
in the case-specific weighting of aetiological factors than to assume that
the aetiological factors might be completely different i n the different
cases. A l o n g similar lines, a proposal for an integrated three-dimen­
sional (genetic, brain-damage, psychosocial) aetiological view of the
schizophrenias was presented b y the Swedish psychoanalyst Johan
Cullberg (1993a, 1993b).
It is interesting to note, from an integrative viewpoint, that the b i o ­
medical findings indicating the heterogeneity of schizophrenia a n d the
psychoanalytic theories show some parallels. T h e group of schizo­
phrenias with the poorest prognosis involves most structural brain
anomalies, a n d patients with this diagnosis suit the psychoanalytic defi­
106 SCHIZOPHRENIA

ciency theory, w h i c h assumes schizophrenia to be d u e to a massive

and early disorder of personality development. The prepsychotic devel­
opment of this group of patients is clearly more seriously disturbed
than that of those patients—often with a better prognosis—whose p s y ­
chosis is more obviously associated with topically exacerbated conflict
situations (and w h o are thus compatible with the notion of the psycho­
dynamics of schizophrenia based o n conflict theory).
The causal chain between the predisposing biological factors a n d
their effect at the psychological level is a question that has not yet been
solved, or even thoroughly investigated. A c c o r d i n g to most researchers,
the answer probably lies in the functional impairment of the integrative
information processes between the different brain centres. It is assum­
able that biological and psychosocial factors are here closely interrelated.
Stephen Fleck (1992) is one of the proponents of such a theory. Fleck
refers to a " c o - e v o l u t i o n " of the neurophysiological organization a n d
the family (social) interactions, and he believes that schizophrenia is best
conceptualized "as a mixed maldevelopment of the neurological, p s y ­
chological a n d social dimensions of personality, rooted i n early or
inborn weakness of neuromodular organization w h i c h is compromised
further b y aberrant a n d contradictory social i n p u t s " . This leads to a
multifaceted developmental aberration, including deficient heterarchical
(Grigsby & Schneider, 1991) neural organization, transmitter instability
a n d inhibition failures, unstable, poorly structured affective-cognitive
systems of reference (vulnerable premorbid personality, " w e a k ego"),
deviant information processing, abstract conceptualization, and relation­
ship difficulties.
The interrelated processes proposed b y Fleck (1992) as well as others
(including this author) s h o u l d — a n d probably will—be one of the crucial
targets of future schizophrenia research. A n d the scope of research
s h o u l d not be restricted to the development of vulnerability, but should
also include a comprehensive examination of the effects of the on-going
illness o n the bio-psycho-social dimensions.
O f the family-dynamic interactional factors, I have emphasized the
importance of both the earliest stage of development and the persistence
of the disturbed context. The multi-layered aetiological factors make u p
a temporal continuum i n w h i c h the development d u r i n g the earliest
years a n d d u r i n g puberty a n d adolescence—"the second separation­
individuation phase"—are of the most crucial significance. Stern's (1985)
theory, w h i c h indicates that the developmental stages begin at different
times but continue as parallel psychological processes of development,
 THE ORIGINS OF SCHIZOPHRENIA 1 07
seems to agree well with this notion. F r o m the individual-psychological
point of view, the problems pertaining to dyadic relationships appear to
be of central importance, but they should be seen as part of a larger,
systemically functioning whole. I demonstrate i n chapter five the impor­
tance of a broader systemic view to be applied w h e n the treatment of a
schizophrenic patient is planned a n d put into practice.
T h e classical studies b y W y n n e and Singer (Singer et al., 1978;
W y n n e et al., 1977) underlined the importance of deviant c o m m u n i c a ­
tion i n the transmission of disorders from one generation to the next.
W e m a y conclude that the intrafamilial communication disorders—as
w e l l as the cognitive defects seen prepsychotically i n m a n y severely
ill schizophrenic patients—contribute i n an important w a y to the pre­
disposition to schizophrenia. T h e emphasis o n their family-dynamic
specificity may, however, have been slightly misleading. I believe—like
C i o m p i (1982,1994) a n d most psychoanalysts—that emotional problems
are of more p r i m a r y significance than are those at the cognitive level,
even if they are more difficult to study i n a systematic a n d empirical
way. I w i l l here refer to the significance of panic-like anxiety for the
outbreak of psychosis.
The most crucial psychological factor predisposing to schizophrenia
consists of problems i n the formation of a symbiotic interactional rela­
tionship and the detachment from it. I have related these issues to the
significance of self-objects relationships for personality development
and its disorders. These factors also seem to make u p the most "specific"
and c o m m o n — t h o u g h aetiologically variable—cluster detectable i n
the pathogenesis of schizophrenia. The disordered development of the
self-object relationships a n d the concomitant lack of psychological
individuation can be seen as an integrative theory, within the framework
of w h i c h the inner problems featured b y projective-introjective p r o ­
cesses m a y be placed. A c c o r d i n g l y , self psychology does not substitute
or exclude other psychoanalytic concepts based o n different approaches,
such as projective identification, w h i c h is very useful for understanding
both the i n d i v i d u a l and the family dynamics of schizophrenia. The term
self-object provides us w i t h an umbrella under w h i c h a more detailed
psychoanalytical approach is needed.
F r o m the viewpoint of family research, it is easy to agree w i t h
Kohut's opinion that self-object relations are of greater significance than
is drive gratification i n developmental psychology (Kohut, 1971). A l ­
though the problems of aggressiveness, i n particular, are clinically very
important i n schizophrenia, their culmination can be seen as a secondary
108 SCHIZOPHRENIA

BIOLOGICAL FACTORS PSYCHOSOCIAL FACTORS

Genetic vulnerability Disorders of early interactional

(self-object) relationships

Minor structural brain Disorders of the interpersonal

abnormalities relationships and communication
in the rearing environment

Inadequate psychological individuation.

Tendency to withdrawal and/or excessive
dependency. Problems of reality-adapted
thinking and self-management

T
Failure in the developmental task of growing adult.
Narcissistic traumata, experience of loss, in some
cases physical stress or influence of drugs. Anxiety,
panic, loss of grip of surrounding social reality

Breakdown of the integrity of psychological functions,

including the loss of reality testing = acutely or
gradually developing psychotic state

i i
Influences connected with

treatment and life events

Recovery Chronicity of
from the disorder \ the disorder

FIGURE 3.2. Development and course of schizophrenic disorder (partly

modified from Ciompi, 1982).

consequence of a deficient neutralization capacity (see Hartmann, 1953),

as w e l l as of the great pressure of symbiotically tinged needs for self­
objects, deriving from experienced lack of empathy and injuries to one's
self-esteem. This view gets support from the fact that the crucial psycho­
logical changes i n schizophrenia occur in the integrative ego functions.
E v e n with regard to the problems connected with self-object relation­
ships, schizophrenic patients present a continuum. A t one extreme are
those w h o have found it difficult to establish relations in the first place,
 THE ORIGINS OF SCHIZOPHRENIA 1 09

while at the other extreme are those whose p r o b l e m is their inability to

detach from the symbiosis and achieve independence. These problems
have an interactional, circular background; they are influenced both b y
the qualitative features of the parental personalities a n d b y the inborn
qualities of the children. I have proposed that children w i t h structural
brain abnormalities m a y present exceptional problems i n establishing
relations w i t h their earliest self-objects, a n d / o r — a s soon as such rela­
tions have been established—a tendency to adhere to them tenaciously.
It is also probable that the parents of such children, for reasons of
interactional stimulation, tend more often than other parents to maintain
continuous symbiotic relationships with them.
L u c C i o m p i has designed a good chart of the onset a n d course of
schizophrenia (1982). I present it here i n Figure 3.2, w i t h some a d d e d
specifications. The most notable change compared w i t h the original is
that I describe i n greater detail the factors precipitating the onset of
psychosis, w h i c h were labelled as "excessive strain through nonspecific
stress" i n C i o m p i ' s original chart.
It is important to note that not all of the factors are present i n every
case. This is especially true of the biological and psychosocial predispos­
i n g factors (top of the chart) a n d the precipitating factors.
Schizophrenia can be conceived of as the deepest a n d , as such, the
most tragic resolution to the problems of h u m a n life, where one can e n d
u p through m a n y parallel routes.
A s the bottom of the chart clearly indicates, the factors pertaining to
the patient's life course a n d treatment are significant for the outcome.
T h e psychotic solution does not necessarily remain unchanged—rather,
there are chances of recovery and renewed development after the onset
of the illness.
CHAPTER FOUR

Contemporary ways
of treating schizophrenia
and psychotherapy research

Introductory remarks

T
he treatment of s c h i z o p h r e n i a i n a w a y that genuinely c o m ­
bines p s y c h o l o g i c a l a n d biological a p p r o a c h e s — a s based o n
the illness m o d e l s described i n E x h i b i t 2.1 at the e n d of c h a p ­
ter t w o — i s still a rarity. C l e a r l y , the most c o m m o n m e t h o d of treating
s c h i z o p h r e n i a is neuroleptic m e d i c a t i o n , m o r e or less c o m b i n e d w i t h
rehabilitative measures.
T h e neuroleptic era came into existence i n a s y m p o s i u m of French
psychiatrists a n d neurologists i n 1952, when Jean Delay, Pierre Deniker,
a n d J. M . H a r l (1952) reported the good results they h a d obtained w i t h
chlorpromazine, a phenothiazine derivative, i n the treatment of schizo­
phrenia a n d other psychoses. The popularity of neuroleptics is easy to
understand. They are relatively easy to administer to large numbers of
patients, i n c l u d i n g outpatients. This medication, together w i t h the
progress of rehabilitative activities, made it possible gradually to shift
the focus of schizophrenia treatment from inpatient to outpatient care i n
the 1960s.
Psychoanalytically oriented psychotherapy has not become general
i n the treatment of schizophrenia. Still, it has a l o n g history b e h i n d it.

in
112 SCHIZOPHRENIA

Jung a n d Federn treated psychotic patients at the beginning of this cen­

tury. In A m e r i c a , the psychotherapy of schizophrenia developed from
the psychobiological approach introduced b y A d o l f M e y e r . T h e most
fruitful period of the Washington School, w h i c h developed under the
influence of Sullivan and Fromm-Reichmann, lasted from the 1940s until
the 1960s. D u r i n g this period there arose a generation of A m e r i c a n
psychosis therapists, w h o created a foundation for the psychological
understanding of schizophrenia and hence for individual psychotherapy
a n d community therapeutic treatment of schizophrenic patients. A t the
same time, two centres of psychotherapy came about i n E u r o p e , one i n
Switzerland (Sechehaye, Benedetti, and Miiller with their students) a n d
the other i n Britain, where the psychoanalysts of Melanie Klein's school
analysed the archaic a n d deep-rooted defence mechanisms of schizo­
phrenic patients.
This tradition has not died out i n the U n i t e d States. L . Bryce Boyer
(1983, 1986, 1989) a n d V a m i k D . V o l k a n (1990, 1995), especially, have
broadened the work of the Washington School, also stimulated b y the
British object relations school; the recent book by Michael Robbins (1993)
represents a psychoanalytic approach based on a biopsychosocial model.
But the position of psychotherapy i n the treatment of schizophrenia has
clearly declined over the past two decades, as has the number of psycho­
therapists interested i n schizophrenia.
O n the other h a n d , d u r i n g the same decades, interest i n the psycho­
therapy of schizophrenic patients has been increasing i n some European
countries, including Finland, N o r w a y , Sweden, a n d Italy (and, as far as
family therapy is concerned, i n Poland). Research o n i n d i v i d u a l , family,
and cornmunity therapy has been stimulated b y a series, of international
symposia o n the psychotherapy of schizophrenia, w h i c h were initiated
b y Benedetti a n d Miiller. Twelve symposia have n o w been held: 1956,
1959,1963, a n d 1978 i n Lausanne (Switzerland), 1971 in T u r k u (Finland),
1975 i n Oslo (Norway), 1981 i n Heidelberg (Germany), 1984 i n N e w
H a v e n , C T (United States), 1988 in T u r i n (Italy), 1991 in Stockholm (Swe­
den), 1994 i n Washington, D . C . (regarding their history, see Benedetti,
1992); and 1997 i n L o n d o n , organized b y the International Society for the
Psychological Treatments of Schizophrenia and Other Psychoses (ISPS).
The general interest i n the treatment of schizophrenic patients has
also been stimulated b y the development of family therapy from the
1950s onwards. But even family therapy has been drifting away from
the psychodynamic frame of reference. In the 1980s psychoeducational
treatment attracted most research interest a n d was practised most fre­
 CONTEMPORARY TREATMENT OF SCHIZOPHRENIA 113

quently (Steinglass, 1987). This is partly related to the o b v i o u s — a n d

frequently recognized—connection between the psychoeducational ap­
proach and the biomedical schizophrenia concept.
The same is also true of rehabilitative activities, which developed
remarkably i n the 1960s and 1970s. D u r i n g the past decade, however, the
development of rehabilitation began to suffer from the effects of the
growing political d e m a n d for a curtailment of public social and health
care expenditure, which i n many countries has been further enhanced b y
the economic recession. However, good examples of the development of
commuruty-based services with profitable results can be found (e.g.
H o u l t et al., 1983; Sledge et al., 1996; Stein, 1993; Stein & Test, 1980;
T u o r i , L e h t i n e n , H a k k a r a i n e n et al., 1997).

Psychotherapy of schizophrenia—
a rarity, but why?
T h e disproportionate p o p u l a r i t y of the b i o m e d i c a l m o d e s of treat­
ment c o m p a r e d w i t h psychotherapy is d u e to m a n y different reasons,
s o m e of w h i c h are presented below:

• M e d i c a l research a n d education h a v e been committed to the

natural-scientific w a y s of t h i n k i n g , w h i c h often m a k e it difficult to
u n d e r s t a n d a n d appreciate the w o r k of researchers representing a
different theoretical outlook.

• T h e r e has been a b o o m of b i o m e d i c a l schizophrenia research,

w h i c h has n u r t u r e d a n d enhanced the belief of m a n y b i o m e d i c a l l y
oriented researchers a n d psychiatrists i n the organic nature of
s c h i z o p h r e n i a a n d the possibilities of treating it exclusively o n this
basis.

• D r u g manufacturers have notably and usually one-sidedly influenced

the doctors' ways of thinking.

• It has been generally believed that psychotherapeutic w o r k requires

extensive staff resources, a n d that widely applied psychotherapy
w o u l d therefore not be possible i n public health care, at least for psy­
chotic patients.
• T h e results of " c o n t r o l l e d " treatment trials have not been particularly
promising, especially with regard to the effects of individual psycho­
therapy of schizophrenia.
114 SCHIZOPHRENIA

• Classical psychoanalytic theory has engendered a pessimistic atti­

tude towards psychotherapeutic treatment of schizophrenics, a n d
schizophrenic patients are rarely suited to formal intensive p s y c h o ­
analytic treatment. Psychosis psychotherapy is rarely i n c l u d e d i n
psychoanalytic training programmes.

• Studies of the psychological causes of schizophrenia arouse anxiety

a n d resistance, especially w h e n they are (erroneously) perceived as
a n accusation of the parents for their child's illness.

• There have been sociopolitical ideologies that have slowed d o w n or

eliminated intensive public health care a n d social welfare that are
essential for the comprehensive treatment of psychotic patients.

In the f o l l o w i n g sections I touch u p o n a n d discuss i n greater detail

the effects of most of these factors a n d the w a y s i n w h i c h w e s h o u l d
address them.

Psychopharmacological treatment

T h e effectiveness of neuroleptic treatment i n relieving psychotic s y m p ­

toms has been verified conclusively: as early as 1969, C o l e a n d D a v i s
r e v i e w e d a h u n d r e d studies i n w h i c h their effectiveness i n schizo­
p h r e n i a w a s c o m p a r e d w i t h placebo groups, u s i n g d o u b l e - b l i n d
procedures. In 86 of the studies the medication alleviated the p s y ­
chotic s y m p t o m s m o r e effectively than d i d placebos. T h e multiple
centre research organized i n the U n i t e d States b y the N a t i o n a l Insti­
tute of M e n t a l H e a l t h a n d headed b y C o l e y i e l d e d most conclusive
results: the c o n d i t i o n of 70% of the patients i m p r o v e d essentially
w i t h i n 6 weeks, w h i l e the corresponding figure i n the placebo g r o u p
w a s o n l y 2 5 % (Cole & D a v i s , 1969).
Nevertheless, the effect of neuroleptics is not specific for schizo­
phrenia, though schizophrenia is a m a i n indicator for their use. N e u r o ­
leptics act o n several different psychotic conditions, and their effect tends
to be the more pronounced, the more distressed a n d / o r restless the
patient is. They d o not cure schizophrenia, but they have a clearly fa­
vourable alleviating a n d anti-psychotic effect o n about two thirds of
schizophrenic patients (Cole & Davis, 1969; Wiesel, 1994). They act most
effectively o n the positive symptoms (thought disorders, hallucinations,
delusions), a n d they also help the patient to control such symptoms i n
 C O N T E M P O R A R Y TREATMENT O F SCHIZOPHRENI A 11 5

the l o n g term. Their effect o n the negative symptoms (isolation, passiv­

ity, affective blunting), however, is less obvious. Especially i n acute
states, they often help to eliminate the symptoms completely. In chronic
cases the effect is less spectacular, and sufficiently long follow-up stud­
ies—see chapter two—indicate that the number of patients w h o have
become permanently cured of their psychotic symptoms has not changed
markedly since the introduction of neuroleptics. However, w i t h the help
of these drugs, the symptoms of the chronic patients are n o w less severe,
reducing the need for inpatient treatment.
The effective mechanism of most neuroleptics—especially the p h e n o ­
tiazine a n d butyrophenone derivatives—on psychoses is due to their
blocking the transmission of nerve impulses between brain cells b y
means of the dopamine 2 (D2) transmitter (Carlsson & Lindqvist, 1963;
Snyder, 1981). Positron emission tomography (PET) studies have shown
that relatively l o w doses of neuroleptics are enough to achieve this.
Blocking at a 65-85% level is considered sufficient, a n d this level is
reached w i t h relative low dosage (Farde, W i e s e l , H a l l d i n , & S e d v a l l ,
1988). A higher dosage, w h i c h has often been recommended, is a mis­
g u i d e d choice, as it n o longer improves the outcome of the treatment
but, rather, increases notably the number of adverse side-effects (drug­
i n d u c e d parkinsonism, tardive dyskinesia, passivity, a n d anhedonism).
M a n y leading psychopharmacologists have recommended the use of
l o w or moderate doses instead of h i g h ones (Baldessarini, C o h e n , &
Teicher, 1988; Donaldson, Gelenberg, & Baldessarini, 1983; M a r d e r et al.,
1987; V a n Putten et al., 1993).
P E T i m a g i n g has shown that the blocking of dopamine functions
begins after the first few doses of neuroleptics. Because of the difference
between the time-course of receptor occupancy a n d the time-course of
antipsychotic effect, researchers (e.g. Wiesel, 1994) have postulated that
the antipsychotic effect of neuroleptics is not exclusively due to the
blocking of dopamine functions, but includes more complex interactions
a m o n g several different neuronal systems. O n e m a y suppose that the
adjustment " o n a low flame" of central nervous system functions, associ­
ated w i t h the neuroleptic effect, m a y also have psychological influences
that help the patient's ego to resume the internal psychic balance.
Clozapine holds a special position among neuroleptics. Its effect o n
the blocking of dopamine 2 receptors is only about half that recorded for
other neuroleptics, but its alleviating effect o n the symptoms of chronic
patients i n particular is, nevertheless, better. This has been tentatively
ascribed to the more extensive action of clozapine o n the functions of
116 SCHIZOPHRENIA

other transmitters, but w e d o not know for certain what mechanisms are
i n v o l v e d in it. Serotonin (5-HT2) antagonists as well as blocking effects
of dopamine 4 (D4) receptors have been proposed as plausible possibili­
ties (Liebeiman, 1993; Seeman, 1993; V a n T o l et al., 1991). T h e use of
clozapine is restricted b y potentially fatal consequences d u e to severe
leukopenia (Idanpaan-Heikkila et al., 1977). The risk of haematological
changes is present i n about 1% of all cases (Alvir et al., 1993) a n d is
greatest i n the first several weeks to three months of treatment.
Recently, a number of compounds currently i n development—such
as risperidone—with combined serotonin (5-HT2) a n d D 2 antagonist
properties, have demonstrated impressive antipsychotic efficacy
(Lieberman, 1993).
The attitude of psychiatrists towards neuroleptic medication is
mostly related to their theory of schizophrenia: some consider neurolep­
tics a necessary basic medication that should be administered regularly
a n d continuously, while others—myself included—see neuroleptics as
important agents to be used with moderation to support psychothera­
peutically and psychosocially oriented therapy.
O f the other psychoactive drugs used i n the treatment of schizophre­
nia, benzodiazepine derivatives are the most c o m m o n . W o l k o w i t z a n d
Pickar (1991), i n their review of the studies o n the use of benzodiaze­
pines i n schizophrenia, concluded that benzodiazepines alleviated
schizophrenic symptoms i n one-third to half of patients. The most t y p i ­
cal indication for the use of benzodiazepines is the need for additional
r a p i d tranquillization along w i t h neuroleptic medication. Antidepressive
drugs are also occasionally used as auxiliary medication for patients of
the schizophrenia group o n a neuroleptic regime, most justifiably i n the
depressive conditions associated with schizo-affective psychoses. P a ­
tients w i t h typical schizophrenia also often feel depressed after an acute
psychotic episode, when their sense of reality has recovered and they are
faced w i t h the fact of being ill. However, psychotherapeutic w o r k w i t h
the patient is generally a better alternative i n these cases than anti­
depressive medication.
Is medication necessary? This question sounds strange to most psy­
chiatrists, not least to those w h o — l i k e myself—remember h o w distress­
ing, restless, and noisy was the atmosphere o n closed psychiatric wards
before the introduction of neuroleptics. There are, however, findings
that justify this question.
Thus, for example, Carpenter, McGlashan, and Strauss (1977) carried
out a therapeutic trial i n the National Institutes of Health Research
 C O N T E M P O R A R Y TREATMENT OF SCHIZOPHRENIA 11 7

Center (NIH) i n the U n i t e d States i n the 1970s, where 49 patients with

acute schizophrenia were treated with intensive and extensive psycho­
therapy (individual therapy sessions 2-3 times a week, group therapy
sessions once a week, and often supplementary family therapy) i n a n
effort to avoid medication. T h e outcome was that just over half the
patients managed without medication, while 22 patients started a
neuroleptic regime 3 weeks after the beginning of the treatment but
discontinued it well before they were discharged from hospital after an
average stay of four months. W h e n the prognosis of these patients was
compared one year later with the prognosis of a matched patient group
treated elsewhere with medication, the results of the multi-dimensional
follow-up were slightly i n favour of those treated at the N I H . There
were, however, n o differences between those treated with a n d those
without medication within the N I H population.
Carpenter, Heinrichs, a n d H a n l o n also f o u n d out i n a later study
(1987) that there were n o differences i n a two-year follow-up between
schizophrenic patients o n continuous medication and patients w h o were
given a brief, symptom-specific neuroleptic regime combined w i t h
psychosocial intervention, although the need for hospitalization was i n i ­
tially lower for patients o n continuous medication.
Rapaport et al. (1978) studied a Californian series of 80 y o u n g male
schizophrenics, half of w h o m were treated w i t h chlorpromazine, the
other half with a placebo. A s could be expected, the results of pharmaco­
therapy were better. The follow-up examinations, however, revealed a
group of patients w h o h a d not received medication either i n the hospital
or afterwards and h a d a better prognosis than any of the other groups.
These patients belonged to the category w i t h a " g o o d p r e m o r b i d p r o g ­
n o s i s " , and their clinical picture was predominantly paranoid.
In the Kupittaa Hospital i n T u r k u , a pilot project was launched u n ­
der the supervision of Viljo Rakkolainen i n 1989, with first-admission
patients of the schizophrenia group being treated without neuroleptics,
one reason being that they also originally underwent P E T scanning,
whose results w o u l d be distorted b y neuroleptic medication. The treat­
ment is characterized b y an intensive and versatile psychotherapeutic
orientation, with the principles of the need-adapted treatment described
i n chapter five. W h e n necessary, patients' anxiety is controlled w i t h
benzodiazepines for a short time. A case report of this series (Catherine)
is presented i n this book i n chapter six.
A c c o r d i n g to follow-up findings over 2-5 years (Rakkolainen et al.,
1994; V u o r i o et al., 1993), only 8 of the 19 first-admission patients h a d to
118 SCHIZOPHRENIA

resort to neuroleptics. Despite the lack of medication, the outcome of the

patients could be considered quite satisfactory. O f the 11 patients treated
without neuroleptics (8 of w h o m h a d a DSM-III-R diagnosis of schizo­
phrenic disorder, a n d 3 of schizophreniform disorder), 8 h a d n o
psychotic symptoms at the latest follow-up. There was, however, the
drawback that the hospital episodes of some patients were relatively
long. A c c o r d i n g to later experiences, a change towards shorter hospital
episodes has been developed.
Rakkolainen a n d colleagues think that the neuroleptic treatment
s h o u l d be regarded unnecessary with acutely ill schizophreniform p a ­
tients treated w i t h comprehensive psychotherapeutic measures. O n the
other h a n d , benefit from neuroleptic treatment was derived b y severely
ill, already chronic patients as well as moderately i l l schizophrenic p a ­
tients w i t h underlying borderline personality structure, as defined b y
Kernberg (1975,1984).
In Finland, the experiences of the Kupittaa Project led to a larger
multicentre study of the indications of neuroleptic a n d non-neuroleptic
treatment of first-admission schizophrenic patients (V. L e h t i n e n et al.,
1996). It was thought that there m a y be certain benefits i n v o l v e d i n not
medicating these patients. These benefits should be taken into account
whenever the therapeutic resources a n d the benignity of the patient's
clinical condition permit it. N o t only can the initial assessment be made
without drugs, but possible side-effects as well as the danger of a need­
less maintenance medication w i l l also be avoided.
Chronic schizophrenic patients benefit from maintenance neurolep­
tic treatment. W i t h these patients, drug discontinuation m a y exacerbate
psychotic symptoms, provoking a recurrent need for hospitalization. O n
the other h a n d , the follow-up results of the psychotherapeutically ori­
ented Scandinavian NIPS Project (Alanen et al., 1994; see chapter five)
very clearly indicated that a continuing maintenance treatment is not
necessary for all patients diagnosed as schizophrenic.

Individual psychotherapy

T h e psychotherapeutic literature o n schizophrenia l o n g consisted

of i n d i v i d u a l case reports written u p b y therapists. T h e y generally
described patients w h o h a d , through a successful l o n g - t e r m d y a d i c
therapeutic relationship, undergone a developmental process that
not o n l y resulted i n a disappearance of psychotic s y m p t o m s , but also
 CONTEMPORARY TREATMENT OF SCHIZOPHRENIA 11 9

i n v o l v e d internal g r o w t h of personality a n d i m p r o v e m e n t i n the p a ­

tient's interpersonal relationships. A s a y o u n g psychiatrist, I f o u n d
the descriptions b y Sechehaye (1955), Johansson (1956), a n d W i l l
(1961) of their experiences especially impressive.
In the i n d i v i d u a l therapy of schizophrenic patients, psychoanalytic
principles are applied, though the actual psychoanalytic technique is
rarely used. T h e treatment is therefore usually called psychoanalytically
oriented or psychodynamic psychotherapy, thus m a k i n g a distinction be­
tween it a n d actual psychoanalysis. The more central to the treatment
are the analysis of the transference emerging i n the patient-therapist
relationships, the observation of the countertransference reactions of the
therapist, a n d the processes related to these phenomena, the more p s y ­
choanalytic the technique. T h e treatment practically always includes
supportive elements whose role is most conspicuous i n therapeutic re­
lationships w i t h infrequent sessions a n d / o r less psychoanalytically
oriented or trained therapists.
Some talented psychosis therapists, such as Boyer (1986), Johansson
(1985), a n d Robbins (1993)—as well as Benedetti (1975), describing the
patients of his student, Bertha N e u m a n n — h a v e published summaries of
therapy outcomes. These accounts have reported a good or satisfactory
outcome i n 50-60% of the patients. Boyer based his data o n as m a n y as
106 patients suffering from or prone to psychosis. Johansson stated,
based o n catamnestic data u p to 30 years, that the patients' satisfactory
integration, verifiable i n psychodynamic, clinical, a n d psychosocial
terms, was achieved i n 50% of the 40 schizophrenic patients treated b y
h i m for a p e r i o d of at least one year with intensive psychoanalytically
oriented psychotherapy. N e u m a n n h a d 20 patients, of w h o m 10 were
fully socially recovered a n d 6 others remarkably i m p r o v e d , w i t h g o o d
social adaptation. Robbins h a d positive outcomes with 9 of 18 patients
w h o satisfied D S M - I I I criteria for schizophrenia; of those w i t h negative
outcomes, 7 treatment efforts h a d failed after less than 2 years of psycho­
therapy.
W e can also include i n this group the therapeutic results achieved b y
Barbro Sandin (1992), w h o w o r k e d with seriously schizophrenic male
patients in the Sater Hospital i n Sweden. Rolf Sjostrom (1985) carried out
a follow-up of these patients a n d a control series collected from the
same hospital. T w o of Sandin's 14 patients h a d committed suicide, but
the others were i n a markedly a n d statistically significantly better c o n ­
dition than the controls. There was a particularly great difference i n
the patients' need for medication after a six-year follow-up; most of the
120 SCHIZOPHRENIA

patients w h o h a d been i n psychotherapy h a d n o medication 6 years

later, the mean dosage i n this group being 25 m g / d a y of chlorpromazine
equivalents per patient, while the corresponding figure i n the control
series was 400 m g / d a y . A n average of 200 hours of psychotherapy per
patient h a d been p r o v i d e d i n this series.
These outcome results were limited to groups of selected patients
and therapists with an aptitude to work with psychotic patients. Poorer
results were obtained i n the more extensive follow-up studies carried
out b y Christian Miiller (1961) o n psychotherapeutically treated schizo­
phrenic patients of the Burgholzli Hospital from 1950 to 1958 a n d b y T.
M c G l a s h a n (1984) o n the prognosis of the schizophrenic patients of the
Chestnut L o d g e Hospital (a vast majority of them being already chronic
at the time of admission). Despite the less favourable general tendency,
however, these follow-up findings also revealed some quite unexpected
recoveries of typical schizophrenic patients.
In the 1960s, the empirical natural-scientific methods that h a d often
been applied to d r u g trials were introduced into psychotherapy re­
search. A c c o r d i n g to these principles, the patient series were to be
unselected and given randomized treatment. This meant, for example,
that every second or third patient was given one type of treatment, while
the other patients went without treatment or were given some other kind
of strictly defined treatment.
In the U n i t e d States, results have been published o n four major c o n ­
trolled psychotherapy trials with individual therapy of schizophrenic
patients. The most cited of these studies is the one from Camarillo H o s ­
pital i n California under the guidance of Philip R. A . M a y (1968; later
follow-ups: M a y , T u m a , & D i x o n , 1981; M a y et aL, 1976). T h e series
consisted of 288 first-admission schizophrenics. Subjects with the best
and poorest predictive prognosis were excluded. The series was d i v i d e d
in a r a n d o m fashion into five groups receiving different kinds of thera­
pies: (1) i n d i v i d u a l therapy, (2) pharmacotherapy (trifluoperazine), (3)
i n d i v i d u a l therapy combined with pharmacotherapy, (4) electroshock
treatment, a n d (5) " m i l i e u therapy". The amount of treatments consid­
ered as successful i n these groups were 65%, 95%, 96%, 79%, a n d 58%,
respectively.
T h e findings of this "five-treatments trial" have, understandably,
been eagerly quoted b y the psychopharmacologically oriented research­
ers, w h o have taken them as objective proof for the superiority of
psychopharmacological treatment over psychotherapy. U s u a l l y they
have ignored the weaknesses of this work, of which the major ones were
 C O N T E M P O R A R Y TREATMENT OF SCHIZOPHRENIA 121

the following. (1) The psychotherapy was carried out b y residents w i t h ­

out psychotherapeutic training, w h o were supported b y guidance a n d
supervision but w o r k e d i n a milieu sceptical about psychotherapy with
schizophrenics. (2) The criterion for the statistical data of outcome was
whether the patient could be discharged from the hospital or whether
h e / s h e h a d been i n hospital continuously for 6-10 months, after w h i c h
time both therapist and supervisor decided that the treatment h a d failed.
Furthermore, the psychotherapeutic relationships were relatively short
(an average of 46 hours per patient) a n d were only maintained for as
long as the patients were i n the hospital The findings clearly confirm the
shortening effect of psychopharmacological treatment o n the duration of
hospital episodes, but they d o not provide an adequate basis for conclu­
sions o n the effects of competent a n d long-term psychotherapy contin­
u e d i n the frames of outpatient treatment.
A n o t h e r project with negative results regarding psychoanalytically
oriented psychotherapy was conducted at H a r v a r d University (Grin­
spoon, Ewalt, & Schader, 1972). The therapists i n v o l v e d i n the study
were more competent, but the patients were seriously ill, consisting of 20
male patients with chronic schizophrenia, w h o h a d been inpatients at the
Boston State Hospital for at least 3 years without interruption. They were
brought to the Massachusetts M e n t a l H e a l t h Center for 1 or 2 therapy
hours weekly—that is, there was n o milieu programme. A c c o r d i n g to the
authors, psychotherapy combined with medication alleviated the p a ­
tients' symptoms to a limited extent, while psychotherapy alone helped
these patients "little or not at a l l " . The book on the findings of this project
also includes the therapists' descriptions of their work, w h i c h they c o n ­
sidered partly beneficial even for some patients of the latter group.
K a r o n a n d VandenBos (1972,1981) carried out a project at M i c h i g a n
State University. M o s t of the patients belonged to the lowest social
g r o u p ; two thirds of them were hospitalized for the first time, a n d the
others were also regarded as relatively recent cases of schizophrenia.
T h e project i n c l u d e d three groups of patients, the first of w h i c h u n d e r ­
went psychoanalytic psychotherapy with " d i r e c t " interpretations a n d
without medication, while the second received "ego-analytical" (also
psychoanalytically oriented) psychotherapy combined with small or
moderate doses of chlorpromazine, a n d the third group was given only
moderate or large doses of chlorpromazine. The psychotherapies were
started rather intensively a n d were continued with longer intervals for
altogether 20 months, including outpatient status. F o l l o w - u p examina­
tions carried out 2 years after the termination of therapy, including both
122 SCHIZOPHRENIA

psychiatric interviews a n d psychological assessments, indicated that

there was a significant difference i n favour of the psychotherapy p a ­
tients, both as regards the duration of hospitalizations a n d the patients'
clinical status. The results achieved b y the experienced therapists were
better than those of the less experienced.
This study b y K a r o n a n d VandenBos was at the other e n d of the
spectrum from M a y ' s survey, but it was largely overshadowed b y the
latter i n reviews. It has also been criticized for the small numbers of
patients (altogether 36 patients) and the difference between the thera­
peutic milieus: the medication group was treated i n a hospital whose
general standard was lower than that of the wards where the psycho­
therapy patients resided.
The most interesting of the U.S. studies is the extensive and meth­
odologically sophisticated project conducted b y Stanton and Gunderson
in M a c L e a n Hospital i n Massachusetts—a milieu favourable for psycho­
t h e r a p y — i n the 1970s a n d 1980s (Gunderson et al., 1984a, 1984b). Its
purpose was to compare two i n d i v i d u a l therapy approaches; both
groups were also given standard doses of medication. The approaches
were, respectively, explorative, insight-oriented (EIO) psychotherapy
(two sessions weekly), and reality-adaptive, supportive (RAS) psycho­
therapy (averaging less than one session per week). Treatments were
p r o v i d e d b y experienced therapists, and the intent was to continue
therapies for at least two years, including outpatient care. The series
included 186 schizophrenic patients. A s i n the M a y study, the most
severely a n d m i l d l y disturbed patients were left out of the sample.
The most important result of this project was that no great difference
was f o u n d i n the outcome of the two groups, even if there were some
differences i n the direction of the findings. A c c o r d i n g to the two-year
follow-up, the E I O patients benefitted somewhat more from their thera­
pies w i t h regard to ego functions (improvement of thought disorders,
development of insight), while the result was clearly better i n the R A S
group concerning social functions (especially occupation).
The project yielded some significant subsidiary findings. These i n ­
c l u d e d the notable number of psychotherapy dropouts i n both groups.
A s early as six months after the beginning of the trial, 42% of the 186
patients initially included i n the series h a d d r o p p e d out, a n d only 51
(31% of the original) patients attended final evaluative sessions two
years later. It was also noted that these dropouts h a d received relatively
frequent psychiatric treatments elsewhere, and that their outcome was
not essentially poorer than that of the other patients i n the series.
 CONTEMPORARY TREATMENT OF SCHIZOPHRENIA 1 23

A d d i t i o n a l analyses of the tape-recorded sessions (Glass et al., 1989)

indicated that the patients' outcomes h a d interesting a n d statistically
significant connections with the methods and procedures used b y the
therapists. A c c o r d i n g to these follow-up findings, a " s k i l f u l psycho­
d y n a m i c exploration" b y the therapist, including a sensitivity to the
patients' subconscious " d e e p currents" and appropriateness of the tech­
nique (in the case of the E I O therapies)—was statistically significantly
related to a decrease of global psychopathology, especially denial of
illness a n d the absence of negative symptoms. O n the other h a n d , h o w ­
ever, the patients' anxiety and depression increased w h e n they emerged
from their apathy a n d isolation. Active support given to the patient—
w h i c h was even more important i n the R A S therapies—correlated with a
decrease of anxiety a n d depression.
O f the E u r o p e a n studies, I have already mentioned Sjostrom's fol­
l o w - u p of Sandin's patients. In 1980, Sjostrom initiated a n e w project,
a i m e d at finding out whether other therapists were able to reproduce
Sandin's results. The project suffered from a scarcity of patients: there
were only 8 therapy patients, all of them male, a n d a 6-year follow-up
revealed n o differences between the patients and a control series of the
same size, even if the mean prognostic development slightly favoured
the therapy patients. Still, the results m a y rather be interpreted as a
negative answer to Sjostrom's question (Sjostrom, 1990).
In O s l o , E n d r e Ugelstad (1978) studied the effects of psychotherapy
with 30 chronic male schizophrenics, w h o h a d all been i n the hospital for
at least 3 years a n d h a d been treated i n Gaustad Hospital for at least 1
year without a break. The psychotherapy group consisted of 12 patients,
of w h o m 6 were i n v o l v e d i n intensive psychoanalytically oriented i n d i ­
v i d u a l psychotherapy and 6 i n active m i l i e u therapy o n a small w a r d
established for this purpose. A control group consisted of 12 patients
with jobs or doing sheltered work outside the hospital, even though they
were still inpatients. A m i n o r control group consisted of 6 patients re­
ceiving less-specific m i l i e u therapy. A n evaluation of the patients'
psychic condition b y means of a quantifying method indicated that the
patients i n the therapy group were clearly more seriously disturbed
initially than the patients i n the larger control group. T h e follow-up
results indicated a better outcome for the therapy patients according to
the R o c k l a n d - P o l l i n scale, psychological tests, a n d discharge data. Later
follow-ups covering u p to 10 years (Haakenasen & Ugelstad, 1986) d e m ­
onstrated, however, a levelling of the difference between the therapy
a n d control groups, especially w i t h regard to the psychosocial outcome,
124 SCHIZOPHRENIA

while the patients given individual psychotherapy still showed a greater

reduction i n psychotic symptoms. The authors emphasized the signifi­
cance of the rehabilitation connected w i t h social factors (work a n d
dwelling) for the achievement and permanence of therapeutic results.
Another Norwegian study published b y V a r v i n (1991) revealed clear
improvements i n one-third of 27 patients treated o n a special psycho­
therapeutic w a r d i n Oslo with a combination of intensive i n d i v i d u a l
therapy a n d m i l i e u therapy. A l l the patients with a good outcome were
female, a n d the good outcome for half of them was f o u n d to be con­
nected w i t h a better preadmission level of global functioning.
A c t i v e non-controlled projects o n individual psychotherapy of
schizophrenia have also been conducted i n Italy (see Borri & Quartesan,
1990: Furlan, 1993).
Despite their ostensible objectivity, controlled psychotherapy
trials i n v o l v e quite significant limitations, w h i c h have not been gener­
ally recognized. These limitations o n l y become apparent w h e n they
are evaluated f r o m a w i d e r clinical v i e w p o i n t . T h e first of these l i m i ­
tations is d u e to the clinical heterogeneity of schizophrenia. T h e p a ­
tients therefore differ i n b o t h their motivation for treatment a n d their
therapeutic needs. Both G u n d e r s o n ' s project a n d o u r experiences i n
T u r k u (see chapter five) indicate that patients differ greatly i n their
ability to benefit f r o m i n d i v i d u a l therapy. But if i n d i v i d u a l therapy is
successful a n d results i n a g o o d outcome only i n a p o r t i o n of patients,
b e i n g unsuitable for others, the g o o d a n d b a d results cancel each other
out i n the statistical analysis of unselected patient populations. E v e n
so, a m o d e of treatment cannot be considered ineffective if it o n l y
benefits some of the subjects. Rather, one s h o u l d try to investigate for
w h i c h patients the treatment s h o u l d be r e c o m m e n d e d .
The second limitation is due to the fact that the treatment of most
schizophrenic patients requires an integrated approach, where several
modes of therapy are optimally combined. The investigation of a single
m o d e cannot give a view of the possibilities of comprehensive psycho­
therapeutic treatment i n schizophrenia.
The third limitation of great significance is the psychotherapist's
personality i n the treatment of schizophrenia. T h e treatment requires
long-term motivation i n both patient and therapist. Their personalities
need to be mutually compatible. This point should be given more atten­
tion at the initial stage of therapy than occurs at present.
O u r T u r k u team has repeatedly brought out these points w h e n pre­
senting our findings and experiences (Alanen, R a k k o l a i n e n , L a a k s o , &
 C O N T E M P O R A R Y TREATMENT O F SCHIZOPHRENIA 1 25

R a s i m u s , 1980; A l a n e n , R a k k o l a i n e n , L a a k s o , R a s i m u s , & Jarvi, 1983).

In our o p i n i o n , the focus should shift from method-oriented studies to
problem-oriented (or need-oriented) ones. The patients' needs a n d not
the researchers' needs should be used as the starting-point. A r m e l i u s et
al. (1989), i n a review they presented to the Swedish National Board of
Social Welfare, doubted the value of research projects employing
unselected series, pointing out that we should rather try to find out i n
the future what takes place i n successful a n d unsuccessful therapies.
T h e y claimed that the time for new controlled trials w i l l only come after
w e have f o u n d out more about the factors that promote a n d sustain the
therapeutic relationships.
The cognitive-behavioural approach to schizophrenia has been aptly
reviewed b y Birchwood a n d Preston (1991). Based o n learning theories,
the cognitive methods are directed more towards those factors that m a i n ­
tain the schizophrenic symptoms than towards factors related to p s y ­
chological origins. In the cognitive-analytical approach, cognitive-based
methods a n d psychodynamic viewpoints are combined. The most w i d e ­
spread application of cognitive methods has emerged i n the field of
family therapy (see below). Perris (1992) described a comprehensive
cognitive psychotherapy programme as it is applied i n an integrated
m i l i e u a n d i n d i v i d u a l therapy i n small, family-style treatment units.

Family therapy

F a m i l y therapy b e g a n to develop later than i n d i v i d u a l therapy, b e ­

cause o u r therapeutic culture h a d been so exclusively d o m i n a t e d b y
the i n d i v i d u a l therapeutic a p p r o a c h i n all of medicine. Psychiatrists
a n d other m e n t a l health field workers first became interested i n
f a m i l y therapy after the Second W o r l d W a r , a n d their interest has
c o n t i n u e d to g r o w ever since. A c c o r d i n g to o u r F i n n i s h findings
(Aaltonen, 1982; A l a n e n , L e h t i n e n , R a k k o l a i n e n , & A a l t o n e n , 1991),
the m o t i v a t i o n of the families of schizophrenics to participate i n joint
discussions is g o o d , especially if they are invited to attend right at the
b e g i n n i n g of the treatment.
F a m i l y research o n schizophrenia gave a crucial stimulus for the
development of family therapy. Ever since the introduction of family
therapy, schizophrenia has been one of the major indicators for its use.
O n e reason for this is found i n the dependency bonds between these
patients a n d their families, w h i c h are reinforced a n d even exaggerated
126 SCHIZOPHRENIA

as a consequence of their illness. M a n y individual therapists—beginning

with Federn (1943,1952)—have also pointed out that the inclusion of the
patient's family i n the treatment, i n one w a y or another, is necessary i n
schizophrenia. Johansson (1956, 1985) a n d Robbins (1993) combined
family meetings or therapy i n their approach at some stage d u r i n g the
i n d i v i d u a l therapy, i n order to safeguard the patient's efforts towards
independence.
Another reason for the increase in family therapy and, more gener­
ally, family-oriented treatment has been the families' need for support to
relieve the strain experienced b y the outbreak of psychosis a n d b y the
often continued psychotic behaviour of the patient. This has become an
intensely crucial question over the past few decades, as the focus of
schizophrenia treatment has shifted from inpatient to outpatient care.
The burdens a n d responsibilities felt b y the families of schizophrenics
have increased (Kuipers, 1993; Winefield & Harvey, 1994). This situation
has presented a new challenge to the therapeutic system a n d has also
stimulated the development of new therapeutic orientations. Further­
more, w h e n supported b y the therapeutic team, m a n y families can give
an important positive impact on the therapeutic activities.
M a n y of the first family therapists of schizophrenics based their
work o n family research, closely combining research and actual therapy.
Experiences were published, for example, b y Jackson a n d Weakland
(1961), Boszormenyi-Nagy, Bowen, Framo, Whitaker, and W y n n e (see
the papers of these authors published i n Boszormenyi-Nagy & Framo,
1965), Scott with co-workers (Scott & A l w y n , 1978; Scott & A s h w o r t h ,
1967), Stierlin (1972,1974,1976), Kaufmann (1976), a n d A l a n e n (1976).
M o s t of the therapies were psychodynamically oriented family therapies,
w i t h the goal of stimulating an intrafamilial developmental process (as
in the case of Paula, i n chapter one). The focus of therapeutic attention i n
these cases is o n the relationships among the family members and not, as
i n i n d i v i d u a l therapy, o n the internal development of the schizophrenic
family member, though it is h o p e d that the developmental process
taking place in the family might also stimulate h i s / h e r individual devel­
opment. Another difference between individual therapy a n d family
therapy has been aptly described b y W y n n e (1965), stating that family
therapy prefers to point out things that are visible, but not recognized,
while i n d i v i d u a l therapy points out things w h i c h can be inferred, but of
w h i c h people are not conscious.
A l t h o u g h the published experiences were generally favourable,
psychodynamic family therapy was gradually overshadowed b y the de­
 CONTEMPORARY TREATMENT OF SCHIZOPHRENIA 1 27

velopment of two other orientations. O n e of these is systemically o r i ­

ented—often called systemic-strategic—family therapy a n d the other
psychoeducational family therapy. There are also m a n y other family
therapy orientations i n field use, but they are not particularly significant
for the treatment of schizophrenics.
O n e of the important pioneers of the systemic-strategic family therapy
of schizophrenics was the M i l a n G r o u p (Selvini Palazzoli et al., 1978,
1980), w h i c h also influenced the thinking of another important European
pioneer, H e l m Stierlin. H e has related that his shift from psychodynamic
family therapy to the systemic-strategic orientation was influenced b y
his observation that the latter type of therapy was feasible far more often
than was p s y c h o d y n a m i c therapy, w h i c h tends to arouse resistance i n
m a n y families of schizophrenics (Stierlin, 1983). Stierlin's team has espe­
cially studied family therapy of schizo-affective and manic-depressive
psychoses (Retzer et al., 1991).
W h e n the technique of systemic-strategic family therapy is a p p l i e d ,
a team is used instead of a single therapist, the sessions are closed b y
g i v i n g the family strategic messages, a n d the sessions are h e l d at rela­
tively l o n g intervals. The purpose is to alter the family's psychological
balance i n a w a y that is favourable for both the patient a n d the other
family members. A l t h o u g h technical details differentiate this orientation
from the older type of psychodynamic family therapy, the psychological
understanding of family situations is essential for success i n both. This
point s h o u l d be emphasized i n order to prevent too radical systemic­
strategic interventions sometimes based o n inadequately grounded c o n ­
clusions.
T h e psychoeducational family therapy orientation, o n the other h a n d ,
has g r o w n f r o m different premises. M o s t of the proponents of this
approach, whose frame of reference is primarily based o n learning
theories, generally perceive schizophrenia as a n organic disease, i n
accordance with the vulnerability-stress theory. U s u a l l y this notion is
also pointed out d u r i n g the therapy, and the goal—for both the schizo­
phrenic patient a n d the family members—is to learn to live with the
illness rather than to w o r k towards a developmental recovery process.
F o r the patient's parents, this orientation has the benefit—but also the
restriction—that the conscious or subconscious feelings of guilt associ­
ated w i t h the child's illness are suppressed.
These premises are compatible with the biomedical orientation that
dominated schizophrenia research i n the U n i t e d States and Britain i n the
1980s. T h e editor of Family Process, Peter Steinglass (1987), stated i n late
128 SCHIZOPHRENIA

1980 that he considered the emergence of this approach the most i m p o r ­

tant advance i n family therapy over the past 20 years. H e especially
emphasized the importance of Schizophrenia and the Family, published
b y C a r o l A n d e r s o n a n d her co-workers i n 1986. Family therapists can
learn m a n y things from this book, especially about the empathy to be
shown towards the parents of schizophrenic patients (which seems inad­
equately outlined i n Selvini Palazzoli's reports, for example) as well as
the willingness to establish a cooperative relationship with them. But
the same authors also emphasize the hypothetical hereditary-biological
aetiology of schizophrenia—which they present as a p r o v e n fact to
both the patients and the families—while ignoring the developmental­
psychological background (Anderson, Reiss, & Hogarty, 1986).
O f the controlled family therapy trials, we might first mention the p i o ­
neering project carried out b y D o n a l d G . Langsley a n d his co­
workers i n Denver, Colorado, i n the late 1960s (Langsley, M a c h o t k a , &
Flomenhaft, 1971; L a n g s l e y , Pittman, & S w a n k , 1969), where the p r i ­
m a r y goal was to avoid hospitalization b y p r o v i d i n g prompt crisis inter­
vention o n a family basis.
Their series consisted of 150 families w h o h a d been seeking admis­
sion for one of their members with a serious psychic disorder. A b o u t
half the patients suffered from psychoses of the schizophrenia group.
Instead of admitting the sick member to a hospital, the families were
introduced to crisis therapy conducted b y Langsley's team as outpa­
tients. The trial included a control group of the same size, where the sick
members were admitted into hospital. The outcome was that only 13%
of the study families h a d to resort to hospitalization d u r i n g the six­
m o n t h follow-up, while i n 29% of the control families the sick member
w h o h a d been initially hospitalized was rehospitalized within the same
period. Repeated follow-up checks 12 and 18 months later indicated that
the differences i n the two groups' needs for hospital treatment a n d their
social coping abilities h a d gradually begun to level off. Langsley et al.
therefore emphasize that the opportunities for family crisis treatment
should be made permanent.
There have been four pioneering groups w o r k i n g o n therapeutic
trials that can be classified as psychoeducational family therapy of
schizophrenia. These are the teams led b y M i c h a e l Goldstein a n d Jerry
Doane (Doane et al., 1986; Goldstein et al., 1978), Julian Leff (Leff et al.,
1982,1985), Gerard E . Hogarty and Carol A n d e r s o n (Hogarty et al., 1986,
1991), a n d Ian R. H . Falloon (Falloon et al., 1982, 1985). They all p u b ­
lished reports o n family intervention projects using the controlled trial
 CONTEMPORARY TREATMENT OF SCHIZOPHRENIA 1 29

arrangement i n the early 1980s (Goldstein in 1978). These projects shared

the following features: the intervention h a d been planned i n advance,
the outcome was measured w i t h the number of relapses and/or
^hospitalizations, a n d the basic treatment of both the study a n d the
control patients consisted of neuroleptic medication.
The family interventions differed somewhat. Goldstein and his co­
workers emphasized that both the acutely i l l patient a n d the family
members h a d to accept the existence of the psychosis and to try to i d e n ­
tify a n d thereafter avoid the stress factors that seemed to make the disor­
der manifest. Leff a n d colleagues, whose series consisted of more chronic
patients, combined lectures given to the families o n the nature of schizo­
phrenia, family members' groups, a n d family therapy sessions w i t h the
goal of lowering the h i g h parental E E values, w h i c h were postulated to
precipitate relapse. Hogarty's team combined psychoeducational family
therapy w i t h social skills teaching with g o o d success, Falloon e m p l o y e d
the most straightforwardly behavioural methods—he even called his
programme " f a m i l y m a n a g e m e n t " — w i t h the goal of educating the fami­
lies to f i n d jointly acceptable solutions to problematic situations.
The outcome findings of these projects were promising: rehospital­
izations a n d relapses or aggravated symptoms were only seen i n 0 - 9 %
of cases i n the study group a n d i n 44-50% of the control cases. T h e
combination of family intervention and medication—and, as i n Falloon's
project, individual-oriented management—hence clearly i m p r o v e d the
patients' prognosis. In Goldstein's first series—where intervention c o n ­
sisted of six sessions only—the differences appeared to level off over a
longer follow-up p e r i o d (Goldstein & K o p e i k i n , 1981). The other teams,
w h o followed their families for longer, reported that the differences
between the study a n d control groups were still observable two years
later. Parallel results have also been reported b y some other research
teams a p p l y i n g psychoeducational family therapy (e.g. Tarrier et al.,
1989).
There has been less research o n systemic-strategic a n d p s y c h o ­
d y n a m i c family therapies of schizophrenia, and their results have been
evaluated differently. W e might, however, mention the pilot study b y
the C a n a d i a n team of Levene (Levene, N e w m a n , & Jefferies, 1989) o n
two modes of family therapy i n a group of ten patients whose response
to neuroleptics was poor. Both psychodynamic family therapy w i t h a
focal p r o b l e m orientation a n d supportive therapy approaching psycho­
educational p r i n c i p l e s — w h i c h were continued for six months after dis­
charge from the hospital—were s h o w n b y a one-year follow-up to have
130 SCHIZOPHRENIA

clearly improved the patients' social skills. Symptoms were significantly

fewer a n d less serious i n the group that h a d been i n psychodynamic
family therapy.
T i m o T u o r i (1987), i n Finland, evaluated the outcomes of systemic
family therapy among schizophrenic patients who h a d been married at
the time their illness became manifest (n = 24), using the non-psychotic
married patients admitted during the same period as a control group.
H e found out that both the motivation for family therapy a n d its out­
come were better i n the former group than i n the latter. T h e therapy
appeared to diminish the need for rehospitalization among the first­
admission patients, while n o similar effect was observable i n the group
of rehospitalized patients. T u o r i considers family therapy especially
necessary whenever the manifestation of psychosis is clearly associated
w i t h the family or marital situation or w h e n the couple has a child w h o
has either been involved in the psychotic symptoms or been ascribed the
role of a scapegoat or has become an object of parental quarrels. These
observations also point to the significance that family-oriented w o r k
m a y have i n preventing mental disorders i n children.
Favourable results from systemic-psychodynamic family therapy i n
the treatment of schizophrenic adolescents have also been reported, for
example, b y Malkiewicz-Borkowska and Namyslowska (1991) as well as
b y Pietruszewski (1991) from Poland. Guntern (1979), i n Switzerland,
became a pioneer i n the application of systemic family a n d m i l i e u
therapy to the psychiatric treatment of the whole population i n a given
area. In the Western Lapland Project (Tornio, Finland), the establishment
of family therapeutic training to practically all mental health workers i n
the district led to similar development (Aaltonen et al., 1997; Keranen,
1992; Seikkula, 1991).

Croups and communities

G r o u p therapy has longer traditions i n the treatment of schizophre­

n i a than does family therapy. Reports o n it were already p u b l i s h e d i n
the 1920s a n d 1930s (Lazell, 1921; M a r s h , 1933). T h e d e v e l o p m e n t of
outpatient care a n d the increase of therapeutic communities i n b o t h
hospitals a n d outpatient units have further p r o m o t e d the interest i n
b o t h g r o u p therapy a n d more general group functions. In therapeutic
c o m m u n i t i e s , g r o u p functions play a central role.
 C O N T E M P O R A R Y TREATMENT O F SCHIZOPHRENIA 131

G r o u p therapy i n the treatment of schizophrenia has a number of

important benefits: it stimulates patients with marked isolative tenden­
cies, gives them practice i n m a k i n g contacts with other people, a n d
improves their social skills. A s an additional benefit, group therapy costs
less than i n d i v i d u a l therapy. Several reviews—for example, b y Parloff
and Dies (1977), M o s h e r and Keith (1979), and Kanas (1986)—emphasize
the significance of group therapy i n these respects. Gonzalez de Chaves
M e n e n d e z a n d Garcia-Ordas A l v a r e z (1992) pointed out that the atmos­
phere i n a group therapy situation is realistic a n d characterized b y
equality and thus promotes the growth of self-esteem and stimulates the
totality of psychotherapeutic functions. Alleviation of symptoms a n d a
decline i n the need for neuroleptic medication have also been reported
as consequences of group therapy. The overall conclusion is, however,
that the improvements of patients' clinical condition are more modest
than are the psychosocial effects.

T h e field of group therapy also has several orientations, some based

o n p s y c h o d y n a m i c a n d others o n a psychoeducational frame of refer­
ence. O f the former type, particularly noteworthy is the extensive experi­
ence collected b y Frank Schwarz (1982) at the M a x Planck Institute i n
M u n i c h i n a programme that combines group a n d i n d i v i d u a l therapy
a n d has also integrated a psychoanalytic family therapy orientation.
Controlled trials o n the effects of group therapy i n schizophrenia
compared with patients treated with other methods have been made
b y , for example, O ' B r i e n et al. (1972), C l a g h o r n et al. (1974), L i n d b e r g
(1981), a n d M a l m (1982). A l l of them noticed a greater effect o n the
improvement of the patients' social and interpersonal skills than o n their
clinical symptoms. In M a l m ' s study, for instance, the group therapy
results showed improvement i n items related to emotional c o m m u n i c a ­
tion, increased leisure activities, and entries into the social field.
The concept of the therapeutic community was introduced into p s y ­
chiatry after the Second W o r l d W a r b y two British innovators, M a x w e l l
Jones a n d T. F. M a i n . Their goal was to turn the psychiatric hospital
wards, w h i c h h a d , u p until then, closely resembled general hospitals,
into communities that were more suited to their purpose a n d actively
p r o m o t e d the patients' psychological skills. Jones (1953) especially e m ­
phasized the need to involve the patients i n the responsibility of p l a n ­
n i n g a n d implementing functions. T h e decision-making power i n the
c o m m u n i t y was h e l d b y the joint meetings of patients a n d staff. M a i n
(1946), w h o coined the term "therapeutic c o m m u n i t y " , was a psychoana­
132 SCHIZOPHRENIA

lyst and tended to consider psychotherapeutic goals as the most i m p o r ­

tant.
Neither of these innovators, however, worked mainly with psychotic
patients. M a i n was mostly interested i n neurotic patients a n d Jones i n i ­
tially i n the war-time shock reactions and later in character disorders,
though he was later acting as the director of a large Scottish mental
hospital. W h e n we speak of the therapeutic communities for psychotic
patients, we should remember the earlier pioneer, H . S. Sullivan, w h o as
early as the 1920s developed the principles of community treatment
suitable for schizophrenic patients at Enoch and Sheppard Pratt Hospital
in M a r y l a n d (Sullivan, 1930,1931; see also Sullivan, 1962). A n important
A m e r i c a n pioneering work dealing with therapeutic milieu i n a mental
hospital was published i n the 1950s b y Stanton and Schwarz (1954).
T h e purpose of applying therapeutic community principles to the
psychiatric w a r d is to establish the supportive structure that is necessary
for psychotherapeutic endeavours i n the context of institutionalized care.
Clinical experiences on wards treating psychotic patients following p s y ­
choanalytically oriented principles have been described, for example, b y
Schulz a n d Kilgalen (1969), Simo Salonen (1975), and M u r r a y Jackson
(Jackson & Cawley, 1992; Jackson & Williams, 1994). O u r approach of
psychotherapeutically oriented w a r d communities treating newly
admitted schizophrenic patients is described i n chapters five a n d six.
Therapeutic communities for schizophrenic patients have been de­
veloped and their effects investigated from several different viewpoints.
P a u l and Lentz (1977) d i v i d e d their series of chronic schizophrenic i n ­
patients into three groups, of which the first underwent a precisely struc­
tured behaviour-therapeutic programme (including token economy), the
second was treated i n accordance with more conventional therapeutic
community principles, and the third served as a control group receiving
conventional mental hospital treatment. W i t h i n three years, 96% of the
patients i n the first group could be discharged, the corresponding fig­
ures being 68% i n the second group and 46% i n the control group. T h e
results thus clearly indicate that behaviour-therapeutic programming,
w h i c h was the method most familiar to the researchers, was effective.
In Scandinavia, an important pioneering work i n this field was
executed b y the Sopimusvuori therapeutic communities i n Finland.
These communities were originally founded b y Erik E . Anttinen and his
co-workers i n Tampere i n 1970 to promote the rehabilitation of chronic
mental patients discharged from the hospital (see chapter seven). T h e
 CONTEMPORARY TREATMENT OF SCHIZOPHRENIA 133

a i m is to create as n o r m a l a living environment as possible, observing

p s y c h o d y n a m i c a n d humanistic principles. A cooperative spirit based
o n interpersonal contacts among the clients and an improvement of self­
confidence is considered to have an important role i n the rehabilitative
process (Anttinen, 1983; Ojanen, 1984).
A c c o r d i n g to follow-up data (Anttinen, 1992), 48% of the first 236
clients of S o p i m u s v u o r i — o f w h o m 50% h a d been i n a mental hospital
for more than 10 years a n d 66% for more than 5 y e a r s — h a d been able to
m o v e to dwellings outside the S o p i m u s v u o r i communities, 17% h a d
remained to live there permanently, 25% h a d been rehospitalized, a n d
7% d i e d .
Therapeutic communities functioning outside hospitals have re­
cently come to have a role of their o w n even i n the treatment of acutely
schizophrenic patients. O n e L o n d o n pioneer i n this field was R. D .
L a i n g , w h o founded residential homes that are still operating. H e h i m ­
self, however, preferred to call them antipsychiatric asylums rather than
therapeutic communities. (When I asked L a i n g i n the early 1980s what
he considered the most important treatment of schizophrenia, he said he
preferred to teach persons called schizophrenic aikido—a Japanese self­
defense skill emphasizing nonviolence). Well-defined therapeutic goals
combining the psychoanalytic a n d family-oriented approaches began to
be observed i n the w a r d c o m m u n i t y V i l l a 21, established i n the Shenley
H o s p i t a l near L o n d o n i n the late 1960s after M i c h a e l B. C o n r a n was
appointed its head (Conran, 1972).
T h e reports b y L o r e n R. M o s h e r a n d A l m a Z . M e n n (1978,1983) o n
the therapeutic results achieved outside the hospital in the Soteria home
are w e l l k n o w n . T h e y founded Soteria i n California i n the early 1970s.
T h e leading principle for the patients i n this home was to experience the
psychotic regression as growth and development under the guidance of
lay staff without professional training but devoted to their work, i n a
home-like m i l i e u , a n d w i t h as little medication as possible.
In the follow-up studies the controls were similar patients treated i n
regular, well-staffed psychiatric hospitals. There was also the further
difference that the period of hospitalization defined as "brief a n d effec­
t i v e " lasted for only 21 days, whereas the average p e r i o d spent i n the
Soteria h o m e ranged from 5 to 6 months. A two-year follow-up i n d i ­
cated that the Soteria clients h a d been coping slightly better than those
w h o h a d been i n the hospital with regard to both subsequent need for
treatment a n d social a n d interpersonal life course.
134 SCHIZOPHRENIA

T h e starting-points were largely similar i n the "Soteria Berne"

Project launched b y L u c C i o m p i and co-workers ( C i o m p i et al., 1992).
T h e y also have a small nursing-home that resembles a n o r m a l living
milieu, where the staff consists of half professionals and half carefully
selected lay persons. Schizophrenia is perceived as a regressive crisis
experienced b y specifically predisposed y o u n g people i n problem situa­
tions d u r i n g their life course.
T h e treatment i n "Soteria Berne" is d i v i d e d into four successive
phases. D u r i n g the first phase the patient is placed i n a "soft r o o m "
together w i t h a maternally protective and soothing staff member, where
h i s / h e r condition is normalized. Patients then resume their daily activi­
ties and return to address their problems at a realistic level with other
staff members. A t the final stages, the patient is rehabilitated socially,
the problems implicit i n leaving the Soteria home are discussed, and the
after-care is planned, emphasizing the strategies for preventing recur­
rence of the illness. The use of neuroleptics is restricted to especially
threatening situations or is started with low doses after 4-5 weeks w i t h ­
out signs of improvement.
A two-year follow-up, where the control group consisted of similar
patients treated i n four psychiatric hospitals, revealed no differences i n
subsequent coping, with the exception that the patients w h o had been
living in the Soteria home h a d m o v e d to live separately from their par­
ents significantly more often than h a d other patients. C i o m p i and
colleagues, however, emphasize that both the Soteria patients and their
families felt the atmosphere of the Soteria home to be friendlier a n d less
labelling than the hospital milieu, and that the therapeutic environment
in these h o m e s — i n c l u d i n g the lack of medication—had helped them to
" r e m a i n themselves" better and to integrate the psychotic experiences
into the totality of their lives.

Community psychiatric developments

T h e rehabilitation of psychiatric patients involves w a y s of i m p r o v i n g

their psychic as w e l l as their physical condition a n d particularly of
p r o m o t i n g their social skills a n d occupational abilities w i t h the objec­
tive of i m p r o v i n g the quality of their lives a n d h e l p i n g them to adjust
to society. Rehabilitation is p r o v i d e d mostly for chronic patients but
 C O N T E M P O R A R Y TREATMENT O F SCHIZOPHRENIA 135

is also n e e d e d m o r e often than is generally realized at the acute stage

of schizophrenia.
T h e rehabilitation of chronic patients usually proceeds along two
tracks, one of w h i c h helps the institutionalized patient to learn to live
outside the hospital, while the other supports h i s / h e r progress towards
w o r k life (see Figure 7.1, p. 250, describing the rehabilitative system
established i n connection with the Sopimusvuori therapeutic c o m m u n i ­
ties i n Finland).
The pioneering p e r i o d i n the development of rehabilitative w o r k
took place in the 1960s. A t that time, rehabilitation of the w o r k i n g capac­
ity was considered the most important task, and it was promoted b y the
development of " i n d u s t r i a l therapy" i n hospitals (pioneered b y Early,
1960, a n d Freudenberg—described b y W i n g , 1960—in Britain) a n d the
foundation of sheltered workshops (e.g. Speijer, 1961) a n d jobs outside
hospitals.
W h e n I was enabled b y a W H O scholarship i n 1969 to travel to
H o l l a n d a n d Britain to visit units of social psychiatry, I saw the great
majority of the patients i n m a n y mental hospitals w o r k i n g i n large i n ­
dustrial therapy halls for most of the day, d o i n g subcontracting w o r k
and thus labouring for the common good. I felt somewhat dubious about
this development, though I was repeatedly assured that the patients' ego
functions were thus supported a n d that they were being prepared for
w o r k i n g outside the hospitals. Someone d i d remark, however, that the
foremen were occasionally reluctant to give u p a g o o d worker.
Things changed i n the 1970s, w h e n the employment situation turned
from a lack of labor to unemployment. B y that time it h a d also been
realized that i n order for rehabilitation to be successful, the patients h a d
to be helped more generally, i m p r o v i n g their interpersonal skills, not
only their work capacity. T h e focus n o w shifted to rehabilitation that
promoted living outside the hospital and support for the patients' other
living skills. But there have also been difficulties i n these efforts, espe­
cially i n the 1980s, w h e n the social political ideologies prevailing i n the
Western w o r l d emphasized the removal of mental patients from hos­
pitals for financial reasons but failed to provide adequate community
services.
The good outcome results achieved b y the rehabilitative V e r m o n t
project (Harding et al., 1987) were referred to in chapter two. A matched
comparison of the outcome of Vermont subjects with those i n M a i n e
w h o were treated more traditionally indicated that the good outcome of
136 SCHIZOPHRENIA

the Vermont patients was due to the rehabilitation programme, i n c l u d ­

i n g an earlier opportunity for community life (De Sisto et al., 1995).
A p a r t from the functions of the rehabilitative system, there are also
semi-institutional modes and units of treatment, such as day-and-night
hospitals a n d other types of, part-time hospital care, as well as different
crisis a n d activity centres for outpatients. Psychiatric home care has been
found to be an expedient method of taking care of chronic patients. The
works published by Anttinen, Eloranta, and Stenij (1971), Davis, Dinitz,
and Pasamanick (1972), Fenton, Tessier, & Struening (1979), and H o u l t et
al. (1983) are good examples of investigations of the use of intensive
home care combined with various supportive social activities as an alter­
native to hospital treatment. T h e y all reported a notable decrease i n the
need for hospital treatment, as well as beneficial effects o n the patients'
social a n d clinical development.
The Dane C o u n t y Project conducted b y Stein and Test i n Wisconsin
in the 1970s (Stein, 1993; Stein & Test, 1980) is generally regarded as a
classic effort to establish an integrated, community-based system of care as
an alternative to psychiatric inpatient treatment. T h e emphasis of the
w o r k has been o n patients recommended for admission into hospital,
including chronic mental patients. Teams created for the project sup­
ported these patients i n m a n y ways, such as b y taking care of their
material needs. In the first phase (Stein & Test, 1980), the central part of
the project consisted of a programme called " T r a i n i n g i n C o m m u n i t y
L i v i n g " , a n d its purpose was to promote the patients' ability to manage
independently i n their daily activities a n d more generally i n life.
The project was found to have diminished greatly the need for hospi­
tal treatment and to have promoted the patients' abilities to cope. But
w h e n the project was discontinued 14 months later, most of the benefits
were lost, a n d the need for hospital treatment increased sharply. T h e
work was resumed later, now based o n the conclusion that the care must
be continuous and must provide a wide variety of services needed b y
patients in order to achieve a stable adjustment to the community (Stein,
1993). Comprehensive community services now include crisis resolution
services, a mobile community treatment team—especially for y o u n g
adults with chronic schizophrenia w h o are, at times, unwilling to come
in for services and must be contacted at h o m e — a psychosocial rehabili­
tation programme, a n d living arrangements visited b y the staff, i n a
continuum from highly structured to minimally structured.
Stein (1993) states that i n the United States, o n the average, 70%
of mental health dollars go to support hospital services, leaving only
 C O N T E M P O R A R Y TREATMENT OF SCHIZOPHRENIA 1 37

30% for c o m m u n i t y services. In contrast, Dane C o u n t y allocates 20% of

mental health dollars for inpatient care while 80% supports community­
based services.
Some of the other reports o n innovative c o m m u n i t y psychiatric
projects should be mentioned. Sledge et al. (1996) compared a conven­
tional inpatient programme i n Connecticut for urban poor severely ill
voluntary patients w h o usually require hospitalization to an alternative
experimental programme consisting of a d a y hospital a n d linked to a
crisis respite c o m m u n i t y residence. The experimental programme h a d
the same effectiveness as an acute hospital: according to follow-ups, the
experimental programme h a d a slightly more positive effect o n meas­
ures of symptoms, overall functioning, and social functioning.
M u i j e n et al. (1992) applied the controlled trial method i n L o n d o n to
study the effects of social skills training (The D a i l y L i v i n g Programme),
c o m b i n e d w i t h m a n y other kinds of outpatient support. D u r i n g a fol­
l o w - u p period of 10 months, the study patients i n the sample—including
both schizophrenic a n d affective psychosis patients, all i n need of h o s p i ­
tal treatment—were i n hospitals for an average of 14 days, while the
controls spent a n average of 72 days o n wards. O p p o s i n g the possibly
overoptimistic—and injurious—hopes of easy money-saving, the a u ­
thors emphasize that the total cost of the treatment per patient was,
nevertheless, the same for the two groups. D e a n et al. (1993) similarly
compared a community-based service, including outpatient care, d a y
treatment, a n d social services, with hospital-based service. T h e former
appeared to be as effective as the latter a n d was preferred b y the rela­
tives. It was also more effective i n keeping people i n long-term contact
w i t h psychiatrists.
The situation i n Italy has been interesting, because legislation ratified
in 1978 permitted a complete abolition of the mental hospital network.
The l a w has not been enforced very consistently, at least i n southern
Italy, a n d it also involves drawbacks: m a n y of the psychotic patients, for
example, are n o w being treated i n the mental hospital wards of prisons.
In m a n y places, however, this innovation resulted i n a vigorous activa­
tion of outpatient care. Favourable experiences have been reported from
V e r o n a , Trieste, A r e z z o , and Perugia (Pylkkanen & Eskola, 1984).
W i t h regard to early case finding and prevention, extremely interesting
even if very preliminary results with regard to the prevention of schizo­
phrenic episodes were reported b y Falloon i n 1992. A p p o i n t e d the h e a d
of the mental health organization i n a catchment area with a population
of 30,000 i n the county of Buckinghamshire, E n g l a n d , he began a case­
138 SCHIZOPHRENIA

finding programme to be able to identify and w o r k with schizophrenic

patients at an early stage of the illness (or actually before that). The work
m a i n l y consisted of explaining the early symptoms of schizophrenia to
the general practitioners a n d public health nurses a n d s u m m o n i n g
the family crisis team immediately to work out situations reported b y
doctors or nurses. H e reported that the incidence of new cases diagnos­
able as schizophrenia d r o p p e d to one tenth of what it h a d been earlier:
d u r i n g a period of four years, only one patient i n this area became so
seriously disturbed as to fulfil the DSM-III-R criteria for schizophrenia
(Falloon, 1992).
Falloon underlines that the family-centred therapeutic programme,
w i t h an intervention b y the team i n any crisis within 24 hours, must be
carried out o n an emergency basis. T h o u g h he thus implies that the
schizophrenic disorder can be prevented, Falloon continues to consider
schizophrenia to be organic i n origin, based o n the vulnerability-stress
hypothesis.
The p a r a d i g m of early intervention has also been emphasized b y
B i r c h w o o d a n d M a c m i l l a n (1993), and new projects aiming at the p r e ­
vention of schizophrenic episodes have been put i n practice, for
example, i n Sweden a n d N o r w a y (Andre, 1995; Larsen, 1994). In F i n ­
land, the comprehensive family- and network-centred Western L a p l a n d
Project has led to a marked decrease i n the annual incidence of first­
episode schizophrenic patients (DSM-III-R), while the admission rates
for patients suffering from p r o d r o m a l symptoms have increased
(Aaltonen et al., 1997). This area of development w i l l undoubtedly re­
ceive increased attention i n the near future, because of the i m p r o v e d
prognostic prospects connected with early therapeutic intervention.
CHAPTER FIVE

Need-adapted treatment
of schizophrenic psychoses:
development, principles, and results

I
n this chapter, I describe o u r experiences a n d f i n d i n g s over the
past two decades i n the C l i n i c of Psychiatry i n T u r k u , w h i c h l e d
to the treatment orientation called need-adapted treatment of schizo­
phrenia-group psychoses. W e h a d a chance to a p p l y o u r a p p r o a c h m o r e
w i d e l y w h e n a national p r o g r a m m e for d e v e l o p i n g research, treat­
ment, a n d rehabilitation of schizophrenics w a s carried out i n F i n l a n d
i n the 1980s u n d e r m y leadership as w e l l as i n connection w i t h the
Inter-Scandinavian N I P S Project ( N o r d i c Investigation o n P s y c h o ­
therapy of Schizophrenia), I h o p e that these experiences m a y be of
benefit to those d o i n g d e v e l o p m e n t a l w o r k of a c o r r e s p o n d i n g nature
elsewhere, despite the differences i n the structure of m e n t a l health
organizations.

139
140 SCHIZOPHRENIA

The Turku Schizophrenia Project

' T u r k u S c h i z o p h r e n i a Project" denotes the research a n d therapeutic

activities undertaken i n the T u r k u C l i n i c of Psychiatry f r o m 1968
o n w a r d s to devise optimal treatment of schizophrenia a n d functional
psychotic disorders related to it. T h e overall goal of the project w a s to
d e v e l o p a treatment of psychoses belonging to the s c h i z o p h r e n i a
g r o u p that is p r e d o m i n a n t l y psychotherapeutic a n d c a n also be a p ­
p l i e d m o r e generally to public psychiatric health care. T o reach this
goal, it w a s necessary to integrate the activities a n d to m a k e them as
versatile as possible.
Since the beginning, our efforts have been towards team-work, with
the central goal of enabling all staff members to d o active, increasingly
independent therapeutic work suited to their personal inclinations and
abilities. T o this end, supervision and training activities were included i n
the developmental project as essential elements. A s far as I can see, it is
n o t — a n d w i l l not—be possible to meet adequately the population's
needs for therapeutic relationships b y p r o v i d i n g only psychiatrists' and
psychologists' services; rather, it is necessary to involve i n this effort
other staff persons, including nurses, w h o are numerically the largest
group, especially i n hospitals. These goals were particularly important
in the T u r k u Clinic, where the staff was numerically small: the staff/
patient ratio remained within 0.4-0.6 for a long time; it rose to 1.0 o n the
acute w a r d only i n the late 1980s.
The T u r k u Clinic of Psychiatry, founded i n 1967, is both a university
hospital a n d a part of the community psychiatric system of the town
of T u r k u , the T u r k u Mental Health District. Together with other units of
the district—the Kupittaa Mental Hospital and the T u r k u Mental Health
Office (the centre for psychiatric open care)—the clinic has been i n
charge of providing psychiatric services for the town of T u r k u , located i n
the southwestern part of Finland.
T u r k u (population 160,000) is the administrative a n d commercial
centre of the area and is k n o w n as a university town; the total number of
students at the three institutions for higher education is approaching
20,000. F o r this reason, the incidence of n e w psychoses is somewhat
greater than among the indigenous population of the town. The Mental
Health District is part of the General Health service organization of the
town, with close connections to the basic health services. T h e urban
character of the catchment area, with short distances between the homes
of the patients a n d service units, facilitates family- a n d environment­
 N E E D - A D A P T E D TREATMENT 1 41

centred activities. The psychiatric health services are quantitatively not

w e l l financed, but they are strengthened b y qualitative resources
through cooperation with the university department.
O u r goal was d i v i d e d into two sub-goals—a developmental objec­
tive a n d a research aim:

1. To develop the treatment of schizophrenia-group patients w i t h a n inte­

grated b u t psychotherapeutically oriented a p p r o a c h , e m p h a s i z ­
ing:

• a basic psychotherapeutic attitude,

• d e v e l o p m e n t of hospital w a r d s into psychotherapeutic c o m ­

munities,

• d e v e l o p m e n t of family therapy a n d other family-centred activi­

ties,

• d e v e l o p m e n t of i n d i v i d u a l therapeutic relationships,

• appropriate use of p h a r m a c o t h e r a p y as a m o d e of treatment

s u p p o r t i n g psychotherapy, a n d

• active participation of all professional g r o u p s i n the therapeutic

work.

2. T o f i n d out, b y means of follow-up investigations of cohorts, i n c l u d ­

i n g all first-admitted s c h i z o p h r e n i a - g r o u p patients f r o m the
T u r k u catchment area a n d representing different stages of d e v e l ­
o p m e n t of o u r a p p r o a c h :
• h o w w i d e l y it has b e e n possible for us to e m p l o y p s y c h o t h e r a ­
peutic activities w i t h this g r o u p of patients,

• w h i c h are the indications for different treatment m o d e s (that is,

w h i c h k i n d of treatment d o the patients need), a n d

• h o w the d e v e l o p m e n t of o u r therapeutic orientation affects the

outcome of treatments.

O u r project w a s carried out as action research. W e consciously a b a n ­

d o n e d the m e t h o d s a p p l i e d i n the k i n d of controlled p s y c h o t h e r a p y
trials I described i n chapter four. T h e m a i n reason for this was the
p r i o r i t y of the d e v e l o p m e n t a l goals, but ethical considerations also
p l a y e d a role. If w e h a d d i v i d e d the patients into r a n d o m i z e d g r o u p s
a n d strictly p r e - d e f i n e d the k i n d s of treatment to be g i v e n to each
g r o u p , w e w o u l d h a v e tied o u r h a n d s i n a w a y that w o u l d h a v e
142 SCHIZOPHRENIA

p r e v e n t e d the d e v e l o p m e n t of the treatment to meet each patient's

p e r s o n a l needs. S u c h a starting-point w o u l d also h a v e d i s c o u r a g e d
the attitudes w e tried to foster a m o n g members of o u r therapeutic
c o m m u n i t i e s a n d w o u l d therefore have been destructive to the thera­
peutic w o r k i n these communities. O t h e r weaknesses of controlled
p s y c h o t h e r a p y trials were p o i n t e d out i n chapter four.

Patient cohorts

Instead of r a n d o m i z i n g the patients, w e d e c i d e d to analyse the re­

sults of o u r w o r k b y c o m p a r i n g the patients' outcomes at different
stages of o u r therapeutic a p p r o a c h . T h i s w a s d o n e b y collecting p a ­
tient cohorts at different times. T h e years of a d m i s s i o n of o u r cohorts,
the n u m b e r of patients i n c l u d e d i n each, a n d the initial a n d f o l l o w ­
u p studies are presented i n Table 5.1, w h i c h also s h o w s the d e v e l o p ­
m e n t a l stage of the therapeutic orientation at the time of the patients'
admission.
E a c h cohort included all the patients aged 16-45 years w h o l i v e d i n
T u r k u and were admitted for the first time due to a schizophrenia-group
psychosis to the various units of the T u r k u Mental Health District within
a certain period. These units included two hospitals, the T u r k u Psychiat­
ric C l i n i c and the Kupittaa Hospital, as well as the T u r k u M e n t a l H e a l t h
Office, w h i c h was responsible for outpatient care. T w o other outpatient
clinics were taken into account: those i n the T u r k u University Central
H o s p i t a l (this hospital d i d not have any psychiatric wards until 1984)
a n d the local health care organization of the university students. Their
share of schizophrenic patients remained small.
T h e diagnostic limits of the schizophrenia group were originally
defined widely, because this suited our developmental goals. H o w e v e r ,
the patients were d i v i d e d into different diagnostic subgroups, following
the International Classification of Diagnoses (ICD 8) and the Scandin­
avian principles of differentiating typical schizophrenia from other
psychoses included i n the schizophrenia group (Achte, 1961, 1967;
Langfeldt, 1953). The patients i n Cohort IV were diagnosed according to
the D S M - I H - R classification, a n d this classification was retrospectively
also a p p l i e d to Cohort III.
Comparability between the initial and follow-up data was ensured
b y using structured schedules (research forms) i n w h i c h the information
on the basic clinical, demographic, and psychosocial items or variables
 NEED-ADAPTED TREATMENT 1 43

TABLE 5.1
The Turku Schizophrenia Project.
Cohorts and follow-up studies

Year of Number Development of Follow-up

Cohort admission of patients psychotherapeutic studies
approaches

I 1965-67 100 (50) single patients 1973-74

(24 mos.) in individual therapy,
approach hospitaf-centred
If 1969 75 (39) single patients 1971, 1977
(12 mos.) in individual or family
therapy, psychotherapeutic
communities initiated
III 1976-77 100 (56) individual therapy and 1978-79,
(19 mos.) psychotherapeuti c 1981-82
communities, well-developed
open care included
IV 1983-84 30 need-adapted approach 1985-86,
(12 mos.) with initial family-centred 1988-89
therapy meetings,
family therapy well developed
V 1995- ? need-adapted approach, 1997-2000
continued sectorization lowers
the barrier between open care
and the hospitals

The numbers in parentheses (Cohorts l-lll) refer to patients diagnosed as "typical

schizophrenia". In Cohort IV, the DSM-HI-R classification was applied. This classifi­
cation was retrospectively applied also to Cohort III (cf. Table 5.4).

was gathered i n a w a y that h a d been designed at the beginning of the

project.
Below, I first describe our developmental experiences a n d then d i s ­
cuss our results i n the light of comparative findings o n the different
cohorts. T h e most important of these surveys are:

• T h e c o m p a r i s o n between the seven-and-a-half-year f o l l o w - u p of

C o h o r t I (year of a d m i s s i o n 1965-67) a n d the eight-year f o l l o w - u p
of C o h o r t II (year of a d m i s s i o n 1969) b y R a i m o Salokangas (1977,
1986).
144 SCHIZOPHRENIA

• T h e t w o - a n d five-year f o l l o w - u p s of C o h o r t III (1976-77) b y o u r

team ( A l a n e n et a l . , 1983,1986).

• T h e two-year f o l l o w - u p b y o u r team ( A l a n e n et a l . , 1991) a n d the

five-year f o l l o w - u p b y K l a u s L e h t i n e n (1993a, 1993b) of C o h o r t I V
(1983-84), c o m p a r i n g the findings w i t h those m a d e o n C o h o r t III.

Development of psychotherapeutic communities

W e use the t e r m "psychotherapeutic c o m m u n i t y " to differentiate

our units f r o m the therapeutic communities of M a x w e l l Jones (1953).
Jones's p i o n e e r i n g activities, w h i c h a i m e d at c h a n g i n g the o l d ­
fashioned mental hospital milieus, p r i m a r i l y e m p h a s i z e d efforts to
achieve m a x i m a l equality a m o n g the various staff categories a n d
b e t w e e n staff a n d patients. W e also m a d e efforts to b r i n g the w a r d
atmosphere closer to n o r m a l l i v i n g milieus b y d i m i n i s h i n g hierarchy
a n d a l l o w i n g b o t h staff a n d patients to wear informal clothing. H o w ­
ever, the line d r a w n between the staff a n d the patients w a s not c o m ­
p r o m i s e d : the staff members were therapists a n d the patients were
receiving therapy, a n d the central task w a s to create a p s y c h o t h e r a ­
peutic attitude a n d to establish therapeutic relationships.
The goals a n d activities of the psychotherapeutic community at the
acute psychosis w a r d can be d i v i d e d as follows (Alanen, 1975):

1. Shared empathic basic attitude towards the patients. T h e m a i n i n s t r u ­

ments i n creating s u c h a n attitude were the s u p e r v i s i o n activities
a n d case meetings, i n w h i c h treatment plans were a r r i v e d at b y
c o m m o n consent.
2. Open mutual communication, both w i t h patients a n d a m o n g staff
m e m b e r s . O f special significance w a s a staff meeting at the e n d of
the w e e k i n w h i c h all the members i n the shift participated a n d the
actual p r o b l e m s were discussed.
3. Various group processes and activities. W e d o not have o r d i n a r y
g r o u p therapy o n o u r acute psychosis w a r d , b u t other g r o u p
activities—such as the m o r n i n g meetings, d o i n g v a r i o u s things
together, as w e l l as excursions—are u s u a l . A m o n g the meetings of
process-like character, the therapy meetings described later have
a special position.

4. Development of therapeutic relationships w i t h i n the therapeutic c o m ­

 N E E D - A D A P T E D TREATMENT 1 45

m u n i t y . E v e r y patient, i n c l u d i n g those w h o s e treatment m a y be

focused i n family therapy, has a personal nurse, w h o s e p r i m a r y
responsibility is to f o r m a n empathic relationship w i t h h i m / h e r .
S o m e of these relationships progress i n a later phase to i n d i v i d u a l
p s y c h o t h e r a p y , based o n a therapy contract, w h i c h m a y continue
after the patient has been discharged f r o m the w a r d . A p r e r e q u i ­
site is the personal s u p e r v i s i o n , w h i c h was g r a d u a l l y m a d e a v a i l ­
able to all staff members.

5. T h e importance of family therapeutic activities has greatly increased

in the course of years, and they are often continued after the patient
has been discharged from the w a r d .

6. Taking care of the patients' continuing contacts outside the hospital ward.
In addition to the family-centred work, this also includes support
given to the patient's other important relationships, as w e l l as—if
needed—contacts w i t h the w o r k i n g environment, for rehabilitative
purposes.

It is natural that w o r k i n g i n a therapeutic community of this k i n d is

more d e m a n d i n g for the members than is w o r k that merely consists of
observing the patients' symptoms a n d obeying the superiors' orders.
Openness a n d empathic qualities are needed, together w i t h a readiness
for increased self-knowledge. After c o m i n g to w o r k o n the w a r d , m a n y
of the community members undergo a personal developmental process,
w h i c h leads to the emergence or confirmation of a new k i n d of theory of
humanity. Quite a few e n d up i m p r o v i n g their professional competence
through personal psychotherapy a n d psychotherapy training. Others
m a y decide to find a job better suited to their inclinations. But those w h o
stay i n the community find their work notably more rewarding than the
previous routine w o r k o n hospital wards.
In his comparative study, Salokangas (1986) found the average p r o g ­
noses roughly similar i n Cohorts I a n d II, with the exception that the
need for pensions and hospitalizations was somewhat greater i n Cohort
II than i n Cohort I (see Tables 5.2 a n d 5.3, p p . 154,155). O n e reason for
this m a y have been the fact that Cohort II included an unusually large
n u m b e r of y o u n g , seriously i l l male patients, whose prognosis is gener­
ally poorer than that of female patients. T h e most essential difference
between the cohorts was, however, crystallized b y Salokangas as fol­
lows: patients i n Cohort II were more content with their inpatient
treatment than were patients i n Cohort I, but they also stayed longer i n
the hospital.
146 SCHIZOPHRENIA

Salokangas (1986) emphasized the need to increase outpatient a n d

rehabilitative services. This criticism was doubtless justified a n d pointed
out the major problem of the early stages of our therapeutic a p p r o a c h —
the excessive inpatient orientation due to a lack of outpatient facilities.
W h e n the clinic was founded, n o outpatient staff was employed, because
the t o w n health care officials assumed that the outpatient activities
w o u l d be totally carried out i n the Mental Health Office. A l r e a d y i n
early 1970s, we tried to improve the situation b y increasing the patients 7

after-care visits to hospital staff and encouraging cooperation with the

M e n t a l Health Office—for example, through psychotherapeutic super­
v i s i o n — a n d w i t h private psychotherapists. Hospital treatment was
defined as a n intermediary stage, with the purpose of planning for the
subsequent outpatient treatment with the staff responsible for it.
These findings o n the early phase of our activities m a y have given
rise to doubts as to whether inpatient therapy of this k i n d w o u l d have
any significance for the subsequent prognosis of the patients. T h e find­
ings o n subsequent cohorts, however, proved these doubts to have been
premature.
T h e benefits derived b y the patients from psychotherapeutic c o m ­
m u n i t y treatment were observable i n the follow-up findings o n Cohort
III (Alanen et al., 1983,1986). A l t h o u g h the first inpatient periods i n the
clinic were, at that time, still clearly longer than were those of patients i n
the Kupittaa Hospital (73 days vs. 27 days), the average duration of the
subsequent inpatient episodes was shorter from the second follow-up
year onwards among those patients admitted into the psychotherapeutic
c o m m u n i t y of the Clinic than for the patients first admitted into the
Kupittaa Hospital, where treatment then consisted mostly of psycho­
pharmacological medication. A statistical analysis indicated that the dif­
ference was not due to other clinical or psychosocial background factors
affecting the patients' prognosis (Alanen et al., 1986).

Development of individual therapy

T h e focus i n the development of therapeutic relationships at that time
w a s clearly o n psychodynamically oriented individual therapy. T h i s w a s
also clearly reflected i n the five-year f o l l o w - u p findings. O f the 100
patients i n C o h o r t III, 26 h a d undergone i n d i v i d u a l therapies for at
least t w o years, consisting of 80 or m o r e sessions, 31 other patients
h a d each h a d a shorter therapeutic relationship defined as i n d i v i d u a l
 NEED-ADAPTED TREATMENT 147

therapy, 15 patients h a d h a d 12 or m o r e joint family therapy sessions

over at least 6 months, w h i l e 10 others h a d h a d at least 3 joint sessions
( A l a n e n et a l . , 1986).
The results of individual therapy were more rewarding than those of
family therapy. M o s t therapists, however, lacked proper therapeutic
training; two-thirds of them were given supervision for their w o r k w i t h
at least one patient. M o r e than 40% of the therapies were conducted b y
nurses. M a n y psychiatric nurses w h o came to k n o w the problems of
psychotic patients i n their w o r k attained, w i t h the help of supervision,
g o o d results as therapists of schizophrenic patients able to benefit from
i n d i v i d u a l therapy (see A a k u , R a s i m u s , & A l a n e n , 1980). In addition to
being naturally inclined to this k i n d of work, m a n y of them also u n d e r ­
took formal training i n psychotherapy later on. Untrained therapists met
w i t h more problems i n family therapy; they were easily i n v o l v e d i n the
" s u c t i o n " of the transactional network, a n d the therapeutic process
therefore got stuck. T h e successful couple therapies of some patients
w h o h a d been married before their illness were exceptions i n this re­
spect.
The favourable effect of long-term i n d i v i d u a l therapy o n the clinical
characteristics of typical schizophrenics appears obvious i n Figure 5.1.
O f the 56 " t y p i c a l schizophrenia" patients i n C o h o r t III, 14 h a d i n d i ­
v i d u a l therapy that met with the aforementioned criteria (at least 2

0 1 1
1 1 i
lyear 2.year 3.year A.year B.year

FIGURE 5.1 The Turku Schizophrenia Project Cohort III. Outcome of

long-term individual psychotherapy of typical schizophrenic patients,
counted as yearly average inpatient days per patient (according to
Alanen et al., 1986).
148 SCHIZOPHRENIA

years, at least 80 therapy sessions). The figure shows the better prognosis
of these patients with regard to the need for inpatient treatment d u r i n g
the follow-up period. A l t h o u g h it can be assumed that the group of
patients given psychotherapy probably included some patients whose
original prognosis was better, it is worth noting that the need for i n p a ­
tient treatment continues to decrease i n this sub-group, unlike the whole
cohort (Alanen et al., 1986).

Development of family therapy

W h i l e c o n f i r m i n g the relatively better outcomes of o u r i n d i v i d u a l

therapies c o m p a r e d w i t h family therapies, the f o l l o w - u p findings o n
C o h o r t III at the same time revealed the significance of the family
m e m b e r s ' attitudes for the patients' outcome. T h e fact that the patient
h a d at least one empathic relative at the time of the initial e x a m i n a ­
tion t u r n e d out to b e one of the most important predictors of a g o o d
prognosis i n the logistic regression analysis five years later ( A l a n e n et
al., 1986).
A s there was a recognizable need for regular family therapy training
i n F i n l a n d , even i n fields other than psychosis therapy, a three-year
multi-professional family therapy training was established i n Finland,
through the Finnish Mental Health Association, i n accordance with the
models available i n some other countries. The training was begun i n
T u r k u and Helsinki i n the autumn of 1979. A majority of the members of
the first training team were psychoanalysts. Right from the beginning,
however, the training was clearly oriented towards systemic family
therapy. I believe that this combination of psychoanalytic a n d systemic
expertise was a great asset both i n the training a n d i n the subsequent
development of family therapy.
T h e effects of the family therapy training were quite soon visible i n
the development of o u r psychotherapeutic orientation. T w o psychia­
trists, Klaus Lehtinen a n d H i l k k a Virtanen, a n d the w a r d nurse Riitta
Rasimus set u p a team in the early 1980s and began, under the guidance
of Viljo Rakkolainen (a psychiatrist with both psychoanalytic a n d family
therapeutic expertise), to arrange regular joint meetings with the newly
admitted patients and their family members, or other people close to the
patients, at the very beginning of the treatment (Lehtinen, 1993b, 1994;
Lehtinen & Rakkolainen, 1986).
 N E E D - A D A P T E D TREATMENT 1 49

T h e n e w w a y to begin the treatment with regular family meetings

soon p r o v e d particularly useful. W e could give quick support both to the
patient a n d the family members, w h o often felt extreme anxiety at that
time. D u r i n g the meeting it was possible to obtain further information o n
the manifestation of the patient's illness a n d the factors associated w i t h
h i s / h e r admission. The labelling of the patient as ill was lessened i n both
the patient's a n d the family members' minds, w h e n the psychosis was
related to their problems. " T h e situation has been defined as something
other than mental illness i n the traditional medical and / o r mystical a n d
magic sense. W h a t is at h a n d is a difficult situation w h i c h , however, is
part of the course of life a n d involves problems that can be described
w i t h ordinary w o r d s " (Klaus Lehtinen, i n A l a n e n et al., 1990a, p. 22).
These meetings were often continued even after the initial analysis
stage, especially if the patient h a d been admitted into hospital. A s they
turned out to have a significant therapeutic effect, w e began to call them
therapy meetings (Alanen et al., 1991; Lehtinen & Rakkolainen, 1986;
Rakkolainen, L e h t i n e n , & A l a n e n , 1991). T h e y were found to be a d v a n ­
tageous not only to the schizophrenia group patients, but also to other
patients recommended for inpatient care. H i l k k a Virtanen (1991) has
reported favourable experiences of family-centred therapy meetings i n
geriatric psychiatry.
T h e n e w orientation was e m p l o y e d systemically i n the treatment of
patients included i n our Cohort IV, collected d u r i n g 1983-84. The activi­
ties were supervised b y a team of four psychiatrists ( A l a n e n , L e h t i n e n ,
R a k k o l a i n e n , & A a l t o n e n , 1991; Lehtinen, 1993a, 1993b). Lehtinen h a d
the m a i n responsibility for the practical work, a n d he was assisted b y
three nurse specialists with family therapy training. T h e y w o r k e d i n the
project alongside their regular jobs. In order to reach developmental
goals i n general, it is better to incorporate the innovative activities as
part of the n o r m a l w o r k i n g routine rather than give them a separate
status as project work.
The families were quite well motivated for team-work at the time of
the first admission of a psychotic family member. A family-centred i n i ­
tial analysis (therapy meeting) was accomplished i n 87% of the 32 cases
originally included i n the series. The initial results were quite encourag­
ing: the psychotic symptoms of m a n y patients disappeared or quickly
decreased as a consequence of family-oriented intervention. A n d , c o m ­
p a r e d w i t h the earlier cohorts, the hospital episodes were significantly
shorter.
150 SCHIZOPHRENIA

T h e supervisory team of the cohort frequently discussed the justifi­

able duration of the treatment. Lehtinen emphasized that the patients
s h o u l d not be needlessly involved i n the therapeutic system, where the
treatment m a y easily become a routine that only maintains the patient
role, while I defended the need to continue the psychotherapeutic treat­
ments, pointing out that schizophrenic disorders are serious and
frequently recur. By that time, individual therapies h a d begun to be
overshadowed b y family therapies; there still were individual therapies,
but they were fewer than i n the previous cohort and their management
was not organized like that of family therapies.
After the follow-ups of Cohort IV (Alanen et al., 1991; Lehtinen,
1993a, 1993b), our views have come closer to each other. Cohort IV
included several patients w h o h a d become psychotic i n an acute crisis,
a n d they were found to cope well after the initial intervention, even
without further therapy. O n the other h a n d , however, it turned out that
the treatment of m a n y more-seriously i l l patients h a d been terminated
m u c h too soon or h a d suffered from discontinuity, because it h a d i n i ­
tially not been planned for a sufficient time span.
O n e consequence of these experiences was the establishment of an
admission clinic i n the hospital. The team working i n this clinic meets the
patients referred to the hospital together with their families even before
the patient is registered as inpatient. Quite often, the patient is not a d ­
mitted to the hospital w a r d , but the team continues the treatment as a
crisis intervention at the admission clinic.
O n the other h a n d , because of the unsatisfied need for trained i n d i ­
v i d u a l therapists, a multiprofessional three-year (special level) training
i n i n d i v i d u a l therapy, with psychotic patients as one target group, was
begun i n T u r k u i n 1986, organized i n connection with the University's
Centre for Extension Studies. Later, advanced special-level training p r o ­
grammes were also established, both i n family therapy and i n individual
psychotherapy, focused o n psychotic and borderline patients, compris­
i n g six years i n all (see p p . 247-248).
T h e initial family- and milieu-oriented interventions employed with
patients recommended for inpatient care are not i n themselves a new
invention. W e remember the work b y Langsley's team (Langsley,
Machotka, & Flomenhaft, 1971; Langsley, Pittman, & Swank, 1969) i n the
1960s, w h i c h was described i n chapter four, whose favourable results
seem to have been regrettably ignored. What is new i n our approach,
however, is that these interventions are incorporated i n an integrated,
systemic, a n d psychodynamically oriented m o d e l of treating psychotic
 NEED-ADAPTED TREATMENT 151

patients, where other psychotherapeutic activities such as i n d i v i d u a l

therapy also play a notable role.

The outcome findings

Because the m a i n stress i n the T u r k u Project was o n therapeutic de­

v e l o p m e n t a p p l y i n g action research principles, the interpretation of
o u r f o l l o w - u p data i n v o l v e d several problems d u e to our research
design. A s the data h a d been collected f r o m different units, they d i d
not specifically represent the effects of o u r o w n therapeutic orienta­
tion. In particular, the orientation i n the K u p i t t a a H o s p i t a l f r o m the
late 1960s to the mid-1980s was different f r o m ours, m a i n l y consisting
of m e d i c a t i o n i n a conventional hospital environment.
T h e patients i n Cohort I (see Table 5.1) were first admitted to treat­
ment before the Clinic of Psychiatry was founded. In Cohort II, as m a n y
as 88% of the patients were admitted into the wards of the newly
founded Clinic. In Cohort III, the clinic wards and outpatient activities
together were responsible for the primary care of 54% of all the patients,
while the Clinic took i n 70% of the patients w h o began as inpatients. In
Cohort IV, the corresponding figures were 67% and 83%. In Cohort III,
we c o u l d compare the effects of different therapeutic environments and
orientations. O n l y i n Cohort IV was the same therapeutic orientation,
beginning w i t h the family-centred intervention, carried out i n the entire
Mental Health District.
Another factor that made the comparison of outcome results of the
cohorts w i t h each other difficult was the difference i n the diagnostic
criteria between Cohorts I—III, o n the one h a n d and Cohort IV o n the
other. While the earlier cohorts included schizophrenia group psychoses
in a notably wide sense, the patients for Cohort IV were selected with the
distinctly stricter criteria of the DSM-III system. Besides, the follow-up
period was seven and a half and eight years i n Cohorts I and II and 5
years i n Cohorts III and IV.
A c c o r d i n g to the original criteria used i n Cohorts I, II, a n d III, the
patients were subdivided into four diagnostic categories. These were
defined as follows:

The group of typical schizophrenia included the patients who, be­

sides a schizophrenic-type thought disorder (in practise, the
criterion for inclusion in the whole series), had some other char­
acteristic schizophrenic symptoms which had arisen without any
152 SCHIZOPHRENIA

toxic or organic precipitating factors and indicated a tendency to

persistence. We paid particular attention to the presence of eight
nuclear symptoms of schizophrenia: autism, schizophrenic
thought disorder, hebephrenic affective disorder ("blunting" of
affect), schizophrenic auditory hallucinosis, physical delusions of
being influenced, massive psychological delusions of being influ­
enced, typical catatonic symptoms (stupor or excitement), and
sensations of depersonalization a n d / o r derealization when the
patient's consciousness is c l e a r . . . . The group of schizophreniform
psychosis included short or recurrent psychotic states, where the
onset of schizophrenic symptoms had regularly been sudden
and the symptoms had been of short duration. . . . Schizo-affective
psychoses were characterized by a simultaneous occurrence of
schizophrenic symptoms and a clearly manic or depressive m e n ­
tal state. . . . The group of borderline schizophrenia included the
patients whose schizophrenic symptoms were mild, less charac­
teristic and usually short in duration, although they tended to
recur i n most cases, occasionally even become chronic. (Alanen et
al., 1986, p p . 33-34)

The D S M - I I I criteria for symptoms are the same for both "schizo­
phreniform disorder" and "schizophreniform psychosis". The groups
are differentiated b y the duration of the characteristic psychotic s y m p ­
toms (including prodromal and residual symptoms), w h i c h is 6 months
or more i n the schizophrenic disorder and more than 2 weeks but less
than 6 months i n the schizophreniform disorder. The criteria for schizo­
phrenic disorder further include "deterioration from the previous level
of functioning i n such areas as work, social relations, and self-care",
compared with the prepsychotic period, or, in younger patients, " a fail­
ure to achieve the expected level of social development", which
attributes are lacking from the criteria of schizophreniform disorder.
A c c o r d i n g to DSM-III, only the group " t y p i c a l schizophrenia" i n our
earlier classification clearly fulfilled the criteria of schizophrenic disor­
der (and even some patients i n this group h a d the DSM-III diagnosis
schizophreniform disorder).
T o make it possible to compare the outcomes, the patients i n Cohort
III were retrospectively rediagnosed b y using the same criteria derived
from the DSM-III-R as were used in the final diagnoses of Cohort IV. The
same rediagnostic procedure (see Kendler, Spitzer, & Williams, 1989)
was also applied to the schizoaffective psychoses. The rediagnoses were
made b y Klaus Lehtinen, w h o used the patient record data and the
patient research forms and also consulted the psychiatric researchers
 N E E D - A D A P T E D TREATMENT 1 53

w h o h a d interviewed the patients at the initial stage. Lehtinen h a d also

been responsible for the final diagnostic characterization of the patients
of C o h o r t IV.
Three different comparisons are made here. In Table 5.2, a c o m p a r i ­
son of the outcome findings i n Cohorts I, II, and III as a whole is
presented, following the wide diagnostic criteria originally used b y us.
In Table 5.3, a comparison of these outcome findings has been restricted
to the patients belonging to the typical schizophrenia group only. In
Table 5.4, the result of the comparison of five-year follow-up findings of
Cohorts III and IV w i t h each other is presented, i n c l u d i n g the patients
w h o , according to the DSM-III-R system, could be diagnosed as suffer­
i n g from schizophrenic disorder (38 patients i n Cohort III a n d 18
patients i n Cohort IV), schizophreniform disorder (respectively, 12 and 8
patients), or schizoaffective disorder (respectively, 3 a n d 2 patients).
Three prognostic variables are included: one clinical (no psychotic
symptoms) and two social (maintenance of w o r k i n g capacity and a v o i d ­
ance of pension). A d d i t i o n a l l y , i n Table 5.4. the average inpatient days
per patient d u r i n g 5 years are included.
There is a tendency towards improvement of the outcome from the
earlier cohorts to Cohort III with regard to the presence of psychotic
symptoms. However, the social outcome criteria do not confirm the posi­
tive prognostic development (which m a y depend partly o n changes i n
the pension policy).
Table 5.4 indicates that there is a definite improvement of the p r o g ­
nosis observable w h e n the outcome findings of Cohort IV are compared
w i t h the findings of Cohort III. A n increasingly large proportion of the
patients h a d n o psychotic symptoms, a n d there was a particularly con­
spicuous change i n the ability to maintain w o r k i n g capacity and a v o i d
being pensioned. There was also a significant decrease i n the amount of
inpatient care needed b y the patients, w h i c h was 132 days per patient o n
an average d u r i n g the whole five-year period i n Cohort IV, while the
corresponding figure i n Cohort III was 272 days. This difference was
especially obvious over the first two follow-up years, but it declined
slightly d u r i n g the fourth and fifth year. A t the end of the follow-up, 3
patients (9.7%) from Cohort IV and 7 patients from Cohort III (13%) were
hospitalized. E v e r y one of our cohorts included a few seriously i l l l o n g ­
term patients, w h o mostly accounted for the need for hospital care over
the later follow-up years.
Lehtinen (1993b) also studied the outcome of these cohorts using the
four-dimensional Strauss-Carpenter scales (inpatient care, social con­
154 SCHIZOPHRENIA

TABLE 5.2
The Turku Schizophrenia Project
Comparison of clinical and social follow-up findings in cohorts
of first-admission patients (original samples of Cohorts M i l )

Outcome variable
Percent Percent
Cohort without Percent without
Year of Size of psychotic fully able disability
No. admission sample symptoms to work pension

I 1965-67 100 48 39 67
(24 mos.)

II 1969 75 46 41 54
(12 m o s . )

Ill 1976-77 100 69 43 59

(19 mos.)

T h e findings are based o n eight-year f o l l o w - u p s of Cohorts I a n d I I , a n d o n a five­

year f o l l o w - u p o f C o h o r t III.
The percentages are calculated for the patients w h o attended t h e f o l l o w - u p
e x a m i n a t i o n s (more than 9 0 % i n all series). There w e r e 5 suicides in C o h o r t I, 2 i n
C o h o r t I I , a n d 3 in C o h o r t III.

tacts, w o r k i n g , symptoms) as prognostic criteria (Strauss & Carpenter,

1972,1974). The s u m of the subscales (range 0-16) was compared, using
the two-tailed t-test. The mean for the 1983-84 series was 12.0 (SD = 4.2)
and that for the 1976-77 series 9.8 (SD = 4.2). The difference between the
cohorts was significant (p = 0.03), being most striking o n the w o r k i n g
("usefully e m p l o y e d " ) variable (p = 0.002)
W h e n examining these follow-up findings, it is useful to remember
that the influence of our therapeutic orientation i n the 1970s d i d not
reach all parts of the mental health district. There were considerable
differences i n the treatment received b y the patients of Cohort III, de­
p e n d i n g o n where they were treated. T h e treatment of the patients i n
Cohort IV was notably more uniform, one reason being that the teams of
family therapists saw all of the patients and their families i n the meet­
ings arranged initially, regardless of the unit responsible for the treat­
ment. H o w e v e r , this fact does not explain the significant difference
between the outcome findings of these two patient cohorts.
 NEED-ADAPTED TREATMENT 1 55

T h e follow-up findings o n our Cohort IV can be considered quite

g o o d , even w h e n compared with the international findings reviewed i n
chapter two. T h e major difference between the treatment of Cohort IV
and the previous cohorts was the establishment of family-oriented
therapy meetings, w h i c h were attended jointly b y the patient, the family
members, a n d the team responsible for treatment, a n d w h i c h were
often continued as family-oriented crisis interventions. T h e families of
the patients i n Cohorts II and III were also met at an early stage of the
treatment, but m a i n l y for purposes of research a n d separately from the
patients. These meetings were therefore not intended as therapeutic i n ­
tervention, as were the meetings of Cohort IV.
A c t u a l family therapy was also notably more c o m m o n i n C o h o r t IV
than previously. W h i l e 25% of the patients i n Cohort III received family
therapy, the corresponding figure i n Cohort IV was 60%. T h e family
therapies were clearly most c o m m o n at the beginning of the treatment:
o n l y two couple therapies continued after the first follow-up year, a n d

TABLE 5.3
The Turku Schizophrenia Project.

Comparison of clinical and social follow-up findings in cohorts

of first-admission patients. Only patients diagnosed as "typical

schizophrenia" included (original samples of Cohorts l - l l l )

Outcome variable
Percent Percent
Cohort without Percent without
Year of Size of psychotic fully able disability
No. admission sample symptoms to work pension

I 1965-67 50 38 29 58
(24 mos.)
II 1969 39 27 24 32
(12 mos.)
III 1976-77 56 49 33 44
(19 mos.)

T h e findings are based o n eight-year f o l l o w - u p s of Cohorts I and I I , and o n five­

year f o l l o w - u p o f C o h o r t III.
The percentages are calculated for those patients w h o attended the f o l l o w - u p
e x a m i n a t i o n s (more t h a n 9 0 % in all series). In this patient group, there w e r e 2
suicides in C o h o r t I, 0 in C o h o r t II, a n d 2 in C o h o r t III.
156 SCHIZOPHRENIA

TABLE 5.4
The Turku Schizophrenia Project.

Comparison of clinical and social f o l l o w - u p findings

of first-admission schizophrenic patients diagnosed according to

DSM-III-R (Cohorts III and IV)

Outcome variable
Percent Percent Hospital days
Cohort without Percent without per person
Year of Size of psychotic fully able disability during
No. admission sample symptoms to work pension 5 years

Ill 1976-77 56 38 30 49 272

(19 mos.)
IV 1983-84 30 61 57 82 132
(12 mos.)

Source: A c c o r d i n g t o Lehtinen, 1 9 9 3 b .

The findings are based o n five-year f o l l o w - u p s o f Cohorts III a n d IV.

The percentages are again calculated for t h e patients w h o attended t h e f o l l o w - u p

e x a m i n a t i o n (53 patients in Cohort III, 2 8 patients in C o h o r t IV). There w e r e 2

suicides in C o h o r t HI a n d 1 in C o h o r t IV.

n e w family therapies were rarely begun at later stages of treatment

(Lehtinen, 1993b).
A b o u t 30% of the patients i n Cohort III received satisfactory i n d i ­
v i d u a l therapy. In Cohort IV, this percentage was 20%, a n d the number
of individual-oriented therapies with relatively infrequent sessions
h a d also decreased, as m a n y of the patients h a d discontinued treatment
quite early (Lehtinen, 1993b). It was probably due to the longer i n d i ­
v i d u a l therapies that the outcome i n Cohort III i m p r o v e d slightly from
the two-year follow-up to the five-year follow-up: the number of " t y p i ­
cal schizophrenic patients" without psychotic symptoms increased, i n
accordance with our original estimates, from 41% to 49% (Alanen et al.,
1983, 1986), while the outcome of the patients i n Cohort IV decreased
slightly, the corresponding percentages being 68% and 61% (Alanen et
al., 1991; Lehtinen, 1993a).
M o s t of the psychotherapeutic treatments i n these cohorts were
conducted b y staff members of the public psychiatric organization, i n ­
cluding nurses. The therapeutic activities (especially individual therapy)
were complemented b y psychiatrists and psychologists w o r k i n g in the
 NEED-ADAPTED TREATMENT 1 57

private sector, either because the patients wanted this or because we

intended to provide more intensive therapeutic opportunities for them. I
do not believe, however, that this w i l l restrict in any w a y the conclusions
we can draw o n the basis of our findings concerning the development of
public psychiatric health care. There is everywhere a tendency to i n ­
crease the cooperation between the public a n d the private sectors. In
F i n l a n d it has been legally possible from 1984 onwards for the public
health care system to b u y psychotherapeutic services from the private
sector to supplement inadequate resources.
It can be concluded o n the basis of these observations that the e m ­
phasis placed o n the initial interventions a n d o n the family orientation
seems to have been beneficial. In the light of these findings, the recovery
from a regressive psychotic state, brought about b y early a n d intensive
family-centred treatment, appears to occupy a key role i n the further
development of the treatment of schizophrenic patients i n community
psychiatry. H o w e v e r , the follow-up findings of C o h o r t III also suggest
that long-term i n d i v i d u a l psychotherapy m a y benefit a number of p a ­
tients considerably. This standpoint was further supported b y the results
of the Inter-Scandinavian N I P S Project, described below.
A c c o r d i n g to the follow-up findings reported b y Lehtinen (1993a,
1993b), the outcome of schizophreniform psychoses a n d paranoid
schizophrenias were statistically significantly better i n Cohort IV than i n
C o h o r t III, while n o similar inter-cohort differences were discernible i n
the outcomes of the patients outside these diagnostic categories, i n c l u d ­
ing the hebephrenic ("disorganized") patients. The principle of candour
inherent i n our therapeutic orientation was probably well suited to the
paranoid schizophrenic patients. O u r clinical experiences confirmed the
effectiveness of early initial interventions i n the treatment especially of
acute psychotic states: the psychotic symptoms were alleviated sooner
than they h a d been previously, a n d the inpatient episodes were shorter.
T h e interventions probably also shortened the schizophrenic psychotic
state of some patients, preventing sufficient duration of the psychosis
compatible w i t h DSM-III-R criteria for "schizophrenic disorder".
T h e prognostic findings presented here need to be confirmed b y
further research. T h e investigators of the Clinic have n o w begun a n e w
cohort research project (see Table 5.1). It w i l l take place at a time w h e n
the activities of the T u r k u M e n t a l Health District have been sectorized.
T h e family-centred orientation has become well established, but the
findings w i l l not be influenced b y the k i n d of special stimuli involved i n
the initial enthusiasm present i n Cohort IV.
158 SCHIZOPHRENIA

Other observations on factors affecting prognosis

and treatability

T h e f o l l o w - u p study of C o h o r t III also i n c l u d e d a n assessment of the

clinical, psychosocial, a n d therapeutic factors that most affected the
patients' outcome i n the light of a logistic regression analysis. W h e n
this w a s measured o n the f o u r - d i m e n s i o n a l prognostic scale of
Strauss a n d Carpenter, the g o o d prognosis of " t y p i c a l s c h i z o p h r e n ­
i c s " w a s explained b y the following variables i n a decreasing order of
importance ( A l a n e n et al., 1986):

1. the patient h a d received less neuroleptic m e d i c a t i o n than the

average d u r i n g the f o l l o w - u p ;

2. the initial examination h a d s h o w n the patient to h a v e at least one

empathic relative;

3. the patient w a s female; a n d

4. the patient h a d been i n long-term i n d i v i d u a l therapy.

In a larger series, w h i c h also i n c l u d e d the m i l d e r disorders of the

s c h i z o p h r e n i a g r o u p , the first three variables were the same, a n d the
fourth variable w a s that the patient h a d been e m p l o y e d at the time of
admission.
The amount of neuroleptic medication given to the patients d u r i n g
the follow-up naturally correlated with the clinical severity of their i l l ­
ness. It was, however, interesting that the severity of the patient's illness
d i d not emerge as an explaining variable in the logistic regression analy­
sis but was " c o v e r e d " i n the analysis b y the neuroleptic variable. W e
interpreted this finding as being related to the effects of the therapeutic
approach as a whole: the patients treated predominantfy psychopharma­
cologically were not engaged i n psychotherapy, whereas the psycho­
therapeutic treatment, on the other hand, h a d a diminishing effect o n the
need of neuroleptics, particularly towards the end of follow-up period.
Moreover, treatment including less neuroleptic medication than was the
average d u r i n g the follow-up retained its extremely strong statistical
significance (p = .001) w h e n we tried to level off i n the logistic regression
analysis the influence of the background variables that h a d the most
notable effect o n the outcome—i.e. Items 2 a n d 3 above. The favourable
effect of the psychotherapy variable o n the prognosis of typical schizo­
phrenic patients, o n the other h a n d , was only marginally significant (p =
0.068) i n that analysis (Alanen et al., 1986).
 NEED-ADAPTED TREATMENT 1 59

The better prognosis for w o m e n than for m e n has also been pointed
out i n m a n y other studies o n the prognosis of schizophrenia (Goldstein
& Tsuang, 1990; Salokangas, 1983). In our o w n study, the difference was
probably further enhanced b y the fact that we were more successful i n
enrolling female patients than males i n psychotherapy. M a l e gender
turned out to be one factor that contributed to the patients' exclusion
from all psychotherapeutic activities i n Cohort III. Other similar factors
i n c l u d e d belonging to the paranoid subgroup, absence of depressive
symptoms, a tendency to alcohol abuse or other addiction, and l o w basic
education.
The follow-up of Cohort IV d i d not involve statistical analyses of this
k i n d . It c o u l d be concluded, however, that the increase i n family ther­
apies reduced the number of patients left outside psychotherapeutic
treatment; m a n y of the patients w h o lacked motivation for i n d i v i d u a l
therapy were n o w i n v o l v e d i n family therapy.

The Finnish National Schizophrenia Project

A national p r o g r a m m e for d e v e l o p i n g the s t u d y , treatment, a n d re­

habilitation of schizophrenic patients organized b y the N a t i o n a l
B o a r d of H e a l t h , the A s s o c i a t i o n of M e n t a l H o s p i t a l s , a n d the L e a g u e
of H o s p i t a l s w a s carried out i n F i n l a n d d u r i n g 1981-87 (Alanen et al.,
1990a, 1990b; State M e d i c a l B o a r d i n F i n l a n d , 1988; T u o r i et al., 1997).
T h e a i m of the p r o g r a m m e w a s to m i n i m i z e the hospital orientation
of treatment, w i t h the special goal of r e d u c i n g the n u m b e r of b o t h
n e w a n d o l d l o n g - t e r m schizophrenic patients i n institutions b y half
d u r i n g a p e r i o d of ten years. I acted as the leader of the p r o g r a m m e
t h r o u g h o u t its implementation.
A more comprehensive description of the results of the programme
appears elsewhere (Tuori et al., 1997). F r o m the viewpoint of this book,
the N S P (New Schizophrenic Patients) Project—one of the two m a i n sub­
projects of the national p r o g r a m m e — i s interesting, because it p r o v i d e d
us w i t h a n opportunity to apply our treatment orientation i n the larger
c o m m u n i t y psychiatric context. The developmental w o r k of this project
was coordinated b y Viljo Rakkolainen a n d the research b y Raimo
Salokangas, w i t h me as a supervisor.
The project was accomplished i n six districts (see Figure 5.2). O f
these, the N o r t h e r n Carelia and N o r t h e r n Savo districts (both located i n
FIGURE 5.2. Districts participating in NSP Project.
 N E E D - A D A P T E D TREATMENT 1 61

eastern Finland) and the M i d d l e Finland district represented the less

wealthy parts of the country, as well as the regions w i t h notably h i g h
numbers of schizophrenic inpatients. The Western Satakunta district is
located i n rural western Finland, whereas the T u r k u and H e l s i n k i dis­
tricts (the latter represented by one part—the Service District of Eastern
Helsinki) constituted the urban environments of southern Finland. The
T u r k u N S P population consisted of Cohort IV described earlier.
T h e districts that participated account for a population of about 1.1
m i l l i o n , w h i c h is more than one fifth of the total population of Finland.
T h e y were mainly selected through their o w n interest, but they were
found to represent rather well the whole of Finland as to their p o p u l a ­
tion structure, degree of urbanization, occupational structure, degree of
unemployment, income level, and availability of public psychiatric serv­
ices. T h e availability of private psychiatric services was higher than
normal, because H e l s i n k i and T u r k u were included. Geographically
speaking, the sample was inadequate i n that it d i d not include any parts
of northern F i n l a n d (Salokangas, Steng&rd, R a k k o l a i n e n , et al., 1991).
The goals of the treatment activities were defined mainly o n the basis
of the experiences obtained i n T u r k u :

1. Treatment w a s to be integrated a n d case-specifically need­

adapted. Its progress was to be followed a n d the treatment plans
revised a n d altered, if the situation required it.

2. Treatment was to be based o n psychotherapeutic a n d f a m i l y ­

oriented principles.

3. A t the b e g i n n i n g of the treatment, a n interactional analysis of the

need for treatment was to be m a d e b y arranging therapy meetings
attended b y the patient, h i s / h e r family members or other people
close to the patient, a n d the team responsible for treatment.
4. T h e treatment was to a i m at outpatient care.
5. T h e role of m e d i c a t i o n was to be kept small.

6. Rehabilitative activities were to be considered at the initial stage

of treatment.

Each of the participating districts set u p a project organization with a

coordinator and contact persons, who attended the seminar arranged
before the beginning of the project and the w o r k i n g meetings arranged
d u r i n g its course. A l t h o u g h the goal of the project was to attain the
defined treatment practices, it was simultaneously emphasized that the
162 SCHIZOPHRENIA

w o r k towards innovative treatment should not be inflexible but should,

rather, proceed from the existing local traditions of care. A c c o r d i n g l y ,
there were differences of treatment practices i n the different districts.
The treatment n a m e d b y the staff as most important for schizophrenic
patients was family therapy i n T u r k u , d r u g treatment i n N o r t h e r n
Carelia, and i n d i v i d u a l therapeutic relationships i n the remaining four
districts (Salokangas et al., 1987,1991).
The patient sample of the project covered all the patients aged 16-45
years w i t h a psychotic disorder that fulfilled certain diagnostic criteria
w h o were admitted for the first time into any of the public mental health
care units i n each participating district during 12 months i n 1983-84. The
diagnostic delineation was according to DSM-III criteria (American Psy­
chiatric Association, 1980) i n such a w a y that schizophrenic disorders
and schizophreniform psychoses were included. The schizoaffective
psychoses based o n R D C criteria (Spitzer, Endicott, & Robins, 1975)
were also included, but their number remained small. A t the basic study
stage, the whole N S P Project covered 227 patients (an annual incidence
of 20.2 per 100,000 inhabitants; regional 16-23); 162 patients were d i a g ­
nosed as suffering from a schizophrenic disorder (incidence 14.4), 58
suffered from schizophreniform psychosis, a n d 7 from schizoaffective
psychosis (Salokangas et al., 1987,1991).
The regional teams, w h i c h were responsible for the basic examina­
tion of the patients, managed to carry out a two-year follow-up check o n
183 patients (84% of those surviving) a n d a five-year follow-up o n 180
patients (84.5% of those surviving). By that time, 14 patients h a d d i e d , 9
of them through suicide a n d 4 i n accidents with suicidal implications
(Salokangas et al., 1991).
The five-year follow-up findings obtained i n the different districts i n
the N S P Project are presented i n Table 5.5. The percentages have been
calculated for the patients w h o attended the follow-up examinations.
The loss i n the whole population was 15.5%. The G A S (Global Assess­
ment Scale) scores refer to an assessment of the patient's functional
status o n a scale of 0-9, where a h i g h value implies a good functional
status.
T h e differences between the districts were not very great. W h e n the
effect of the background variables that most significantly influenced
the outcome was controlled i n the statistical analysis, the T u r k u series
differed from the rest of the population i n h a v i n g better G A S scores
a n d fewer patients o n pensions i n the five-year follow-up. The H e l s i n k i
series also differed favourably from the other districts i n the social p r o g ­
 C

I 5 w ^

C gj fcn c no CO m O) <N CO <D

M ^ N O t « ­ CO
4—• < ^5 r­ CM r­ C N —
r r­

c
E

T— o r\ <N co
co o w L O ^ LO

E o

u £
if) FT <u , <TS

CL r\ ^j­ r­ o ro fO
±1 Q_ U <£) (N LO CN (N <N
co CO *C
a;
i_
JZ
CL
O
N
to
In
u 5 r- q oq C N
LO L O L O L O L O L O
v>
C
0> 2 w

-g
»—
f-
O
a>
E
o O r- l/l N m
LO

u \D \D \£> \D ir>
ro ^* T O LO co
4
•—* ro ro CN m LO ro
o CM

rC
c
^= o
t ro c a;
> to
c
I c
—
13 11 o
Z
164 SCHIZOPHRENIA

nosis; the difference i n maintaining work capacity was significant, which

is interesting because relatively many of the Helsinki patients continued
w i t h psychotic symptoms. This suggests that an urban environment is
more beneficial i n this respect than a rural environment. T h e
psychosocial outcome was clearly less favourable i n the rural districts
(Salokangas et al., 1991).
The percentage of patients not receiving any treatment at the time of
the five-year follow-up was highest i n T u r k u (54.8%, while the figures
for the other districts ranged from 11.4% to 33.9%). This was related to
the relatively good outcome of the T u r k u patients, but also to the fact
that the series included—as already mentioned earlier—a few patients
w h o h a d d r o p p e d out of treatment too early. Generally, the need for
treatment not actually given was found to have increased i n all the
districts over the follow-up period.
T h e family-oriented initial session, where members of the patient's
family were present together w i t h the patient, was arranged i n 70% of all
cases. This shows that the family members were quite often motivated to
meet the therapeutic team at this stage, despite occasional long dis­
tances. It was an unexpected finding that 72% of the patients were i n
need of rehabilitation a n d sociotherapy at the time admission. This need
was most notable i n the districts of central a n d eastern Finland. T h e
modes of rehabilitation and sociotherapy most frequently needed were
social interaction practice, vocational guidance, and assistance in finding
jobs.
T h e amount of neuroleptic medication used was clearly smaller i n
T u r k u than i n the other districts, from early stages onward. A t the end of
the five-year follow-up, more than 60% of the T u r k u patients were w i t h ­
out neuroleptics, while the corresponding number was 25% i n the whole
N P S series. It was interesting to note that inpatient treatment was least
c o m m o n d u r i n g the five-year period i n the two districts—Northern
Carelia a n d T u r k u , see Table 5.5—which differed the most with regard
to d r u g treatment. O n e reason for the situation prevailing i n N o r t h e r n
Carelia was a well-established practice of active home care. Neither this,
nor the high-level neuroleptic medication, however, resulted i n g o o d
outcome i n other respects.
In the light of statistical analyses, the good outcome i n the N S P study
was predicted best b y good working capacity a n d w o r k i n g situation, a
g o o d functional status, and a grip o n life at the initial examination (see
Salokangas et al., 1989), the presence of a heterosexual relationship, a n d
acute onset of the illness (Salokangas et al., 1991). After these predictor
 NEED-ADAPTE D TREATMEN T 165

variables h a d been taken into account, the effect of treatments o n the

outcome was insignificant i n the five-year follow-up. The only exception
was family therapy with the p r i m a r y family, w h i c h was significantly
related to the scarcity of negative symptoms of schizophrenia.
It is difficult to compare the prognostic findings of the N S P Project
w i t h those of other studies, because different evaluative criteria have
been used i n the different studies. T h e N S P Project—which was carried
out as action research—also h a d its methodological shortcomings,
i n c l u d i n g the fact that the patients' condition was assessed b y the
same teams that were responsible for their treatment. T h e findings can,
however, be considered relatively favourable w h e n compared w i t h cor­
responding recent international projects. The N S P Project is best c o m p a ­
rable with projects that are similar to it i n that they include first-episode
schizophrenic patients. There are three recent E u r o p e a n studies that,
similarly to the N S P Project, dealt with unselected patients treated i n
c o m m u n i t y psychiatry over a five-year follow-up, namely those c o n ­
ducted i n M a n n h e i m , G e r m a n y (Schubart, K r u m m , B i e h l , & S c h w a r z ,
1986; Biehl et al., 1986), Buckinghamshire, E n g l a n d (Watt, K a t z , & S h e p ­
h e r d , 1983; Shepherd et al., 1989), a n d Scotland (Scottish Schizophrenia
Research G r o u p , 1987,1992). T o these, the T u r k u Cohort III (Alanen et
al., 1986) as well as the Inter-Scandinavian N I P S study (Alanen et al.,
1994) described below can also be a d d e d .

T h e E n g l i s h a n d G e r m a n studies refer to themselves as presenting

findings o n the " n a t u r a l course" of first-episode schizophrenics, i m p l y ­
i n g that these patients have been given " u s u a l " treatment a n d services.
T h e Scottish—and initially also the English—project i n c l u d e d a thera­
peutic trial o n the use of two different neuroleptic drugs. N o n e of these
projects was psychotherapeutically oriented.
The outcome of psychotic symptoms is relatively good i n all of these
studies: only about 50% of the patients were symptomatic u p o n follow­
u p . W i t h regard to the social prognostic criteria, 57% of the E n g l i s h
patients h a d " m i n i m a l or m i l d " impairment, while 26% of the G e r m a n
patients h a d " g o o d , s o u n d adjustment", 39% "intermediate", a n d 35%
" p o o r " . O f the Scottish patients, only 19% were i n o p e n employment
after 5 years. In the light of Table 5.5, the social outcome of the F i n n i s h
N S P series as a whole c o u l d perhaps be characterized as intermediate
c o m p a r e d w i t h the results of these E u r o p e a n studies, the T u r k u a n d
H e l s i n k i patients representing an exception for the better. T h e mean
duration of total stay i n hospital d u r i n g follow-up was 26 weeks (182
days) for the English first-admitted patients—almost exactly the same as
166 SCHIZOPHRENIA

that for the N P S patients as a whole (see Table 5.5)—while it was about
9 months (270 days) for the G e r m a n series and 272 days for the T u r k u
Cohort III.
T h e N S P findings indicated that the therapeutic orientation devel­
o p e d b y us was also applicable elsewhere i n F i n l a n d and that it seemed
to i m p r o v e the outcome of schizophrenia. The prognostic findings d o
not, however, justify any further conclusions concerning the influence of
the orientation, because the qualitative resources for psychotherapeutic
activities were poor and the implementation of family-oriented activities
was only beginning i n most districts. In addition to this, the active
period of treatment was often too short i n all districts because of limited
resources. M a n y of the patients w o u l d have needed notably more inten­
sive psychotherapy than was offered.
T h e number of long-stay schizophrenic inpatients i n Finnish p s y c h i ­
atric hospitals declined 63% from 1982 to 1992. A t the same time the
n u m b e r of staff i n outpatient care h a d risen from 2.7 to 5.1 per 10,000
inhabitants. A summary of the results of the ten-year evaluation of the
N a t i o n a l Schizophrenia Project is presented in Table 5.6 (Tuori et al.,
1997).

TABLE 5.6
The Finnish National Schizophrenia Project.

A c h i e v e m e n t of the national goals

Number at end-of- Years Decrease

year patient count 1982 1986 1990 1992 1982-1992

New long-term 406 348 161 60%

schizophrenic patients
Old long-term 5,687 4,419 3,083 1,822 68%
schizophrenic patients
Psychiatric hospital 17,368 13,641 10,026 7,401 67%
patients, total
Psychiatric hospital 19,692 16,460 12,336 9,730 51%
beds, total

Source: According to Tuori et al., 1997.

Note: In proportion to population, the number of psychiatric beds decreased
from 4.1 per mil in 1982 to 1.9 per mil in 1992. The number of staff working in
psychiatric outpatient care increased from 2.7 per 1,000 inhabitants in 1982 to 5.1
per 1,000 inhabitants in 1992.
 NEED-ADAPTED TREATMENT 1 67

The Inter-Scandinavian NIPS Project

T h e T u r k u district also participated i n the Scandinavian project o n

the development a n d research of the psychotherapeutic treatment of
schizophrenia (Nordic Investigation on Psychotherapy of Schizophrenia,
NIPS: A l a n e n et al., 1994), using Cohort IV i n the same way as i n the N S P
Project. The other regions participating i n the project were U p p s a l a a n d
its environs i n Sweden (headed b y Rolf Sjostrom), part of Oslo i n N o r ­
w a y (Endre Ugelstad), a n d Roskilde and its environs i n D e n m a r k (Bent
Rosenbaum). A l l these centres used the same diagnostic criteria to collect
an unselected population of first-episode schizophrenia group patients
admitted to public mental health units i n their catchment area, o n w h o m
the initial a n d follow-up examination were made using standardized
research forms.
The therapeutic orientations were notably different, though they
were all based o n psychodynamic principles. T h e D a n i s h project was
oriented towards i n d i v i d u a l therapy, focusing o n outpatient care. T h e
Swedish project was also individual-therapeutic, but it favoured l o n g ­
term m i l i e u therapy o n a hospital w a r d . N o r w a y advocated long-term
psychodynamic-supportive individual therapy supplemented with fam­
ily therapy w h e n necessary. Finland used o u r m o d e l of need-adapted
treatment emphasizing initial family-oriented interventions, while the
n u m b e r of i n d i v i d u a l therapies was relatively small.
A t the stage of processing the results, the project was joined b y Bengt-
Ake A r m e l i u s (Umea, Sweden) as an outside researcher, w h o carried out
the statistical analysis of the five-year follow-up findings.
A m o n o g r a p h w a s recently p u b l i s h e d o n the findings of the
project ( A l a n e n et a l . , 1994). T h e central prognostic findings are
s h o w n i n F i g u r e 5.3, w h e r e the five-year f o l l o w - u p findings o n the
w h o l e p o p u l a t i o n (n originally = 63; at f o l l o w - u p = 57) h a v e been
categorized i n accordance w i t h the Strauss a n d Carpenter scale
(Strauss & C a r p e n t e r , 1972). T h e figure shows the n u m b e r of patients
f o u n d to fill the d e m a n d s of the best categories i n each item. F u r t h e r ­
m o r e , the n u m b e r of patients without neuroleptic m e d i c a t i o n at the
e n d of f o l l o w - u p is also s h o w n . T h e s h a d o w e d c o l u m n indicates the
f i n d i n g s o n the w h o l e p o p u l a t i o n a n d the black c o l u m n the findings
o n the nuclear g r o u p of schizophrenics ( D S M - I I I - R diagnosis schizo­
p h r e n i c disorder, n at f o l l o w - u p = 41).
A b o u t half of the patients h a d n o psychotic symptoms (even 39% of
those diagnosed as h a v i n g a schizophrenic disorder), and a similar p r o ­
168 SCHIZOPHRENIA

Percent of patients at follow-up

Good social
relations

Working

No symptoms
No psychosis

diagnosis

No neuroleptics

No hospital care

FIGURE 5.3 Five-year follow-up findings of the NIPS Project. Shaded

columns indicate findings in the whole patient series (n = 57), black
columns those of patients with a DSM-III-R diagnosis schizophrenic
disorder (n = 41). (Alanen et al., 1994.)

portion were able to work. Clearly more than half h a d retained good or
satisfactory social relationships. The proportion of patients w h o h a d
received hospital treatment d u r i n g the last follow-up year (see the l o w ­
est c o l u m n i n Figure 5.3) was slightly increased b y the prolonged
institutional care of the Swedish project (then carried out i n a treatment
h o m e located i n an ordinary residential area).
C o m p a r e d with other studies (Biehl et al., 1986; Scottish Schizophre­
n i a Research G r o u p , 1992; Shepherd et al., 1989) referred to above, it
must be remembered that a considerably smaller proportion of the NIPS
patients than those i n the other studies received neuroleptic treatment
d u r i n g the five-year follow-up phase. A t this stage, more than half—that
is, 56%—of our patients were without neuroleptic medication (as m a n y
as 46% of those with a schizophrenic disorder), and only 8 patients (14%
of the whole series) h a d daily doses of neuroleptics corresponding to
more than 250 m g chlorpromazine equivalents per day. A s m a n y as 79%
of the patients i n the Scottish study, for example, were o n antipsychotic
medication d u r i n g the last follow-up year. It is well k n o w n that these
drugs m a y suppress particularly the positive symptoms of schizo­
phrenia a n d are often recommended for continuous maintenance
treatment. In the NIPS Project, however, the goal was to improve the
patients' condition sufficiently to render antipsychotic medication u n ­
necessary.
 NEED-ADAPTED TREATMENT 169

The regression analysis b y Armelius (in A l a n e n et al., 1994) indicated

that almost 70% of the variance i n outcome of the NIPS patients was
influenced b y the effects of the patient's status at intake and the diagnos­
tic subgroup to w h i c h h e / s h e belonged. W h e n these variables were
taken into account, the differences i n treatment represented only an a d d i ­
tional 18% of the outcome (which, it should be remembered, was psycho­
therapeutically oriented in all regions). If we assume that the early a n d
intensive treatment practised especially i n T u r k u prevented some of the
patients with an initial diagnosis of schizophreniform psychosis from
fulfilling the criteria for schizophrenic disorder later on, the impact of the
treatment variable o n the outcome should be estimated to be somewhat
higher.
A t the e n d of the NIPS Project we concluded that psychotherapeutic
modes of treatment i n this study d i d affect the outcome, but that this
effect should not be exaggerated, because the effects of the other v a r i ­
ables were greater. However, even if we attain only relatively modest
changes i n the number of the patients w h o recover fully b y early p s y ­
chotherapeutic treatment—which m a y be an increase of 10-20%—this
w i l l have a considerable economic and quality-of-life impact in the long
run.
The follow-up results of the Finnish sub-project i n the NIPS were
better than those of the others, but a regression analysis showed this to be
due to the fact that our population included more patients with a diagno­
sis of schizophreniform psychosis than d i d the other sub-populations,
resulting—in addition to the probable effects of our intensive initial stage
of treatment—from the fact that the diagnostic criteria, despite our at­
tempts at m a k i n g them uniform, apparently continued to be stricter for
them (especially for the Swedish group), i n accordance with Scandin­
avian traditions.
The treatment model as defined i n the monograph based on the NIPS
Project experiences (Alanen et al., 1994) ascribed crucial significance to
intensive family-oriented interventions at the initial stage. It was further
emphasized that the results of long-term individual psychotherapy i n
the NIPS Project were shown b y regression analysis to be o n the whole
gratifying, contradicting adverse opinions based o n earlier studies (see
chapter four) regarding its usefulness. Psychodynamically oriented sup­
portive psychotherapy with a low frequency of sessions, practised b y
committed therapists (especially i n the Norwegian project), showed re­
sults that were as good as more insight-oriented techniques. Outpatient
care was recommended as a priority, but patients requiring long-term
170 SCHIZOPHRENIA

treatment also seemed to benefit from therapeutic communities. T h e

authors also emphasized the need for psychosocial rehabilitation in first­
episode patients addressing problems with social relationships, employ­
ment, a n d lodging, as well as developing daily living skills.

Concept and principles of need-adapted treatment

T h e term " n e e d - a d a p t e d treatment", w h i c h denotes o u r therapeutic

orientation, w a s inspired b y the heterogeneity a n d uniqueness of
therapeutic needs of each schizophrenic patient. T h e term has also
been criticized. W e have been asked, for example, w h a t w e m e a n b y
" n e e d s " a n d h o w w e c a n define the needs i n each case. W e d o not
speak of needs i n terms of philosophical or social psychological p h e ­
n o m e n a , b u t as a clinical concept that describes w h a t is needed for a
particular patient.
U n a m b i g u o u s definition of therapeutic needs is not easy, nor are
tests or check-lists for the assessment of such needs useful. What we are
proposing is a hermeneutic approach: a psychological understanding of
problems a n d the therapeutic situation a n d acting o n the basis of this
understanding. Aaltonen and Rakkolainen (1994) developed the concept
of " s h a r e d mental representation guiding the therapeutic process",
w h i c h they consider a prerequisite for achieving integrated treatment of
schizophrenia. By this they mean the understanding shared b y the thera­
peutic team concerning the patient's situation and the significance of
h i s / h e r symptoms. It may happen i n successful therapy meetings that a
shared understanding—though often at different levels—is achieved b y
the team a n d the patient together with the family members, a n d this
helps to alleviate the psychotic condition.
A significant part of the understanding comes from realizing that the
treatment is a process, where the needs m a y also change. O u r w i s h to
emphasize this point was the reason w h y we gave u p the term " n e e d ­
specific treatment" (Alanen et al., 1986), and replaced it with the more
flexible term "need-adapted treatment" (Alanen et al., 1991).
A further justification for the term "need-adapted treatment" is the
fact that, as far as I can see, few schizophrenic patients are currently
receiving the k i n d of treatment that they need. Conversely, m a n y are
being given treatment that they do not need, such as excessive use of
neuroleptic drugs. T h e concept of "need-adapted treatment" also i m ­
plies that unnecessary treatments are avoided.
 NEED-ADAPTED TREATMENT 1 71

General principles
of need-adapted treatment

T h e general principles of o u r therapeutic orientation can be expressed

i n terms of four m a x i m s ( A l a n e n et a l . , 1991; A l a n e n , 1992).

1. The therapeutic activities are planned and carried out flexibly and indi­
vidually in each case, so that they meet the real, c h a n g i n g needs of the
patients as w e l l as of the people m a k i n g u p their personal inter­
actional networks; it is therefore important to assess b o t h the p a ­
tient's subjective clinical, psychological, a n d social c o n d i t i o n a n d to
evaluate the p s y c h o l o g i c a l c o n d i t i o n of the family or other essential
interactional networks to w h i c h h e / s h e belongs.
The family-centred investigation of the therapeutic needs is indicated
i n order to alleviate the strains that the outbreak of a psychosis a n d the
continued psychotic behaviour are likely to arouse i n the family m e m ­
bers. Furthermore, the interactional approach is of utmost importance i n
the p l a n n i n g of treatment, because the treatment of schizophrenic p a ­
tients is, to a great extent, dependent o n the quality of the interpersonal
relationships prevailing i n their close environment. The reason for this
is the patient's p r i m a r y a n d secondary—illness-induced—dependence
o n others, a n d frequently also the dependence of others o n the patient
through intrafamilial psychodynamic processes, such as mutual s y m ­
biotic relationships a n d related introjective-projective processes.
It is therefore necessary i n the initial examination both to search for
the possible presence of such psychodynamics and to note the needs of
the patient and the other family members (and occasionally of other
individuals close to the patient) to get help i n a difficult life situation.
The positive resources brought out b y them should be noted a n d taken
into account while p l a n n i n g the treatment. The subsequent orientation
of the treatment i n either an individual-therapeutic or a family-thera­
peutic direction is largely determined b y this initial investigation. A
systemic evaluation of the situation is best achieved through joint
therapy meetings described below.
The patient's social situation and the need for measures to improve it
should also be considered u p o n admission.

2. Examination and treatment are dominated by a psychotherapeutic

attitude.
"Psychotherapeutic attitude" refers to an attempt to understand
what has happened and is happening to patients and the people i n their
172 SCHIZOPHRENIA

interpersonal network and how we can use this understanding as a basis

for approaching and helping them. Sullivan (1954) called investigators
a n d / o r therapists with such an attitude participant-observers because
they try to approach the patients i n an empathic w a y , b u t simultane­
ously retaining an external attitude that allows ego-level observation
a n d helps the observer to keep the necessary separateness.
A n attitude of this kind essentially also involves observation of one's
o w n emotional reactions. A s Searles (1965), Benedetti (1985), Boyer
(1986,1989), a n d Herbert Rosenfeld (1987), among others, have repeat­
edly emphasized, the therapist's countertransference is critically i m p o r ­
tant i n the treatment of schizophrenic patients. This attitude serves as the
basis i n the planning a n d implementation of all treatments, including
psychopharmacological regimes.

3. Different therapeutic approaches should supplement each other rather

than constituting an "either / or" approach.
Therapeutic activities should be integrated with one another, w h i c h
is as essential for psychotherapeutic and psychopharmacological modes
as it is for the various psychotherapeutic modalities. A further prerequi­
site for integration is cooperation between different persons and units
responsible for the treatment of a patient, including appropriate aware­
ness of the course of therapeutic activities, yet retaining the confidential­
ity necessary i n particularly individual therapies.

4. The treatment should attain and maintain the quality of a continuous

process.
This means that the treatment must be conceived of as a develop­
mental event, a continuous interactional process, w h i c h should not be
allowed to decline into a routine sequence of sessions. Optimally, the
process activates internal development a n d new capacity for interper­
sonal relationships. Naturally, setbacks are possible, but i n a continuous
process they are generally less serious than the patient's previous crises
and m a y occasionally be a necessary prerequisite for progress (a fact not
w i d e l y recognized b y psychiatrists).
The process quality of treatment can be maintained, if its course a n d
outcomes are monitored and evaluated, with the consequent possibility
of changing treatment plans. In hospitals, this is best done b y arranging
new therapy meetings. T h e y are often also useful i n crises encountered
in outpatient relationships. In i n d i v i d u a l therapy, follow-up is best
assisted b y supervision o r — i f no supervision is available—discussions
with colleagues w h e n necessary.
 NEED-ADAPTE D TREATMEN T 1 73

5. Follow-up of the individual patients and of the efficacy of the treatment

methods is also important for the evaluation a n d d e v e l o p m e n t of the
f u n c t i o n i n g of the w h o l e therapeutic system. In his m o n o g r a p h d e a l ­
i n g w i t h f a m i l y therapy a n d schizophrenia, K l a u s L e h t i n e n (1993b)
a d d e d this p o i n t as the fifth general p r i n c i p l e to the four presented
above.
These principles are closely related to each other. Need-adapted
treatment is not possible unless they are all observed.

Progression of need-adapted treatment

and the weighting of different modes of treatment

W h e n therapy meetings became the central starting-point for o u r

activities, as systemic t h i n k i n g gained g r o u n d , our t e a m p r o d u c e d a
d i a g r a m (Figure 5.4) to represent the u s u a l relative w e i g h t i n g of the
psychotherapeutically oriented m o d e s of treatment a p p l i e d d u r i n g
the course of n e e d - a d a p t e d treatment of schizophrenic psychoses. In
a d d i t i o n to s c h i z o p h r e n i a , the d i a g r a m can also be a p p l i e d to other
functional psychoses i n c l u d e d i n the s c h i z o p h r e n i a s p e c t r u m (esp.
p a r a n o i d psychoses a n d acute psychotic disorders).
In Figure 5.4 the primary therapeutic concern is indicated. This does
not exclude the possibility that other treatment modes should also be
used at the same time: o n the contrary, it is quite c o m m o n that the
patient has an i n d i v i d u a l therapeutic relationship along with attending
family t h e r a p y — i n psychotherapeutic communities this is the r u l e — b u t
the focus of treatment m a y first be o n family therapy a n d only m o v e
over to i n d i v i d u a l therapy w h e n the basis for successful i n d i v i d u a l
therapeutic relationships has been created through family therapy.
The bottom of the diagram represents the starting-point, the initial
analysis u p o n admission, w h i c h is achieved mainly through therapeutic
meetings. The shaded vertical arrows indicate h o w the focus of treat­
ment subsequently shifts, differently for different patients, from one
m o d e of treatment to another, while the light diagonal arrows indicate
the termination of treatment, w h i c h — a s shown b y the diagram—is pos­
sible at all stages.
Figure 5.4 must not be interpreted too literally. N e e d adaptation m a y
occasionally require that the therapeutic focus is shifted i n a direction
opposite to that indicated b y the arrows: if, for example, a patient u n d e r ­
going i n d i v i d u a l therapy becomes i n v o l v e d i n a permanent couple
174 SCHIZOPHRENIA

MODE OF THERAPY COURSE OF THERAPY

Individual

therapy

\ rene Jed therd^ meetings

Therapy of the

family of procreation

Therapy of the

family of origin

Psychotherapeutic

community

Family-and envir­

onment-centered

crisis intervention

Initial
investigation social situation,
in the first family situation,
therapy meeting individual state
of the patient

FIGURE5,4. The usual weighting of psychotherapeutic modes of treat­

ment during the course of need-adapted treatment.

relationship, it m a y be indicated that the patient should be met together

w i t h his or her partner. O r it may turn out that the decision concerning
the m o d e of treatment was not successful after all—that it m a y be best to
discontinue individual therapy and resume joint meetings. It is certainly
not easy i n all cases to achieve adequate psychological understanding of
the situation i n which the patient and the people close to h i m / h e r l i v e —
this process m a y take a l o n g time.
In general, the following principle is valid: w h e n several modes of
treatment are needed, it is usually expedient to proceed from the less
specific family- or environment-oriented modes to the more specific i n ­
dividual-focused ones. This major trend in shifting the focus of treatment
is s h o w n i n Figure 5.4. This figure was designed based o n experience
w i t h first-admission patients of the schizophrenia group. It is, however,
also applicable w h e n the patient is re-admitted or discharged into out­
 NEED-ADAPTED TREATMENT 1 75

patient care. In such cases the m o d e of treatment is quite often chosen o n

the basis of previous experience—especially if the patient has a n existing
therapeutic relationship—but a therapy meeting is, nevertheless, i n d i ­
cated i n order to re-assess the situation and achieve therapeutic integra­
tion.

Initial examination and beginning of treatment:

therapy meetings

E x a m i n a t i o n a n d treatment always merge into a n inseparable w h o l e

i n p s y c h i a t r y . T h e attitudes a n d definitions that patients face i n the
initial e x a m i n a t i o n w i l l have a significant impact o n their expecta­
tions r e g a r d i n g the therapeutic staff a n d o n the attitudes towards
them. M a r t t i Siirala (1986) once aptly p u t this into a few w o r d s : the
illness a n d the w a y it is encountered equals the illness at its next
stage.
The therapy meeting (Alanen et al., 1991; Rakkolainen et al., 1991)
constitutes the most central part of the initial examination, a n d it is also
the part that is therapeutically the most i m p o r t a n t A p a r t from being
diagnostically important—with the diagnosis of the therapeutic needs as
the core of the procedure—it also begins crisis intervention, w h i c h is
often continued b y arranging new joint meetings over the next few days.
The functions of the therapy meeting can be summarized as follows:

1. O b t a i n i n g a n d s h a r i n g information o n factors associated w i t h

the manifestation a n d stages of the patient's illness a n d h i s / h e r
a d m i s s i o n for treatment: informative function.

2. A chance to examine the family d y n a m i c s in vivo a n d to diagnose

therapeutic needs o n the basis of a n interactional interpretation of
the situation: diagnostic function,

3. A chance to give s u p p o r t to the patient a n d the family m e m b e r s

right f r o m the b e g i n n i n g : therapeutic function.

D e p e n d i n g o n case-specific circumstances, the therapeutic signifi­

cance of the meetings is enhanced b y the f o l l o w i n g a d d i t i o n a l factors:

4. T h e meetings m a k e it possible to observe directly the topical

p r o b l e m s a n d controversies i n the interactional relationships,
176 SCHIZOPHRENIA

s u c h as reactions to the patient's a d m i s s i o n into hospital a n d the

p a r a n o i d attitudes that m a y be i n v o l v e d . A p r e l i m i n a r y w o r k i n g ­
t h r o u g h of this k i n d of p r o b l e m is thus m a d e possible.

5. T h e y m i n i m i z e the experiences of rejection felt b y the patient

admitted into hospital a n d make it easier for h i m / h e r to m a i n t a i n
the existing interpersonal relationships outside the hospital.

6. T h e y often lessen the tendency to label the patient as i l l a n d the

consequent psychological isolation h e / s h e m a y experience (see
" c l o s u r e " , as described b y Scott & A s h w o r t h , 1967).

7. A c c o r d i n g to our experiences, these meetings also often alleviate the

patient's psychotic regression; I think that this m a y be due to two
ostensibly opposite factors:

a. the adult side of the patient is s u p p o r t e d t h r o u g h listening a n d

attending to h i m / h e r at the same level as the other participants
i n the meeting;

b. the meeting is likely to satisfy the symbiotic needs of b o t h

patient a n d parent(s).

8. The meetings motivate family members to attend family-focused

treatment at later stages, whenever such treatment is indicated.

If possible, the first therapy meeting s h o u l d be arranged e v e n before

the patient is registered as an inpatient. In the T u r k u M e n t a l H e a l t h
District this is carried out b y the team w o r k i n g i n the a d m i s s i o n clinic
jointly maintained b y the hospitals. In m a n y other districts i n F i n ­
l a n d , the therapy meetings are arranged b y acute psychosis teams (see
chapter seven), r e c o m m e n d e d b y the F i n n i s h N a t i o n a l S c h i z o p h r e n i a
Project ( A l a n e n et al., 1990a) a n d w o r k i n g i n the M e n t a l H e a l t h O f ­
fices. Patients w h o have been admitted as emergencies d u r i n g the
n i g h t are met o n the following m o r n i n g together w i t h a w a r d staff
m e m b e r . If there are no family members or friends, or if they cannot
be contacted, the patient alone is present i n the meetings. If the p a ­
tient is to be registered as a n inpatient, the n e w therapeutic meetings
that follow are arranged b y the w a r d staff teams, w i t h a m e m b e r of
the acute psychosis team present for the transmission of information.
In the Finnish N S P Project, 68% of the first-admission schizophrenia
group patients were admitted into hospital for observation against their
will. O f these, 20% were admitted as voluntary inpatients after an obser­
vation p e r i o d (5 days at that time). A c c o r d i n g to the experiences of the
 N E E D - A D A P T E D TREATMENT 1 77

T u r k u C l i n i c of Psychiatry, the proportion of patients who thus came to

realize their need for hospital care increased when the practice of arrang­
ing therapy meetings became established and the w a r d staff made a
concentrated effort towards an empathic approach to the patient during
the first few inpatient days. By the late 1980s, nearly 50% of the patients
admitted for observation continued their inpatient treatment voluntarily
after the observation period. This is notably significant for the establish­
ment of therapeutic relationships.
If the joint or i n d i v i d u a l meetings w i t h the patient are continued
over the next few days as an effective crisis intervention, it is often
possible to avoid hospital admission altogether. For m a n y patients, be­
i n g taken into a mental hospital w i l l effect a life-long trauma on their
self-esteem. W h e n admission proves to be necessary, it is best to explain
the reasons for treatment to the patient i n such a w a y that h e / s h e is able
to understand, though not necessarily accept, them.
T h e arrangement of therapy meetings is facilitated b y the fact that
the psychotic patient's relatives or friends often come to consult the
therapeutic staff or escort the patient for the first visit. If they first come
to a basic health care unit, from where the patient is further referred to a
psychiatric hospital or outpatient unit, the referring physician should
see to it that these relatives or friends accompany the patient. E v e n if a
patient is re-admitted into the hospital, it is useful i n most cases to
arrange a new therapy meeting to study the situation more extensively,
unless the patient refuses this.
I have h a d some experience of h o w important the contact w i t h the
family m a y be even at later stages of treatment w i t h psychotic patients.
Probably the most memorable experience was with a youngish female
patient w h o h a d been rejected b y her husband a n d h a d then, h a v i n g
realized her o w n lack of balance, given u p her child to a children's home
a n d finally regressed into a completely uncommunicative a n d autistic­
ally w i t h d r a w n state. Attempts to make the patient's mother a n d sister
attend a therapy meeting failed at first; the mother promised to come,
but she always cancelled. The attempts of the w a r d staff to establish
contact with the patient continued to be unsuccessful—she continued
mute even with her personal nurse. After a couple of months the mother
finally came a n d attended a meeting. The patient d i d not speak d u r i n g
the meeting, but a couple of days later she began to speak, though quite
psychotically at first. The patient's recovery over the following few
weeks was compatible with the developmental processes described i n
178 SCHIZOPHRENIA

textbooks o n psychoanalysis: having recovered from her autistic c o n d i ­

tion, she fell i n love symbiotically with a male patient, trying to h o l d his
h a n d wherever he went. After that she began to be interested i n other
relationships around her, she went to see her child i n the children's
home, and she was discharged from the w a r d in a fully organized condi­
tion. Throughout, the process of recovery was catalyzed b y her personal
nurse relationship.
The patient's individual clinical and psychological condition is also
assessed i n the therapy meeting. This assessment, however, often needs
to be supplemented b y i n d i v i d u a l discussions with the patient. This is
quite essential whenever the patient asks for a private interview, or the
team notices that the patient hopes for one, or it turns out that privacy is
necessary for analysing the situation a n d / o r establishing a confidential
relationship with the patient. A patient who is admitted into the hospital
must immediately be provided with a chance to have discussions and to
establish a therapeutic relationship on an i n d i v i d u a l level.
Some psychotherapeutically oriented A m e r i c a n psychiatrists have
suggested that the psychotic symptoms of a schizophrenic patient a d ­
mitted for treatment must first be suppressed with intensive neuroleptic
medication, after which it becomes possible to approach the patient's
condition psychotherapeutically. I disagree with them. The introduction
of medication—and particularly neuroleptic medication—should, if pos­
sible, be postponed at the initial stage, and the m a i n effort should be on
approaching and establishing a psychological contact with the patient
and h i s / h e r life situation. This is especially important with first-admis­
sions. Otherwise, we lose the opportunity of seeing the patient's i n d i v i d ­
u a l and transactional situation in vivo and define and label the patient's
condition as an illness i n the medical sense, without having tried to
avoid such labelling initially. A l s o , the psychological approach is often
just as effective i n calming d o w n the patient as are neuroleptics.
It is also important at the initial stage to inquire into the patient's
social situation and the rehabilitative needs associated with it—as we
found out particularly clearly i n the N S P Project. Matters of this k i n d
m a y already come u p d u r i n g the therapy meetings. Later on, rehabilita­
tion is best discussed i n cooperation with the patient and the unit's social
worker, and the discussions often involve contacts with the patient's
employer and co-workers or social work officials, for example. The p a ­
tient should give consent for such contacts and preferably participate in
carrying out the arrangements.
 NEED-ADAPTED TREATMENT 1 79

Who needs the hospital?

I h a v e e m p h a s i z e d the significance of outpatient treatment for the

self-esteem of m a n y patients i n cases where inpatient treatment can
justifiably be a v o i d e d . T h i s is not, however, always the case a n d
s h o u l d not be a n e n d i n itself. A s far as I can see, treatment i n a
psychotherapeutic c o m m u n i t y is still necessary for m o r e than half of
the first-admission schizophrenia-group patients. It is not always
necessary for them to be admitted as inpatients, because psychothera­
peutic communities function quite w e l l o n d a y - h o s p i t a l w a r d s .
Hospital treatment is generally necessary for psychotic patients of
three kinds. The first of these—partly overlapping—groups consists of
those where the degree of regression or the quality of the disorder (e.g.
behaviour imperilling the safety of the patient or other people) requires
a safe or constraining environment. In this group, involuntary treatment
is usually indicated. The second indication concerns the patient's ( a n d /
or the family members') motivation for adequate psychotherapeutic
treatment. Especially for many first-admitted, seriously ill patients, a
long-term (usually a few months') treatment i n the psychotherapeutic
community is a necessary prerequisite for the continuation of treatment
on an outpatient basis. The third group consists of patients w h o find the
w a r d a temporary a n d necessary social refuge i n a difficult life situa­
tion—for example, following a divorce or loss of a dwelling.
T h e duration of the inpatient period needed depends entirely o n
i n d i v i d u a l , patient-specific factors. There are, however, a few points I
w i s h to emphasize. First, the time spent i n hospital should really benefit
the patient. This does not mean that the treatment should be paced so as
to hasten the patient's discharge. O n e colleague of mine once compared
the hospital to w h i c h he referred his patient to a broken slot-machine,
w h i c h ejects the coin as soon as it has been inserted. This should not be
the case—on the contrary, as soon as the indications for inpatient treat­
ment have been established and the treatment begun, the therapeutic
staff should concentrate on the patient's problems without undue haste,
aiming at a favourable therapeutic relationship and promoting the de­
velopmental process stimulated b y it.
This m a y take time i n some cases, but it should clearly be more than
mere idle existence. T o avoid the risk of institutionalization, we must
also continuously support the patient's contacts outside the hospital b y
arranging leaves, using day-hospital services, a n d occasionally encour­
180 SCHIZOPHRENIA

aging the patient to work or to study. This is naturally easier i n urban

environments than i n the country.
W e soon learnt i n the T u r k u Clinic to guarantee the continuity of
therapeutic relationships by avoiding patient transfers from one w a r d to
another while treatment was going on. There are n o w three kinds of
patients o n the closed acute w a r d of the clinic: those w h o are there
following a decision for involuntary treatment, those who are full-time
inpatients voluntarily (many of them after a period of involuntary treat­
m e n t — w h o n o w have a right to move about freely, including home
leaves), and those who h a d started their treatment as full-time inpatients
but have n o w become day patients. This arrangement is also expedient
for the w a r d : it is easier to concentrate on the more difficult patients i n
the evenings, when the ward is relatively empty; also the presence of the
day patients, w h o are generally i n a better condition, makes the w a r d
atmosphere less closed and more hopeful even for those patients whose
condition is not so good. Transfers from the closed to the open w a r d or
to the special day-hospital w a r d (and sometimes also i n the opposite
direction) occur occasionally, depending on patient-specific factors, but
they are relatively rare and usually take place during the early stages of
the treatment, before a therapeutic relationship with the patient has be­
come established.
Finally, we must remember that one purpose of hospital treatment
s h o u l d always be planning for after-care o n an outpatient basis, w h e n ­
ever there is a need for i t — a n d there usually is such a need i n the case of
schizophrenic patients. For some patients treated in the psychotherapeu­
tic community, the continuation of the treatment with the same therapist
should be made possible after discharge. However, this is often not
feasible. The preparatory work for the continuation of treatment should
be carried out i n cooperation with the person or persons responsible for
outpatient care, regardless of whether they are members of the hospital
staff or outsiders. Therapy meetings with the patient present are the best
tool for this planning.
Some psychoanalysts or psychoanalytically oriented therapists
(though not all of them) who refer their patients for a temporary hospital
treatment a n d / o r resume the therapy of their patient after an inpatient
episode are u n w i l l i n g to attend such meetings, fearing that the transfer­
ence-based therapeutic relationship m a y be impaired. In the case of
schizophrenic patients, such caution is often u n d u l y excessive, p r o v i d e d
that the therapist maintains a consistent therapeutic attitude even during
the meetings as well as the confidentiality of the relationship with the
 NEED-ADAPTED TREATMENT 1 81

patient. The advantages of this procedure outweigh such risks, both to

the therapeutic relationship a n d to the integration of treatment; this is
the best w a y to prevent projective biases possibly present i n both staff
communities a n d outside professionals.

On the indications
of different modes of psychotherapy

Internal i n d i v i d u a t i o n a n d external separation are always less a d ­

equately d e v e l o p e d i n schizophrenics than i n m i l d e r , particularly
neurotic disorders. F o r a n y assessment of the therapeutic needs of
a psychotic patient, it is important to have a n i d e a of the severity
of the d i s o r d e r i n this r e s p e c t — i n other w o r d s , to f i n d out whether
the patient's m a i n p s y c h o l o g i c a l problems lie i n h i s / h e r internalized
p s y c h o l o g y o r whether, a n d h o w concretely, they l i e i n m u t u a l
d e p e n d e n c y relationships w i t h other p e o p l e (the degree o f related
individuation, to use Stierlin's term (1983; Stierlin et a l . , 1977). A l ­
t h o u g h one o f the psychotherapeutic goals is always to p r o m o t e the
patient's d e v e l o p m e n t towards i n d i v i d u a t i o n , it m a y be impossible
to achieve this i n i n d i v i d u a l therapy alone unless s o m e d e v e l o p m e n t
also takes place i n the relationships w i t h others.
T h e acute or long-term quality of the disorder is also significant
for p l a n n i n g the m o d e a n d duration of treatment. Hence, for example,
a prompt crisis intervention following the first therapy meeting m a y
be sufficient for h a n d l i n g psychotic or near-psychotic crises that are
obviously related to acute p r o b l e m situations. A re-assessment of the
situation a few weeks later is, however, frequently necessary to ensure
that the crisis is genuinely over. It is always useful to advise the different
parties i n the crisis to contact the therapeutic team, if necessary, w h i c h
m a y i n itself serve to increase the feeling of security. The need for further
treatment at a family or i n d i v i d u a l level remains to be assessed together
w i t h the patient a n d / o r the family.
The crisis intervention is generally family- or milieu-oriented, but it
m a y also take place or continue at an individual level. It w o u l d be useful
to include i n the discussions—with the patient's permission a n d i n h i s /
her presence—people from the patient's studying or w o r k i n g e n v i r o n ­
ment more often than has been customary. A n attitude of openness m a y
be helpful for both the patient a n d the environment, lessening m u t u a l
mistrust.
182 SCHIZOPHRENIA

T h e development of family-oriented crisis intervention into family

therapy often takes place gradually through continued joint meetings.
T h e label " f a m i l y therapy" may arouse resistance i n some cases, n o r is
its use always indicated even in those cases where the process is being
gradually transformed into long-term treatment. W y n n e and his co­
workers (Wynne et al., 1986), for example, prefer to use the term " c o n ­
sultation". In Finland, we prefer to speak of " f a m i l y meetings". In
practice, these meetings turn into family therapy w h e n it is explicitly
agreed that they w i l l be continued a n d certain goals are defined for
them.
Conjoint therapies of families of origin are most often needed b y y o u n g
patients w h o have become psychotic gradually, whose contacts outside
the home are quite limited, and whose differentiation from parents is
inadequate. The personalities of many such patients are fragile and have
further regressed i n the psychotic development, because of w h i c h s y m ­
biotic relationships with their parents constitute a central part of their
internal psychodynamics, or at least of the part accessible to us.
In these cases the problems of the families are always serious, either
p r i m a r i l y — a s I tend to interpret them i n most cases—or at least second­
arily, as a consequence of the patient's illness. The goals of therapy are
often twofold: o n the one h a n d , support is p r o v i d e d for the whole fam­
ily, while, o n the other h a n d , the process of differentiation between the
patient a n d h i s / h e r parents is encouraged a n d facilitated. E v e n w h e n
the therapeutic community and individual therapy have succeeded i n
arousing the patient's symbiotic tendencies—which may also exist h i d ­
d e n i n autistic individuals—the further development of the therapeutic
relationship m a y be thwarted without family therapy if a parent finds it
difficult to give u p his or her symbiotic attachment to the child. In some
successful therapeutic processes, the focus of treatment is shifted to i n d i ­
v i d u a l therapy at the same time as the parents change over to couple
therapy, w h i c h helps them to differentiate from the patient a n d makes
their relationship more satisfying—factors that are often interrelated.
The most serious cases of schizophrenia also include those where the
prerequisites for i n d i v i d u a l therapy seem permanently poor a n d both
the patient a n d the family benefit most from long-term family-oriented
treatment, w h i c h may even go on for decades.
But family therapy of the family of origin may be n e e d e d — a n d fre­
quently is quite successful—even in the treatment of less seriously ill
y o u n g patients w i t h acute psychosis or classified as h a v i n g borderline
 NEED-ADAPTED TREATMENT 1 83

schizophrenia, whenever the core of their problems appears to lie i n the

ambivalence of growing independent from their families.
Therapy of the family of procreation or couple therapy of the patient
and h i s / h e r spouse or partner is indicated at the initial stages of the
treatment of most patients w h o have established a family or a couple
relationship. The manifestation of psychosis i n these patients, w h o
have made some progress i n both their internal development a n d their
interpersonal relationships—though they still have a notable need
for dependence—is often clearly associated with intrafamilial problems,
mostly pertaining to the couple relationship. Other aspects of interper­
sonal relationships are also significant. It may, for example, be important
to get the patient's parents or parents-in-law to be present i n the first
meetings. Psychosis is usually a regressive decompensation, a n d our
experience has s h o w n that the chances of recovery are both quicker and
better i n family or couple therapy than i n i n d i v i d u a l therapy. If the
treatment completely lacks any family orientation, there is the risk that
the situation is prolonged i n a w a y that—being compatible with the
partner's psychodynamics—results i n permanent changes of the family
homeostasis that are unfavourable for the patient a n d solidify h i s / h e r
role as a patient.
M a n y psychiatrists m a y not like the idea of including the children i n
the family therapy of a psychotic patient, h o p i n g to protect them from
traumatic experiences. It is our experience, however, that this argument
is justified less often than one might expect, because the psychotic s y m p ­
t o m s — w h i c h are familiar to the children from the home environment i n
any case—are frequently alleviated i n a therapy situation; the final effect
m a y actually m i n i m i z e the previous traumas and mystification. H a v i n g
the children present naturally requires particular sensitivity a n d control
from the therapeutic team, w h i c h m a y have to interfere i n the discussion
quite firmly, if necessary. The role of the children i n family dynamics is
often very important, a n d their inclusion m a y also be informative. M y
o w n w a y of h a n d l i n g such situations is to have the children present i n
some of the initial meetings but to leave them out of the following
therapy sessions, though questions concerning them w i l l continue to be
discussed. It m a y also be necessary to restrict the treatment to couple
therapy because the problems pertain to the spouses' sexual relationship
a n d / o r one of them has an extramarital relationship or lover.
F a m i l y or couple therapy is not possible i n all cases, as the spouse
m a y refuse to attend, w h i c h is more c o m m o n for female than for male
patients. In such cases, one has to rely o n i n d i v i d u a l therapy. Individual
184 SCHIZOPHRENIA

therapy is necessary as a continuation of family or couple therapy, w h e n

the couple relationship ends in a divorce, or the m a i n core of the psycho­
logical problems is ultimately located i n the patient's o w n internal
development. The quality of the continued treatment is determined b y
case-specific motivations.
It is hence relatively c o m m o n that the focus shifts from family
therapy to individual therapy i n advancing treatment (see Figure 5.4).
T h i s shift is most natural and most clearly predictive of a good outcome
w h e n the initiative to start long-term individual therapy comes from the
patient a n d the matter is also discussed d u r i n g the family therapy ses­
sions.
Individual therapy right from the beginning (Figure 5.4, right panel)
is best suited to patients whose personality development is more differ­
entiated than that of the average schizophrenic. M o s t w i l l also have
m o v e d out of their primary families—although concrete separation as
such cannot be considered an indicator of the psychological separa­
tion-individuation stage.
A logistic regression analysis i n the five-year follow-up of the T u r k u
Cohort HI (Alanen et al., 1986) showed that the patients w h o ultimately
underwent long-term psychodynamically oriented i n d i v i d u a l therapy
differed from the rest of the schizophrenic patients o n four background
variables: (1) an initial insight into the connections between their p r o b ­
lems a n d symptoms, (2) lack of acting-out behaviour, (3) acute onset of
symptoms, a n d (4) the presence of neurotic symptoms along with p s y ­
chotic ones. Borderline schizophrenias were slightly more c o m m o n i n
this group than the other clinical categories, but numerically the largest
sub-group consisted of patients with typical schizophrenia w h o h a d a
tendency to establish symbiotic relationships.
The theories concerning the indications for i n d i v i d u a l therapy i n
schizophrenia are unexpectedly confused. M a n y of the leading thera­
p i s t s — s u c h as Benedetti (1985) and Boyer (1986)—emphasize personal
factors associated with the countertransference experienced b y the thera­
pist. V o l k a n (1990) also says that he prefers to start w o r k i n g with the
patients whose problems and symptoms appear understandable to h i m
right f r o m the beginning, often at a primary process level. Such u n d e r ­
standing m a y naturally also be achieved at later stages of treatment.
F r o m the viewpoint of public health care, it is important to try to
a v o i d useless attempts at treatment. It is therefore important i n i n ­
d i v i d u a l therapy to underline the difference between supportive thera­
peutic relationships with relatively infrequent sessions and an empathic
 N E E D - A D A P T E D TREATMENT 1 85

attitude—which are notably useful for m a n y patients—and intensive,

psychoanalytically oriented relationships aiming at developing the
patient's personality. Therapy of the latter k i n d is most successful w h e n
(1) the patient's disorder does not belong i n the most serious clinical
category, as regards both symptoms (the personality disorganization is
not very deep or has not lasted long) and the ability to relate, (2) insight­
ful motivation for long-term work is being or has been aroused i n both
the patient and the therapist, and (3) the prerequisites for sufficient
continuity of the therapeutic relationship exist. Neglect of the latter point
m a y result i n disappointments that could be fatal for some patients.
T h e absence of group therapy i n Figure 5.4 m a y seem surprising. A s
far as I can see, however, its significance i n schizophrenia is less primary
a n d less crucial for the pathology of the disorder than the significance of
family a n d i n d i v i d u a l therapies. Its development has therefore received
less attention a n d fewer resources i n our work. T h e participation of
m a n y schizophrenic patients i n group therapy has, however, p r o v e d
beneficial, especially for their social rehabilitation.
A l t h o u g h our o w n experiences of actual group therapy are relatively
scant, various w i d e l y defined group activities have gradually become
more a n d more significant i n the psychotherapeutic communities of the
clinic. T h e y are essentially important both for shaping the overall struc­
ture of the activities of the w a r d community and for i m p r o v i n g patients'
social skills a n d contacts. The need for group activities is particularly
great i n the case of long-term patients, a n d it can also be felt i n the
rehabilitation homes, hostels, a n d other units outside the hospital, as
was s h o w n , for example, b y the experiences of Anttinen (1983,1992).

How can modes of psychotherapy

with different frames of reference be combined?

H o w is it possible to c o m b i n e systemic family therapy a n d p s y c h o ­

d y n a m i c i n d i v i d u a l therapy? D o e s not the difference between their
frames of reference give rise to problems? T h e answer is that these
m o d e s of treatment s h o u l d not be perceived as contradictory, but as
c o m p l e m e n t a r y to each other. Some psychoanalysts a n d family thera­
pists h a v e tended to exaggerate the differences between these m o d e s
of treatment, but this has been d u e either to prejudice or to ignorance
of the real nature of one or the other m e t h o d . W h a t is n e e d e d is a
g e n u i n e l y respectful attitude towards each other's m o d e of w o r k .
186 SCHIZOPHRENIA

In T u r k u , the integration has been facilitated b y the fact that m a n y of

the psychoanalysts have been interested i n family therapy a n d some
have even taught it. This probably suffices to show that the two modes
of treatment can be combined under one basic conception of the nature
of psychotic a n d other psychic disorders. This is not always the case,
however, and problems m a y therefore arise. But there may equally well
be problems between family therapists with different theories of illness,
a n d also between psychoanalysts with different ideas of schizophrenia.
There are more differences in the techniques of these modes of treat­
ment than i n their basic conceptions or goals. The technical differences,
i n turn, are easy to understand as a consequence of what is being done i n
each k i n d of therapy: psychoanalytic individual therapy aims at under­
standing and influencing internal processes, while family therapy works
on interactional networks consisting of several individuals. The treat­
ment processes described i n the final part of chapter six illustrate h o w
family therapy can be a prerequisite of individual therapy. W h e n the
transactional defence mechanisms and external supporting structures
become unnecessary, the ability to forego them makes it easier to recog­
nize internal problems and to approach them through i n d i v i d u a l
therapy.
Systemic family t h e r a p y — i n the form that is practised w i t h i n our
therapeutic orientation—also aims at reaching a psychodynamic under­
standing, w h i c h helps us to formulate the hypotheses a n d interpretative
communications that we present to the families. A p a r t from achieving
this empathic understanding, it is also necessary for both family and
individual therapists to observe a neutral distance. This is one important
reason for carrying out family therapy as team-work, w h i c h m a y seem
strange to psychoanalysts. A family therapist w h o works alone is nota­
bly more prone to losing the observing stance and unwittingly assuming
the role of a family member.
The combination of psycho-educative family therapy w i t h i n d i ­
v i d u a l therapy of a psychodynamic orientation m a y be more p r o b l e m ­
atic than that of systemic family therapy. W i t h long-term schizophrenic
patients, psycho-educative elements can be included more easily i n the
global treatment plans.
C o m b i n i n g psychopharmacological treatment and psychotherapy is
c o m m o n i n the treatment of psychoses, notwithstanding that the thera­
peutic frames of reference and foci of treatment are clearly different.
Despite this, medication can also be integrated as part of the need­
adapted therapeutic activities based o n psychodynamic understanding.
 N E E D - A D A P T E D TREATMENT 1 87

Conclusions

T h e term " n e e d - a d a p t e d treatment" of schizophrenic psychoses re­

fers to a comprehensive b u t i n d i v i d u a l i z e d , psychotherapeutically
oriented a p p r o a c h to s c h i z o p h r e n i a a n d related psychoses. It w a s
d e v e l o p e d at the T u r k u C l i n i c of Psychiatry g r a d u a l l y over a p e r i o d
of two decades a n d is n o w also e m p l o y e d elsewhere i n F i n l a n d a n d
i n the other N o r t h e r n E u r o p e a n countries. Treatment is based o n a
p s y c h o d y n a m i c u n d e r s t a n d i n g of the case-specific therapeutic needs
of the patients. W e f o u n d this important because of the heterogeneity
of schizophrenic disorders, b o t h clinically a n d w i t h regard to the
patients' psychological a n d social condition. T h i s leads to a diversity
of therapeutic challenges. W e also f o u n d that it is important to e v a l u ­
ate the therapeutic needs of the family a n d of any other essential
interactional network to w h i c h the patient belongs a n d to r e s p o n d to
t h e m , b o t h because of the strains that the patient's psychosis is apt
to arouse i n the people related to h i m / h e r a n d because the treatment
is to a great extent dependent o n the quality of the schizophrenic
person's interpersonal relationships. D r u g treatment is considered a n
auxiliary measure s u p p o r t i n g p s y c h o t h e r a p y a n d is u s e d i n s m a l l o r
moderate doses, according to the patients' needs.
The family-oriented approach led us to the establishment of the i n i ­
tial joint meetings (therapy meetings) attended b y the therapeutic team,
the patient, a n d family members or other persons close to the patient.
T h r o u g h their informative, diagnostic, and therapeutic functions, these
system-oriented meetings p r o v e d to be of great importance i n p l a n n i n g
and carrying out the treatment. The psychotic symptoms of acutely i l l
patients often disappeared or quickly diminished. W i t h m a n y patients,
therapy meetings are continued as crisis intervention, as family therapy,
or as renewed diagnostic a n d integrating means at a later stage of the
treatment. However, d u r i n g the course of therapy it is often expedient to
transfer the focus of the therapeutic process from the less specific family­
a n d environmental modes to the more specific ones, including psycho­
dynamically oriented long-term individual psychotherapy.
Both the T u r k u Schizophrenia Project and the Finnish Multicentre
(NSP) Project were based o n problem-oriented action research p r i n ­
ciples, a n d they were aimed at a development of therapeutic activities
within c o m m u n i t y psychiatry rather than being separate research trials
studying the results of specific treatment modes. A c c o r d i n g to strict
scientific principles applied i n the controlled psychotherapy trials, it is
188 SCHIZOPHRENIA

easy to identify weaknesses of our projects. However, as pointed out

earlier, controlled studies can also be criticized because of their rigid
methodology. A treatment approach trying to respond to the diversity of
therapeutic needs of individual patients cannot be studied following
rules that might, for example, prevent any change of treatment practices.
T h e only way of applying controlled methodology to the study of the
results of need-adapted treatment w o u l d be to compare two or more
catchment areas with each other—with one area carrying out its p r i n ­
ciples as a whole and the other(s) practising treatments based on
different premises. E v e n then, it should be realized that this k i n d of
approach cannot be established all of a sudden i n a certain area but is a
product of developmental processes of longer duration including, for
example, different training and supervision activities.
W e have compared our follow-up findings w i t h earlier studies of
first-admitted schizophrenic patients, both i n Finland a n d elsewhere,
and we found that the need-adapted approach has clearly improved the
outcome for first-admitted schizophrenic patients, especially with re­
gard to their psychosocial prognosis. The outcome of Cohort IV of the
T u r k u Project i n which the approach was practised i n its advanced
form was clearly better than that of the earlier T u r k u cohorts and other
earlier follow-up studies made in Finland. The follow-up findings of the
N S P Project, i n which the approach was initiated within a geographi­
cally larger context, were also promising a n d compared well with the
results of other contemporary European studies. Related though differ­
ent psychotherapeutic approaches included i n the Inter-Scandinavian
C o m m u n i t y Psychiatric NIPS Project were likewise successful. A con­
spicuous finding both i n the T u r k u cohorts and i n the NIPS Project was
the considerable decrease in the patients' need for neuroleptic drugs
brought about by psychotherapeutic approaches. M o r e than half of the
schizophrenic patients of the T u r k u Cohort IV managed well without
neuroleptics five years after their first admission, and the same was true
of the NIPS sample as a whole.
O n e additional factor should be emphasized: the humanizing effect
of our orientation. The treatment is based o n a psychotherapeutic atti­
tude, w h i c h prevails i n the treatment milieu as a whole and is character­
ized b y an attempt to approach the patient as a h u m a n being rather than
as a container of abnormal biological mechanisms to be treated with a
pharmacological approach o n its own. The problems of family members
are also considered, and the positive resources found i n the families are
taken into account. N o t only doctors and psychologists are involved: the
 N E E D - A D A P T E D TREATMENT 1 89

members of the nursing staff also have the opportunity to develop their
talents through active participation i n the therapeutic processes.
Reductionistic attitudes should be abandoned with regard to the use
of various psychotherapeutic modes. In the field of community p s y c h i ­
atry, there is no possibility for treating all schizophrenic patients with
intensive individual psychotherapy, nor is this indicated.
In summary, four points of our therapeutic experiences m a y be re­
iterated:

1. T h e systemic (family- a n d network-centred) orientation i n c l u d i n g

therapy meetings i m p r o v e d the outcome for n e w schizophrenic
patients as a w h o l e . A c c o r d i n g to Lehtinen's (1993b) analysis, this
was connected w i t h a better outcome for acutely ill patients, o n the
one h a n d , a n d for patients i n c l u d e d i n the g r o u p of p a r a n o i d
schizophrenias, o n the other. In the first g r o u p , it appeared that the
family-centred emphasis clearly accelerated the reintegration of
m a n y patients; i n the second g r o u p , it became possible to reach
psychotherapeutically those patients w h o h a d n o m o t i v a t i o n for
i n d i v i d u a l psychotherapy, at least initially. In F i n l a n d , these expe­
riences led to the establishment of acute psychosis teams (see
chapter seven), n o w responsible for p l a n n i n g a n d initiating the
treatment of n e w a n d recurrent psychotic patients i n a large part
of the country.

2. T h e systemic orientation a n d family therapy cannot replace the

n e e d of a large n u m b e r of the schizophrenic patients for a l o n g ­
term i n d i v i d u a l therapeutic relationship a i m e d at personality
development. T h e experiences of the T u r k u C o h o r t III, as w e l l as
those of the N I P S Project, indicated the positive effects of i n d i ­
v i d u a l therapy for m a n y severely i l l schizophrenic patients.

3. Psychotherapeutic c o m m u n i t y treatment, family therapy, a n d i n ­

d i v i d u a l therapy s h o u l d be seen as complementary m o d e s of
treatment, used either separately or i n combination, as indicated
b y the case-specific needs. F o r m a n y patients, c o m m u n i t y treat­
ment a n d / o r family therapy are important prerequisites for
successful i n d i v i d u a l treatment, both t h r o u g h their increased m o ­
tivation to study their problems a n d through a sufficient loosening
of inner psychological resources b o u n d into symbiotic intrafamil­
ial relationships.

4. Referring to m y v i e w of the therapist functioning as a n e w a n d

190 SCHIZOPHRENIA

committed self-object for the schizophrenic patient, I emphasize

the importance of the therapist's personality—already indicated
b y a n early study b y W h i t e h o r n a n d Betz (1960)—as w e l l as the
" f i t " between the therapist a n d patient, p r o m o t i n g the m u t u a l
introjective processes. Both our experiences w i t h nurse therapists
i n T u r k u as w e l l as the experiences of p s y c h o d y n a m i c a l l y oriented
s u p p o r t i v e i n d i v i d u a l psychotherapies i n the O s l o subproject
of the N I P S confirm this theory. It m a y also explain, for example,
the f i n d i n g b y G u n d e r s o n et al. (1984) that n o difference w a s
f o u n d between the results of insight-oriented a n d supportive p s y ­
chotherapy i n the M a c L e a n H o s p i t a l study. A p r e c o n d i t i o n for
the extension of the n u m b e r of therapists is a broad-based o r g a n i ­
z a t i o n of psychotherapy supervision a n d training. In T u r k u , the
findings of o u r project encouraged us to establish m u l t i p r o ­
fessional training programmes for b o t h i n d i v i d u a l a n d family
therapy, e m p h a s i z i n g the treatment of severely i l l patients.
CHAPTER SIX

Therapeutic experiences

I
b e g i n this chapter b y evaluating the application a n d content of
the m o s t c o m m o n m o d e s of p s y c h o t h e r a p y i n c l u d e d i n the n e e d ­
a d a p t e d treatment of schizophrenic psychoses, based o n personal
experiences g a i n e d w h i l e w o r k i n g i n p u b l i c health care i n the T u r k u
C l i n i c a n d as a private psychiatrist. I also c o m m e n t o n the use of
m e d i c a t i o n i n psychotherapeutic treatment. A f t e r this, three case
vignettes illustrate the integrated n e e d - a d a p t e d a p p r o a c h .

Experiences of applying
the different modes of treatment

The psychotherapeutic community

T h e k i n d of psychotherapeutic communities best suited to acutely

p s y c h o t i c patients are somewhat different f r o m b o t h the o r i g i n a l
m o d e l p r o p o s e d b y Jones a n d the communities for p r i m a r i l y b o r d e r ­
line patients. M a t t i Isohanni (1983) i n his F i n n i s h s t u d y i t e m i z e d
three major w a y s of influencing patients therapeutically i n a hospital

191
192 SCHIZOPHRENIA

w a r d c o m m u n i t y : a h u m a n e environment, organized interaction, a n d

p r e - p l a n n e d treatment p r o g r a m m e s . A l l of these are n e e d e d i n a
c o m m u n i t y for psychotic patients, b u t establishing a h u m a n e e n v i ­
r o n m e n t is the priority.
Differences i n focus were also clearly observable i n the developments
of the psychotherapeutic communities of the T u r k u clinic, between the
wards i n w h i c h a majority of the patients showed less severe disorders,
a n d the wards for psychotic patients. T h e former relied o n organized
group activities requiring more conjoint participation, whereas the
activities of the psychosis wards were shaped more i n d i v i d u a l l y i n
response to each patient's degree of regression.
I have described the functional structure of o u r w a r d of acutely
psychotic patients w h i l e discussing the development of the T u r k u
S c h i z o p h r e n i a Project (pp. 144-145), b u t some fundamental p s y c h o ­
d y n a m i c v i e w p o i n t s s h o u l d be a d d e d .
Simo Salonen (1975), w h o worked i n the T u r k u clinic i n the 1970s,
pointed out, using Kohut's terms, that for psychotic patients the w a r d
c o m m u n i t y should be a re-created early self-object environment, where
empathy, "justifiable o p t i m i s m " (an expression introduced b y Erik
Anttinen, 1992), and gratification of some of the patients' symbiotic needs
i n a humane environment provide for them a starting-point for the
processing of their problems a n d reintegration and growth of their per­
sonalities.
A s long ago as the 1960s, I wrote to Otto A . W i l l Jr. (then Director of
Psychotherapy at Chestnut Lodge), asking h i m what he considered the
most essential goal i n the psychotherapy of schizophrenic patients. W i l l
replied that there is some hope i n the patient's future, if h e / s h e gets back
something of the condition of children whose life is moderately satisfac­
tory. H e pointed out that such children are curious a n d eager to learn,
not constantly o n their guard, not torn apart b y guilt, relatively open to
new interpersonal relationships, and h a p p y with their o w n growth a n d
development. A psychotherapeutic community has accomplished some­
thing if it has aroused some of these qualities i n its patients (personal
communication, 1963).
Personal nurses play a crucial role i n helping the patient i n a psycho­
therapeutic community. A l r e a d y i n the early 1970s, w h e n choosing
personal nurses, we considered it important that the contacts that h a d
arisen spontaneously between patients a n d staff members should be
continued. W e postulated that therapeutic relationships emerging at the
primary-process level w o u l d turn out more fruitful i n the therapy of
 THERAPEUTIC EXPERIENCES 193

schizophrenic patients than patient-therapist selections made at the re­

ality l e v e l A s m a n y as 70% of the therapeutic relationships established
o n the psychosis w a r d a n d continued for at least 2 months d u r i n g
1970-76 were found to have come about i n this way ( A a k u et al., 1980). It
turned out that the nurses w h o h a d spontaneously p i c k e d out a patient
h a d experienced something that can be called " a n immediately i n ­
v o l v e d , caring countertransference' (Orma, 1978) often right after the
7

patient h a d been admitted to the w a r d . Such experiences are familiar to

people w o r k i n g w i t h psychotic patients fighting to maintain their psy­
chological existence.
It m a y also happen that the patient spontaneously chooses a per­
sonal therapist, being sometimes motivated at a psychotic level. She
m a y , for example, resort to a person w h o m she considers her sister,
because they have the same first name. I think it is important not to
ignore such choices: although they m a y involve transference a n d / o r
countertransference problems, the benefits generally outweigh the p r o b ­
lems. Sidsel Gilbert and Endre Ugelstad, i n the N o r w e g i a n part of the
NIPS Project (Alanen et a l , 1994), also emphasized the importance of the
patient's active participation i n finding a matching therapist. It is essen­
tial, however, that the therapist observes h i m - or herself at the ego level,
to prevent emotional overinvolvement. H e l p for this comes best f r o m
supervision, w h i c h should be made available to all members of the thera­
peutic staff working on psychosis wards, regardless of their professional
background.
H o w e v e r , spontaneity is not enough for establishing a personal
nurse relationship i n every case; there are also patients w h o are not
chosen b y anybody, and they tend to be therapeutically the most diffi­
cult. In these cases the personal nurse is best appointed i n a c o m m o n
discussion b y the w a r d staff, preferably with somebody volunteering,
rather than being ordered to take o n the task.
A l t h o u g h the personal nurse plays a crucial role i n the treatment of
the patient, the psychotherapeutic team always functions as a whole.
Individual therapeutic relationships are d o o m e d to failure unless they
are supported b y the whole community. The personal nurse or therapist
is not the only person w h o m the patient meets o n the w a r d a n d w h o
influences h i m or her. Joint meetings and negotiations—both w i t h a n d
without patients—are essential for the promotion a n d integration of
the therapeutic activities, and they should take place frequently. Salonen
(1975)—and Schulz (1975)—pointed out h o w significant it is for the
patient's personal integration that the theories of the different staff
194 SCHIZOPHRENIA

members concerning h i m or her are also integrated. A disorganized,

psychologically regressed patient may apply to the people around h i m
quite different, even mutually contradictory, transferences, a n d it is i m ­
portant that they w i l l be understood as parts of a connected whole.
A l t h o u g h responsible for the w a r d and clinical decisions, the psy­
chiatrist s h o u l d not assume an omnipotent role and learn from team­
w o r k . While serving as senior psychiatrist, I realized that I could learn a
great deal b y listening to others and considering their suggestions; this
w i l l also help to prevent "passive resistance" o n the w a r d , w h i c h m a y
arise if the staff are merely given orders to carry out treatment. It is not
infrequent that the nurses w h o observe the patients at a close range have
ideas that are more i n keeping with the natural course of the therapeutic
process than an order given b y a superior. Occasionally the staff tried to
use me i n an interpersonal power struggle, o n , for example, whether or
not the dosage of medication for a given patient should be increased. I
became particularly wary of hints or suggestions o n therapy made to me
privately b y staff members, and I only promised to take u p the matter at
the next joint meeting.
Openness, unprejudiced elimination of unnecessary and detrimental
hierarchies, a n d an effort to integrate the therapeutic activities are
a m o n g the goals of psychotherapeutic communities treating psychotic
patients. Considering openness, we also discussed the limits of our o w n
emotional expressions towards the patients. It is not good if the c o m m u ­
nity has an atmosphere where all negative emotions towards the
patients are consciously avoided in the same way as i n a pseudomutual
family; openly expressed irritation at a patient w h o intentionally breaks
a plate is better than suppressed rage, and it certainly also helps the
patient to learn the limits to h i s / h e r behaviour. But a c o m m u n i t y with
uninhibited emotional expression w o u l d be both chaotic a n d at the
mercy of the k i n d of acting-out that prevents the development of a good
and psychotherapeutic working climate. Self-scrutiny of one's emotional
reactions and an effort to become conscious of their causes and to utilize
them therapeutically are important elements i n the therapeutic process.
Different opinions have been put forth concerning the optimal w a r d
c o m m u n i t y attitude towards the regression of a psychotic patient into a
condition that reflects the earliest developmental stages. M a n y i n d i ­
v i d u a l therapists, such as Boyer (1986), have emphasized that it is not
possible to correct developmental defects without w o r k i n g o n the level
of regressive psychological phenomena. But it should also be borne i n
m i n d that the regression i n itself does not help the patient unless there is
 THERAPEUTIC EXPERIENCES 1 95

some insight into its causes. This, i n turn, requires that the patient,
t h o u g h tending towards regression, should also be made conscious of
these tendencies a n d enabled to counter them at the ego level. This is
best achieved b y transference and countertransference relationships d u r ­
ing long-term individual therapy, and it does not mean that the therapist
w o u l d gratify the patient's regressive needs.
It m a y , however, be useful or even necessary to gratify the needs of
some seriously regressive patients o n the w a r d — f o r example, b y feeding
them. E v e n so, excessive b a b y i n g c a r e — w h i c h m a y also gratify the
needs of the care-giver—should not be an end i n itself: the goal should
always be to help the patient out of the regression. For this purpose, a
temporary gratification of regressive needs and a simultaneous attempt
to establish a n empathic contact w i t h the patient are a better alternative
than electroshock treatment or high-dose medication.
But different views concerning the atmosphere o n acute psychosis
w a r d communities can also be presented. F o r example, C i o m p i a n d
colleagues (1992), describing the Soteria Berne community a n d i n keep­
i n g w i t h his theory of affect logic (Ciompi, 1982), emphasize not only the
h o l d i n g atmosphere, but also a clearly defined structure as a w a y of
p r o m o t i n g the integration of the patient's psychic functions. I agree that
the w a r d communities must have clearly defined rules a n d that the
attitudes of the w a r d staff and the limits they set for patients' behaviour
must not result i n d o u b l e - b i n d - t y p e situations. Joint meetings of both
the staff alone a n d the staff a n d patients together are therefore highly
important for the functioning of the therapeutic communities. H o w e v e r ,
the rigid rules characteristic of most medical wards must be avoided. I
learnt, for example, to arrange patient rounds i n such a w a y that we met
together informally w i t h 6-10 patients a n d the w a r d staff o n d u t y i n a
certain r o o m , a n d there we discussed the situation of each patient i n
turn. W h e n there were patients unable or unwilling to attend these meet­
ings, w h i c h was quite seldom, I visited them separately.

Family therapy

M y experiences w i t h f a m i l y therapy of schizophrenics cover two

p e r i o d s : the p s y c h o d y n a m i c approaches of the 1960s a n d 1970s a n d
the systemic family therapy a p p r o a c h of the 1980s. I d i d not a b a n d o n
m y p s y c h o a n a l y t i c a l l y based w a y s of t h i n k i n g e v e n d u r i n g the latter
p e r i o d b u t considered t h e m equally essential i n systemic—strategic
196 SCHIZOPHRENIA

f a m i l y therapy. C o n v e r s e l y , it c a n also be said that p s y c h o d y n a m i c

family therapy w i l l not be successful unless it is based o n an
interactional a p p r o a c h .
It is therefore important i n family therapies of all orientations to see
the family field as a whole, with members constantly influencing each
other. Equally important is the effort of the therapist or therapists to see
the events through empathic understanding of each family member, to
"take everybody's p a r t " (Allparteilichkeit: Stierlin et al., 1977). If a w o r k ­
ing atmosphere of this k i n d has been established a n d the family
members recognize it, the therapist m a y temporarily align with one
family member at a time—usually the one w h o seems to find it most
difficult to make h i m - or herself understood i n the conversation. In
systemic-strategic family therapy, " t a k i n g everybody's p a r t " often
means that the messages given towards the end of the session have been
formulated i n a w a y that is significant for everybody.
A s a psychodynamic family therapist, I was one of the "reactor ana­
lysts", w h o act as catalyzers i n developmental processes but prefer to
remain i n the background, rather than a " c o n d u c t o r " , w h o seems to
k n o w i n advance what is best for each family. The attitude of the family
therapist is, however, always somewhat more active than the attitude of
a psychoanalyst w o r k i n g with an individual. A t the beginning of the
therapy, h e / s h e must try to involve each family member i n the thera­
peutic process b y presenting questions to each member a n d supporting
the efforts of the least successful ones, as w e l l as b y translating the
psychotic expressions of the patient into ordinary language. The thera­
pist s h o u l d also be ready to intervene a n d create security a n d order i n
the conversation, whenever there is a need for that. W h e n w o r k i n g w i t h
two-generation families, the therapist is often assigned the position of an
understanding grandparent, whose presence makes it possible to deal
w i t h things that w o u l d otherwise take the family into a roadless wilder­
ness.
M y experiences with psychodynamic family therapy were reason­
ably satisfactory. W o r k i n g w i t h relatively seriously ill adolescents a n d
their families d u r i n g the 1960s and 1970s, m y colleagues a n d I obtained
clearly favourable results i n about half of the cases (Alanen, 1976). T h e
same was also true of the couple therapies of patients w h o were married
at the time of their illness (Alanen & K i n n u n e n , 1975). The outcome was
best i n those families that were genuinely motivated to undertake a
therapeutic process. The narcissistically featured self-object relations of
 THERAPEUTIC EXPERIENCES 1 97

parents to their children could, w h e n empathically understood b y the

therapist, transfer to positive resources important for the developmental
progress. Healthy resources were found rather unexpectedly i n schis­
matic families—the family therapy of Paula, w h i c h I described i n
chapter one, is one of the best examples of t h i s — i n w h i c h the parents'
w i s h , b e h i n d their frustrations, to improve their m u t u a l relationship
sometimes appeared to be an important factor. One-parent families a n d
skewed families w i t h a strong symbiotic axis, o n the other h a n d , more
often showed m u c h resistance towards therapeutic work. In some fami­
lies the motor for change was the patient, i n others the patient's healthier
sibling, w h o showed particular understanding of the patient's problems.
In chaotic families the therapist must support the whole family,
especially trying to improve the family's sense of reality. In some
cases—which also include families w i t h a symbiotic axis—family­
oriented treatment can best be implemented b y m a k i n g a supporting
person available to the parent or parents. R i g i d l y p a r a n o i d parents are
the most difficult therapeutically; i n families dominated b y such a p a r ­
ent or parents, it seemed best to concentrate o n i n d i v i d u a l therapy,
trying simultaneously to maintain a favourable separate contact with the
parents. T h e outcome of the couple therapy of patients w h o were a l ­
ready married w h e n their illness became manifest depended more often
on the spouse's than the patient's attitude.
Psychodynamic family therapies usually require a relatively l o n g
time, preferably 2-4 years, i n order to be successful. E v e n in cases where
it is difficult to initiate a dynamic process of development i n v o l v i n g the
whole family, it is often possible for the therapist to protect the growing
space of the y o u n g patient, supporting h i s / h e r efforts towards i n ­
dependence a n d allowing the possessive parent to transfer h i s / h e r
symbiotic needs for dependence from the patient to the therapist, s i m u l ­
taneously h e l p i n g the parent i n the w o r k of m o u r n i n g that m a y follow
this loss. It is important i n all family therapies with schizophrenic
patients—regardless of the orientation—to scrutinize the parents' back­
g r o u n d , for that makes it more possible to understand them a n d the
roots of the problems i n their relationships with their parents a n d chil­
dren, respectively.
Psychodynamic family therapy was subsequently overshadowed b y
the use of the systemic-strategic approach. H o w e v e r , it should still be
available for families where it is clearly indicated b y the motivation of
the family or couple for therapeutic work.
198 SCHIZOPHRENIA

The breakthrough of the systemic-strategic orientation was partly

d u e — a t least i n F i n l a n d — t o the brilliance of the M i l a n group (Selvini
Palazzoli et al., 1978) and the fact that the therapy i n v o l v e d team-work,
w h i c h is both safer and more pleasant than w o r k i n g alone. There is also
the additional advantage that the sessions are infrequent and the ther­
apies relatively short, w h i c h makes them easier to carry out i n public
health care than the psychodynamic family therapy processes, w h i c h
tend to be longer and require more frequent visits (usually once a week).
T e a m - w o r k often intensifies family therapy, a n d the closing of the
sessions with jointly prepared interpretative messages m a y effect
changes even i n families where the prerequisites for psychodynamic
process w o r k are poor. I have found particularly useful the positive
connotations engendered b y the systemic approach. T h e y often are also
useful i n i n d i v i d u a l therapy. I a m less familiar with paradoxical inter­
pretations, and the assignments given to families, because I a m u n c o m ­
fortable with their manipulative implications.
Positive connotations refer to the identification of symptoms i n family
members a n d their interpretation as positive phenomena, w h i c h they
actually are from the viewpoint of their role i n maintaining family
homeostasis a n d the psychic balance of the other family members. Para­
doxical interpretations are counterparadoxes for the family's o w n p a r a ­
doxical behaviour. T h e y encourage the family members to continue the
identified m o d e of behaviour b y saying that any change i n it w o u l d be
risky. This interpretation helps family members to realize the cul-de-sac
they are i n and does so in a w a y that—supported b y the therapist's
emphasis to maintain the homeostasis—often arouses a counter-stimu­
lus i n the family to change the situation—that is, it makes them side with
the forces aiming at change (Selvini Palazzoli et a l , 1978).
A n example of such family-therapeutic interventions follows. The
relationships of m a n y young—especially male—schizophrenic patients
w i t h their mothers are characterized b y mutual symbiotic dependence.
A c c o r d i n g to the classical individual-psychological view, this is a sign of
the patient's inability to detach himself from his mother because of early
fixations. It w o u l d not be particularly therapeutic to state this to the
patient, however. A p p r o a c h i n g the situation from a systemic point of
view, we m a y be better able to perceive another dynamic factor: the
loyalty b o n d of the patient with his mother, who—because of her o w n
separation anxiety—finds it essential to keep her son at home. U s i n g
positive connotation, we can recognize a n d appreciate the w a y the p a ­
 THERAPEUTIC EXPERIENCES 199

tient behaviourally shows through his responsibility for his mother.

Empathic recognition and interpretation of such psychology tends to
improve the patient's self-esteem—unlike the individual-psychological
interpretation I referred t o — a n d , simultaneously, similarly to interpreta­
tions i n general, gives h i m a stimulus to change his family-psychological
position. If the positive connotation is accompanied b y a paradoxical
interpretation—"You h a d better continue to stay at home, even giving up
the idea of having friends of your own, because this is important for your
mother and because changes i n life even otherwise tend to provoke
anxiety"—the effect may be further strengthened.
It should be emphasized that extensive knowledge of family p s y ­
chodynamics, combined w i t h skill acquired through training and
experience, are necessary prerequisites for applying paradoxical inter­
pretations. A c c o r d i n g to the experience of some of m y colleagues, h o w ­
ever, they m a y be useful stimuli for change within the family, p r o v i d e d
that they are based o n a careful consideration aroused b y a thorough
analysis of the family dynamics. Inadequately thought out, however,
they m a y represent therapists' acting out. A s senior psychiatrist, I was
consulted a couple of times by perplexed parents, whose report of the
assignment they h a d been given by the family therapy team seemed
perplexing to me as well.
Exhibit 6.1 presents the central contents of systemically oriented
family therapy with schizophrenic patients as I understand it.
Klaus Lehtinen (1993b, 1994) examined the experiences of systemic­
strategic family therapy obtained i n T u r k u i n the follow-up of Cohort IV
patients of our schizophrenia project. H e d i v i d e d the patients into three
groups.
The first group consisted of patients whose psychosis was quite o b v i ­
ously related to contemporary problems, and whose prior life course
h a d not been outwardly different from that of their age-mates. In these
cases, immediate intervention by the family therapy team a n d a psycho­
d y n a m i c re-definition of the situation resulted i n a disappearance of
psychotic behaviour quickly, usually after 2-5 sessions, w i t h a good
subsequent prognosis.
T h e second group d i d not differ notably from the first as regards the
patients' prior life course, though their social adjustment h a d not been
quite so good. There was, however, a greater difference observable d u r ­
ing the intervention. A l t h o u g h the connection between the illness and
life problems was also recognized i n this group, their interpretation or
200 SCHIZOPHRENIA

re-definition d i d not result i n an equally good outcome. The team expe­

rienced this as a feeling of losing their grip, and different types of further
treatment—continuation of family therapy or i n d i v i d u a l therapy—be­
came necessary. A s far as I can see, the families i n this second group
s h o w e d greater resistance towards change; many of them were classifi-

EXHIBIT 6.1
Central contents of the s y s t e m i c - p s y c h o d y n a m i c a l l y o r i e n t e d
f a m i l y therapy of s c h i z o p h r e n i a
1. Therapists form a team
• all team members should be presented to the family
• the team may use a therapy room or an observation room provided
with audiovisual and telephone connection between the team
members
2. Empathic contact is established with all family members
• an atmosphere of "taking everybody's part"
• stimulating the discussion through circular questioning and/or
confronting the family members with each other
3. Systemic-psychodynamic approach to the intra-familial relationships
• identification of family homeostasis and striving to change it
• identification of symbiotic interrelationships and of strivings for
separation and individuation
• what do the symptoms mean from a systemic viewpoint?
• attention to three-generational dynamics (the relationships of the
parents with their parents)
4. Systemic interventions
• positive connotations
• messages thought out together and given to the family at the end
of the session
• the team should analyse each session afterwards and also before
the beginning of the next session
5. Some central goals
• the family members should gain better understanding of their
thoughts, feelings, and intentions towards each other
• support for healthy strivings and resources
• support for establishing boundaries between the family members
and respective individuation
• support for the patient's extrafamilial relationships
• support for the mourning work resulting from the loosening of
symbiotic ties
 THERAPEUTIC EXPERIENCES 201

able as rigid families. Lehtinen also pointed out that m a n y of the female
patients i n this group later started i n d i v i d u a l therapy, w h i c h often
turned out successful after a couple of years. The male patients more
frequently withdrew from therapy a n d developed chronic symptoms.
Lehtinen underlines the importance of p r o v i d i n g special responsibility
or case management teams for patients i n this category, to guarantee the
continuity of their treatment.
The third group consisted of patients w h o were already chronically
ill at the time of their admission; the psychosis h a d developed gradually
and been preceded b y social isolation. Families h a d often shown increas­
ing isolation from their environment. Short interventions are not suffi­
cient i n these cases, w h i c h require long-term work, including, according
to Lehtinen, methods of psycho-educational family therapy—primarily,
re-learning of social skills a n d learning new ones.
I also conclude that the principles of psychoeducational family therapy
are best suited to the treatment of chronic patients. In less chronic cases
this approach has the notable disadvantage of confirming the patient's
role as a sick person, because the disorder is typically presented as being
due to biological causes a n d therefore permanent and i n need of c o n ­
tinuous medication. I felt this quite poignantly w h e n I asked a repre­
sentative of this orientation whether he d i d not consider it harmful that
such a n idea be conveyed to the patient. H e replied: " W e l l , it gives the
patient an explanation for w h y he has not been able to reach the goals he
has set for himself i n life."
E v e n so, particularly w h e n listening to C a r o l A n d e r s o n (1979) i n the
U n i t e d States a n d to Julian Leff (1994) i n T u r k u , I have also realized that
the differences i n the therapeutic attitude between the different
orientations may, i n fact, be greater i n theory than i n practice. Leff, for
example, invites attention to the goals, whose psychological contents
were partly quite similar to those presented i n Exhibit 6.1, i n c l u d i n g
support given to the patient's developing independence and elimination
of emotionally overinvolved or unwisely critical parental behaviour.
The k i n d of internal process of development that optimally takes
place i n i n d i v i d u a l therapy is seldom achieved i n family therapy, with
the exception of some long-term psychodynamic family or couple ther­
apies. A l t h o u g h systemic-strategic family therapy often releases the
individual's potential for development a n d thereby increases his or
her readiness to resume spontaneously h i s / h e r temporarily arrested
growth, I recommend beginning i n d i v i d u a l therapy after the family
202 SCHIZOPHRENIA

therapy stage, whenever the patient clearly suffers from a more p r o ­

found disorder of personality development and has developed insight
into h i s / h e r problems d u r i n g the family therapy.

Individual psychotherapy

B e l o w , I discuss i n d i v i d u a l therapy f r o m a v i e w p o i n t that s h o u l d be

applicable e v e n i n public health care. I have excluded therapeutic
relationships requiring visits to a trained psychoanalyst four or five
times a week. T h i s also corresponds to m y o w n experience: most of
the psychotic patients w h o m I have treated since the 1950s were seen
twice weekly.
H o w e v e r , it needs to be emphasized that the frame of reference i n
less intensive psychodynamic psychotherapy of psychotic patients
should be based o n psychoanalytic insights. Psychodynamic i n d i v i d u a l
therapy is often d i v i d e d quite strictly into psychoanalytically oriented
psychotherapy and supportive psychotherapy. In the treatment of p s y ­
chotic patients, this dividing line is blurred. E v e n w h e n a schizophrenic
patient is i n psychoanalytically oriented therapy, there are always i m ­
portant supportive elements present. Moreover, a therapeutic process
that is intended to be supportive soon activates processes of identifica­
tion and projection and feelings of transference and countertransference,
connected with the patient's developmental deficits. Therefore, the expe­
riences that have been described b y Searles (1965), Boyer (1983, 1986,
1989), V o l k a n (1990,1994,1995), and Benedetti (1979,1985), for example,
have been of great importance i n T u r k u , both i n our supervision activi­
ties a n d d u r i n g our individual psychotherapy training, of w h i c h an
important part is dedicated to psychotherapy of psychotics. I a m not
here referring to the less psychotherapeutic, directive therapeutic rela­
tionships combined with d r u g treatment, which also provide support to
a schizophrenic patient.
In psychosis psychotherapy, the use of the couch is not recom­
m e n d e d , and it is often not even possible (even if there are some psycho­
analysts w h o try to approach the classical method as m u c h as possible i n
the therapy of these patients). For many schizophrenic patients, the con­
crete face-to-face contact is a necessary precondition for therapy, because
they need it for the establishment of the therapeutic process a n d for
remaining reality-oriented.
 THERAPEUTIC EXPERIENCES 203

Searles (1965) defines the central goal of psychoanalytically oriented

psychotherapy of schizophrenia to be a beneficial, corrective re-working
of the patient's early ego development. The focus is o n the relationship
that is created between the patient a n d the therapist. This can also be
expressed b y stating that the therapist becomes a new self-object for the
patient. W h e n psychosis psychotherapy is compared with neurosis p s y ­
chotherapy, the therapeutic process i n the former may, i n m a n y respects,
correspond to a continuation of half-finished construction, whereas the
focus i n neurosis therapy is o n the reparation a n d renewal of structures
that seem distorted. T h e patient's identification w i t h the behaviour of
the therapist plays a crucial role i n the psychotherapy of schizophrenic
patients (Volkan, 1994).
T h r o u g h an empathic attitude—often called holding, following
Winnicott's (1960) description of the early p a r e n t - c h i l d relationship—
the schizophrenia therapist creates an interactional relationship w i t h the
patient, i n order to induce integrating developmental processes. H o l d ­
ing must include an ability to tune i n o n the patient's wavelength a n d an
empathic sensitivity to a v o i d excessive distance o n the one h a n d a n d
intrusion o n the other. A permanent contact w i t h autistic schizophrenic
patients i n particular becomes possible only w h e n the patient has repeat­
e d l y experienced that h e / s h e is able to trust the therapist. Empathic
attitude also means that the therapist sets limits whenever the regressive
patient needs them. It is important to listen, but it is not g o o d to be too
passive and non-committal. The most essential requirements i n p s y c h o ­
sis therapy are persistence, honesty, a n d an ability to convey to the
patient hope for a better future, even if a distant one. T o be able to meet
these requirements, the therapist must personally believe i n the patient's
potential w i t h i n the limits of justifiable optimism.
By becoming a n increasingly important self-object for the patient
(Kohut, 1971; see also chapter three), the therapist corrects the deficien­
cies of the earlier self-object relationships, helping the patient to inte­
grate h i s / h e r personality. It is important to emphasize, following
V o l k a n (1994), that the therapist should not p u s h h i m / h e r s e l f into this
function, as such behaviour w o u l d threaten the patient. The process of
development is rooted i n the patient's transference relationship with the
therapist and proceeds through transference o n the patient's terms. The
ego-strengthening process involves both an identification with the ther­
apist a n d h i s / h e r attitudes a n d a release of the patient's previously
constrained resources for personality growth. This process can well be
204 SCHIZOPHRENIA

described, in Kohut's term, as "transmuting internalization", as long as

we remember that the therapist is not only a passive bystander i n the
process. A s emphasized b y Benedetti (1985), the interactional process
requires that the therapist also identifies with the patient.
U s i n g his concept of "self-object", K o h u t emphasized the signifi­
cance of the therapist as an idealized internal object for the patient.
Rothstein (1980) has therefore labelled the Kohutian therapeutic process
as supportive, suggesting that the idealized object relationship is not
analysed. This is sometimes—though not with all patients!—the case i n
psychosis therapy.
A l t h o u g h Kohut's self-object theory is widely recognized as a v a l u ­
able approach to narcissistic disorders, it has so far not been applied to
psychotic conditions to any appreciable extent. I found the term "self­
object" especially useful with regard to the understanding of disturbed
p a r e n t - c h i l d relationships leading to vulnerability to schizophrenia.
H o w e v e r , it also draws attention to the varying degrees of danger
to the individual's sense of self and the need for empathic interaction o n
the part of the therapist.
A s expressed elsewhere i n this book, I still think that the term "self­
object" should be seen as an umbrella under w h i c h a more detailed
psychoanalytic approach is needed. U s i n g terms of Kleinian origin, we
might also call the therapist a "container" a n d emphasize the signifi­
cance of projective identification i n the constructive efforts based o n
the transference process. The term "self-object" m a y also serve as a con­
ceptual introduction to the exploration of psychodynamically more
primitive levels of "part-object" relationships when it is necessary and
appropriate.
Connected with the function as the self-object, the therapist's person­
ality is more significant i n the therapy of psychosis patients than i n more
technically structured neurosis therapy. I referred to this w h e n I related
some of the favourable experiences w e h a d in our clinic with therapists,
often nurses, w h o h a d less formal training but were otherwise familiar
with the problems of psychosis patients. Most of these therapists are
w o m e n . H o l d i n g at a psychological level requires that even male ther­
apists show characteristics that—in the development of us all—have
come about through early identification with the mother. M e n fre­
quently feel such characteristics to threaten their masculinity a n d
therefore tend to suppress or deny them. Such male persons are also
found among psychiatrists, and they make perfectly good managers or
 THERAPEUTIC EXPERIENCES 205

rehabilitators, but they are less well suited to become psychosis thera­
pists. T h e same is naturally also true of other mental health staff.
Overemphasized rationality, w h i c h is sometimes observable i n psycho­
analysts, m a y also be detrimental to one's work as a psychosis therapist,
as is overemphasized emotionality.
Barbro Sandin, a well-known Swedish psychosis psychotherapist
whose therapies were particularly successful with male patients (see
Sjostrom, 1985), pointed out i n an interview b y Levander and Cullberg
(1994) that certain " m a l e " characteristics, especially resolute tenacity,
m a y have been useful for the reconstruction of her patients' personalities
through identification with the therapist's personality traits. Therapists
must be more of a mother and father to psychotic patients than to less
seriously disturbed patients—though naturally maintaining the role of a
therapist—and they therefore benefit from internal multidimensionality
of their o w n personalities.
Both patient a n d therapist m a y undergo deep emotional involve­
ment d u r i n g the therapy. If the frequency of therapy hours is once or
twice weekly, the process generally requires slightly less emotional c o m ­
mitment from the therapist than d o more intensive long-term therapies.
O n e of the benefits to a less experienced therapist of a less intensive
therapy is that it gives a better facility for maintaining an observing
attitude towards h i s / h e r o w n involvement and, accordingly, a sufficient
internal distance from the patient.
A less well trained therapist should be especially wary of presenting
interpretations too early. I agree with Boyer (1986), w h o pointed out that
the time is ripe for interpretations only when the therapeutic relation­
ship has advanced so far that the " g o o d " introjects created through it
have b e g u n to replace the patient's fixation to the previously internal­
ized " b a d " introjects. In other words, a positive transference relationship
has been established, including identification with the therapist, and it
has begun to replace the effect of previous negative interpersonal rela­
tionships. A n d the interpretations should usually begin from the surface
a n d only gradually proceed to deeper layers. It is often sufficient i n
successful therapies to point out the connections between the patient's
current experiences of symptoms and anxiety and h i s / h e r previous sen­
sations a n d experiences, particularly those related to past life a n d
parents, as indicated b y interpretations of the transferences attributed to
the therapist. A special m o d e of w o r k i n g with schizophrenic patients is
represented b y "interpretations u p w a r d s " (see the case history of Eric,
206 SCHIZOPHRENIA

chapter one)—interpretations that not only point out such connections

but also translate the patient's concretized expressions into normal lan­
guage.
Paula (see chapter one) believed delusionally that part of her brain
h a d been removed on the hospital ward. W h e n I said that she might be
thinking this because she has a feeling that now that she is i l l and i n the
hospital, she is not able to think as clearly as earlier, the delusion disap­
peared. W h e n more than two decades later I related this experience to
Bryce Boyer, then visiting T u r k u , he pointed out to me that even if
Paula's thinking was influenced by m y "interpretation u p w a r d s " , a pre­
condition for its success was also her instinctual acceptance of m y
empathic attitude, which helped her to give u p her delusion, character­
ized b y an accusing and projectively hostile attitude towards us, the
hospital people, "take i n " m y interpretation, and give u p the delusion. I
agreed and thought this to be a good example of the significance of
projective and introjective processes i n the psychology of schizophrenia.
Transference interpretations pointing out connections occasionally
have a dramatic effect o n the anxiety of a patient whose relationship
w i t h the therapist is well-established. One of m y patients, w h o h a d
previously h a d several psychotic episodes but h a d n o w been free from
psychotic symptoms for a couple of years, once called me i n a s u d d e n
panic, saying that this was the end of everything, as the communists
were taking over i n Finland. She also mentioned i n passing that she h a d
written such an angry letter to me that she h a d not dared to m a i l it. I
said, " T h e communists will not take over i n Finland, even if y o u mail the
letter". The patient understood the connection between her panic and
the anger that she h a d felt towards me a n d w h i c h she dreaded w o u l d
threaten our good mutual relationship, and she calmed d o w n .
No deeper drive-psychological content interpretations m a y be
needed. Deep interpretations—which have sometimes been given i n ­
appropriately to psychotic patients right from the beginning of therapy
b y representatives of the Kleinian school—may, if used b y non-experts,
only disintegrate the patient further. Besides, they may underline the
omnipotence of the therapist i n a way that is not advantageous to
the later phases i n the therapy.
The core of transference is the emergence of a symbiotic dependent
relationship between the patient and the therapist. The mutuality of the
process gives rise to nuances that are reminiscent of the parent-child
relationship. It is, however, important for the therapist to maintain h i s /
her role, being careful not to show excessive activity, such as making
 THERAPEUTIC EXPERIENCES 207

decisions on the patient's behalf, a n d certainly not to make delegation­

like suggestions or demands. The therapist is best able to help the
patient come to h i s / h e r o w n decisions b y taking u p alternatives a n d
discussing the problems they involve and by occasional encouraging
questions, but b y leaving the decision-making to the patient.
The most critical aspect of long-term psychosis therapies is often the
ability of the therapist to handle a n d control h i s / h e r countertransfer­
ence. Countertransference is a major asset for the therapist, but the p r o b ­
lems i n v o l v e d i n it constitute the most c o m m o n obstacles thwarting the
therapeutic process. The greatest problem is due to the aggressive p s y ­
chotic accusations b y the most seriously ill patients directed at their
therapists, w h i c h the latter consider unreasonable. E v e n so, the therapist
should not become involved b y venting h i s / h e r o w n internal anger at
the patient's distorted emotions or claims. Instead, the foundation of the
patient's transference should be analysed a n d patiently interpreted. It
w i l l generally turn out that the patient expects from the therapist the
k i n d of emotions a n d attitudes that were s h o w n b y a parent or other
early objects, and trying to induce the therapist to take their role, confus­
i n g the therapist with parents. But at the same time the therapist must
realize that not all anger is necessarily due to transference; h e / s h e m a y
have given a realistic cause for it b y showing a lack of empathy or
otherwise offending the patient.
T h e expression of critical and hostile feelings towards the therapist
often evokes anxiety i n the patient, but their expression is extremely
important, as it helps to integrate the dualistic d o m a i n of good a n d evil
mental images. E v e n at the early stages of therapy, the patients often
f i n d it a significant experience that they can feel angry towards the
therapist without h a v i n g the relationship break d o w n . This part of the
w o r k is, however, most important towards the end of the therapy, a n d it
is generally manifested as feelings of anger triggered b y the therapist's
vacations—but also b y other unavoidable frustrations. A t the same time,
the idealization of the therapist begins to level off, and h e / s h e is reduced
to the status of ordinary mortals i n the patient's m i n d .
It is gratifying for the therapist to bask i n the role of an idealized
object, but the therapeutic process should go further, and because of this,
the inclusion of the negative transference i n the dialogue may be essen­
tial. O n e of m y patients gave me a very illustrative experience of this
after one of our summer breaks.
T h e patient, n o w a married w o m a n i n her 40s, h a d been i n m y
therapy twenty years earlier, because of a transient psychotic episode
208 SCHIZOPHRENIA

during her university studies. N o w she h a d visited me anew for a couple

of years, because of the reproachful and threatening voices she h a d
begun to hear. H e r relationship to me was characterized by an idealized
and also erotically tinged positive transference, with the help of w h i c h
her condition had improved, despite continuing auditory hallucinations.
A t her first visit after the break, she told me h o w m u c h she h a d
longed for me during the long summer without the therapy hours a n d
h o w difficult this h a d been for her. Because she h a d earlier expressed
guilt feelings related to her fantasies of me, I said that she should not
reproach herself because of this. She became angry, a n d said that I d i d
not understand her at all—the matter i n question was h o w difficult it
was for her not to see me. She wanted to give up her visits altogether—
"that's the only solution". I listened to her and confirmed the time of her
next visit.
The patient came to her therapy session and apologized for her
anger. I said to her that I regarded this an important matter that we
should discuss. She then continued to criticize me, expressing rather
strong feelings of envy of the "better-off" therapist. It appeared that she
experienced me as an authority and even consciously resisted the inter­
pretations given by myself. This h a d obvious connections with the defi­
ance she h a d secretly felt for her mother and other persons during her
childhood a n d adolescence, even if she h a d ostensibly adopted their
opinions; it was her way of protecting her inner identity. The discussion
of these matters and the interpretation of their connection with transfer­
ence to the therapist helped the stagnated therapeutic process to get
started again, followed by the patient's more active participation i n the
c o m m o n therapeutic work. The erotically tinged transference h a d served
as a defence against the aggressive feelings towards myself, including an
effort to destroy m y interpretations b y not introjecting them.
Another important aspect of therapeutic work is attention to and sup­
port for the patient's adult characteristics, w h i c h is often ignored i n the
literature dealing with psychosis psychotherapy. A s emphasized also b y
Jackson and Williams (1994), the a d u l t — a n d , more generally, non-psy­
chotic—aspects of the patient's personality are important to recognize
and nurture from the first contact onward. A n d i n the process of organi­
zation a n d development that takes place d u r i n g the therapy, this part
of the patient's personality continues to play an indispensable role. The
patient's subsequent ability to avoid psychotic regression depends
significantly o n the strengthening of this adult quality, w h i c h involves
 THERAPEUTIC EXPERIENCES 209

reflective thinking and interest in trying to understand the nature of his

disorder.
I have found it to be especially important i n therapy to show interest
in the patient's life a n d personality i n general, not concentrating exclu­
sively o n symptoms a n d problems. D u r i n g therapy sessions, attention is
m a i n l y focused on matters related to the patient's current life situation;
analysis of any previous interpersonal relationships always starts at the
contemporary level, pointing out connections. A l t h o u g h the problems
and anxiety associated with the current situation—including the rela­
tionship w i t h the therapist—are the m a i n object of attention, it is useful
to show interest even i n " o r d i n a r y " matters, such as the patient's work,
studies, or hobbies. The interest should not be artificial, but genuine; a n d
genuineness is generally easy to achieve through the countertransfer­
ence that the therapist has developed towards the patient and h i s / h e r
developmental potential. The support given to the patient's adult char­
acteristics also includes acknowledgement of that person's o w n contri­
bution i n the therapeutic process.
I consider it a significant observation that I have achieved m y best
therapeutic results with psychotic patients whose life course or interests
have borne some similarity to m y o w n life experiences. This p h e n o m ­
enon is related to the spontaneous choices of personal nurses a n d thera­
pists that I mentioned w h e n discussing psychotherapeutic communities.
The development that the patients show i n an appropriately p r o ­
gressing therapy is frequently reflected as an attempt also to develop
themselves i n domains other than psychotherapy. Thus, people w h o are
recovering or have recovered from psychosis m a y become interested i n
various kinds of creative work, such as art, writing, or music, or begin a
n e w period of studies. Creative interests m a y even i n themselves be of
notable therapeutic value. Artistically talented patients often benefit
f r o m a combination of art therapy with their psychotherapy.
Sidsel Gilbert a n d Endre Ugelstad (1994) described cogently the role
of the creative efforts of two of their NIPS Project patients i n supporting
their process of recovery after long-term psychotherapy. O n e of the p a ­
tients, a seriously i l l y o u n g m a n , wrote a paper o n his experiences
d u r i n g the therapy, where he described h o w he used self-suggestion i n
his battle against the fears that h a d resulted i n massive isolation, a n d
also tried to promote clear thinking b y studying philosophy. It was
important to integrate the different levels of activity b y "feeling like a
child a n d thinking maturely".
210 SCHIZOPHRENIA

Separations are especially critical events for schizophrenic patients

because of their dependence. O n e should therefore refrain from starting
a therapeutic relationship that is doomed to e n d quickly because the
therapist is going to move or is only temporarily employed i n the w o r k ­
i n g community. It is not simple to replace one therapist w i t h another
w h e n we are dealing with self-object relations, i n which the therapist has
become a k i n d of new parent to the patient through transference. The
final stage of therapy is often long: it is advisable to start w o r k i n g to­
wards it 10-12 months before the intended discontinuation of sessions.
The patient must also be told of the therapist's vacations early enough,
so that the future period of separation and the emotions associated with
it can be discussed i n advance. The discussion should not be restricted to
the patient's ideas of h o w h e / s h e will manage d u r i n g the therapist's
vacation; it is also necessary to discuss the feelings aroused b y the vaca­
tion. It is r e c o m m e n d e d — a n d sometimes necessary—to arrange for the
patient to have a substitute therapist during the vacation.
E v e n so, separations associated with vacations and other events are
difficult for the patient despite the preparatory work, especially d u r i n g
the early stages of long-term therapy, because they always signify a
rejection at a deeper level. The patient's psychotic condition m a y dete­
riorate or recur during a separation. These situations also involve an
increased risk of suicidal behaviour. Most of psychotic patients' suicides
follow an experience of feeling rejected. I too have a few sad experiences
of this.
A l t h o u g h the psychodynamics related to the patient's family back­
ground is mostly worked through as related b y the patient a n d , as the
therapy advances, through transference and countertransference m a n i ­
festations, I consider it useful even for the i n d i v i d u a l therapist to meet
the parents at the beginning of therapy, especially if the patients still live
with their primary families. The patient should be present at these meet­
ings. T h e y are important for two reasons: first, because they give the
therapist some idea of the current state of family dynamics, and, second,
because a contact w i t h the parents may diminish their distrust towards
the therapist. In the need-adapted m o d e l such an initial contact comes
about naturally d u r i n g the therapy meetings arranged d u r i n g the p a ­
tient's admission, p r o v i d e d that the future i n d i v i d u a l therapist attends
these meetings.
T h e parents or other relatives may occasionally contact the therapist
in crisis situations. If they do, the therapist must respect the confidential­
ity of the therapeutic relationship and also refuse to keep the patient
 THERAPEUTIC EXPERIENCES 21 1

ignorant of the contact. If the therapist works i n a public health care unit,
repeated contacts by the parents must be referred to another worker
w i t h an assignment to support the parents. In more serious crises, it may
be useful to arrange a therapy meeting attended jointly b y the patient,
the relatives, the therapist, a n d the other members of the team.
Since the goal of the therapy is to promote the patient's increasing
individuation and liberation from h i s / h e r internal—and often also exter­
n a l — d e p e n d e n c y bonds with the parents, the therapeutic w o r k must
continuously focus o n questions pertaining to this. Theodore a n d R u t h
L i d z (1982) expressed this pointedly: "Efforts are made to imbue i n the
patient trust i n his o w n ideas a n d feelings while questioning those that
are essentially the parents' feelings a n d percepts w h i c h the patient offers
as his o w n . " T h e relationship with the therapist fills part of the v a c u u m
that m a y threaten the patient as a consequence of h i s / h e r efforts towards
independence a n d also interferes with these efforts. In the final part of
therapy a positive, conciliatory development m a y occur i n the patient's
feelings towards parents, w h i c h m a y include attempts at reparation for
things felt to have been done to them, i n fact or i n phantasy. A precondi­
tion for this is the patient's individuation a n d a rebuilding of the m u t u a l
relationships at a new level, allowing for more separateness.
In the case of patients w i t h children, the therapist should also give
some attention to the relationship between them a n d the patient, helping
the latter to avoid the risk of transmitting the psychopathology from one
generation to the next. M a n y of the patients are aware of this possibility.
O n e female patient of mine, w h o obviously h a d an admirably empathic
attitude towards her children, said that she was trying to do the g o o d
turn of not d e m a n d i n g from her children the k i n d of "responsibility"
and care she h a d h a d to assume for her o w n mother (the mother was not
psychotic, but transferred her o w n problems to her relationship to the
daughter, w h i c h was both b i n d i n g and deprecatory).
The recommended frequency of visits for i n d i v i d u a l therapies, even
w h e n carried out w i t h i n the public health care system, is twice or, if
possible, three times a week, and at the initial stages i n the hospital w a r d
three times a week or more often. If necessary (though not preferably),
the frequency of visits can later be d r o p p e d to once a week without
notably i m p a i r i n g the intensity of the therapeutic relationship. A t times
of crisis, however, it should be possible to arrange for more frequent
visits. W o r k i n g w i t h long-term patients w h o already show advanced
development towards independence, I have sometimes used a two-week
interval between the sessions at later stages. A t the earlier stages, h o w ­
212 SCHIZOPHRENIA

ever, such long intervals w o u l d transform the therapy into maintenance

treatment instead of advancing the process.
M a n y of the therapeutic relationships last long—usually for 4-10
years. The best signs of the approaching end of a successful therapy are
the permanent elimination of psychotic symptoms a n d , even more i m ­
portantly, the integration of the patient's internal development i n such a
w a y that h e / s h e is able to face problems independently, using internali­
zations made d u r i n g therapy and the resources that have been released
internally. This stage is often also characterized b y an important new
interpersonal relationship. The therapist should naturally support such
a development but also ascertain that the patient is not merely transfer­
ring h i s / h e r needs for dependency to a new object. In that case, a
possible new rejection o n the part of the new object c o u l d be disastrous.
M a n y patients retain a certain constructive internal dependency on
the therapist, w h i c h may result i n occasional contacts even long after
therapy.
The longest of m y o w n therapeutic relationships has lasted for 38
years a n d is still going on. D u r i n g the early years there were several
interruptions: m y patient was hospitalized for several years altogether,
but afterwards resumed the visits. N o w she has not been in a hospital for
more than 20 years and is asymptomatic. She visits me only three times
a year, discussing both some current problems a n d problems that date
back to earlier times, even her childhood, w h i c h still are active i n her
mind.

Comments on psychopharmacological treatment

In the need-adapted treatment m o d e l , d r u g treatment is considered
to be a n auxiliary m e t h o d , used to support the psychotherapeutically
oriented treatment.
Neuroleptic medication in small or moderate doses often makes it
easier to establish contact with the patient, especially if h e / s h e is restless
a n d dominated b y psychotic delusions. In the treatment m o d e l report
of the Finnish National Schizophrenia Project (Alanen et al., 1990a), we
specified that an important goal is to find "the m i n i m a l neuroleptic
dosage required to keep the patient's ability for contact and communica­
tion optimal i n the situation". A t the same time, we emphasized the need
to justify the medication to oneself, the patient, a n d frequently also the
patient's environment, i n a way that everybody readily understands.
 THERAPEUTIC EXPERIENCES 21 3

The illness i n itself is not a sufficient reason for medication, b u t the

explanation c o u l d be, for example, that the patient is n o w i n need of
medication i n order to be better able to control anxiety a n d agitation a n d
to be able to live at h o m e without hospitalization, o r — i n a little more
interpretative sense—in order to be able to control better the occasional
feelings of anger a n d anxiety that m a y arise.
Psychopharmacologically oriented researchers and clinicians prefer
to describe neuroleptic medication as a stimulus barrier, w h i c h helps the
patient to maintain h i s / h e r psychic balance. Leff et al. (1983) have re­
ported findings that suggest that the protective dosage should be higher
i n family environments with h i g h E E values than i n environments with
low E E values, i n order to help the patient to remain out of hospital.
A s a counter-argument, one might claim—referring, for example, to
the N I P S outcome results (Alanen et aL, 1994; see also Figure 5.3)—that
an established therapeutic relationship often gives the patient a sense of
security, w h i c h makes it possible to lower the dosage a n d eventually
discontinue medication. F r o m the viewpoint of psychotherapy, too,
low-dose neuroleptic medication, even when used continuously, is often
beneficial, whereas higher doses tend to be detrimental to the therapeu­
tic process a n d to prevent progress. Few patients undergoing psycho­
therapy need a daily dose higher than 150-200 m g of thioridazine or
12-16 m g of perazine.
A s the patient's condition improves, the dosage should be lowered
gradually, preferably aiming at discontinuation. This is not, however,
possible i n all cases, a n d I also k n o w of patients w h o want to keep the
small dose they take i n the evening, mostly for psychological reasons, as
a concrete s y m b o l of their internal dependency o n their previous thera­
pist; the pharmacological effect of the dose m a y be insignificant. W e also
k n o w that sudden discontinuation after a relatively h i g h dose involves a
risk for the patient's psychic stability.
Some of m y patients have given interesting descriptions of the
changes brought about b y the discontinuation of even a small dose of
medication, saying, for example, that " b o t h one's o w n feelings and the
feelings of others became more visible", or of trying h a r d to maintain
their current state a n d prevent the previously felt lack of boundaries
between oneself and the others from recurring. It is important to take u p
such problems d u r i n g the therapy sessions, a n d they can usually be
w o r k e d out successfully.
Referring to these experiences, and naturally also to the side-effects
of psychoactive drugs, it seems justifiable to support the efforts of
214 SCHIZOPHRENIA

Rakkolainen a n d his co-workers (Rakkolainen et al., 1994; V u o r i o et al.,

1993), w h i c h I described i n chapter four: they suggest that i n particular
m a n y first-admission schizophrenics should preferably be treated w i t h ­
out neuroleptics. But i n order to be able to do so, we must vigorously
develop our psychotherapeutic resources i n a comprehensive way.
Otherwise there w i l l be the danger that prolonged in-patient periods
w i l l result i n poorer outcomes, especially through the negative effects
that institutionalization m a y have o n the patients' social status a n d so­
cial skills. For long-term patients—especially those without a psycho­
therapeutic relationship—a maintenance medication i n low or moderate
doses is usually i n order.
Neuroleptic medication administered as injections at longer inter­
vals, w h i c h is advocated i n order to guarantee the regularity of treat­
ment (e.g. Hogarty, 1994), is not compatible with psychotherapeutic
approaches and their primary goal of promoting the patient's independ­
ence. Forced medication has adverse effects o n the therapeutic c o n ­
tacts—I experienced the mental violence associated w i t h it personally
w h e n I visited a camp arranged b y the Society of Psychiatric Rehabilitees
i n F i n l a n d and was assigned a sociodrama role of a patient w h o was fed
pills b y force. Nevertheless, involuntary medication is frequently neces­
sary on an acute psychosis w a r d ; it should, however, always be c o m ­
b i n e d w i t h an effort to establish a different k i n d of contact with the
patient b y discussing what made h i m / h e r feel so bad.
It is important that the medication and the dosage are discussed with
the patient, taking h i s / h e r opinion into consideration. M a n y of the out­
patients soon learn to regulate their medication, increasing the dosage at
times of crisis.

Need-adapted treatment: case excerpts

Marjorie, single parent with three children

T h e case of Marjorie, a patient i n c l u d e d i n the T u r k u C o h o r t I V (see

chapter five), shows particularly w e l l b o t h the i n d i v i d u a l " t a i l o r i n g "
of o u r therapeutic activities a n d the benefits of family-oriented treat­
ment, b o t h for the patient a n d for the larger family g r o u p .
Marjorie, aged 33, began to hear voices u p o n her return from Sweden
to her h o m e t o w n of T u r k u with her 3 children. The voices h a d started
 THERAPEUTIC EXPERIENCES 215

f r o m fits of fear, being partly accusing, and Marjorie h a d lately b e g u n to

respond to them a n d burst into compulsive laughing fits. She thought
this to be caused b y some k i n d of hypnosis, saying that she occasionally
heard a w h i p p i n g s o u n d near her ear, as if she were being hit.
Marjorie h a d m o v e d to Sweden at the age of 16. There she h a d been
married twice a n d h a d h a d several partners living w i t h her for short
periods. H e r second marriage ended in divorce a year before she m o v e d
back to Finland. O u t of her marriages she h a d 3 children w h o l i v e d with
her, the oldest one 13 years old. She told us that both marriages h a d been
wrecked for the same reason: the husbands were aggressive a n d a d ­
dicted to alcohol (as Marjorie's father h a d been, too).
In T u r k u , Marjorie h a d a few short, unsuccessful jobs. She tended to
go for help to her mother, although their relationship was liable to c o n ­
flicts. H a v i n g heard voices for more than 6 months, Marjorie consulted
the M e n t a l Health Office o n her o w n initiative a n d thereby became
i n c l u d e d i n our series. She received medication, a n d a therapeutic rela­
tionship with a psychologist was arranged for her. However, after taking
an overdose of her drugs, she was hospitalized for 5 weeks. H e r medica­
tion i n the hospital consisted of 8 m g perphenazine a n d 50 m g thiorid­
azine a day. T h e dose was later cut b y half.
Investigation of the family situation i n the initial therapeutic meet­
ing, w h i c h was also attended b y Marjorie's mother a n d the children,
revealed the anxiety of all. It indicated also that Marjorie h a d notable
problems w i t h her children, especially the eldest daughter, w h o tyran­
n i z e d her; she was quite helpless w h e n faced b y her anger. The older
children h a d also begun to play a parental role i n relation to their
mother.
Joint sessions were thereafter arranged b y the same therapeutic team
four times, at intervals of about month. T h r o u g h their messages, the
family therapy team made efforts to support Marjorie i n her maternal
role a n d to liberate the children from parentification. O n e transactional
defence that appeared central from the family-dynamic point of view
was the patient's unconscious projective identification with her children.
She seemed to profit b y their outbursts of anger through projecting onto
them her o w n suppressed aggressions directed at her mother a n d then,
b y identifying w i t h them, to " m a i n t a i n " i n them this intrapsychic e m o ­
tion, w h i c h was originally her o w n .
The family situation seemed to have become easier after the summer,
w h e n Marjorie a n d her eldest daughter h a d h a d more distance between
216 SCHIZOPHRENIA

them while the daughter spent some weeks i n Sweden w i t h her father.
The focus of Marjorie's therapy now shifted to individual therapy. It h a d
been going o n all the time but only acquired a real significance w h e n the
transactional defences were clarified a n d weakened through the family
sessions. She visited the psychologist at the M e n t a l Health Office twice
weekly; later, the visits were d r o p p e d to once a week.
T h e family was invited to a new joint session at the time of the two­
year follow-up. Marjorie h a d been continuing her i n d i v i d u a l therapy.
She clearly h e l d the mother's role i n relation to her children now. The
children's psychological individuation h a d advanced, a n d they no
longer displayed the kinds of transactionally based problems of aggres­
sion to the extent that h a d coloured the initial therapeutic process. Both
Marjorie and the children increasingly directed their attention to new
fields of interest and relationships outside the home. A similar develop­
mental process h a d taken place in Marjorie's relationship with her
mother, w h i c h h a d become more distant but thereby also less conflicted.
Marjorie's attitude towards life and her mental w o r l d were, however,
still characterized b y timidity and wariness, a n d she still heard voices
from time to time, though she understood them to be her o w n internal
experiences. Socially, she h a d been supported through vocational c o u n ­
selling.
Family intervention and i n d i v i d u a l therapy made u p a c o n t i n u u m
here, w h i c h shows the implementation of the need-adapted therapeutic
approach from the point of view of both patient a n d family. The most
essential outcome of the family intervention, which was important for all
the family members, was the preliminary breakdown of the transac­
tional defence mechanisms as unnecessary. Simultaneously, the family
therapy created, both through the external support and through an
emancipation of the patient's inner psychological resources, a necessary
and sufficient prerequisite for Marjorie's i n d i v i d u a l treatment. The pre­
ventive importance of family therapy for the children's development is
also reflected i n this case vignette.

Catherine, a young woman in search of her identity

[with Irene Aalto]

Catherine, a 27-year-old u n m a r r i e d clothing designer, attractive a n d

energetic but lacking persistence, belonged to the series of
R a k k o l a i n e n et al. (see p p . 117-118), w h i c h consisted of first-admis­
 THERAPEUTIC EXPERIENCES 21 7

s i o n patients of the schizophrenia g r o u p treated w i t h comprehensive,

need-adapted psychotherapy a n d , whenever possible, without n e u r o ­
leptics. She b e g a n her treatment i n the K u p i t t a a H o s p i t a l i n T u r k u i n
September 1991.

CLINICAL FEATURES AND STAGES OF TREATMENT

Catherine h a d been suffering f r o m stress for four years, t r y i n g to

p a y back the loans that r e m a i n e d after she h a d closed d o w n her s m a l l
b o u t i q u e . She h e l d various temporary jobs, alternately w o r k i n g over­
time a n d b e i n g u n e m p l o y e d . She h a d started the boutique w i t h her
p r e v i o u s c o m m o n - l a w h u s b a n d , R i c h a r d , w h o n o w joined his rela­
tives i n pressing Catherine for the repayment of loans a n d g u a r a n ­
tees. R i c h a r d h a d e v e n battered Catherine a n d h a d tried to d r i v e over
her; the matter h a d been taken to a court.
W h e n R i c h a r d a n d Catherine broke off their relationship, she s o o n
f o u n d a n e w b o y - f r i e n d , D e n i s , a n d she w a s p l a n n i n g to get m a r r i e d
to h i m . W i t h o n l y a w e e k to go before the w e d d i n g , Catherine became
restless a n d sleepless, s p o k e incoherently, a n d kept leafing t h r o u g h
her papers, repeating " e v e r y t h i n g ' s all right, everything's all r i g h t " .
A doctor w a s called w h e n she was f o u n d r u n n i n g n a k e d i n the c o r r i ­
dor, talking about the e n d of the w o r l d a n d the c o u n t d o w n . She was
a d m i t t e d into the K u p i t t a a H o s p i t a l o n 12 September 1991.
O n the closed w a r d of the hospital, Catherine was at first agitated,
confused, a n d restless, hyperactively o r g a n i z i n g things, t r y i n g to u n ­
dress, a n d f i n d i n g her e n v i r o n m e n t m e n a c i n g w i t h r a d i o a n d televi­
s i o n messages of perils threatening herself a n d Denis. A l t h o u g h one
member of the staff was appointed to be available to Catherine at all times,
she h a d to be isolated several times d u r i n g her first few days i n the
hospital, especially at night. W h e n necessary, she was g i v e n benzo­
diazepines (lorazepam) intramuscularly a n d orally. N e u r o l e p t i c d r u g s
w e r e not g i v e n at any stage.
Catherine's hospital stay was l o n g a n d eventful. Involuntary hos­
pitalization w a s considered necessary at first, because the need for
occasional isolation persisted a n d Catherine d i d not have a sense of
illness. Despite this, she b e g a n to v i e w the hospital as a refuge about
a w e e k after her a d m i s s i o n . She continued her anxious, affectively
restless activity, w h i c h i n v o l v e d h y p o m a n i c a n d histrionic features,
218 SCHIZOPHRENIA

but since she was able, despite her psychotic b e h a v i o u r , to collect

herself i n strict realities a n d interaction a n d felt that the atmosphere
i n the closed w a r d o n l y increased her restlessness, she w a s m o v e d to
a n o p e n w a r d for daytime care as early as 19 September, t h o u g h she
c o n t i n u e d to s p e n d the nights o n the closed w a r d . O n e of the mental
nurses o n the o p e n w a r d was appointed her personal nurse, a n d she
contributed significantly to Catherine's c o p i n g i n hospital.
Catherine's agitation gradually calmed d o w n , but her hyperactiv­
ity a n d unrealistic t h i n k i n g , w h i c h expressed b o t h her omnipotent
level of functioning a n d her potential for creative imagination, c o n ­
tinued until December, a n d partly even longer. She n o w became
m o r e depressed, but also w i l l i n g to deal w i t h her p r o b l e m s at the
level of realities. Involuntary treatment was discontinued o n 12 D e ­
cember 1991, although she still s h o w e d psychotic behaviour at that
time. T h i s stage of hospital treatment was characterized b y discussion
and clarification of Catherine's interpersonal borderline psychodynamics in
repeated therapy meetings (see p p . 175-177), mostly f r o m a systemic
perspective; the most essential aspects were her strong a n d ambivalent
d e p e n d e n t relations. Catherine's identity crisis was reflected i n her
semipsychotic attempt to change b o t h her C h r i s t i a n n a m e a n d her
s u r n a m e (she wanted to be called Sealand, because, as a n infant, she
h a d l i v e d o n a n island w i t h her maternal grandmother, w h o still
l i v e d there). Since Catherine was still depressed, i n n e e d of care,
unable to w o r k , a n d continued to have problems w i t h her interper­
sonal relationships, her hospital treatment was c o n t i n u e d , mostly o n
a day-patient basis, until 11 June 1992, after w h i c h she still kept her
d a y - h o s p i t a l registration until 16 October 1992, although she came to
the hospital only for therapy sessions a n d art therapy. D u r i n g the
s p r i n g , she was also o n antidepressive medication (citaloprame 20
m g daily), w h i c h d i d not i m p r o v e her condition.
Catherine's diagnosis i n the patient record was psychosis schizo­
phreniformis.
W h e n Catherine was discharged f r o m the hospital, she began
regular individual therapy sessions w i t h I.A., a specialized nurse e d u ­
cated i n b o t h p s y c h o d y n a m i c psychotherapy a n d family therapy.
Catherine h a d come to k n o w her d u r i n g the therapy meetings. H e r
i n d i v i d u a l therapy has since continued. Y . O . A . has been the s u p e r v i ­
sor of her i n d i v i d u a l therapy.
Catherine wasreadmitted a n d remained hospitalized f r o m 4 M a r c h
to 30 A p r i l 1993, after she h a d taken 100 pills (1 mg) of lorazepam. She
 THERAPEUTIC EXPERIENCES 219

w a s depressed but not psychotic at that time. T h e r e w a s n o break i n

Catherine's i n d i v i d u a l therapy sessions because of the hospitaliza­
tion. T h e clarification of her interpersonal relationships (especially
her strained relation w i t h her mother) was continued at r e n e w e d
therapy meetings.

SYSTEMIC THERAPY PROCESS AND CATHERINE'S FAMILY ANAMNESIS

T h e therapy process consisted of several integrated aspects. T h e

w e e k l y therapy meetings, w h i c h are arranged regularly for all patients
o n the w a r d , p r o v i d e d the core for systemic w o r k . Catherine attended
altogether 73 therapy meetings (some of t h e m after her discharge).
A p a r t f r o m these, she a n d D e n i s also attended 8 couple sessions, a n d a n
unsuccessful attempt was m a d e to i n v o l v e Catherine's p r i m a r y f a m ­
ily i n m o r e regular f a m i l y therapy. Catherine also participated i n
group therapy a n d art therapy.
T h e first therapy meetings were arranged o n the w a r d o n the d a y of
a d m i s s i o n a n d the f o l l o w i n g day. T h e y were attended b y C a t h e r i n e
a n d her escorts, w h o s e variety illustrated the p o o r differentiation,
controversiality, a n d tendency to interdependence that characterized
her interpersonal relations: the persons present were Catherine's
mother, her step-father, her y o u n g e r step-sister, a female friend, a n d
D e n i s a n d his sister. T h e persons w h o continued to attend most r e g u ­
larly w e r e her mother a n d D e n i s , a n d therapy meetings were also
arranged w i t h Catherine present w i t h o u t her relatives. A s far as p o s ­
sible, the basic members of the therapy team were always present.
T h e team consisted of three members of the w a r d staff—a specialized
nurse w i t h family a n d i n d i v i d u a l therapy training ( L A . ) , Catherine's
p e r s o n a l nurse, a n d another mental nurse—less frequently also a
doctor a n d occasionally s o m e other m e m b e r of the n u r s i n g staff.
The family anamnesis w a s taken d u r i n g the therapy meetings. N o
one k n e w of a n y psychotic disorders i n the family. Catherine was the
o n l y c h i l d of her parents, w h o h a d d i v o r c e d w h e n she was 3 years
o l d . T h e mother r e m a r r i e d w h e n Catherine was 5, a n d she h a d twins
(a girl a n d a boy) two years later. Catherine's father a n d mother
quarrelled over her custodianship. Catherine f o u n d out later that her
m o t h e r h a d g i v e n her u p as a 3-month-old baby to her maternal
grandparents, w h o h a d then h a n d e d the 11-month-old b a b y over to
220 SCHIZOPHRENIA

her paternal grandmother (though she h a d also spent s o m e periods

w i t h her mother). T h e mother o n l y w a n t e d her back w h e n she h a d
d i v o r c e d her h u s b a n d , a n d the father simultaneously w a n t e d to have
her custodianship. Catherine was told about all this b y her maternal
g r a n d m o t h e r . T h e controversial quality of Catherine's parents' rela­
tionship is s h o w n b y the fact that her mother m a d e sure that she w a s
a w a y w h e n her father came to visit. W h e n the mother r e m a r r i e d , the
step-father a d o p t e d Catherine, w h o was thereby g i v e n his surname.
T h e team h a d a n i m p r e s s i o n that Catherine's relatives, i n c l u d i n g her
maternal a n d paternal grandparents, h a d been quarrelling over w h o
w a s the best p e r s o n to take care of her, a n d that these quarrels still
c o n t i n u e d i n part, w h i c h m a d e Catherine feel that people were inter­
fering w i t h her life a n d preventing her f r o m b e i n g autonomous.
T h e relatives h a d considered Catherine a g o o d , cheerful, loveable
girl, a " p r i n c e s s " w h o always p u t other people's interests before hers.
It w a s quite obvious that Catherine's interpersonal relations were
characterized b y a deep-rooted n e e d to please others a n d a desire to
h a v e substitute figures ready to step i n whenever she w a s rejected
b y the others. T h i s tendency was still visible i n her interpersonal re­
lations, e v e n i n hospital. A t the same time, however, she v e n t e d her
irritation at not b e i n g able to take care of her o w n affairs. F o r ex­
a m p l e , b o t h her o w n family a n d her in-laws-to-be h a d been i n t r u d i n g
o n the arrangements for her w e d d i n g , w h i c h then h a d to be c a n ­
celled.
T h e interviews that were conducted d u r i n g the therapy meetings
(and e v e n m o r e significantly Catherine's subsequent individual
therapy) revealed a great deal of m u t u a l e n v y a n d jealousy i n her
early environment. Catherine a n d her y o u n g e r step-sister c o m p e t e d
for their mother's favours, of w h i c h Catherine felt d e p r i v e d , w h i l e
the mother was jealous of the affection that the step-father—who was
p r o b a b l y the least disturbed m e m b e r of the f a m i l y — s h o w e d towards
Catherine as w e l l as of Catherine's affectionate relationship w i t h her
maternal grandmother.
Catherine d r o p p e d out of h i g h - s c h o o l — f o r w h i c h she later
b l a m e d her m o t h e r — a n d studied clothing manufacture a n d d e s i g n
i n trade school. She received a designer's d i p l o m a but gave u p the
further-education p r o g r a m m e she h a d started. She h a d her first l o n g ­
t e r m d a t i n g relationship w h i l e still a teenager, but she broke it off as
a protest to her mother, w h o l i k e d the boy. W h e n she w a s 19, she
began to see R i c h a r d , w h o was to become her first " o p e n h u s b a n d " ,
 THERAPEUTIC EXPERIENCES 221

against her mother's w i l l . T h e m a n was eight years older than she.

W h e n C a t h e r i n e h a d to close d o w n the b o u t i q u e she h a d been keep­
i n g together w i t h R i c h a r d , she took various o d d jobs as a salesperson,
waitress, seamstress, a n d m o d e l , w h i l e p l a n n i n g v a r i o u s educational
possibilities that she never seriously explored.
Catherine h a d been meeting D e n i s for two years, b u t they o n l y
moved i n together about six months before her hospitalization.
D u r i n g these m o n t h s Catherine h a d come to realize that D e n i s w a s
i n c l i n e d to abuse b o t h alcohol a n d sedatives, w h i c h fact he tried to
d e n y f r o m himself a n d h i d e f r o m other people. C a t h e r i n e later s a i d
that the onset of her psychosis just before the w e d d i n g w a s a s i g n of
a n " u n c o n s c i o u s realization that the marriage w o u l d never w o r k
o u t " . She also faced another serious p r o b l e m i n a diagnosis of endo­
metriosis, w i t h the consequent possibility of sterility. T h i s diagnosis
came as a b l o w to her femininity a n d her dreams of h a v i n g a b a b y .
T h e p r i m a r y therapeutic function of the therapy meetings w a s to
give Catherine a chance to talk about herself i n a n increasingly o r g a n ­
i z e d fashion. She l i k e d this m o d e of w o r k i n g a n d w a s active, occa­
sionally firing a battery of questions at her m o t h e r or someone else. In
that w a y , she also b e g a n her process of differentiation (though she
later n e e d e d i n d i v i d u a l therapy to a c c o m p l i s h this successfully). F o r
Catherine's relatives, the meetings p r o v i d e d a chance to establish
contact w i t h the therapeutic c o m m u n i t y a n d to d e v e l o p a n e n h a n c e d
u n d e r s t a n d i n g of the connections between Catherine's illness a n d the
p r o b l e m s i n her life. T h e therapy ^meetings also p r e v e n t e d the q u a r ­
rels between the relatives, w h i c h p r o v o k e d anxiety i n Catherine, f r o m
interfering excessively w i t h her therapy. Despite this, the relatives'
attitudes s h o w e d n o major signs of progress d u r i n g the meetings. T h e
therapy meetings, c o m b i n e d w i t h the meetings of the w a r d c o m m u ­
nity, also p r o v i d e d a f o r u m for discussing the tendency to split, w h i c h
was apparent i n the w a r d community and was enhanced by
Catherine's fragmentary transference relations. T h i s split w a s m a n i ­
fested, for example, b y a disagreement as to whether C a t h e r i n e
s h o u l d be " p u t i n a better o r d e r " or g i v e n space to exercise her s e m i ­
psychotic creativity.
T h e couple sessions of Catherine a n d D e n i s , w h i c h were a corollary
of the therapy meetings i n the s p r i n g of 1992, took place at a time
w h e n it was discussed whether Catherine s h o u l d m o v e i n w i t h D e n i s
after her discharge. W h e n Catherine began to s p e n d part of her time
w i t h D e n i s , D e n i s b e g a n to d r i n k ; Catherine a n d Denis then b e g a n to
222 SCHIZOPHRENIA

use b e n z o d i a z e p i n e together, a n d Catherine became depressed.

Catherine's p r o l o n g e d hospital treatment was partly related to these
p r o b l e m s . After the couple sessions, Catherine a n d D e n i s d e c i d e d to
separate.
Catherine l i k e d group therapy (12 sessions) a n d especially art ther­
apy, w h i c h was g i v e n i n small groups. She established a close a n d
favourable relationship w i t h the art therapist. Catherine appreciated
m o s t h i g h l y her p a i n t i n g of a s w a n , a southern b i r d , s w i m m i n g i n a n
ice-clad landscape a n d clearly threatened b y destruction.

INDIVIDUAL THERAPY PROCESS

I n d i v i d u a l therapy was already considered to be indicated for

Catherine at the early stages of her hospitalization. T h e b e g i n n i n g of
individual therapy was, however, notably delayed, because
Catherine refused to accept the idea (especially w h e n a therapist
w o r k i n g outside the hospital was suggested for her), p r o b a b l y be­
cause of the confused a n d b i n d i n g complexity of her actual a n d trans­
ference relations. She only accepted the idea of i n d i v i d u a l therapy
w h e n she was about to be discharged f r o m the hospital, a n d she
n a m e d three " c a n d i d a t e s " a m o n g the hospital staff (I.A., art therapist,
personal n u r s e ) — w h i c h she herself associated w i t h the fact that she
h a d h a d "three m o t h e r s " as a baby. L A . was p r e p a r e d for the therapy
(and was the most competent of the candidates), but considered it
i m p o r t a n t that Catherine s h o u l d choose the therapist herself. T h e
confidential relationship between Catherine a n d I.A. h a d b e e n estab­
lished g r a d u a l l y d u r i n g the therapy meetings, where L A . h a d been
present as a staff member.
T h e frequency of i n d i v i d u a l therapy sessions was three times a
w e e k d u r i n g the initial stage a n d at times of crisis, a n d twice a w e e k
later. T h e transference relationship was at first characterized b y pas­
sively " s y m b i o t i c " reliance for omnipotent support a n d a search for
love. Catherine b e h a v e d endearingly to " d i s a r m " the therapist, but
she s o o n began to act out a n d s h o w her unconscious ambivalence. O n
the one h a n d , she asked for extra appointments as a sign of the
therapist's love, w h i l e o n the other h a n d she presented various ration­
a l i z e d reasons for cancelling her regular appointments. T h e therapist
s h o w e d caring, motherly countertransference: she s a i d that at first she
 THERAPEUTIC EXPERIENCES 223

felt Catherine to be a " s m a l l , attractive, talented c h i l d " . Catherine's

aggressiveness (initially unconscious, later conscious) d i d not p r o ­
v o k e aggressive irritation i n the therapist; she says her patient " c o n ­
fined the aggression w i t h i n herself" without significantly transferring
it t h r o u g h projective identification to the therapist. D u r i n g vacations
a n d at times w h e n Catherine w a s i n crisis, the therapist a l l o w e d her
to telephone her at h o m e . Catherine also tried to repeat her p r e v i o u s
pattern of " f i n d i n g substitute p e o p l e " b y contacting her p r e v i o u s art
therapist to talk about her problems or " e s c a p i n g " to her biological
father, o n l y to be d i s a p p o i n t e d even there. T h e supervisor of the
therapy process therefore p o i n t e d out the n e e d to increase g r a d u a l l y
the regularity of the therapy b y m a k i n g a friendly, b u t clarifying
intervention i n Catherine's acting-out tendencies. After interpreta­
tions, Catherine d i d not w a n t a substitute therapist e v e n w h e n L A .
w a s a w a y o n h o l i d a y , but she called her at the agreed times. Later o n ,
h o w e v e r , the w o r k at the transference level focused increasingly o n
the p r o b l e m s d e r i v i n g f r o m Catherine's early mother relationship,
w h i c h are discussed i n greater detail below.
Catherine w a s n o longer psychotic w h e n she began a n d continued
her i n d i v i d u a l therapy, a l t h o u g h she felt p a n i c k y anxiety a n d fears of
b e c o m i n g psychotic d u r i n g her frequent crises. H e r most important
defence mechanisms were denial a n d projection (which s o o n decreased,
however), projective identification (mostly w i t h the therapist), as w e l l
as the acting-out of her desire to have other contacts outside the
therapeutic relationship. H e r m o o d s ranged f r o m creative e n t h u s i ­
a s m to depressive sadness. T h e depressive periods i n v o l v e d fatigue
a n d excessive eating (during late 1993 she p u t o n 20 k g , o n l y to lose it
a g a i n gradually). Catherine was g i v e n n o other medication d u r i n g her
therapy except 1 m g of l o r a z e p a m w h e n necessary. Occasionally,
w h e n she felt anxiety a n d depression, she took 5-6 m g daily, but
w h e n her anxiety lessened, she stopped taking pills altogether.
O u t w a r d l y , Catherine's life course r e m a i n e d unstable for a l o n g
time. She c h a n g e d jobs a n d w a s variably able to w o r k d u r i n g her
therapy: she generally f o u n d a job easily, despite the recession, b u t
she w a s not able to keep it, partly because of her desire to please
l e a d i n g to stressful submissiveness, partly because of her fatigue a n d
depressive tendencies. She h a d several short sick-leaves for p s y c h i ­
atric reasons or because of the treatment of her endometriosis. A t first
she l i v e d w i t h her mother a n d step-father, but after her hospitaliza­
tion i n the s p r i n g of 1993 she m o v e d to live i n a flat. A t about that
224 SCHIZOPHRENIA

time she got a d o g , Daffy, w h i c h was a n important transitional object

for her. She p a m p e r e d the d o g a n d identified it w i t h her o w n desires
("I'm the most important person for D a f f y " ) . Catherine even brought
Daffy to the therapy session a few times. Catherine h a d one of her
m o s t intense feelings of hatred ever discussed d u r i n g the therapy
towards her friend, w h o m she h a d asked to take care of her d o g for a
w h i l e , a n d w h o h a d done this caring inadequately ("I c o u l d have
killed her").
H a v i n g separated f r o m D e n i s , Catherine h a d a few male friends
over the years, but the relationships i n v o l v e d problems of ambivalent
dependence a n d other difficulties. Quite obviously, Catherine's o w n
p r o b l e m s — b o t h those d u e to her relationship w i t h her mother a n d
those based o n her oedipal need for p u n i s h m e n t — c o n t r i b u t e d to her
tendency to make unfortunate choices. In the s u m m e r of 1995, almost
i m m e d i a t e l y after the marriage of her therapist, she became " e n ­
g a g e d " to a n older m a n she h a r d l y k n e w , w h o w a s just d i v o r c i n g
his wife, a n d she m o v e d i n w i t h h i m , leaving her o w n recently re­
m o d e l l e d flat. W h e n the relationship failed d u e to the m a n ' s despot­
i s m a n d inadequate separation f r o m his previous wife, Catherine
again h a d n o w h e r e to live. It was pointed out i n the therapy that i n
b e c o m i n g engaged she wanted to follow her therapist's example; b u t
feelings of e n v y were not interpreted at this point. A year later
Catherine went to live w i t h a pathologically jealous a n d clinging m a n ,
w h o even tried to strangle her after she, unconsciously p r o v o k i n g the
m a n , h a d a l l o w e d a n innocent dancing partner to see her h o m e i n his
car, w h i l e her friend was suspiciously waiting for her. W h e n this
relationship came to an e n d i n late 1996, it became possible i n the
therapy to discuss Catherine's relationships w i t h m e n i n a w a y that
increased her insight a n d m a d e her attitudes more s o l i d a n d realistic.
W h e n her attention was d r a w n to her obsessive pattern of choosing
male friends w h o always failed i n their attempt to b u i l d a relation­
s h i p , she said she repeated a pattern related to her m o t h e r — t r y i n g to
" f o r c e " the other person to change a n d to m a k e h i m u n d e r s t a n d
Catherine b e t t e r — a n d projecting murderousness into h i m w h e n this
failed.
Catherine's relationship w i t h her mother was characterized b y
complex problems of dependence a n d independence a n d , especially,
a constant wish that her mother might begin to understand and love her
better, w h i c h defied all disappointments. T h e mother relationship
w a s taken u p i n the therapy, especially after Catherine's suicide at­
 THERAPEUTIC EXPERIENCES 225

tempt i n the s p r i n g of 1993. She realized that she h a d tried " r e v e n g e "
o n her mother, w h o h a d caused her intense frustrations. D u r i n g
the therapy session she felt " f u r i o u s l y a n g r y " w i t h her mother. But
her h a t r e d w a s not directed exclusively at her mother. She also be­
came conscious of her hatred towards her therapist, w h o h a d h a d to
cancel a n extra session despite her patient's anxiety. A year later
C a t h e r i n e h a d a d r e a m : the mother was in hospital wearing high-heeled
shoes and had had a lump removed from her body. The other patients were
nervous. Catherine tried to calm her mother who was also nervous, hut when
this attempt failed, she attacked her murderously. In another d r e a m she
h a d at the same time she quarrelled with her therapist. T h e r e w a s yet
another d r e a m o n the same theme: "It was wartime. I set the house on
fire and went out with the dog. Then I came back, woke up the sleeping
people, and saved them." These dreams seem to p o r t r a y v e r y v i v i d l y
b o t h m u r d e r o u s feelings towards her " b a d " mother a n d her therapist
a n d her reparation wishes to protect them.
T h e r e were m a n y other events d u r i n g the course of the therapy
that d i s t u r b e d C a t h e r i n e , not the least of w h i c h was the marriage of
her therapist, as m e n t i o n e d above. H o w e v e r , she was able to w o r k
w i t h her therapist o n these events, a n d her p r o b l e m s of e n v y a n d
jealousy b e g a n to resolve themselves. Catherine's o w n relationships
w i t h m e n broke d o w n , a n d the attempts to treat her infertility h a d
failed. H e r y o u n g e r step-sister m a r r i e d , a n d Denis also m a r r i e d a n d
he a n d his wife h a d a b a b y ; the step-sister also h a d a baby. A t about
this time Catherine a n d her latest male friend joined a n artificial
i n s e m i n a t i o n p r o g r a m m e r e c o m m e n d e d b y her gynaecologist, d e ­
spite the p r o b l e m s a n d the p o o r prognosis of their relationship a n d
half i n secret f r o m her therapist. H a v i n g discussed the matter i n her
therapy, h o w e v e r , Catherine cancelled her participation. A c c o r d i n g
to the therapist's u n d e r s t a n d i n g , Catherine's desire for a baby was
not o n l y d u e to the inferiority she felt about her o w n femininity a n d
her e n v y of other w o m e n — w h i c h h a d been discussed f r e q u e n t l y —
but was also related to the i n a d e q u a c y of her relationship w i t h her
mother: she w a n t e d to compensate for her o w n lack of love b y h a v i n g
a b a b y of her o w n (indication of projective identification).
T h e insights Catherine d e v e l o p e d t h r o u g h transference interpre­
tations i n c l u d e d her g r o w i n g consciousness of her o w n e n v y a n d the
pathological aspect of her desire to please her mother: " I f I cannot
please her, I w i l l lose e v e r y t h i n g " , she said. T h e g r o w i n g hatred a n d
bitterness towards her mother was relieved by the insight she h a d
226 SCHIZOPHRENIA

w h e n the therapist (who h a d seen the mother i n the therapy meet­

ings) pointed out that the mother herself was a disturbed p e r s o n w h o
l i v e d t h r o u g h other people. T h e therapist pointed out that w h i l e
Catherine tried to a v o i d her destructive envy, she also lost part of
her creativity. T h i s was particularly true of the depressive phases:
Catherine recognized the connections between her depressive feel­
ings a n d her destructive impulses. T h e processing of o e d i p a l jealousy
p r o c e e d e d i n relation to the d i v o r c e d wife of her " f i a n c e " — a situa­
tion that w a s reminiscent of the relationship between her step-father
a n d mother. Catherine also began to become aware of her need for
p u n i s h m e n t , a n d she said: " I ' m afraid of b e i n g p u n i s h e d if things go
w e l l . " She began to w o n d e r more a n d more w h y she h a d for so l o n g
kept u p relationships that exposed her to violence.
In the s p r i n g of 1996 Catherine faced yet another cause of stress:
her maternal grandmother, w h o m she felt to be v e r y close to her
(despite the intrusiveness she s h o w e d towards her granddaughter),
d e v e l o p e d b r a i n cancer, a n d she d i e d i n the early a u t u m n . Catherine
grieved for her death a n d participated actively i n the funeral arrange­
ments, despite her mother's jealous reactions, v i v i d l y revealed i n her
reproachful r e m a r k to her daughter: "It was me w h o lost a mother,
a n d it's m e w h o s h o u l d cry, not y o u . " Catherine told her therapist
afterwards that her grandmother's death h a d eliminated her " c o m ­
p u l s i o n " to please others—she realized that she n o longer n e e d e d to
please others for fear of h a v i n g something b a d h a p p e n to her, be­
cause her grandmother's death d i d not result i n her o w n death. "I
w i l l not become psychotic any l o n g e r " , she assured her therapist,
Catherine has become clearly more insightful, especially over the
last year of therapy, a n d she is simultaneously d e v e l o p i n g m o r e real­
istic relationships w i t h other people. She is more i n contact w i t h her
feelings of grief a n d better able to tolerate them a n d deal w i t h t h e m i n
the therapy, a n d her feelings of depression have become m u c h m o r e
manageable. She has n o psychoactive medication. H e r fragmentary
occupational efforts are also being replaced b y a more focused e d u c a ­
tional p l a n . H e r therapy is still incomplete, a n d she has not yet
started the process of separating f r o m the therapist, w h i c h w i l l be a n
important part of the therapy. T h e situation has, h o w e v e r , stabilized
sufficiendy to warrant our agreement w i t h Catherine's assurance: she
is h a r d l y at risk of b e c o m i n g psychotic any longer.
 THERAPEUTIC EXPERIENCES 227

SUMMARY

W e are d e a l i n g w i t h the s c h i z o p h r e n i f o r m psychosis of a y o u n g

woman w i t h borderline features and deeply placed unfulfilled
longings for symbiotic love a n d empathic understanding. D u r i n g her
psychotic state of m i n d she d i s p l a y e d severe confusion, loss of reality
testing, a n d h y p o m a n i c a n d histrionic features. She was treated w i t h ­
out a n y neuroleptics; her anxiety was relieved w i t h the help of benzo­
diazepines.
Catherine actually h a d three mother figures, all of w h o m b o t h
rejected her a n d competed for the right to " p o s s e s s " her. She grew u p
i n a n atmosphere of e n v y a n d jealousy, w h i c h was clearly d e m o n ­
strated to be still active i n her family i n the present. Since she h a d not
been able to resolve her o w n e n v y a n d jealousy—feelings that m a y
h a v e been intensified b y the arrival of t w i n step-siblings at the age of
7—these coloured the various relationships d u r i n g the illness a n d the
important transference processes i n the therapy. T h e y were one rea­
s o n that caused her hospital treatment to be p r o l o n g e d , b u t it p r o v e d
possible to expose a n d clarify these processes i n the course of the
w e e k l y therapy meetings w i t h Catherine a n d the m e m b e r s of her
family, to a n extent that was sufficient to p r o v i d e the m o t i v a t i o n a n d
to i m p r o v e the preconditions for her e m b a r k i n g o n the i n d i v i d u a l
psychotherapy.
After the stage of inpatient treatment, the therapy continued i n the
f o r m of p s y c h o d y n a m i c i n d i v i d u a l therapy, w i t h 2-3 w e e k l y sessions.
H e r therapist is a specialist nurse w i t h training i n b o t h i n d i v i d u a l a n d
family therapy. I n d i v i d u a l therapy has been g o i n g o n for four years
n o w , a n d there have been n o recurrences of psychosis. Catherine has
n o psychoactive medication. H e r personality has g r a d u a l l y become
consolidated, but the treatment has not yet been completed, a n d the
process of separation remains to be accomplished. T h e therapist has
b e c o m e a significant n e w self-object for Catherine. She has p r o v i d e d
the empathic u n d e r s t a n d i n g that Catherine has always needed. T h i s
has m a d e possible Catherine's constructive identification w i t h her
" c o n t a i n i n g " a n d " t h i n k i n g " therapist. A t the same time, it has been
possible to use the transference relationship to interpret Catherine's
internal, a n x i e t y - p r o v o k i n g problems, i n c l u d i n g her feelings of
hatred, e n v y , a n d guilt. A t first the therapist's countertransference
mostly consisted of the role of a symbiotic a n d secure mother, w h i l e
228 SCHIZOPHRENIA

she has later concentrated increasingly o n interpretations that help

Catherine to f i n d a more balanced a n d satisfactory identity.

John, the youngest son in an enmeshed family

[ w i t h Jyrki H e i k k i l a ]

J o h n , a 22-year-old carpenter, was l i v i n g w i t h his parents w h e n he

first came to treatment i n M a r c h 1992. H e is the youngest of three
brothers a n d the only one still residing at home. J o h n h a d been awake
over the w h o l e w e e k e n d a n d h a d eaten almost n o t h i n g . H e s a i d his
thoughts teased h i m , a n d he fell to pieces. H e thought he c o u l d not
remember a n y t h i n g . H e agreed to see a doctor (a general p r a c t i ­
tioner), a n d his brother Jack p h o n e d the resident o n d u t y i n the C l i n i c
of Psychiatry. T h e y agreed that John w o u l d come to the admission
clinic (see chapter five) the following d a y w i t h members of his family.
Jack w o u l d stay w i t h h i m until then.
John's treatment history, with the different therapeutic measures i n ­
c l u d e d , is depicted i n Figure 6.1. The team at the admission clinic (a
psychiatrist, a specialized nurse, and a mental nurse) first met John, Jack,
a n d their parents together (the first therapy meeting). Their father spoke
for all of them, trying to explain the situation. O n e of his first ideas was
that there was no need for John to move away from home. A b o u t a year
earlier his father h a d noticed that John h a d become more withdrawn. A
m o n t h before the breakdown, John h a d been i n an automobile accident:
a girl driver h a d crashed into John's car, w h i c h was a write-off. Both
John a n d the girl were uninjured. Because of the accident, there was a
trial, w h i c h John later w o n .
John d i d not display any marked delusions or hallucinations, but
he was very severely confused. H e h a d thought about being m a d . H e
answered after long intervals, and he was suspicious. The situation was
not very clear, a n d the family was given another appointment for the
following day.
T o the second therapy meeting Jack came with John, without the par­
ents. This h a d been John's wish. H e h a d stayed u p for the whole night.
H e was confused, afraid, but more talkative. It appeared that a m a n h a d
somehow seduced h i m as a child. There h a d been a trial, but John could
not speak about it at all. W h e n encouraged to talk, he simply said, " i t
becomes dark i n the attic" and w o u l d say no more. Jack h a d noticed that
 • <-
ON V>

! m

i
i 2

OH

ON

£ E

ON

00
2 o
3
c
*N
C
Ti­
o ^ <u
en
Q_
E
E 2 cu
E c
3 c C
CO

i 2 E O DO C OJ

7»
LU 03
i oo *Z3 <J
CD ~ 8 y^
•*-»
E §

X LU
ii

O 2
<

o
ON

00

ON O
~ :3

J3

229
230 SCHIZOPHRENIA

the accident with the car h a d m u c h too strong an influence o n both John
and his father. Father himself h a d been in a car accident at exactly the
same crossroads three years earlier, resulting i n a back disorder that
forced h i m to retire o n a pension. John only kept repeating that it goes
r o u n d a n d r o u n d i n his head, he forgets things a n d has n o grip of time.
H e said he suspected that a certain girl was actually another girl.
The situation was defined to the family as an individuation crisis
concerning both John and the family. It was thought that the accident
h a d quite concretely threatened John's identity and masculinity. Because
of his strong confusion, w h i c h could not be handled very well b y the
patient or b y the relatives, John was admitted into an open w a r d at the
C l i n i c of Psychiatry (J.H. being the senior physician of the ward). T h e
situation w o u l d be defined more accurately o n the w a r d .

John's first hospitalization. A t first John was quite w i t h d r a w n a n d

suspicious of everything. H i s appearance was very stiff—almost cata­
tonic. H e answered v e r y slowly or not at all. F r o m the b e g i n n i n g , he
h a d a personal nurse, a female mental nurse w i t h n o o r d i n a r y p s y c h o ­
therapeutic training. She tried to get into a n empathic contact w i t h
J o h n a n d succeeded i n this w i t h i n a few days. H o w e v e r , John's atti­
tude w a s still reserved, a n d he was not motivated to explore his
problems. Because John, too, was i n c l u d e d i n a research project deal­
ing with first-admitted patients of the schizophrenia group
preferably without neuroleptics (see V . L e h t i n e n et al., 1996), he w a s
g i v e n benzodiazepines (lorazepam), w h i c h w a s of great h e l p . H i s c o n ­
fusion g r a d u a l l y disappeared, a n d he w a s discharged after 16 days.
A t the therapy and family meetings before and d u r i n g John's hos­
pital stay, the history of the family was investigated. The father, a retired
book-seller, was the dominating figure i n the family, while the mother
seemed submissive. The mother was still active as a hairdresser. John's
success at school was moderate, and he d i d well i n military service.
Trained and pressed b y his father, a one-time wrestler himself, John h a d
belonged to the top wrestling team i n Finland, but he gave u p wrestling
w h e n he was 17. H e h a d dated girls only temporarily. But he related
p r o u d l y that he h a d h a d five cars in his possession. W i t h regard to the
seduction episode in John's childhood, the family was as reticent as John
himself.
John's father dominated these sessions a n d tried to find somatic
explanations for John's condition, referring, for example, to amalgam
 THERAPEUTIC EXPERIENCES 231

fillings i n his teeth. A g a i n , he opposed the idea of John m o v i n g away

from home. In that meeting, John was very confused a n d withdrawn.
W h i l e listening to the father, the team often thought that the boundary
between h i m and John was blurred. H i s mother h a d a more passive
attitude, w h i c h reflected her submissiveness to her husband.
The parents thought that they h a d h a d quite a good relationship with
each other. H o w e v e r , John's maternal grandmother, w i d o w e d 7 years
earlier, h a d lived i n the same house with the family for 24 years, a n d the
relationship between this grandmother a n d John's father h a d been very
difficult; they wondered whether they could sit together i n the same
room.
John's E E G was recorded, and it was normal. Psychological tests
showed delusional and also schizophrenic features, as well as height­
ened dependency. Cognitively, John managed a little below average.
The family was seen as pseudomutual a n d rated by the O l s o n c i r c u m ­
plex m o d e l (Olson, Sprenkle, & Russell, 1979) as being relatively rigid
(axis: rigid-chaotic) and enmeshed (axis: enmeshed-disengaged).
A t an integrative meeting of the treating team at the e n d of the hospital
treatment, John's situation was considered to be an emancipation crisis,
as well as a sexuality crisis. There were features of homosexual panic.
Symptoms h a d started after a sauna evening with friends. The automo­
bile accident h a d obviously endangered John's phallic stability. A big
news event, boxer M i k e Tyson's rape trial, h a d a special meaning to
John, a n d he once thought he could foretell his sentence. It looked as
though John h a d identified himself with T y s o n and the frightening idea
of aggressive sexuality. The automobile accident as such and i n the
context of the two trials seemed to have the same k i n d of meanings.
John's official diagnosis was brief reactive psychosis. H e agreed to visit
his o w n nurse once a week after his discharge, and a continuation of a
systemically oriented family therapy was planned. John was given no
medication after the hospital care.
John h a d two further hospitalizations, the first as soon as a month after
his first discharge. A contributing fact may have been that John's visits
to his personal nurse h a d not turned out as planned because the nurse
h a d been i l l ; they h a d met only once after the first hospital stay. John
was again sleepless d u r i n g the second hospitalization, h a d not eaten,
was w i t h d r a w n and suspicious, asking whether there was a conspiracy
against h i m and whether everything b a d was his fault. H e d i d not want
to go out, because people might suggest that he was homosexual. H e
232 SCHIZOPHRENIA

h a d suicidal thoughts and climbed to a h i g h chimney, threatening to

j u m p . H e suspected that the staff accused h i m of evil acts, and shouted:
" O t h e r s w o u l d have it better if I were d e a d . " However, he came d o w n
after a brief discussion. H e was then transferred to the closed w a r d , and
a neuroleptic medication (perphenazine 8 mg daily) was initiated.
D u r i n g the third hospitalization i n 1993, John h a d taken an overdose
of hypnotics, was depressed, and h a d suicidal thoughts. Some time
earlier, he h a d m o v e d to live with his girlfriend. H e was bitter towards
his father and h a d thoughts of revenge. D u r i n g these later hospitaliza­
tions, the diagnosis of schizoaffective psychosis was defined, because of
John's depressive features.
After the hospital periods, the team of the admission clinic h a d the
m a i n responsibility for John's treatment. H e and his parents were seen
regularly i n family meetings, and small-dosage neuroleptic medication
was continued; however, because of John's reluctance to take medicines,
it was repeatedly interrupted. A t the same time, the visits to the personal
nurse were continued o n a more regular basis. D u r i n g the following
years, John h a d some crisis periods, and rapid therapy meetings were
then arranged at the admission clinic.
Family meetings differed from therapy meetings i n that they aimed
at a longer systemically oriented family therapy. The team consisted of a
senior psychiatrist, a specialized nurse with family therapy training
working o n the ward, and a specialized nurse who h a d met the family at
the admission clinic. Sessions were conducted by the nurse with family
therapy training, the other members of the team staying behind a one­
w a y mirror.
Methods included circular questioning, reframing, and positive con­
notations directed especially at promoting more structural flexibility i n
the family and trying to make a mutual differentiation possible between
John a n d his parents. It was repeatedly found that the father invaded
John's privacy and h a d difficulties i n differentiating his o w n life from
that of John's—even more so after he had retired. H e saw John as a weak
person w h o could easily be deceived and was afraid that John h a d used
anabolic steroids or narcotics, without any grounds for this suspicion.
H e also interfered i n John's relationship with his girlfriends. D u r i n g his
third hospital period, John had delusions about the meaning of his father
shaking hands with his girlfriend and his comments to her; he h a d
doubts about his dating because he thought that his father w o u l d not
accept her.
 THERAPEUTIC EXPERIENCES 233

The meetings were continued until December 1993. It was then

thought, both b y the team a n d the family, that there was n o w more
m u t u a l differentiation between John a n d his parents a n d that both p a r ­
ties c o u l d manage o n their o w n . A s a sign of this the team saw that John
n o w c o u l d arrange his treatment issues alone. Father a n d grandmother
h a d n o w tried to come to terms with each other. John w o r k e d , a n d he
was l i v i n g w i t h a girlfriend, although there were m i n o r conflicts be­
tween them.
D u r i n g John's second hospital p e r i o d , his relationship to his personal
nurse seemed the only thing that was somehow clear i n John's m i n d and
free from suspicions. Visits to this nurse were continued after the hos­
pital periods—as a general rule, once weekly—supervised b y another
nurse therapist w i t h psychotherapeutic training. In 1996, the frequency
was d i m i n i s h e d to once a fortnight. There were some breaks, however,
and John was very sensitive to them—for example, i n January 1995 a
m o n t h after he h a d stopped visits to the personal nurse as then agreed
mutually, he became more anxious a n d sleepless and was o n sick-leave
for a week. O n the other h a n d , John was often reluctant to continue the
visits, because he wanted to deny his illness. Another reason was that he
was n o w living w i t h a new girlfriend and was afraid about what she
w o u l d think of the visits.
The contact remained at a supportive level because of the nurse's
lack of psychotherapeutic experience. John's actual problems—espe­
cially his relationship to his father—were discussed, a n d gradually he
became more capable of criticizing his father a n d opposing h i m . It be­
came clear that the m u t u a l relation between mother a n d John was very
close. John never said a b a d w o r d about his mother, and he often visited
her i n her beauty salon. The therapist thought that John h a d remained at
h o m e for so long because he was afraid to leave the mother at home
alone w i t h the father. D u r i n g his first hospital p e r i o d John h a d h a d
nightmares about his relatives fighting a n d killing each other.
It seems obvious that John's relationship to his therapist was an
idealized mother transference, and this was also reflected i n the counter­
transference. A l s o , John only wanted to talk about nice things with the
therapist, because " h i s head w o u l d break otherwise". H e also a v o i d e d
the expression of negative feelings in connection with separations. H o w ­
ever, he c o u l d strongly criticize his girlfriend's mother (sign of a split
transference). W h i l e he was talking about this girlfriend, he made indis­
tinct hints at "another g i r l " ; only gradually d i d the therapist understand
234 SCHIZOPHRENIA

that this meant herself. The eroticized transference was dealt with with
the nurse's remark that she was i n the role of John's therapist, not of a
girlfriend. N o interpretations dealing with John's mother relationship
a n d his aggression problems were given, nor any transference interpre­
tations.
John h a d his last (until now) m i l d l y psychotic episode i n N o v e m b e r
1995. There were marks of auditory hallucinations, but afterwards John
denied them. It came out that the wife of John's eldest brother was
pregnant, and John and his girlfriend also h a d plans about h a v i n g chil­
dren. John and his girlfriend were then repeatedly met at the admission
clinic, a n d the situation calmed d o w n in three weeks. For the first time,
John n o w accepted the idea of taking neuroleptics regularly to prevent
relapses. In a follow-up at the admission clinic i n October 1996, it was
found that there had been no symptoms during the previous ten months.
John visits his o w n nurse regularly, he continues his neuroleptic dosage
(perphenazin 8 m g daily), he works normally, and he plans to marry and
perhaps to have children.

SUMMARY

T h i s case history can be criticized w i t h regard to the i n d i v i d u a l

therapeutic relationship w i t h a n untrained a n d inexperienced p s y ­
chotherapist, w h i c h w a s due, o n the one h a n d , to the patient's relative
unsuitability for a m o r e exploratory psychotherapy because of his
lack of motivation a n d the fragility of his personality, a n d to a (rela­
tive) lack of m o r e experienced therapists, o n the other. Still, the s u p ­
portive contract w i t h the nurse therapist was important for John.
T o the credit side of John's treatment belong the rapid family-centred
interventions b y the admission clinic team, repeated also after his h o s p i ­
tal periods d u r i n g crisis situations threatening his stability. Despite the
diagnosis of schizoaffective psychosis, one could ask whether John's
psychotic regression w o u l d have been more severe if he h a d not received
treatment very quickly. There were signs of imminent catatonic a n d
paranoid disintegration both at the beginning of his illness and later on.
In this respect, the work of the admission clinic team i n their care of John
offers a good illustration of the usual functions of the psychosis teams i n
F i n l a n d (see p p . 244-246). T h r o u g h their activity, the teams have been
able to prevent or alleviate psychotic states of numerous schizophrenic
 THERAPEUTIC EXPERIENCES 235

patients as well as their social labelling. John's case—like C a t h e r i n e ' s —

is also a good example of the support given both through family- and
individual-oriented approach to the individuation-separation processes
of y o u n g patients of the schizophrenia group, w h i c h often also requires
an increasing separation of the parents from their children.
H o w e v e r , a comparison of Catherine's and John's treatments also
illustrates the importance of a psychoanalytically oriented i n d i v i d u a l
psychotherapy for the patient's further development and prognosis. In
Catherine's treatment the initial systemic process was continued w i t h a
psychodynamically oriented psychotherapy, giving stimulus to an inner
developmental process deep enough to bring about a gradual personal­
ity growth. This also lessened considerably the danger of new psychotic
episodes. This was not the case with John, w h o is still clearly dependent
o n the supportive contact with his therapist and neuroleptic medication
to avoid the threat of further psychotic breakdown.
John's case m i g h t also be considered a n illustration of the p r o b ­
lems presented b y the shortage of therapists w i t h a d v a n c e d training
i n the p s y c h o t h e r a p y of psychosis. G i v e n the d a i l y p r o b l e m of u s i n g
w h a t is available, John's therapy is more " r e s o u r c e - a d a p t e d " than
"need-adapted". In the frames of c o m m u n i t y psychiatry, this is
often necessarily the case. Nonetheless, w e believe that endeavours
exemplified b y John's treatment, i n c l u d i n g his i n d i v i d u a l t h e r a p y —
preferably backed b y competent s u p e r v i s i o n — s h o u l d be strongly e n ­
c o u r a g e d . L o n g - t e r m a n d regular supportive relationships can help a
great m a n y patients to resolve their problems i n the f r a m e w o r k of
o p e n care. T h e psychotherapeutic orientation offers a h u m a n quality
that m a y be m i s s i n g i n a p u r e l y biological approach. T h i s k i n d of
relationship w i t h patients is also a part of the educational process i n
the field, a i m i n g at a n increasing interest i n the problems of psychosis
p s y c h o t h e r a p y , as w e l l as at staff members' perception a n d m o t i v a ­
tion to acquire further training for it.
CHAPTER SEVEN

Treatment of schizophrenia
and society

T
he last chapter of this book deals w i t h the social d i m e n s i o n
i n the treatment of schizophrenia. M y thoughts are closely
connected, as is o n l y natural, w i t h the current developments
a n d contemporary challenges i n the p u b l i c health system for p s y ­
chiatric treatment i n F i n l a n d a n d the other S c a n d i n a v i a n countries.
I h o p e that this b a c k g r o u n d does not u n d u l y restrict the interest of
readers i n countries i n w h i c h the development of the treatment
of psychiatric disorders has taken a course different f r o m ours. A l l
over the w o r l d , a n o v e r w h e l m i n g majority of schizophrenic patients
are b e i n g cared for i n a c o m m u n i t y psychiatric framework, because
most patients n e e d a variety of services, i n c l u d i n g both outpatient
a n d inpatient care as w e l l as supportive measures a n d social welfare
services. O n the other h a n d , because of limits to p u b l i c resources, a
g r o w i n g cooperation between the p u b l i c a n d private services has
b e c o m e m o r e a n d m o r e typical i n m a n y countries, the S c a n d i n a v i a n
countries i n c l u d e d .

237
238 SCHIZOPHRENIA

Political factors affecting the treatment of schizophrenia

D u e to both ideological a n d economic considerations, political factors

have often influenced the fate of schizophrenic patients. T h e i r i n f l u ­
ence o n the attitudes towards schizophrenics a n d their treatment has
been most conspicuous i n societies w i t h extreme ideologies. In the
twentieth century, s u c h extremist policies prevailed i n t w o totalitar­
i a n systems: N a z i G e r m a n y of the 1930s a n d the Soviet U n i o n of the
past few decades.
L i the N a z i doctrine of eugenics, schizophrenia was considered
a degenerative illness that was to be eliminated from society. Support
for this view was obtained from heredity research, and further confirma­
tion was p r o v i d e d b y some leading German psychiatrists, w h o later
launched an extensive programme for sterilizing schizophrenic patients
before a n d during the Second W o r l d War. The number of mentally ill
people w h o died i n extermination camps is not known.
In the Soviet U n i o n , the forensic psychiatrists blackened their reputa­
tion b y agreeing to support the authoritarian power-holders' habit of
incarcerating dissidents i n mental hospitals b y misapplying the d i a g ­
nosis of schizophrenia (Bloch & Reddaway, 1984). Disagreement with
the prevailing regime was said to be a psychiatric s y m p t o m c o m m o n i n
those with "insidious schizophrenia". E v e n i n this case the malpractice
was connected with biomedical theories of the causes a n d postulated
incurability of schizophrenia.
In democratic societies, the influence of social-political ideologies o n
psychiatry is less obvious, but it is still clearly detectable. D u r i n g the last
decades, psychiatric hospitals have begun to be closed d o w n i n m a n y
Western countries, mostly for purely financial reasons, despite the p r o ­
tests of psychiatrists (e.g. Borus, 1981; Weller, 1989). A s there was insuf­
ficient semi-institutional care available, large numbers of patients were
left without a place to live; they have made u p one of the many marginal
groups i n a society with hard values.
Svein Haugsgjerd (1971) pointed out that theories tend to be shaped
so as to justify existing practice. W o u l d it be going too far to postulate
that this may, to some extent, be reflected i n the predominance of bio­
medical theories of schizophrenia prevalent especially i n the leading
Western nations? The idea that schizophrenia " i s n o w considered
chronic and virtually incurable, a belief transmitted to both patients and
families, and therapy is directed towards suppressing the symptoms a n d
towards rehabilitation at a low level of social functioning" are quite
 TREATMENT OF SCHIZOPHRENIA A N D SOCIETY 239

compatible with the social policies at the 1980s. The quotation is f r o m

the abstract of the lightly nostalgic presentation b y R u t h W . L i d z (1993)
at the International S y m p o s i u m o n the Psychotherapy of Schizophrenia
i n T u r i n i n 1988. She also emphasized her o w n opinion that it was
w r o n g , through long-term high-dose d r u g treatment, to deprive the p a ­
tients of the opportunity to resolve i n psychotherapeutic treatment "the
very real problems that have existed between themselves and persons
closely related to t h e m " and to be stimulated towards a healthier devel­
opment.
Stephen Fleck (1995) recently published a critical survey o n d e h u ­
m a n i z i n g developments i n A m e r i c a n psychiatry i n recent decades. H e
pointed out that there has been a regressive development of reduction­
istic ideas of patient care, leading to a view of patients as containers of
neurochemical aberrations, i n place of the emphasis placed earlier o n
interviewing skills and understanding patients i n terms of their personal
development. Management programmes have displaced psychothera­
peutic treatment, a n d psychiatrists have been reduced to the role of
diagnostician a n d prescription writer. Fleck also criticizes the policy of
insurance companies a n d their managed care agents, w h i c h have i n ­
creasingly balked at payments for " p r o l o n g e d " psychiatric treatments,
interfering with lengthy a n d intensive psychotherapies or full-time hos­
pitalization. The decisive factor is the cost of treatment—of short d u r a ­
t i o n — a n d inexpensive choices are preferred.
U n t i l n o w , the situation i n Northern European societies has been
better. But the recession a n d the prevailing economic-political theories
have also begun to lend an increasing significance to these issues i n our
countries. C o n t i n u i n g progress i n public psychiatric care system is n o w
being threatened (Pylkkanen, 1994). A n d it is not only a matter of contin­
u e d development that w i l l be debated i n the near future, but it is also
questionable whether we will be able to maintain functioning at a level
compatible with our knowledge and required by our shared responsibil­
ity for the c o m m o n good of our citizens.

It is worth while to develop treatment

C o n n e c t e d w i t h the N a t i o n a l Schizophrenia Project i n F i n l a n d , V i n n i

(1987) presented a s u m m a r y of the overall costs o f s c h i z o p h r e n i a
i n F i n l a n d i n 1985. A c c o r d i n g to his calculation, the total financial
240 SCHIZOPHRENIA

expenses d u e to schizophrenia a d d e d u p to 2,500 m i l l i o n F i n n i s h

marks. T h e costs directly related to treatment (mostly hospital ex­
penses) accounted for 4 0 % of this amount, w h i l e the indirect costs
(mainly d u e to the loss of earnings) a m o u n t e d to 60%. More-or-less
parallel findings o n the ratio of direct to indirect costs were m a d e b y
Rice, K e l m a n , M i l l e r , & D u n m e y e r (1990), w h o calculated the cost of
all psychiatric illnesses (except alcohol a n d d r u g abuse) i n the U n i t e d
States (at the federal, state, a n d private levels) i n 1985: the direct
losses were calculated at 42,500 m i l l i o n U . S . dollars, a n d the indirect
ones at 56,700 m i l l i o n dollars.
T h e w e l l - k n o w n British social psychiatrist D a v i d Goldberg (1991)
reviewed the research o n the cost of the treatment of schizophrenia, i n
the Schizophrenia Bulletin. H e primarily concentrated o n four controlled
studies conducted i n the United States, Australia, Britain, and Canada.
H i s most central conclusions were as follows:

° C a r e i n the c o m m u n i t y is generally cheaper than care i n a hospital.

T h i s is true also of the treatment of acute psychoses. H o w e v e r , it is
important to note that these results cannot be generalized to a l l
patients r e q u i r i n g full-time admission to psychiatric beds.

° T h e m o r e expensive treatment m a y sometimes be cheaper for soci­

ety i n the l o n g r u n .

° F o r patients w h o require p r o l o n g e d hospital stays, hostel w a r d s

p r o v i d e a cost-effective alternative that is preferred b y the patients
themselves.

T h e financial profitability of the rehabilitation of l o n g - t e r m schizo­

phrenic patients is easy to understand, because the staff expenses per
patient are notably smaller i n rehabilitative a n d residential homes
than i n hospitals. T h e case w i t h acute patients is m o r e complex. It
seems that the w o r k of family-centred teams w o r k i n g i n the c o m ­
m u n i t y can m a r k e d l y reduce the use of hospitals b y p r o m o t i n g the
treatment of acute patients, as indicated b y the experiences of
L a n g s l e y et a l . (1971) a n d F a l l o o n (1992) described i n chapter four.
T h e most important financial justification for the development
of the treatment of n e w schizophrenic patients, however, is i n the
a m o u n t of indirect losses reported b y V i n n i (1987) as w e l l as b y
Rice et al. (1990). If it is possible to increase notably the n u m b e r of
schizophrenic patients w h o become capable of r e s u m i n g w o r k , as it is
 TREATMENT OF SCHIZOPHRENIA A N D SOCIETY 241

i m p l i e d b y the most recent findings of the Scandinavian projects w i t h

a comprehensive psychotherapeutic orientation, there w i l l be o p p o r ­
tunities for l o n g - t e r m financial savings i n indirect losses ( A l a n e n et
al., 1994). A p r e c o n d i t i o n is that short-sighted profitability-based d e ­
cisions can be a v o i d e d , a n d m o r e possibilities for l o n g - t e r m p s y c h o ­
therapeutic r e l a t i o n s h i p s — i n c l u d i n g longer inpatient periods w h e n
n e c e s s a r y — w i l l be p r o v i d e d for schizophrenic patients. T h i s w o u l d
also reflect a m o r e h u m a n e attitude towards the mentally i l l .

Development of the treatment organization

In this section, the developmental needs of treatment systems are

e x a m i n e d , starting specifically f r o m the premises for carrying o u t the
n e e d - a d a p t e d treatment of schizophrenic patients.

The catchment area model

T h e sectorized m o d e l is clearly the best alternative for d e v e l o p i n g
therapeutic systems i n psychiatry. There is w i d e s p r e a d agreement o n
this internationally.
In the sectorized m o d e l , there is a n overall responsibility to p r o ­
v i d e care a n d treatment to a g i v e n p o p u l a t i o n . T h e therapeutic
systems i n each area are responsible for both outpatient a n d inpatient
care: instead of b e i n g limited to a g i v e n institution o r g i v e n therapeu­
tic p r o c e d u r e , the system is responsible for all specialized psychiatric
treatment. U s u a l l y there is a stratified structure: i n F i n l a n d , for ex­
a m p l e , the u p p e r stratum consists of major mental health districts
w i t h a n average p o p u l a t i o n of 220,000, w h i c h , i n turn, are d i v i d e d (at
least i n the sphere of outpatient care) into local mental health d i s ­
tricts, each w i t h 25,000-40,000 inhabitants, a n important part of their
w o r k consisting of cooperation w i t h basic health care system.
T h e close connections between psychiatric i n - a n d outpatient care
outlined i n the catchment area m o d e l are of vital importance to a guar­
anteed consistent overall planning of treatment and rehabilitation and a
continuity of therapeutic relationships. This need for consistency a n d
continuity is generally felt to be a problem i n psychiatric work. Once the
242 SCHIZOPHRENIA

administrative d i v i d i n g - w a l l between hospital a n d outpatient care has

been removed, it is easier for a member of the outpatient staff to keep u p
a significant therapeutic relationship, even d u r i n g the patient's temp­
orary inpatient episodes, or for a relationship first established i n a
hospital to be continued after the patient's discharge.
A n even more important benefit of the sectorized m o d e l is the prox­
imity of the services to the users. Decentralization of the functions makes
it easier to arrange locally family- and milieu-oriented activities, home
visits, a n d day-hospital services. A s a consequence of all this, the thera­
peutic system becomes more flexible a n d mobile a n d at the same time
more open, a n d the hospital orientation subsides. Cooperation w i t h the
basic health care and social welfare units also becomes easier. It is hence
o p t i m u m for the local mental health centres to be located i n the same
buildings as the basic health care units.
F r o m the viewpoint of psychiatric functions, it is useful to keep the
units—that is, the hospital and day-hospital wards and the rehabilitative
and residential homes—sufficiently small. The upper limit for therapeu­
tic communities is generally considered to be about 15 patient members;
units larger than this should be d i v i d e d u p to keep the group activities
effective. It is also easier i n a small unit to achieve a peaceful a n d u n ­
hurried atmosphere, which is beneficial for the work of the psychothera­
peutic community.
It is possible that the significance of hostel-type units separate from
actual hospitals will increase i n the care of acutely psychotic patients.
The benefits of such units have been demonstrated, for example, b y the
experiences i n "Soteria Berne", described i n chapter four ( C i o m p i et al,
1992). In Sweden, where psychiatric hostels have increased i n number
over the past few years, a study into their effects has been organized b y
A r m e l i u s (1989). M o s t of these hostel units have been established b y
private foundations, but their integration with the public mental health
care system is just as feasible as that of rehabilitative a n d residential
homes for long-term patients.
It is important that the knowledge gained w o u l d not be lost o n the
w a y towards decentralization but w o u l d , rather, be transferred to
smaller units. This can best be guaranteed b y promoting training a n d
education. It is, however, possible that the patients i n decentralized hos­
pital units m a y be so heterogeneous that the units w i l l be unable to
develop sufficiently specialized skills required b y patients to achieve
appropriate differentiation i n treatment.
 TREATMENT O F S C H I Z O P H R E N I A A N D SOCIETY 243

In T u r k u , with a population of 160,000, the following efforts have

been m a d e to avoid this: although the outpatient functions have been
d i v i d e d into four sectors, w h i c h coincide with the basic health care
districts, the inpatient functions are carried out by two units, each
consisting of several wards, w h i c h collaborate with the teams of two
outpatient sectors. The staff of the wards for acute patients also have
after-care activities. The single geropsychiatric w a r d for acute patients
serves the whole town. There is a special rehabilitation team responsible
for integrating rehabilitative functions, arranging preparatory meetings
o n the wards together with the patients and the staff, a n d for supervision
of the rehabilitative homes and supported dwellings.

Qualitative resources are crucially important

Suitably allocated qualitative resources turned out to be clearly the

most important factor i n p r o m o t i n g the care of patients i n o u r state­
w i d e s c h i z o p h r e n i a project. T h e n u m b e r of w o r k i n g staff is naturally
also important, but w e realized that n u m e r i c a l increase is not i n itself
sufficient to guarantee a n increase i n efficiency. In several districts
w h e r e outpatient staff were relatively n u m e r o u s , n o changes took
place u n t i l the qualitative d e v e l o p m e n t of functions was defined as a
goal.
T h e most important qualitative resources a n d their target areas i n the
treatment a n d rehabilitation of schizophrenics are:

• p r o v i d i n g effective cooperation between specialized mental health

care services a n d the basic health care system t h r o u g h consultation
a n d counselling, w i t h a n emphasis o n earlier detection a n d a d m i s ­
s i o n as one of the m a i n goals;

• establishing acute psychosis teams able to carry out the f a m i l y - a n d

milieu-oriented initial examination of psychotic patients w i t h re­
sponsibility for the p l a n n i n g a n d integration of the treatment of
these patients, as w e l l as counselling i n family-oriented therapy;

• establishing case management to guarantee the continuity of treat­

ment necessary for l o n g - t e r m psychotic patients;
• i m p r o v i n g staff competence for psychotherapeutic work with psy­
chotics a n d establishing supervision a n d training for i n d i v i d u a l ,
g r o u p , a n d family therapists;
244 SCHIZOPHRENIA

• creating a n adequate rehabilitative system w i t h the necessary units

a n d establishing a rehabilitative team to integrate rehabilitative
functions;

• developing the wards, day wards, and rehabilitative homes into effec­
tively goal-oriented therapeutic communities.

T h e c o m m i t m e n t of b o t h administrative a n d m e d i c a l leadership to
the developmental w o r k a n d its goals is of crucial importance.

Acute psychosis teams

O f these different categories of resources, the acute psychosis teams

are particularly important for the development of the treatment of
s c h i z o p h r e n i a i n the frame of c o m m u n i t y psychiatry. T h e idea of
establishing psychosis teams arose i n the project g r o u p responsible
for the F i n n i s h N a t i o n a l Schizophrenia Project. T h e actual impetus
for the establishment of the teams w a s the practical experience w i t h
the joint therapeutic meetings at the initial stages of treatment i n
T u r k u . After a n integrated trial organized i n one of the mental health
districts (The N o r t h e r n Savo Project), the establishment of s u c h teams
became one of the central recommendations issued b y the state-wide
project (Alanen et al., 1990a).
The most essential task of the psychosis team was defined above.
T h e teams are also responsible for most of the collaboration with the
health care centres concerning the schizophrenic patients admitted there.
T h e psychosis team consists of three or four people with different
occupational backgrounds (including a psychiatrist), w h o should be
particularly knowledgeable i n the treatment of psychoses from an inter­
actional point of view. This usually means that one or two of the m e m ­
bers have h a d family therapy training.
In 1992, three-quarters of the districts responsible for psychiatric
health care i n Finland h a d established one or several psychosis teams
(Tuori et al., 1997)—a total of about 50 such family-centred teams w o r k ­
i n g i n a population of 5 million. T h e Finnish m o d e l has also inspired
the development of similar family-oriented methods i n Sweden a n d
Norway.
In the spring of 1991,1 needed data for a presentation at the tenth
International S y m p o s i u m for the Psychotherapy of Schizophrenia i n
 TREATMENT OF SCHIZOPHRENIA A N D SOCIETY 245

Stockholm (Alanen, 1992). A t the time I knew of about 20 teams that h a d

already h a d some experience i n this work and i n organizing it, and I sent
them each a questionnaire. I received replies from 14 teams working i n 6
districts. A summary of their replies illustrates the development of such
teamwork.
Most of the teams worked part-time, because their members also h a d
other obligations. A b o u t half of them h a d their " h o m e base" i n mental
health offices, while the other half were stationed i n hospitals. O u t p a ­
tient connections seemed better for p r o v i d i n g a good mobility, w h i c h is
necessary for the team's work. A l l of the teams were multiprofessional.
T h e y generally included a psychiatrist and one or two nurses, frequently
a psychologist, but rarely a social worker, although the inclusion of
social workers h a d been recommended. It therefore seemed that the
assessment of the patient's social condition and need for rehabilitation
were, for practical reasons, outside the sphere of responsibility of the
psychosis teams, w h i c h seemed to concentrate o n treatment. The signifi­
cance of the social aspects of the overall treatment should not be
underestimated and should be accomplished as a separate function.
T h e teams were responsible for carrying out the family-oriented i n i ­
tial examination that analysed the patient's condition and life situation
and assessed the therapeutic needs of patients a n d of the interactional
network to w h i c h they belonged. Included were patients recommended
for hospital admission a n d patients i n a n acute psychotic crisis. T h e
w o r k was not limited to patients w i t h schizophrenia but included other
psychoses and often also other crises, such as suicidal patients.
T w o aspects of the w o r k were emphasized i n particular: (1) the abil­
ity to respond quickly to the needs of the patients and their families, and
(2) the integration of the different modes of treatment and therapeutic
relationships. Consultations and cooperation with the other psychiatric
units were considered important. T h e team members often attended
therapeutic meetings i n the units—such as hospital wards—that h a d
become responsible for the patient's treatment, a n d they made home
visits as well. Cooperation with the health care centres also increased.
L o n g - t e r m follow-up of the patients a n d their treatment, however, a l ­
though recommended, h a d generally not been p u r s u e d further than the
p l a n n i n g stage. In the future development of treatment, arranging such
follow-up should be a priority. F o l l o w - u p c o u l d be accomplished b y
using case management teams, as proposed b y K . Lehtinen (1993b) a n d
the N I P S Project (Alanen et al., 1994).
246 SCHIZOPHRENIA

The following consequences were regularly reported following the

establishment of teams:

• it was possible to obtain treatment m o r e q u i c k l y than p r e v i o u s l y ;

• the n u m b e r of hospital admissions clearly decreased;

• cooperation w i t h the families increased; a n d

• (as one team p u t it) it became more c o m m o n to assume that a

p e r s o n w h o has undergone a psychotic crisis w i l l be able to c o n ­
tinue n o r m a l life a n d resume w o r k .

M a n y of the teams described their family-therapeutic orientation as

systemic consultation (Wynne et al., 1986) or a combination of sys­
temic-strategic a n d p s y c h o d y n a m i c orientations, w h i l e some others
said that their approach varied, d e p e n d i n g o n the case. A few teams
also a p p l i e d psychoeducational or structural techniques i n their
w o r k . Interestingly, the patients' family members were as often felt to
be co-workers as they were felt to be patients; they were frequently
also thought to have both roles simultaneously.
The feedback from the families was favourable i n a majority of the
cases. W h e n I inquired whether the family members' guilt feelings pos­
sibly associated with the patient's illness h a d been a problem i n the
team's work, the answer was negative. M a n y of the teams said that they
told the families that they wanted to analyse the factors that h a d led to
the crisis, not to find the guilty ones. Some said they w o u l d point o u t —
if necessary—that guilt feelings and self-accusations are a normal part of
the situation and that it is useful to discuss such matters.
Some teams had had problems i n cooperating with other psychiatric
units. T o prevent this, it w o u l d be important to define clearly the d i v i ­
sion of tasks between the psychosis teams and the teams of the different
units. M u t u a l trust and respect are an important prerequisite for co­
operation. It should be underlined, moreover, that the psychosis teams
certainly cannot assume overall responsibility for the treatment of
the patient, which requires expertise of various kinds. The m a i n respon­
sibility for treatment belongs to the unit where the patient has been
registered.
 TREATMENT O F S C H I Z O P H R E N I A A N D SOCIETY 247

Psychotherapy training
and psychotherapeutic work in practice
It is not possible to learn psychotherapy d u r i n g the basic training of
m e n t a l health staff, a l t h o u g h aspects of psychotherapy are naturally
presented. T h e capacity for psychotherapeutic work is always
acquired t h r o u g h special further training.
In F i n l a n d , a basic d i v i s i o n of psychotherapy training w a s estab­
lished d u r i n g the 1980s. T h e training p r o g r a m m e s were d i v i d e d into
two l e v e l s — a special level a n d a n advanced special level, of w h i c h the
former requires approximately three years a n d the latter i n its entirety
five to six years of training, along w i t h regular w o r k . F o r entrance into
a d v a n c e d special training, a university degree is generally r e q u i r e d
(though exceptions to this h a v e been made, especially i n family
therapy), whereas the special training is available to all mental health
professionals.
Training programmes are p r o v i d e d b y the Centres for Extension
Studies of the universities o n the one h a n d , and private associations o n
the other. D u r i n g the 1980s the training activities increased notably. A t
the e n d of 1994, there were about 1,200 professionals—including psy­
chiatrists, child psychiatrists, psychologists, nurses, social workers, as
well as some general practitioners and theologians—who h a d completed
special-level psychotherapy training either i n psychodynamic i n d i ­
v i d u a l therapy, family therapy (the largest group), cognitive therapy, or
group therapy.
F r o m the viewpoint of developing the treatment of schizophrenia,
m a n y of the individual therapy training programmes have the weakness
that they are, i n practice, restricted to the treatment of less seriously
disturbed patients. This is particularly true of psychoanalytic training,
w h i c h is the most prestigious type of advanced special-level training as
regards both theoretical level a n d the general quality of content. It con­
sists m a i n l y of presenting the classical psychoanalytic method, w h i c h is
well suited to the treatment of neuroses and narcissistic disorders but is
hardly applicable to the treatment of psychoses. The situation i n family
therapy training has been different, although the time allotted to the
treatment of psychoses i n these programmes has varied.
In T u r k u , the m a i n emphasis of the special-level i n d i v i d u a l therapy
training has for the past year been o n the treatment of psychotic dis­
orders—most specifically schizophrenia. W e considered this justified
248 SCHIZOPHRENIA

because schizophrenic disorders make special demands on public psy­

chiatric health care. O u r experiences have been favourable. In order for
therapy to be successful, it is important that the therapist have suitable
personal characteristics and training. Personal psychotherapy of the
trainee is one of the preconditions of training, and it often helps i n
achieving a good outcome of long-term therapies. The Centre for Exten­
sion Studies of the University of T u r k u has n o w also initiated advanced
special training in psychodynamic individual therapy, with an emphasis
o n borderline and psychotic-level disorders, to close the gap i n system­
atic training for the treatment of the most serious psychiatric disorders.
T h e accomplishment of intensive long-term therapeutic relationships i n
public mental health care is problematic, because they consume a great
deal of staff time. This is true especially of individual psychotherapy. In
this respect, family therapy is better suited to public health care. T h o u g h
even family therapy may require frequent sessions at times of crisis, the
normal interval between sessions in systemic-strategic therapy is several
weeks. The teamwork approach is well suited to public health care prac­
tices. The same is also true of group therapy, w h i c h has the further
advantage that several patients can attend therapy at the same time.
Psychodynamic individual therapy of schizophrenic patients re­
quires sessions at least twice weekly at the initial stage to activate a
sufficiently intensive developmental process. Later o n , it may become
possible to space the sessions at weekly intervals. Since therapeutic rela­
tionships often last for years, it is, quite understandably, difficult for the
mental health offices and hospital wards to provide adequate therapeu­
tic services to meet their patients' needs. Cooperation with therapists
w o r k i n g i n the private sector increased i n Finland especially after 1984,
w h e n it was made possible for the public sector to purchase their serv­
ices.
F r o m the viewpoint of the development of the public health care
units, however, it is essential that they are also able to conduct a certain
n u m b e r of sufficiently intensive long-term individual therapeutic rela­
tionships. It is also important that supervision of the therapeutic w o r k is
w i d e l y p r o v i d e d , using both each unit's o w n staff with psychotherapy
training a n d outside experts as supervisors. It has been said, a n d with
good reason, that supervision is just as indispensable for the activities
of a psychotherapeutic unit as X - r a y and laboratory facilities are for
somatic wards. A l l the staff members participating i n therapeutic
w o r k should have an opportunity to benefit from it. This improves the
outcome of the treatment, promotes the staff members' professional
 TREATMENT OF SCHIZOPHRENIA A N D SOCIETY 249

development, and often also alleviates the anxiety evoked b y the w o r k

and prevents burnout. A non-authoritarian atmosphere based o n co­
operation is an inseparable part of the therapeutic work: each person
should feel that it is possible for h i m or her to develop and use his or her
abilities and skills i n a creative and versatile way.
A s E n d r e Ugelstad (1979) emphasized i n the late 1970s, the number
of individuals w h o annually become schizophrenic is so s m a l l — a n d the
long-term financial losses incurred b y society due to their illness so
large—that it should be possible i n the future to provide m u c h more
active a n d intensive treatment for these patients than is available
currently. T h e qualitative resources for this w i l l come from the increas­
i n g numbers of psychosis teams on the one h a n d and trained psycho­
therapists o n the other. A c c o r d i n g to the experiences based o n the
need-adapted m o d e l , all schizophrenics do not need long-term i n d i ­
v i d u a l therapy i n order to be treated adequately.

Development of rehabilitative activities

In 1993 E r i k A n t t i n e n illustrated the integrated step-wise system

of rehabilitation used at the S o p i m u s v u o r i r.y. (registered associa­
tion), as s h o w n i n F i g u r e 7.1.
T h e figure shows the progression of long-term patients, m a n y of
w h o m have been living o n hospital wards for years, first into rehabilita­
tive homes a n d then, along the left branch of the ladder, towards less
sheltered and constrained living and, along the right branch, towards
new adjustment into working life. The chances to reach the topmost step
are better i n residential rehabilitation than i n occupational rehabilitation.
Sopimusvuori r.y. was founded i n Tampere i n 1970 without any
money, the patients a n d their relatives being responsible for the costs.
Soon afterwards, financial support began to be p r o v i d e d b y municipali­
ties a n d parishes, a n d later b y the state-controlled Finnish Slot Machine
Association. The progress that has been made is shown by a summary of
the society's resources 21 years later:

• 9 rehabilitative h o m e s for 110 clients

• 7 small h o m e s for 31 clients
• 20 s u p p o r t e d dwellings for 31 clients
• 2 day-care h o m e s for 55 clients
250 SCHIZOPHRENIA

• 3 therapeutic sheltered w o r k s h o p s for 128 clients

• a social club for 30-35 clients

• a preventive rehabilitative h o m e for 15 clients

A c c o r d i n g to A n t t i n e n , the purpose of these therapeutic communities

is to p r o v i d e their members w i t h " a n e w safe, unconstrained a n d
h u m a n e social network, whose purpose is to replace their previous, at
least temporarily 'frozen' or lost, h u m a n relations w i t h n e w o n e s " . H e
also calls the rehabilitative homes " p r i m a r y schools of a n e w l i f e " ,

MENTAL HEALTH CENTERS

CONSULTATIONS,HOME CARE

CIVIC & WORKERS

COLLEGES
Living PARISHES Activities

OWN FREE

APARTMENTS
LABOUR MARKE"

VOCATIONAL
RENTED SCHOOLS, COURSES
RESIDENCES

TEST WORKING

SHELTERED
SUPPORTED WORKSHOPS
RESIDENCES
THERAPEUTIC
SHELTERED WORKSHOPS

SMALL HOMES DAY CARE HOMES

r-J SOCIAL CLUBS

REHABILITATION REHABILITATION

HOMES HOMES

PSYCHIATRIC HOSPITALS

Steps run by mental health district

Steps run by social welfare system or the society in general

FIGURE7.1 Integrated step-wise system of rehabilitation for long-term

psychiatric patients. [Courtesy of Erik E. Anttinen]
 TREATMENT O F S C H I Z O P H R E N I A A N D SOCIETY 251

w h e r e the plans a n d decisions are m a d e together a n d the tasks a n d

duties are shared. T h e n u m b e r of p a i d staff is intentionally kept s m a l l ,
to encourage the clients to take responsibility for their activities a n d
to enhance their o w n role i n their treatment a n d rehabilitation.
In the 1980s, similar organizations were set u p both at the initiative
of the state-wide schizophrenia project and outside it. Some of them are
following the Sopimusvuori model, others employ learning-theory m o d ­
els w i t h a more strictly defined organization.
The Sopimusvuori model brings to m i n d the follow-up findings of
the W H O multicentre study (World Health Organization, 1979), w h i c h
suggested that the outcome of schizophrenia seems to be better i n devel­
oping than i n industrialized countries, probably because the atmosphere
in the former is i n a more "symbiotic" way based on mutual caring. O n e
of the m a i n factors impairing the prognosis of mental health disorders i n
the Western societies are the weakness of the closest interpersonal rela­
tionships and social networks and the therapeutic practice that tends to
isolate the patients from their natural environments and communities. In
our differentiated culture, individuals whose ability to differentiate is
inadequate are easily isolated. The task of the mental health organiza­
tions is to create n e w developmental environments for them through
family- and milieu-oriented treatment o n the one h a n d and rehabilita­
tive milieus that provide new interpersonal relationships o n the other.
It is not always necessary to use a rehabilitative system with as m a n y
steps as i n Sopimusvuori: rehabilitative homes and day-centres p r o v i d ­
ing shared activities a n d hobbies m a y suffice, if the most advanced
clients are assisted i n their efforts to find dwellings. Sheltered work is
also important for many, especially y o u n g clients, despite the poor
chances of getting jobs n o w that there is widespread unemployment i n
m a n y European countries.
A s demonstrated b y the Sopimusvuori organization, the need for
staff is small. However, a long-term relationship with a person w o r k i n g
i n a M e n t a l Health Centre or i n the framework of the basic health serv­
ices w o u l d be beneficial for many clients of such rehabilitative homes.
F a m i l y therapy training is often useful i n this work, especially w h e n
collaborative relationships with the clients' families are to be established.
A d v a n c e planning is also needed. The best way to provide for this is
to set u p a special rehabilitation team to integrate the functions. This team
is responsible for such matters as arranging patient-staff meetings o n
rehabilitation, allocating the patients into rehabilitative and residential
homes, and supervising the use of residential units.
252 SCHIZOPHRENIA

T o achieve successful rehabilitation, it is important to establish col­

laborative relationships with private associations, especially with patient
associations, w h i c h have became more c o m m o n i n Finland d u r i n g the
1980s i n the field of psychiatry. This can be interpreted as a sign of a
favourable change i n the atmosphere regarding discrimination against
the mentally i l l . Previous inpatients i n particular find i n the patient
associations an important social network of new interpersonal relation­
ships. It is also important to cooperate with the relatives' associations,
both to support the relatives and to prevent conflicts that m a y arise
between them a n d the therapeutic organizations, as such conflicts may
obviate the efforts of both patients and relatives as well as of staff.

Is it possible to prevent schizophrenia?

Q u i t e a few psychiatrists a n d researchers w i l l reply to this question i n

the negative—or, like some biologically oriented researchers, they
m a y p o i n t out that a competent management of deliveries (especially
if the mother is psychotic) a n d vaccinations preventing v i r a l i n f l u ­
enzas d u r i n g the second trimester of pregnancy m a y have a l i m i t e d
effect.
These matters should naturally be considered. But even so, I a m not
pessimistic about the significance of even other kinds of preventive
w o r k to reduce the risk for schizophrenia. The Finnish National Schizo­
phrenia Project included a special group to discuss matters pertaining to
prevention. Most of the following points are based o n their report.
The group started from the assumption that h u m a n life—including
the lives of schizophrenic individuals—involves a process between the
i n d i v i d u a l and h i s / h e r environment. They also referred to the adoption
study findings reported b y Tienari (1992; Tienari et al., 1987,1993,1994;
see also chapter three), which showed that a psychically healthy family
environment may protect even children with a hereditary predisposition
from becoming schizophrenic.
If we accept this starting-point, we should conclude that the preven­
tion of schizophrenia is part of a large-scale development of constructive
a n d prophylactic mental health work at the level of families, c o m m u n i ­
ties, a n d societies.
O n e of the most important aspects of this effort is to support families
through maternity a n d child welfare clinics, starting d u r i n g the preg­
 TREATMENT O F SCHIZOPHRENIA A N D SOCIETY 253

nancy a n d continuing afterwards, not forgetting the fathers a n d the

totality of the intrafamilial relationships. It is also extremely important
to provide support for families d u r i n g crises. In families where the
parents divorce, special attention should be given to the children's w e l ­
fare. M a n y families also need support i n other situations of crisis, of
w h i c h the problems a n d conflicts faced b y children a n d adolescents i n
their individuation are particularly important for the liability for schizo­
phrenia. E v e n before adolescents leave home, it is important to observe
children's adjustment i n day-care and at school. A thorough survey of
family-centred psychiatric prevention throughout the personal a n d
familial life cycles was published i n the U n i t e d States b y the G r o u p for
the Advancement of Psychiatry (1989).
A l l these issues are especially critical i n families k n o w n to be at h i g h
risk for psychosis. W h e n the parent of a family is admitted because of
psychosis, it is essential to carry out a family-oriented examination a n d
to analyse the condition a n d situation of the children. W h e n necessary,
each child s h o u l d also be given a n opportunity to have a c h i l d - p s y c h i ­
atric consultation and treatment.
Both day-care and school staff as well as school health care personnel
s h o u l d make a n effort to support children w h o d o not adjust easily or
are shy a n d tend to withdraw a n d isolate themselves from others. T h e
supporters should have the professional skill to act i n such a w a y that
the children w i l l not be p i c k e d o n b y others. Supervision for teachers
might be a g o o d part of preventive mental health w o r k o n a large scale.
W i t h i n the psychiatric care organization, it is important to develop
youth-psychiatric function services o n the one h a n d a n d to promote
consulting and counselling cooperation with the basic health care work­
ers, particularly public health nurses, o n the other. T h e experiences of
Falloon (1992) i n Buckinghamshire indicated that the ability of these
workers to detect early signs of psychic disorders m a y contribute to the
prevention of psychotic developments. Early case-finding projects have
also been initiated elsewhere—in Finland, the pioneering activities of the
family- a n d network-centred Western L a p l a n d Project (Aaltonen et al.,
1997) should be followed b y acute psychosis teams w o r k i n g i n other
districts.
Other opportunities that m a y require more active attention than is
customary at present exist i n social welfare procedures, conscription
check-ups, a n d student health care services, among others. But a w o r d of
w a r n i n g is also i n order at this point: looking for signs of disorder a n d
interfering inexpertly m a y lead to unnecessary anxiety a n d b r i n g about
254 SCHIZOPHRENIA

h a r m a n d damage. Preventive mental health work requires both profes­

sional skill a n d empathy; coercion has no place i n it.
In chapter two I mentioned the as yet unverified findings that seem
to suggest that schizophrenia appears to be decreasing i n the Western
countries. I a m inclined to agree that such a development may be slowly
taking place—based o n m y observations in Finland during the past forty
y e a r s — a n d that the decline is particularly notable i n the most severe
forms of schizophrenia. I consider it possible that one of the factors
contributing to this favourable development has been the increasing
contacts of children with their environment from the day-care stage
onwards, as well as the decrease of rigid families that embrace their
children too tightly. O n the other side of the coin, however, living
milieus have become less stable, with an increasing number of separa­
tions, whose effects m a y be seen in the increase of borderline disorders,
d r u g abuse, depressions, a n d psychosomatic illnesses rather than a l i ­
ability for schizophrenia.

What does the future look like?

T h e future of psychiatric treatment a n d research is difficult to predict,

as i n d e e d is the future i n general. A s indicated b y the history of
psychiatry, development has been carried f o r w a r d — o r occasionally
b a c k w a r d — b y unexpected observations a n d influences. T h e r e are
some points I w i s h to emphasize here.
In chapter four, when discussing the factors that have prevented the
development of psychodynamic psychiatry and psychotherapy, I m e n ­
tioned the attitudes frequently prevailing i n faculties of medicine a n d
medical training. W h e n a majority of the professors view science as
exclusively natural science—such as a respected colleague of mine i n
T u r k u , w h o once said that he only appreciates matters that have been
established at the molecular level—it is often questionable whether
psychodynamic or other qualitative research can gain any ground at all.
This, however, is mostly u p to the representatives of psychiatry them­
selves and their ability and willingness to defend the special characteris­
tics of their field. The attitudes of leading psychiatrists have a notable
influence o n h o w the next generation of psychiatrists w i l l perceive their
duties of research a n d treatment. N o r is their significance restricted to
psychiatry; it is also felt more widely i n medical training. Psychiatrists
 TREATMENT OF SCHIZOPHRENIA A N D SOCIETY 255

have a chance to emphasize the h u m a n aspects of doctor-patient rela­

tionships i n contrast to the alienating dehumanization frequently felt b y
the students attending biologically oriented medical courses. Being
cured of an illness is not merely a molecular process.
In chapter two, I referred to the G e r m a n philosopher Habermas
(1968) w i t h regard to the hermeneutic interest of knowledge differing
from the natural-scientific ways of thinking. The Finnish psychiatrist and
author Oscar Parland (1991) recently touched u p o n these questions i n an
interesting manner, using the thoughts of the philosopher V . Sesemann
(1927) as his starting-point. Sesemann differentiated between objective
knowledge [Gegenstandliche Erkenntnis] a n d non-objective k n o w i n g [Un­
gegenstandliches Wissen], The act of knowledge is "rational a n d observant
and isolates, objectifies a n d conceptualizes its object", while the act of
k n o w i n g is based o n "intuitive insight, interpretation a n d empathic
understanding of the object". The latter definition comes close to the
epistemological theories of several psychoanalysts concerning their re­
search (e.g., Bion, 1967; K i l l i n g m o , 1989; K o h u t , 1977; Matte-Bianco,
1988). Psychiatric research a n d work, if any, need both knowledge a n d
k n o w i n g . Without k n o w i n g based o n empathy, w e cannot understand a
schizophrenic person, or indeed any other person.

I hope that the position of the more liberal epistemological theories

w i l l gradually be strengthened i n future faculties and psychiatric prac­
tices. This w o u l d also make it possible to integrate the research a n d
treatment of schizophrenia i n a better a n d more versatile w a y than is
possible at present.
A s biomedical schizophrenia research advances, n e w findings w i l l
be made to elucidate i n greater detail both the cellular structures of
different parts of the brain and the functional effects of and links among
transmitter substances, including differences in psychotic states. Genetic
researchers will continue their as yet not very successful efforts to find
chromosomal loci specific for schizophrenia. Psychopharmacological re­
search and the pharmaceutical industry are working h a r d to find neuro­
leptics a n d other psychoactive drugs that w o u l d act more selectively
than those currently i n use a n d permit differentiation of antipsychotic
effects from side-effects. It should be h o p e d that possible attempts at
new kinds of discriminating practice against schizophrenic patients,
based o n reductionistic ideas, will be avoided.
I d o not consider it possible that the fundamental problems i n the
treatment of schizophrenia will be solved pharmacologically, because
this disorder has such obvious connections to h u m a n personality devel­
256 SCHIZOPHRENIA

o p m e n t F o l l o w - u p findings such as described i n this book suggest that

comprehensive, psychotherapeutically oriented approaches improve the
patients' prognosis as compared with exclusively biopsychiatric treat­
ment. It m a y therefore be hoped—as is also to be expected o n the basis
of the general pendular movement of research—that psychotherapeutic
and psychosocial orientations w i l l soon make a comeback, w h i c h w i l l
probably also bring more conclusive evidence o n the significance of the
interactionally oriented treatment approaches.
Thanks to the increasing integration of the various research orien­
tations, the indications for need-adapted treatment of schizophrenia
w i l l i n the future probably not be defined o n the basis of psychological
criteria alone. They w i l l be supported b y biopsychiatric a n d neuro­
psychological assessments, which will also be useful i n estimating the
indications for psychotherapeutic treatment. Such a development, which
has been anticipated b y the ideas of Cullberg (1993a, 1993b), among
others, w i l l not diminish the need for psychotherapeutic a n d psycho­
social measures, but it w i l l probably affect the ways of setting treatment
goals for different patients. I w o u l d , however, caution against interpret­
ing biopsychiatric findings too exclusively—it is always beneficial to
shape a therapeutic relationship specifically i n each case a n d to study the
prospects for psychotherapeutic treatment in the light of this assessment.
Psychodynamic psychotherapy of schizophrenia is still far from
reaching the goals that will clarify its place i n the future. This is not
only because of a lack of qualitative a n d quantitative resources, but
also because of a lack of adequate differentiation from methods that are
primarily applicable i n the treatment of milder disorders. A s far as I can
see, such differentiation can be achieved b y combining the interactional
and i n d i v i d u a l psychological treatment orientations and b y promoting
therapeutic measures that support the rebuilding of personality. W e
cannot ignore the obviously favourable effects of family-oriented treat­
ment, especially at the onset of the illness, any more than the fact that
m a n y patients also urgently need long-term psychodynamic i n d i v i d u a l
therapy to reach a more stable and permanent balance. Both the experi­
ences of the Finnish psychosis teams a n d the observations b y Sidsel
Gilbert and Endre Ugelstad (1994) suggest that the active participation of
the patient a n d h i s / h e r relatives i n making therapeutic plans should be
routine, w h i c h is not the case at present.
T h e need-adapted treatment of schizophrenia, based o n a c o m ­
prehensive psychotherapeutic orientation that focuses b o t h o n the
 TREATMENT O F S C H I Z O P H R E N I A A N D SOCIETY 257

i n d i v i d u a l a n d the context, has been d e v e l o p e d i n order to advance

these types of v i e w s a n d to oppose reductionistic a n d d e h u m a n i z i n g
v i e w s of schizophrenia a n d its treatment. W e have f o u n d o u r follow­
u p results e n c o u r a g i n g a n d h o p e that they w i l l stimulate others to
carry out similar d e v e l o p m e n t a l approaches.
REFERENCES AND BIBLIOGRAPHY

A a k u , T., Rasimus, R., & Alanen, Y . O . (1980). N u r s i n g staff as individual

therapists i n the psychotherapeutic community. Psychiatria Fennica.
Yearbook: 9-31. Helsinki: The Foundation for Psychiatric Research i n
Finland.
Aaltonen, J. (1982). Basis for Family-Centred Treatment Process in Psychiatric
Outpatient Care [in Finnish, with English summary]. Annates Universi­
tatis Turkuensis, Ser. C, V o l . 35 (Turku, Finland).
Rakkolainen, V , , & Aaltonen, J. (1994). The shared image guiding the
treatment process. A precondition for integration of the treatment of
schizophrenia. British Journal of Psychiatry, 164 (Suppl. 23): 97-102.
Aaltonen, J., Seikkula, J., Alakare, B., et al. (1997). "Western L a p l a n d
Project: a comprehensive family- and network-centred community
psychiatric project. Abstract with preliminary results." Presented at
the Twelfth International Symposium for the Psychotherapy of
Schizophrenia, L o n d o n .
A b r a h a m , K . (1916). The first pregenital stage of the libido. In: Selected
Papers of Karl Abraham, M.D. (pp. 248-279). L o n d o n : Hogarth Press,
1949 [reprinted L o n d o n : Karnac Books, 1988].
Achte, K . A . (1961). Der Verlauf der Schizophrenien und der schizophrenic
formen Psychosen. Acta Psychiatrica Scandinavica, 36 (Suppl. 155).

259
260 REFERENCES A N D B I B L I O G R A P H Y

Achte, K . A . (1967). On Prognosis and Rehabilitation in Schizophrenic and

Paranoid Psychoses. Acta Psychiatrica Scandinavica, 43 (Suppl. 196).
Achte, K. A . , Lonnqvist, J., Piirtola, O., & Niskanen, P. (1979), Course and
prognosis of schizophrenic psychoses i n Helsinki. Psychiatric Journal
of the University of Ottawa, 4: 344-348.
Alanen, Y . O . (1958). The Mothers of Schizophrenic Patients. A Study of the
Personality and the Mother-Child Relationship of 100 Mothers and the
Significance of These Factors in the Pathogenesis of Schizophrenia, in Com­
parison with Heredity. Acta Psychiatrica et Neurologica Scandinavica, 33
(Suppl. 124).
Alanen, Y . O . (1962). Erfarenheter av supportiv psykoterapi m e d schizo­
frenipatienter [in Swedish, with English summary]. Nordisk Psykia­
trisk Tidsskrift, 16: 443-456.
Alanen, Y . O . (1968). F r o m the mothers of schizophrenic patients to
interactional family dynamics. In: D . Rosenthal & S. S. Kety (Eds.),
The Transmission of Schizophrenia (pp. 201-212). N e w York: Pergamon
Press.
A l a n e n , Y . O . (1975). The psychotherapeutic care of schizophrenic
patients i n a community psychiatric setting. In: M . H . Lader (Ed.),
Studies of Schizophrenia (pp. 86-93). British Journal of Psychiatry (Spe­
cial Publication N o 10).
Alanen, Y . O . (1976). O n background factors a n d goals i n the family
therapy of young schizophrenic patients. In: J. Jorstad & E . Ugelstad
(Eds.), Schizophrenia, 75. Psychotherapy, Family Studies, Research (pp.
173-186). Oslo: Universitetsforlaget.
Alanen, Y . O . (1980). In search of the interactional origin of schizophre­
nia. The Stanley R. Dean A w a r d Lecture. In: C . K. Hofling & J. M .
Lewis (Eds.), The Family, Evaluation and Treatment (pp. 285-313). N e w
York: B r u n n e r / M a z e l ,
Alanen, Y . O . (1992). Psychotherapy of schizophrenia in community psy­
chiatry. In: A . Werbart & J. Cullberg (Eds.), Psychotherapy of Schizo­
phrenia: Facilitating and Obstructive Factors (pp. 237-253). Oslo:
Scandinavian University Press.
Alanen, Y . O . (1994). A n attempt to integrate the individual-psycho­
logical a n d interactional concepts of the origins of schizophrenia.
British Journal of Psychiatry, 164 (Suppl. 23): 56-61.
Alanen, Y . O . (1997). Vulnerability to schizophrenia a n d psychothera­
peutic treatment of schizophrenic patients: towards an integrated
view. Psychiatry, 60:142-157.
Alanen, Y . O . , Anttinen, E . E . , Kokkola, A . , Lehtinen, K . , Ojanen, M ,
 REFERENCES A N D B I B L I O G R A P H Y 261

Pylkkanen, K . , & Rakkolainen, V . (1990). Treatment and Rehabilitation

of Schizophrenic Psychoses. The Finnish Treatment Model Nordic Journal
of Psychiatry, 44 (Suppl. 22).
A l a n e n , Y . O . , & Kinnunen, P. (1975). Marriage and the development of
schizophrenia. Psychiatry, 38: 346-355.
A l a n e n , Y . O . , Lehtinen, K., Rakkolainen, V . , & Aaltonen, J. (1991). N e e d ­
adapted treatment of new schizophrenic patients: experiences and
results of the Turku project. Acta Psychiatrica Scandinavica, 83:
363-372.
Alanen, Y . O . , Rakkolainen, V . , Laakso, J., & Rasimus, R. (1980). Prob­
lems inherent i n the study of psychotherapy of psychoses: conclu­
sions from a community psychiatric action research study. In: J. R.
Strauss, M . Bowers, T . W . Downey, S. Fleck, S. Jackson, & I. Levine
(Eds.), The Psychotherapy of Schizophrenia (pp. 115-129). N e w York:
Plenum Medical.
A l a n e n , Y . O . , Rakkolainen, V . , Laakso, J., Rasimus, R., & Jarvi, R. (1983).
Psychotherapy of schizophrenia i n community psychiatry: two-year
follow-up findings a n d the influence of selective processes o n psy­
chotherapeutic treatments. In: H . Stierlin, L . C . Wynne, & M.
Wirsching (Eds.), Psychosocial Intervention in Schizophrenia. An Inter­
national View (pp. 67-82). Berlin & Heidelberg: Springer-Verlag.
Alanen, Y . O . , Rakkolainen, V . , Laakso, J., Rasimus, R., & Kaljonen, A .
(1986). Towards Need-specific Treatment of Schizophrenic Psychoses.
Heidelberg: Springer-Verlag.
A l a n e n , Y . O . , Rekola, J. K . , Stewen, A . , Takala, K . , & Tuovinen, M .
(1966). The Family in the Pathogenesis of Schizophrenic and Neurotic
Disorders. Acta Psychiatrica Scandinavica, 42 (Suppl. 189).
A l a n e n , Y . O . , Salokangas, R. K. R., Ojanen, M . , Rakkolainen, V . , & Pylk­
kanen, K. (1990b). Tertiary prevention: treatment and rehabilitation
of schizophrenic patients. Results of the Finnish national p r o ­
gramme. In: D . Goldberg & D . Tantam (Eds.), The Public Health Im­
pact of Mental Disorders (pp. 176-191). Toronto, Ontario: Hogrefe &
Huber.
A l a n e n , Y . O . , Ugelstad, E . , Armelius, B.-A., Lehtinen, K . , Rosenbaum,
B., & Sjostrom, R. (Eds.) (1994). Early Treatment for Schizophrenic Pa­
tients. Scandinavian Psychotherapeutic Approaches. Oslo: Scandinavian
University Press.
Allebeck, P., Adamsson, C , Engstrom, A . , & Rydberg, U . (1993). C a n n a ­
bis and schizophrenia: a longitudinal study of cases treated i n Stock­
h o l m County. Acta Psychiatrica Scandinavica, 88: 21-24.
262 REFERENCES A N D B I B L I O G R A P H Y

A l v i r , J. M . J., Lieberman, J. A . , Safferman, A . Z., et al. (1993). Clozapine­

incluced agranulocytosis: incidence and risk factors i n the United
States. New England Journal of Medicine, 329:162-167.
American Psychiatric Association (1980). Diagnostic and Statistical
Manual for Mental Disorders, DSM-IIL Washington, D C .
American Psychiatric Association (1994). Diagnostic and Statistical Manual
of Mental Disorders, DSM-IV. Washington, D C .
Anderson, C . M . (1979). Family therapy session, presented at sympo­
sium, N e w Haven, C T .
Anderson, C . M . , Reiss, D . J., & Hogarty, G . E . (1986). Schizophrenia and
the Family. N e w York: Guilford Press.
A n d r e , G . (1995). Oral report on the Falun project (Sweden).
Andreasen, N . C , Arndt, S., Swayze, V . II, et al. (1994).Thalamic abnor­
malities in schizophrenia visualized through magnetic resonance
image averaging. Science, 266: 294r-298.
Andreasen, N . C , Ehrhardt, J. C , Swayze, V . W . II, et al. (1990). Magnetic
resonance imaging of the brain i n schizophrenia. Archives of General
Psychiatry, 47: 35-44.
Andreasen, N . C , & Olsen, S. A . (1982). Negative vs. positive schizo­
phrenia: definition and validation. Archives of General Psychiatry, 39:
789-794.
Anthony, E . J. (1968). The developmental precursors of adult schizophre­
nia. In D . Rosenthal & S. S. Kety (Eds.), The Transmission of Schizophre­
nia (pp. 293-316). N e w York: Pergamon Press.
Anthony, E . J. (1969). Clinical evaluation of children with psychotic par­
ents. American Journal of Psychiatry, 126:177-184.
Anttinen, E . E . (1983). C a n the vicious circle of chronicity and institution­
alization be broken? Psychiatria Fennica. Yearbook: p p . 21-31. H e l ­
sinki: The Foundation for Psychiatric Research i n Finland.
Anttinen, E . E . (1992). Flexiblare och kombinerade insatser ger battre
resultat. In: M . Thorslund (Ed.), Fler vardbehovande, Familjens roll och
samhdllets ansvar (pp. 121-130) [in Swedish]. Helsingfors, Finland:
Social- och halsovards-ministeriet.
The Care and Rehabilita­
Anttinen, E . E . , Eloranta, K. J., & Stenij, P. (1971).
tion of Schizophrenic Out-Patients with Home Care [in Finnish, w
English summary]. Kansanelakelaitoksen julkaisuja A: 8. Helsinki: N a ­
tional Pension Institute.
Arieti, S. (1955). Interpretation of Schizophrenia. N e w York: Brunner.
A r l o w , J., & Brenner, C. (1969). Psychopathology of the psychoses: a
proposed revision. International Journal of Psycho-Analysis, 50: 5-14.
 REFERENCES AND BIBLIOGRAPHY 263

Armelius, B . - A . (1989). Samordnadsforskning kring behandlingshem for psy­

kotiska patienter. Research project [in Swedish, mimeographed]. Umea,
Sweden.
Armelius, B.-A., Armelius, K . , Fogelstam, H . , et al. (1989). Effekter av
psykoterapi for psykotiska patienter: En oversikt om forskningslitteraturen
[in Swedish]. Stockholm: Socialstyrelsen, Rapport 4.
Baldessarini, R., Cohen, B. M . , & Teicher, M . H . (1988). Significance of
neuroleptic dose and plasma level i n the pharmacological treatment
of psychoses. Archives of General Psychiatry, 45: 79-91.
Barnes, T. R. E . (Ed.) (1989). Negative symptoms in schizophrenia. British
Journal of Psychiatry, 155 (Suppl. 7).
Barr, C . L . , Kennedy, J. L . , Pakstis, A . J., et al. (1994). Progress i n a
genome scan for linkage i n schizophrenia i n a large Swedish k i n ­
dred. American Journal of Medical Genetics, 54: 51-58.
Bateson, G . (1973). Double b i n d , 1969. In: Steps to an Ecology of Mind (pp.
242-249). Frogmore, St. Albans, U . K . : Paladin.
Bateson, G . , Jackson, D . D., Haley, J., & Weakland, J. H . (1956). Towards
a theory of schizophrenia. Behavioural Science, 1: 251-264.
Benedetti, G . (1975). Ausgewahlte Aufsdtze zur Schizophrenielehre. Gottin­
gen: Vandenhoeck.
Benedetti, G . (1979). The structure of psychotherapeutic relationship i n
the individual treatment of schizophrenia. In: C . Miiller (Ed.), Psy­
chotherapy of Schizophrenia (pp. 31-37). Amsterdam: Excerpta Medica.
Benedetti, G . (1985). Personliche Entwicklung i n der Psychotherapie der
Schizophrenen. Schzveizer Archiw fur Neurologic und Psychiatrie, 136:
23-28.
Benedetti, G . (1992). F r o m the First to the Tenth International Sympo­
sium for the Psychotherapy of Schizophrenia. In: A . Werbart &c J.
Cullberg (Eds.), Psychotherapy of Schizophrenia: Facilitating and Ob­
structive Factors (pp. 15-27). Oslo: Scandinavian University Press.
Beres, D . , & Obers, S. J. (1950). The effects of extreme deprivation i n
infancy on psychic structure in adolescence. The Psychoanalytic Study
of the Child, 5: 212-235.
Bertalanffy, L . v o n (1956). General systems theory. General Systems, 1:
1-10.
Biehl, H . , Maurer, K., Schubart, C , et al. (1986). Prediction of outcome
and utilization of medical services in a prospective study of first
onset schizophrenics: results of a prospective 5-year follow-up
study. European Archives of Psychiatry and Neurological Sciences, 236:
139-147.
264 REFERENCES A N D B I B L I O G R A P H Y

Bion, W . R. (1967). Second Thoughts. Selected Papers on Psycho-Analysis.

L o n d o n : William Heinemann [reprinted London: Karnac Books,
1990].
Birchwood, M . , & Macmillan, F. (1993). Early intervention in schizophre­
nia. Australian and New Zealand Journal of Psychiatry, 27: 374-378.
Birchwood, M . , & Preston, M . (1991). Schizophrenia. In: W . D r y d e n & R.
Rentoul (Eds.), Adult Clinical Problems. A Cognitive-Behavioural Ap­
proach (pp. 171-202). London: Routledge.
Bland, H . C , Parker, J. H . , & O r n , H . (1976). Prognosis i n schizophrenia:
a ten-year follow-up of first admissions. Archives of General Psychia­
try, 33: 949-954.
Bleuler, E . (1911). Dementia Praecox oder die Gruppe der Schizophrenien.
Handbuch der Psychiatrie, herausgegeben von Prof G. Aschaffenberg. Spe­
cial Section 4: 1. Leipzig, Vienna: Deuticke.
Bleuler, M . (1972). Die schizophrenen Geistesstorungen im Lichte langjahr­
igen Kranken- und Familiengeschichien. Stuttgart: Georg Thieme.
Bloch, S., & Reddaway, P. (1984). Soviet Psychiatric Abuse—The Shadow
over World Psychiatry. London: Gollancz.
Borri, P., & Quartesan, R. (Eds.) (1990). USA-Europe Joint Meeting on
Therapies and Psychotherapy of Schizophrenia. Perugia: Assoziane per la
Ricerca i n Psychiatria.
Borus, J. F. (1981). Deinstitutionalization of the chronically mentally ill.
New England Journal of Medicine, 305: 339-342.
Boszormenyi-Nagy, I., & Framo, J. L . (Eds.) (1965). Intensive Family
Therapy. Theoretical and Practical Aspects. N e w York: Hoeber Medical
Division, Harper & Row.
Bowen, M . (1960). A family concept of schizophrenia. In: D . D . Jackson
(Ed.), The Aetiology of Schizophrenia (pp. 346-372). N e w York: Basic
Books.
Bowen, M . , Dysinger, R. H . , Brodey, W . M . , & Basamania, B. W . (1961).
The family as the unit of study and treatment. American Journal of
Orthopsychiatry, 31:40-86.
Bowlby, J. (1969). Attachment and Loss, V o l . 1: Attachment. London:
Hogarth Press.
Boyer, L . B. (1983). The Regressed Patient. N e w York: Jason Aronson.
Boyer, L . B. (1986). Technical aspects i n treating the regressed patient.
Contemporary Psychoanalysis, 22: 25-44.
Boyer, L . B. (1989). Countertransference and technique i n working with
the regressed patient: further remarks. International Journal of Psycho-
Analysis, 70: 701-714.
 REFERENCES A N D BIBLIOGRAPHY 265

Bremner, J. D Randall, P., Scott, T. M , et a l (1995). MRI-based measure­

v

ment of hippocampal volume i n patients with combat-related post­

traumatic stress disorder. American Journal of Psychiatry, 152:973-981.
Brown, G . W . , Birley, J. L . T , &. Wing, J. K. (1972). Influence of the family
life o n the course of schizophrenic disorders: a replication. British
Journal of Psychiatry, 121: 241-258.
Brown, G . W . , Bone, M . , Dalison, B, & W i n g , J. K. (1966). Schizophrenia
and Social Care. London: Institute of Psychiatry, The Maudsley H o s p i ­
tal.
Burnham, D . L . , Gladstone, A . I., & Gibson, R. W . (1969). Schizophrenia
and the Need-Pear Dilemma. N e w York: International Universities
Press.
Caldwell, C . B., & Gottesman, 1.1. (1990). Schizophrenics kill themselves
too: a review of risk factors for suicide. Schizophrenia Bulletin, 16:
571-589.
Cameron, N . (1938). Reasoning, regression and communication i n
schizophrenics. Psychological Monographs, 50, N o 1.
Cannon, T. D . , Mednick, S. A . , Parnas, J., et al. (1993). Developmental
brain abnormalities i n the offspring of schizophrenic mothers. I.
Contributions of genetic and perinatal factors. Archives of General
Psychiatry, 50: 551-564.
Carlsson, A . , & Lindqvist, M . (1963). Effect of chlorpromazine and halo­
peridol o n formation of methoxytyramine and normetanephrine in
mouse brain. Acta Pharmacology and Toxicology, 20:140-144.
Carlsson, M . , & Carlsson, A . (1990). Schizophrenia: a subcortical neuro­
transmitter syndrome? Schizophrenia Bulletin, 16: 425-432.
Carpenter, W . T., Heinrichs, D . W . , & Hanlon, T . E . (1987). A compara­
tive trial of pharmacological strategies i n schizophrenia. American
Journal of Psychiatry, 144:1466-1470.
Carpenter, W . T., McGlashan, T. H . , & Strauss, J. S (1977). Treatment of
acute schizophrenia without drugs: an investigation of some current
assumptions. American Journal of Psychiatry, 134: 14-21.
C i o m p i , L. (1980). The natural history of schizophrenia in the long term.
British Journal of Psychiatry, 136: 413-420.
C i o m p i , L . (1982). Affektlogik. Stuttgart: Klett-Cotta [English edition: The
Psyche and Schizophrenia. The Bond Between Affect and Logic. C a m ­
bridge, M A : Harvard University Press, 1988.]
C i o m p i , L . (1991). Affects as central organizing and integrating factors. A
new psychosocial/biological model of the psyche. British Journal of
Psychiatry, 159: 97-105.
266 REFERENCES AND BIBLIOGRAPHY

C i o m p i , L . (1994). Affect logic: an integrative model of psyche and its

relations to schizophrenia. British Journal of Psychiatry, 164 (Suppl.
23): 51-55.
C i o m p i , L . , Dauwalder, H . - P . , A e b i , E . , et aL (1992). A new approach of
acute schizophrenia. Further results of the pilot project "Soteria
Berne". In: A . Werbart & J. Cullberg (Eds,), Psychotherapy of Schizo­
phrenia: Facilitating and Obstructive Factors (pp. 95-109). Oslo:
Scandinavian University Press.
C i o m p i , L . , & Miiller, C . (1976). Lebensweg und Alter der Schizophrenen.
Fine katamnestische Langzeitstudie bis ins Senium. Berlin & Heidelberg:
Springer Verlag.
Claghorn, J. L . , Johnstone, E . E . , Cook, T. H . , et al. (1974). G r o u p therapy
and maintenance treatment of schizophrenics. Archives of General
Psychiatry, 31: 361-365.
Cleghorn, J. M . , Zipursky, R. B., & List, S. J. (1991). Structural and func­
tional brain imaging in schizophrenia. Journal of Psychiatry & Neuro­
science, 1: 53-74.
Cole, J. O . , & Davis, J. M . (1969). Antipsychotic drugs. In: L . Bellak & L .
Loeb (Eds.), The Schizophrenic Syndrome (pp. 478-568). N e w York:
Grune & Stratton.
Conran, M . B. (1972). The relationship between blame and hope. In: D .
Rubinstein & Y . O . Alanen (Eds.), Psychotherapy of Schizophrenia (pp.
207-210). Amsterdam: Excerpta Medica.
Coon, H v Jensen, S., Holik, J., et al. (1994). Genomic scan for genes
predisposing to schizophrenia. American Journal of Medical Genetics,
54: 59-71.
Cooper, J. E . , Kendell, R. E . , Gurland, B. J., et aL (1972). Psychiatric Diag­
nosis in New York and London. Maudsley Monograph No 20. L o n d o n :
Oxford University Press.
C r o w , T. J, (1985). The two-syndrome concept: origins and current status.
Schizophrenia Bulletin, 11: 471-485.
C r o w , T . J. (1994). Prenatal exposure to influenza as a cause of schizo­
phrenia. There are inconsistencies and contradictions i n the evi­
dence. British Journal of Psychiatry, 164: 588-592.
Cullberg, J. (1993a). A proposal for a three-dimensional aetiologic view
of the schizophrenias. I. Nordic Journal of Psychiatry, 47: 355-359.
Cullberg, J. (1993b). A three dimensional aetiologic view of the schizo­
phrenias. II. Hypothetical clinical consequences. Nordic Journal of
Psychiatry, 47: 421-424.
Davis, A . E . , Dinitz, S., & Pasamanick, B. (1972). The prevention of hospi­
 REFERENCES A N D B I B L I O G R A P H Y 267

talization i n schizophrenia. American Journal of Orthopsychiatry, 42:

1375-1388.
Davis, O . R., Breier, A . , Buchanan, R. W . , & Holstein, C . (1991). Obstetric
complications in schizophrenia. Schizophrenia Research, 4: 254.
Dean, C , Phillips, J., G a d d , E . M . , et al. (1993). Comparison of c o m m u ­
nity based service with hospital based service for people with acute
severe psychiatric illness. British Medical Journal, 307: 473-476.
Dein, E . (1964). Personlighedstyper v e d skizofreni og skizofreniforme
psykoset [in Danish]. Nordisk Psykiatrisk Tidskrift, 18: 87-105.
Delay, J., Deniker, P., & Green, A . (1957). Essai de description et de
definition psycho-pathologique des parents des schjizophrenes. Con­
gress Report of the Second International Congress for Psychiatry, IV: 4 9 ­
56. Zurich: Orell Fiissli.
Delay, J., Deniker, P., & Green, A . (1962). L e milieu familial des schizo­
phrenes. Vencephal, 51: 1-73.
Delay, J., Deniker, P., & H a r l , J. M . (1952). Traitment des etats d'excitation
et d'agitation par une methode medicamenteuse derivee de l'hiberno­
therapie. Annates Medico-psychologique, 110: 267-273.
DeLisi, L . E . , G o l d i n , L . R., Hamovit, J. R., et al. (1986). A family study
of the association of increased ventricular size with schizophrenia.
Archives of General Psychiatry, 43:148-153.
Dell, P. (1980). Researching the family theories of schizophrenia: an exer­
cise i n epistemological confusion. Family Process, 19: 321-335.
De Sisto, M . J., H a r d i n g , C . M . , McCormick, R, V . , et al. (1995). The
Maine and Vermont three-decade studies of serious mental illness. I.
Matched comparison and cross-sectional outcome. II. Longitudinal
course comparisons. British Journal of Psychiatry, 167: 331-342.
Der, G . , Gupta, S., & M u r r a y , R. M . N . (1990). Is schizophrenia disap­
pearing? Lancet, 335: 409-413.
Doane, J. A . (1978). Family interaction and communication deviance i n
disturbed and normal families. A review of research. Family Process,
17: 357-376.
Doane, J. A . , Falloon, I. R. H . , Goldstein, M . J., & Mintz, J. (1985). Parental
affective style and the treatment of schizophrenia. Predicting course
of illness and social functioning. Archives of General Psychiatry, 42:34­
42.
Doane, J. A . , Goldstein, M . J., Miklowitz, D . J., & Falloon, I. R. H . (1986).
The impact of individual and family treatment o n the affective cli­
mate of families of schizophrenics. British Journal of Psychiatry, 148:
279-287.
268 REFERENCES A N D B I B L I O G R A P H Y

Domarus, E . von (1944). The specific laws of logic in schizophrenia. In J.

S. Kasanin (Ed.), Language and Thought in Schizophrenia (pp. 104-113).
Berkeley, C A : University of California Press.
Donaldson, S. R., Gelenberg, A . J., & Baldessarini, R. J. (1983). The phar­
macological treatment of schizophrenia: a progress report. Schizo­
phrenia Bulletin, 9: 504-527.
Done, D . J., Johnstone, E . C , & Frith, C D . (1991). Complications of
pregnancy and delivery in relation to psychosis in adult life: data
from the British perinatal mortality survey sample. British Medical
Journal, 302:1576-1580.
Early, D . C . (1960). The industrial therapy organization (Bristol). Lancet,
2: 754-757.
Eaton, W . W . (1985). Epidemiology of schizophrenia. Epidemiological Re­
view, 7: 105-126.
E m d e , R. (1988). Development terminable and interminable. I. Innate
and motivational factors from infancy. International Journal of Psycho-
Analysis, 69: 23-42.
Ernst, K . (1956). "Geordnete Familienverhaltnisse" spaterer Schizo­
phrener i m Lichte einer Nachuntersuchung. Archiv fur Psychiatrie
(Berlin), 194: 355-367.
Falloon, I. R. H . (1992). Early intervention for first episodes of schizo­
phrenia: a preliminary exploration. Psychiatry, 55: 4^15.
Falloon, I. R. H „ Boyd, J. L . , M c G i l l , C . W . , et al. (1982). Family manage­
ment i n the prevention of exacerbations of schizophrenia. New Eng­
land Journal of Medicine, 306:1437-1440.
Falloon, I. R. H „ Boyd, J. L . , M c G i l l , C . W . , et al. (1985). Family manage­
ment i n the prevention of morbidity of schizophrenia. Clinical out­
come of a two-year longitudinal study. Archives of General Psychiatry,
42: 887-896.
Farde, L . , Wiesel, F . - A . , Halldin, C , & Sedvall, G . (1988). Central D 2 ­
dopamine receptor occupancy i n schizophrenic patients treated with
antipsychotic drugs. Archives of General Psychiatry, 45: 71-76.
Farde, L v Wiesel, F . - A . , Stone-Elander, S., et al. (1990). D2 dopamine
receptors i n neuroleptic-naive schizophrenic patients. A positron
emission tomography study with (11C) Raclopride. Archives of Gen­
eral Psychiatry, 47: 213-219.
Federn, P. (1943). Psychoanalysis of psychoses. Psychiatric Quarterly, 17:
3-19,246-257,470-487. [Also in: E . Weiss (Ed.), Ego Psychology and the
Psychoses. N e w York: Basic Books, 1952; reprinted London: Karnac
Books, 1977.]
 REFERENCES A N D B I B L I O G R A P H Y 269

Federn, P. (1952). Ego Psychology and the Psychoses. (Ed. E . Weiss). N e w

York: Basic Books [reprinted London: Karnac Books, 1977].
Fenichel, O . (1945). The Psychoanalytic Theory of Neurosis. N e w York:
W . W . Norton.
Fenton, F. R., Tessier, L . , & Struening, E . L . (1979). A comparative trial of
home and hospital psychiatric care. One-year follow-up. Archives of
General Psychiatry, 36:1073-1079.
Fischer, M . (1973). Genetic and Environmental Factors in Schizophrenia. Acta
Psychiatrica Scandinavica, 49 (Suppl. 238).
Fleck, S. (1992). T h e development of schizophrenia: a psychosocial and
biological approach. In: A . Werbart & J. Cullberg (Eds.), Psychotherapy
of Schizophrenia: Facilitating and Obstructive Factors (pp. 179-192). Oslo:
Scandinavian University Press.
Fleck S. (1995). Dehumanizing developments i n American psychiatry i n
recent decades. Journal of Nervous and Mental Diseases, 183:195-203.
Forssen, A , (1979). Roots of Traditional Personality Development among the
Zaramo in Coastal Tanzania. Publication 54. Helsinki: Lastensuojelun
Keskusliitto.
Freud, S. (1911c). Psychoanalytic notes on an autobiographical account
of a case of paranoia (Dementia paranoides). Standard Edition, 12:
3-79. L o n d o n : Hogarth Press, 1958.
Freud, S. (1914c). O n narcissism: an introduction. Standard Edition, 14:
121-144. L o n d o n : Hogarth Press, 1958.
Freud, S (1915e). The unconscious. Standard Edition, 14:161-215. L o n d o n ,
Hogarth Press, 1958.
Freud, S. (1917e). M o u r n i n g and melancholia. Standard Edition, 14:
237-259. L o n d o n : Hogarth Press, 1958.
Freud S. (1924b). Neurosis and psychosis. Standard Edition, 19: 149-170.
L o n d o n : Hogarth Press, 1961.
Freud S. (1924e). The loss of reality i n neurosis and psychosis. Standard
Edition, 19: 183-187. L o n d o n : Hogarth Press, 1961.
Fromm-Reichmann, F. (1950). Principles of Intensive Psychotherapy. C h i ­
cago, IL: University of Chicago Press.
Fromm-Reichmann, F. (1952). Some aspects of psychoanalytic psycho­
therapy with schizophrenics. In: E . B. Brody & F. C . Redlich (Eds.),
Psychotherapy with Schizophrenics (pp. 89-111). N e w York: Interna­
tional Universities Press. [Reprinted in: D . M . Bullard (Ed.), Psycho­
analysis and Psychotherapy. Collected Papers of Frieda Fromm-Reichmann
(pp. 176-193). Chicago: University of Chicago Press, 1959.]
Furlan, P. M . (1993). Psychotherapeutic factors i n different settings of
270 REFERENCES A N D B I B L I O G R A P H Y

individual treatment of psychoses. In: C . Benedetti & P. M . Furlan

(Eds.), The Psychotherapy of Schizophrenia. Effective Clinical Ap­
proaches—Controversies, Critiques, & Recommendations (pp. 115-123).
Toronto, Ontario: Hogrefe & Huber.
Gelder M . , Gath D . , & M a y o u , R. (1984), Oxford Textbook of Psychiatry.
Oxford: Oxford University Press.
Gilbert, S., & Ugelstad, E . (1994). The patients' o w n contributions to
long-term supportive psychotherapy of schizophrenic disorder. Brit­
ish Journal of Psychiatry, 164 (Suppl. 23): 84-88.
Glass, L . L . , Katz, H . M . , Schnitzer, R. D . , et al. (1989). Psychotherapy of
schizophrenia: an empirical investigation of the relationship of pro­
cess to outcome. American Journal of Psychiatry, 146: 603-608.
Goethe, J. W . (1808). Samiliche Werke, V o l . 32 (p. 44). Stuttgart & Berlin:
Cotta'sche Buchhandlung.
Goffman, E . (1961). On the Characteristics of Total Institutions. N e w York:
Garden City.
Goldberg, D . (1991). Cost-effectiveness studies i n the treatment of
schizophrenia. Schizophrenia Bulletin, 17: 453-459.
Goldstein, J. M , & Tsuang, M . T. (1990). Gender and schizophrenia: an
introduction and synthesis of the findings. Schizophrenia Bulletin, 16:
179-184.
Goldstein, K. (1948). Language and Language Disturbances. N e w York:
Grune & Stratton.
Goldstein, M . J. (1985). Family factors that antedate the onset of schizo­
phrenia and related disorders: the results of a fifteen year prospec­
tive longitudinal study. Acta Psychiatrica Scandinavica, 71 (Suppl.
319): 7-18.
Goldstein, M . J. (1987). The U C L A high risk project. Schizophrenia Bulle­
tin, 13: 505-514.
Goldstein, M . J., & Kopeikin, H . S. (1981). Short and long time effects on
a program combining drug and family therapy. Unpublished m a n u ­
script. [Cited in: J. G . Gunderson & A . Carroll, " C l i n i c a l considera­
tions from empirical research". In: H . Stierlin, L . C . Wynne, & M .
Wirsching (Eds.), Psychosocial Intervention in Schizophrenia (pp.
125-142). Berlin & Heidelberg: Springer-Verlag.]
Goldstein, M . J,, Rodnick, E . H . , Evans, J. R., et al. (1978). D r u g and
family therapy i n the aftercare of acute schizophrenics. Archives of
General Psychiatry, 35:1169-1677.
Gonzalez de Chaves Menendez, M . , & Garcia-Ord&s Alvarez, A . (1992).
G r o u p therapy as a facilitating factor i n the combined treatment
 REFERENCES A N D B I B L I O G R A P H Y 271

approach to schizophrenia. In: A . Werbart & J. Cullberg (Eds.), Psy­

chotherapy of Schizophrenia—Facilitating and Obstructive Factors (pp.
120-130). Oslo: Scandinavian University Press.
Gottesman, I. I., & Bertelsen, A . (1989). Confirming unexpressed geno­
types for schizophrenia. Risks in the offspring of Fischer's Danish
identical and fraternal discordant twins. Archives of General Psychia­
try, 46: 867-872.
Gottesman, I. I., & Shields, J. (1966). Schizophrenia i n twins: 16 years'
consecutive admissions to a psychiatric clinic. British Journal of Psy­
chiatry, 112: 809-818.
Greenspan, S. I. (1989). The development of the ego: biological and envi­
ronmental specificity i n the psychopathological developmental pro­
cess and the selection a n d construction of ego defences. Journal of
American Psychoanalytic Association, 37: 608-638.
Grigsby, J., & Schneider, J. L . (1991). Neuroscience, modularity and per­
sonality theory: conceptual foundation of a model complex human
functioning. Psychiatry, 54: 21-38.
Grinspoon, L . , Ewalt, J . , & Shader, R. (1972). Schizophrenia: Pharmaco­
therapy and Psychotherapy. Baltimore, M D : Williams & Wilkins.
Grotstein, J. S. (1977). The psychoanalytic concept of schizophrenia. I.
The dilemma. II. Reconciliation. International Journal of Psycho-Analy­
sis, 58: 403-452.
G r o u p for the Advancement of Psychiatry (1989). Psychiatric Prevention
and the Family Life Cycle. Risk Reduction by Frontier Practitioners. Re­
port N o 127. N e w York: B r u n n e r / M a z e l .
Gunderson, J. G . , Frank, A . F . , Katz, H . M . , et al. (1984). Effects of psycho­
therapy i n schizophrenia: comparative outcome of two forms of
treatment. Schizophrenia Bulletin, 10: 564-598.
Guntern, G . (1979). Social Change, Stress and Mental Health in the Pearl of
the Alps. A Systemic Study of a Village Process. Berlin & Heidelberg:
Springer-Verlag.
Haakenaasen, K., & Ugelstad, E . (1986). What is effective i n the psycho­
social treatment of younger schizophrenic inpatients? A 10-year fol­
low-up study. Nordic Journal of Psychiatry, 40: 255-265.
Habermas, J. (1968). Erkenntnis und Intresse. Frankfurt: Suhrkamp.
Hafner, H . , Maurer, K . , Loffler, W . , et a l (1994). The epidemiology of
early schizophrenia: influence of age and gender o n onset and early
course. British Journal of Psychiatry, 164 (Suppl. 23): 29-38.
H a r d i n g , C M . , Brooks, G . W . , Ashikaga, T., et al. (1987). The Vermont
longitudinal study of persons with severe mental illness. II. L o n g ­
272 REFERENCES A N D B I B L I O G R A P H Y

term outcomes of subjects w h o retrospectively met DSM-III criteria

for schizophrenia. American Journal of Psychiatry, 144: 727-735.
Harlow, H . F., Harlow, M . K. (1966). Learning to love. American Science,
54: 244-272.
Harris, A . , Linker, I., & Norris, V . (1956). Schizophrenia: a social a n d
prognostic study. British Journal of Preventive and Social Medicine, 10:
107-114.
Hartmann, H . (1953). Contribution to the metapsychology of schizophre­
nia. The Psychoanalytic Study of the Child, 8:177-198.
Hartmann, H . (1958). Ego Psychology and the Problem of Adaptation, N e w
York: International Universities Press.
Hartmann, H . , Kris, E . , & Loewenstein, R, M . (1946). Comments on the
formation of psychic structure. The Psychoanalytic Study of the Child,
2: 11-38.
H a u g , J. O . (1962). Pneumoencephalographic Studies in Mental Disease. Acta
Psychiatrica Scandinavica, 38 (Suppl. 165).
Haugsgjerd, S. (1971). Nytt perspektiv pa psykiatrin [in Swedish]. Stock­
holm: Prisma.
Hauser P., Altshuler, L . L . , Berritini, W . , et al. (1989). Temporal lobe
measurements i n primary affective disorder by magnetic resonance
imaging. Journal of Neuropsychiatry & Clinical Neuroscience, 1:
128-134.
Hegarty, J. D . , Baldessarini, R. J., Tohen, M . , et al. (1994). One hundred
years of schizophrenia: a meta-analysis of the outcome literature.
American Journal of Psychiatry, 151:1409-1411.
Heston, L . L . (1966). Psychiatric disorders in foster-home-reared children
of schizophrenic mothers. British Journal of Psychiatry, 112: 819-825.
Hietala, J., Syvalahti, E . , Vuorio, K., et al. (1994). Striatal D2 dopamine
receptor characteristics i n neuroleptic-naive schizophrenics studied
with positron emission tomography. Archives of General Psychiatry,
51: 116-123.
Hietala, J., Syvalahti, E . , Vuorio, K., et al. (1995). Presynaptic dopamine
function i n striatum of neuroleptic-naive schizophrenic patients.
Lancet, 346:1130-1131.
Hirsch, S. R., & Leff, J. P. (1971). Parental abnormalities of verbal com­
munication i n the transmission of schizophrenia. Psychological Medi­
cine, 1: 118-127.
Hirsch, S. R., & Leff, J. (1975). Abnormalities in Parents of Schizophrenics.
Institute of Psychiatry, Maudsley Monographs, N o 22. London: O x ­
ford University Press.
 REFERENCES A N D B I B L I O G R A P H Y 273

Hjort, H . , & Ugelstad, E . (1994). Dually diagnosed patients in the N o r w e ­

gian sample—schizophrenia and drug abuse. Appendix to: Y . O .
Alanen, E . Ugelstad, B.-A. Armelius, et al., Early Treatment for Schizo­
phrenic Patients: Scandinavian Psychotherapeutic Approaches (pp.
155-162). Oslo: Scandinavian University Press.
Hogarty, G . E. (1994). "Integration of psychopharmacologic and psycho­
social therapies i n schizophrenia/' Paper read at the Eleventh Interna­
tional Symposium for Psychotherapy of Schizophrenia, Washington,
DC.
Hogarty, G . E . , Anderson, C M . , Reiss, D . J., et al. (1986). Family psycho­
education, social skills training, and maintenance chemotherapy i n
the aftercare treatment of schizophrenia. I. One-year effects of a con­
trolled study on relapse and expressed emotion. Archives of General
Psychiatry, 43: 633-642.
Hogarty, G . E . , Anderson, C . M . , Reiss, D . J., et al. (1991). Family psycho­
education, social skills training and chemotherapy i n the aftercare
treatment of schizophrenia. II. Two-year effects of a controlled study
on relapse and adjustment. Archives of General Psychiatry, 48:340-347.
Hoult, J., Reynolds, I., Charbonneau-Powis, J., et al. (1983). Psychiatric
hospital versus community treatment: the results of a randomized
trial. Australian and New Zealand Journal of Psychiatry, 17:160-167.
H s i a , C . Y . , & C h a n g , M . Y . (1978). L o n g term follow-up study of schizo­
phrenia. Chinese Medical Journal, 4: 266-270.
Huber, G . (1961). Chronische Schizophrenic Synopsis klinischer und neuro­
radiologischer Untersuchungen an defektschizophrenen Anstaltpatienten.
Einzeldarstellungen aus der theoretischer und klinischer Medizin, Band 13.
Heidelberg: D r . A H u t h i g Verlag.
Huber, G . , Gross, G . , Schuttler, R., & L i n z , M , (1980). Longitudinal stud­
ies of schizophrenic patients. Schizophrenia Bulletin, 6: 592-605.
Huttunen, M . O . , M a c h o n , R. A . , & Mednick, S. A . (1994). Pre-natal fac­
tors in the pathogenesis of schizophrenia. British Journal of Psychiatry,
164 (Suppl. 23): 15-19.
Idanpaan-Heikkila, J., A l h a v a , E . , Olkinuora, M . , et al. (1977). Agranulo­
cytosis during treatment with clozapine. European Journal of Clinical
Pharmacology, 11:193-198.
Illowsky, B., Juliano, D . M . , Bigelow, L . B., & Weinberger, D . R. (1988).
Stability of C T scan findings i n schizophrenia: results of an 8-year
follow-up study. Journal of Neurology, Neurosurgery & Psychiatry, 51:
209-213.
Inoye, E . (1961). Similarity and dissimilarity of schizophrenia i n twins.
274 REFERENCES A N D BIBLIOGRAPHY

Proceedings of the Third World Congress of Psychiatry, 1:524-530. M o n ­

treal: University of Toronto Press.
Isohanni, M . (1983). The Psychiatric Ward as a Therapeutic Community. Acta
Universitatis Ouluensis, Series D Medica, N o 111. (Oulu, Finland).
Jablensky, A . , Sartorius, N . , Ernberg, G., et al. (1992). Schizophrenia: Mani­
festation, Incidence and Course in Different Cultures. Psychological
Medicine Monographs (SuppL 20). Cambridge: Cambridge Univer­
sity Press.
Jackson, D . D . (1957). The question of family homeostasis. Psychiatric
Quarterly (Suppl. 31): 79-90.
Jackson, D . D . , & Weakland, J. H . (1961). Conjoint family therapy: some
considerations o n theory, technique, and results. Psychiatry, 24
(SuppL 2): 30-45.
Jackson, M . , & Cawley, R. (1992). Psychodynamics and psychotherapy
on an acute ward. The story of an experimental unit. British Journal of
Psychiatry, 160: 41-50.
Jackson, M v & Williams, P. (1994). Unimaginable Storms: A Search for
Meaning in Psychosis. London: Karnac Books.
Jacob, T . (1975). Family interaction in disturbed and normal families: a
methodological and substantive review. Psychological Bulletin, 82:
33-65.
Jenkins, J. H . , & Karno, M . (1992). The meaning of expressed emotion:
theoretical issues raised b y cross-cultural research. American Journal
of Psychiatry, 149: 9-21.
Johansson, A . (1956). Psychotherapeutische Behandlung eines Falles v o n
Schizophrenic. Psyche, 10: 568-587.
Johansson, A . (1985). Skitsofrenian analyyttisen psykoterapian ongelma. [The
problem of the psychoanalytic psychotherapy of schizophrenia; i n
Finnish]. Annales Universitatis Turkuensis, Ser. C, V o l . 53 (Turku, F i n ­
land),
Johnstone, E . C , C r o w , T, J., Frith, C. D . , et al, (1976). Cerebral ventricu­
lar size and cognitive impairment in chronic schizophrenia. Lancet, 1:
924r-926.
Jones, M . (1953). The Therapeutic Community. N e w York: Basic Books.
Jones, P., Rodgers, B,, Murray, R., & Marmot, M . (1994), C h i l d develop­
ment risk factors for adult schizophrenia i n the British 1946 birth
cohort. Lancet, 344:1398-1402.
Kallmann, F. J. (1946). The genetic theory of schizophrenia. A n analysis
of 691 schizophrenic twin index families. American Journal of Psychia­
try, 103: 309-322.
 REFERENCES A N D B I B L I O G R A P H Y 275

Kanas, N . (1986). G r o u p therapy with schizophrenics: a review of con­

trolled studies. International Journal of Group Psychotherapy, 36: 339­
351.
Karon, B. P., & VandenBos, G . R. (1972). The consequences of psycho­
therapy for schizophrenic patients. Psychotherapy: Theory, Research
and Practice, 9:111-119.
Karon, B. P., & VandenBos, G . R. (1981). Psychotherapy of Schizophrenia—
Treatment of Choice. N e w York: Jason Aronson.
Kasanin, J. (1933). The acute schizoaffective psychosis. American Journal
of Psychiatry, 13: 97-126.
Kasanin, J., Knight, E . , & Sage, P. (1934). The parent-child relationship i n
schizophrenia: I. Over-protection—rejection. Journal of Nervous and
Mental Diseases, 79: 249-263.
Kaufmann, L . (1976). Long-term family therapy with schizophrenics. In.
J. Jorstad & E . Ugelstad (Eds.), Schizophrenia, 75, Psychotherapy, Family
Studies, Research (pp. 229-242). Oslo: Universitetsforlaget.
Kavanagh, D . J. (1992). Expressed emotion and schizophrenia. British
Journal of Psychiatry, 160: 601-169.
Kendler, K . S., & Robinette, C . D . (1983). Schizophrenia i n the National
A c a d e m y of Sciences—National Research Council T w i n Registry: a
16-year update. American Journal of Psychiatry, 140:1551-1563.
Kendler, K. S., Spitzer, R. L . , & Williams, J. B. W . (1989). Psychotic disor­
ders i n DSM-III R. American Journal of Psychiatry, 146: 953-962.
Kemberg, O . F. (1975). Borderline Conditions and Pathological Narcissism.
N e w York: Jason Aronson.
Kernberg, O . F. (1984). Object Relations Theory and Clinical Psychoanalysis.
N e w York: Jason Aronson.
Keranen, J. (1992). The Choice between Outpatient and Inpatient Treatment in
a Family Centred Psychiatric Treatment System [in Finnish, with E n g ­
lish summary]. Jyvaskyla Studies in Education, Psychology and Social
Research, 93 (Jyvaskyla, Finland).
Kety, S, S., Rosenthal, D . , Wender, P. H . , et al. (1968). The types a n d
prevalence of mental illness i n the biological and adptive families of
adopted schizophrenics. In: D . Rosenthal & S. S. Kety (Eds.), The
Transmission of Schizophrenia (pp. 345-362). N e w York: Pergamon .
Kety, S. S., Wender P. H . , Jacobsen, J., et al. (1994). Mental illness i n the
biological and adoptive relatives of schizophrenic adoptees. Archives
of General Psychiatry, 51: 442-455.
Killingmo, B. (1989). Conflict and deficit: implications for technique.
International Journal of Psycho-Analysis, 70: 65-79.
276 REFERENCES A N D B I B L I O G R A P H Y

Klein, M . (1946). Notes on some schizoid mechanisms. International Jour­

nal of Psycho-Analysis, 27: 99-110. [Also in: The Writings of Melanie
Klein. V o l . 3: Envy and Gratitude and Other Works. London: Hogarth
Press and the Institute of Psychoanalysis [reprinted London: Karnac
Books, 1993.]
Klein, M . (1975). Envy and Gratitude and Other Works, 1946-63. London:
Hogarth Press and the Institute of Psychoanalysis [reprinted L o n ­
don: Karnac Books, 1993].
Kohut, H . (1971). The Analysis of the Self. A Systematic Approach to the
Psychoanalysis of Narcissistic Personality Disorders. N e w York: Interna­
tional Universities Press.
Kohut, H . (1977). The Restoration of the Self N e w York: International
Universities Press.
Kringlen, E . (1967). Heredity and Environment in Functional Psychoses, Vols.
I—II. Oslo: Universitetsforlaget.
Kringlen, E . (1978). A d u l t offspring of two psychotic parents with spe­
cial reference to schizophrenia. In: L . C . Wynne, R. L . Cromwell, & S.
Matthysse (Eds.), The Nature of Schizophrenia (pp. 9-24). N e w York:
John Wiley & Sons.
Kringlen, E . (1994). Is the concept of schizophrenia useful from an aetio­
logical point of view? A selective review of findings and paradoxes.
Acta Psychiatrica Scandinavica, 90 (Suppl. 384): 17-25.
Kringlen, E . , & Cramer, G . (1989). Offsprings of monozygotic twins dis­
cordant for schizophrenia. Archives of General Psychiatry, 46: 770-779.
Kuipers, L . (1993). Family burden i n schizophrenia: implications for
services. Social Psychiatry & Psychiatric Epidemiology, 28: 207-210.
K u u s i , K . (1986). Prognosis of Schizophrenic Psychoses in Helsinki in 1975­
1983 [in Finnish, with English summary]. Monographs of Psychiatria
Fennica, N o 13. Helsinki.
Laing, R. D . , & Esterson, A . (1964). Sanity, Madness and the Family. V o l . I:
Families of Schizophrenics. London: Tavistock Publications.
Lambo, T . A . (1955). The role of cultural factors i n paranoid psychoses
among the Yoruba tribe. Journal of Mental Science, 101: 239-266.
Langfeldt, G . (1939). The Schizophreniform States. Copenhagen: M u n k s ­
gaard.
Langfeldt, G . (1953). Some points regarding the symptomatology and
diagnosis of schizophrenia. Acta Psychiatrica et Neurologica Scandin­
avica, 28 (Suppl. 80): 7-26.
Langsley D . G . , Machotka, P., & Flomenhaft, K. (1971). A v o i d i n g mental
 REFERENCES A N D B I B L I O G R A P H Y 277

hospital admission: a follow-up study. American Journal of Psychiatry,

127:1391-1394.
Langsley, D . G . , Pittman, F. S., & Swank, G . E . (1969). Family crises i n
schizophrenics and other patients. Journal of Nervous and Mental Dis­
eases, 149: 270-276.
Larmo, A . (1992). The Parent's Psychosis, Impact on Family and Children.
Annates Universitatis Turkuensis, Ser. D, V o l . 84 (Turku, Finland).
Larsen, T . K . (1994). " E a r l y detection of first-episode schizophrenia."
Paper read at the Eleventh International Symposium for the Psycho­
therapy of Schizophrenia, Washington, D C .
Lazell, E . (1921). T h e group treatment of dementia praecox. Psychoana­
lytical Review, 8:168-179.
Leff, J. (1994). W o r k i n g with the families of schizophrenic patients. Brit­
ish Journal of Psychiatry, 164 (Suppl. 23): 71-76.
Leff, J., Kuipers, L . , Berkowitz, R., et al. (1982). A controlled trial of social
intervention i n the families of schizophrenic patients. British Journal
of Psychiatry, 141: 121-134.
Leff, J . , Kuipers, L . , Berkowitz, R., et al. (1983). Life events, relatives'
expressed emotions a n d maintenance neuroleptics i n schizophrenic
relapse. Psychological Medicine, 13: 799-807.
Leff, J., Kuipers, L . , Berkowitz, R., & Sturgeon, D . (1985). A controlled
trial of social intervention i n the families of schizophrenic patients:
two-year follow-up. British Journal of Psychiatry, 146: 594-600.
Lehtinen, K . (1993a). Need-adapted treatment of schizophrenia: a five­
year follow-up study from the T u r k u project. Acta Psychiatrica Scan­
dinavica, 87: 96-101,
Lehtinen, K. (1993b). Family Therapy and Schizophrenia in Public Mental
Health. Annates Universitatis Turkuensis, Ser. D, V o l . 106 (Turku, F i n ­
land).
Lehtinen, K. (1994). Need-adapted treatment of schizophrenia: family
interventions. British Journal of Psychiatry, 164 (Suppl. 23): 89-96.
Lehtinen, K . , & Rakkolainen, V . (1986). System-analytic treatment of
acute psychosis [in Finnish]. In: V . - P . Avento (Ed.), Suomen Psyki­
atriyhdistyksen syksyn koulutuspaivien luentojulkaisu. Skitso­
frenian hoidon kehittaminen. Psychiatria Fennica. Reports, N o . 71: 79­
91. Helsinki: Foundation for Psychiatric Research i n Finland.
Lehtinen, V . , Aaltonen, J., Koffert, T . , et al. (1996). Integrated treatment
model for first-contact patients with schizophrenia-type psychosis.
The Finnish API-project. Nordic Journal of Psychiatry, 50: 281-287.
278 REFERENCES A N D B I B L I O G R A P H Y

Lehtinen, V . , & Joukamaa, M . (1987). Mental disorders i n the sample

representative of the whole Finnish adult population, In: B. Cooper
(Ed.), Psychiatric Epidemiology: Progress and Prospects (pp. 4J-54). L o n ­
don: C r o o n H e l m .
Levander, S., & Cullberg, J. (1994). Psychotherapy i n retrospect. A c ­
counts of experiences i n psychotherapy obtained from five former
schizophrenic patients. Nordic Journal of Psychiatry, 48: 263-269.
Levene, J. E . , N e w m a n , F., & Jefferies, J. J. (1989). Focal family therapy
outcome study. I. Patient and family functioning. Canadian Journal of
Psychiatry, 14: 641-647.
Lewis, S. (1990). Computerised tomography i n schizophrenia 15 years
on. British Journal of Psychiatry, 157: 16-24.
L i d z , R. W . (1993). The effect of neurotropic drugs on the psychotherapy
of schizophrenic patients. In: G . Benedetti & P. M . Furlan (Eds.), The
Psychotherapy of Schizophrenia (pp. 311-317). Toronto, Ontario:
Hogrefe & Huber.
L i d z , R. W . , & L i d z , T. (1949). The family environment of schizophrenic
patients. American Journal of Psychiatry, 106: 332-345.
L i d z , T. (1964). The Family and Human Adaptation. London: Hogarth Press
and the Institute of Psycho-Analysis.
L i d z , T. (1992). The Relevance of the Family to Psychoanalytic Theory. M a d i ­
son, C T : International Universities Press.
L i d z , T . , & Blatt, S. (1983). Critic of the Danish-American studies of the
biological a n d adoptive relatives of adoptees w h o became schizo­
phrenic. American Journal of Psychiatry, 140: 426-434.
L i d z , T . , Cornelison, A . R., Fleck, S., & Terry, D . (1957a). The intra­
familial environment of the schizophrenic patient: I. The fathers.
Psychiatry, 20: 329-342.
L i d z , T . , Cornelison, A . R., Fleck, S., & Terry, D . (1957b). The intra­
familial environment of schizophrenic patients: II. Marital schism
and marital skew. American Journal of Psychiatry, 114: 241-248.
L i d z , T., Cornelison, A . R., Fleck, S., & Terry, D . (1958). Intrafamilial
environment of the schizophrenic patient: VI. The transmission of
irrationality. A.M.A. Archives of Neurology and Psychiatry, 79: 305­
316.
L i d z , T., Fleck, S., & Cornelison, A . R. (1965). Schizophrenia and the Family.
N e w York: International Universities Press.
L i d z , T . , &c L i d z , R. W . (1982). The curative factors i n psychotherapy of
schizophrenic disorders. In: S. Slipp (Ed.), Curative Factors in Dynamic
Psychiatry. N e w York: M c G r a w - H i l l .
 REFERENCES A N D B I B L I O G R A P H Y 279

Lieberman, J. A . (1993). Understanding the mechanism of action of

atypical antipsychotic drugs. A review of compounds i n use and
development. British Journal of Psychiatry, 163 (Suppl. 22): 7-18.
L i n , K . - M . , & Kleinman, A . M . (1988). Psychopathology and clinical
course of schizophrenia: a cross-cultural perspective. Schizophrenia
Bulletin, 14: 555-574.
Lindberg, D . (1981). Management of Schizophrenia. Acta Psychiatrica Scan­
dinavica (Suppl. 283).
Linszen, D . H . , Dingemans, P. M . , & Lenior, M . E . (1994). Cannabis abuse
and the course of recent-onset schizophrenic disorders. Acta Psychi­
atrica Scandinavica, 51: 273-279.
L o n d o n , N . J. (1973). A n essay on psychoanalytic theory: two theories of
schizophrenia. Parts I and II. International Journal of Psycho-Analysis,
54: 169-193.
MacFarlane, J. (1975). Olfaction in the development of social references
in the human neonate. In: M . Hofer (Ed.), Parent-Infant Interaction.
Amsterdam: Elsevier. [Cited in Stern, 1985.]
Mahler, M . S. (1968). On Human Symbiosis and the Vicissitudes of Individu­
ation. V o l . 1: Infantile Psychosis. N e w York: International Universities
Press.
Mahler, M . S., Pine, F., & Bergman, A . (1975). The Psychological Birth of the
Infant. N e w York: Basic Books.
M a i n , T. F. (1946). The hospital as a therapeutic institution. Bulletin of the
Menninger Clinic, 10: 66.
Malkiewicz-Borkowska, M . , & Namyslowska, I. (1991). Results of family
therapy of hospitalized adolescents. Abstracts: Third World Family
Therapy Congress, 2-6 June, Jyvaskyla, Finland (p. 234). Jyvaskyla:
University of Jyvaskyla.
M a l m , U . (1982), The Influence of Group Therapy on Schizophrenia. Acta
Psychiatrica Scandinavica (Suppl. 297),
Malmivaara, K., Keinanen, E . , & Saarelma, M . (1975). Factors affecting
child psychiatric hospital care and its immediate results. Psychiatria
Fennica. Yearbook: 225-238. Helsinki: The Foundation for Psychiatric
Research i n Finland.
Malson, L . (1972). Wolf Children and the Problem of Human Nature. N e w
York: Monthly Review Press. [Includes two papers by J. Itard, on the
" w i l d boy of A v e y r o n " , 1799 and 1806.]
Marder, R. S., V a n Putten, T., Mintz, J,, et al. (1987). L o w - and conven­
tional-dose maintenance therapy with fluphenazine decanoate. T w o ­
year outcome. Archives of General Psychiatry, 44: 518-521.
280 REFERENCES A N D B I B L I O G R A P H Y

Marsh, L . C (1933). Experiments i n group treatment of patients at

Worcester State Hospital. Mental Hygiene, 17: 396-416.
Martinot, J.-L., Peron-Magnan, P., Huret, D . - C , et al. (1990). Striatal D2
dopaminergic receptors assessed with positron emission tomo­
graphy and (76Br) Bromospiperone i n untreated schizophrenic p a ­
tients. American Journal of Psychiatry, 147: 44-50.
Matte Blanco, I. (1988). Thinking, Feeling and Being. London: Routledge.
M a n i l a , V . (1984). Onset of Functional Psychoses in Later Middle Age: A
Social Psychiatric, Psychodynamic and Family-Dynamic Study. Annales
Universitatis Turkuensis, Ser. D, V o l . 16 (Turku, Finland).
M a y , P. R. A . (1968). Treatment of Schizophrenia. A Comparative Study of
Five Treatment Methods. N e w York: Science House.
M a y , P. R. A . , T u m a , A . H . , & Dixon, W . J. (1981). Schizophrenia: a
follow-up study of the results of the five forms of treatment. Archives
of General Psychiatry, 38: 776-784.
M a y , P. R. A . , T u m a , A . H . , Yale, G , et al. (1976). Schizophrenia: follow­
u p study of results of treatment. Archives of General Psychiatry, 33:
474-486.
M c G h i e , A . (1961). A comparative study of mother-child relationship in
schizophrenia. British Journal of Medical Psychology, 34: 195-221.
McGlashan, T. H . (1984). The Chestnut Lodge follow-up study. I. Follow­
up methodology and study sample. II. Long-term outcome of schizo­
phrenia and the affective disorders. Archives of General Psychiatry, 41:
573-601.
M c G o r r y , P. D . , McFarlane, G , Patton, G . G , et al. (1995). The prevalence
of prodromal features in adolescence: a preliminary survey. Acta
Psychiatrica Scandinavica, 92: 241-249.
M c N e i l , T. F . , Cantor-Graae, E . , Torrey, E . F . , et al. (1994). Obstetric
complications in histories of monozygotic twins discordant and con­
cordant for schizophrenia. Acta Psychiatrica Scandinavica, 89:196-204.
Mednick, S. A . , Machon, R., Huttunen, M . O , & Bonett, D . (1988). A d u l t
schizophrenia following prenatal infection to an influenza epidemic.
Archives of General Psychiatry, 45:189-192.
Mednick, S. A . , Parnas, J„ & Schulsinger, F. (1987). The Copenhagen
high-risk project. Schizophrenia Bulletin, 13: 485-495.
Mednick, S., & Schulsinger, F. (1968). Some pre-morbic characteristics
related to breakdown in children with schizophrenic mothers. In: D .
Rosenthal & S. S. Kety (Eds.), The Transmission of Schizophrenia (pp.
267-291). N e w York: Pergamon Press.
Meyer, A . (1906). Fundamental conceptions of dementia praecox. British
 REFERENCES A N D BIBLIOGRAPHY 281

Medical Journal 2: 755-759. [Also in: E . E . Winters (Ed.), The Collected

Papers of Adolph Meyer. Baltimore, M D : The Johns H o p k i n s Univer­
sity Press, 1950-1952.]
Meyer, A . (1910). The dynamic interpretation of dementia praecox,
American Journal of Psychology, 21: 385. [Also i n : E . E . Winters (Ed.),
The Collected Papers of Adolph Meyer. Baltimore, M D : The Johns
Hopkins University Press, 1950-1952.]
Miles, C . (1977). Conditions predisposing to suicide: a review. Journal of
Nervous and Mental Diseases, 164: 231-246.
Mishler, E . G . , & Waxier, N . (1968). Family interaction and schizophre­
nia. Alternative frameworks of interpretation. Journal of Psychiatric
Research, 6: 213-222.
Moises, H . W . , Yang, L . , Kristbjarnarson, H . , et al. (1995). A n interna­
tional two-stage genome-wide search for schizophrenia susceptibil­
ity genes. Nature Genetics, 11: 321-324.
Mosher, L . R., & Keith, S. J. (1979). Research o n the psychosocial treat­
ment of schizophrenia: a summary report. American Journal of Psy­
chiatry, 136: 623-631.
Mosher, L . R., & M e n n , A . Z . (1978). Community residential treatment
for schizophrenia: two-year follow-up data. Hospital & Community
Psychiatry, 29: 715-723.
Mosher, L . R., & M e n n , A . Z . (1983). Scientific evidence a n d system
change: the Soteria experience. In: H . Stierlin, L . C . Wynne, & M .
Wirsching (Eds.), Psychosocial Intervention in Schizophrenia (pp. 9 3 ­
108). Berlin & Heidelberg: Springer-Verlag.
Muijen, M . , Marks, I. M . , Connolly, J . , et al. (1992). The daily living
programme. Preliminary comparison of community versus hospital­
based treatment for the seriously mentally ill facing emergency a d ­
mission. British Journal of Psychiatry, 160: 379-384.
Muller, C . (1961). Die Psychotherapie Schizophrener an der Zurcher
Klinik. Versuch einer vorlaufigen katamnestischen Ubersicht. Nerv­
enarzt, 32: 354-368.
Munk-Jorgensen, P., & Mortensen, P. B. (1992). Incidence a n d other
aspects of the epidemiology of schizophrenia in Denmark 1971-87.
British Journal of Psychiatry, 161: 489-495.
M u r p h y , H . B. (1973). Current trends i n transcultural psychiatry. Pro­
ceedings of the Royal Society of Medicine, 66: 711-716.
M y e r s , J. K., Weissman, M . M . , Tischler, G . L . , et al. (1984). Six-month
prevalence of psychiatric disorders i n three communities. Archives of
General Psychiatry, 41: 959-967.
282 REFERENCES A N D BIBLIOGRAPHY

Nasrallah, H . A . , McCalley-Whitters, M . , & Jacoby, C G . (1982). Cortical

atrophy in schizophrenia and mania: a comparative C T shady. Jour­
nal of Clinical Psychiatry, 43: 439-442.
Nasrallah, H . A . , Olson, S. C , McCalley-Whitters, M . , et al. (1986). Cere­
bral ventricular enlargement in schizophrenia: a preliminary follow­
u p study. Archives of General Psychiatry, 43:157-159.
National Pension Institute (1989). Yearbook. Helsinki: National Pension
Institute.
Niederland, W . G . (1984). The Schreber Case (expanded edition).
Hillsdale, N J : The Analytic Press.
Nyback, R , Wiesel, F . - A , Berggren, B . - M , & Hindmarsh, T. (1982). C o m ­
puted tomography of the brain i n patients with acute psychosis and
in healthy volunteers. Acta Psychiatrica Scandinavica, 65: 403-414.
O'Brien, C . B„ H a m m , K. B., Ray, B. A . , et al. (1972). G r o u p vs. individual
psychotherapy with schizophrenics: a controlled outcome study.
Archives of General Psychiatry, 27: 474-478.
O'Callaghan, E . , Gibson, T., Colohan, H . A . , et al. (1991). Season of birth
i n schizophrenia: evidence for confinement of an excess of winter
births to patients without a family history of mental disorder. British
Journal of Psychiatry, 158: 764-769.
O g d e n , T. H . (1979). O n projective identification. International Journal of
Psycho-Analysis, 60:357-373.
Ojanen, M . (1984). The Sopimusvuori Society: an integrated system of
rehabilitation. International Journal of Therapeutic Communities, 5:
193-207.
Olson, D . H . , Sprenkle, D . R , & Russell, C . S. (1979). Circumplex model
of marital and family systems: I. Cohesion and adaptability dimen­
sions, family types, and clinical applications. Family Process, 18:3-28.
Onstad, S., Skre, I., Torgersen, S., & Kringlen, E . (1991). T w i n concord­
ance for D S M - I I I R schizophrenia. Acta Psychiatrica Scandinavica, 83:
395-440.
Onstad, S., Skre, I., Torgersen, S., & Kringlen, E . (1994). Family interac­
tion: parental representation i n schizophrenic patients. Acta Psychi­
atrica Scandinavica, 90 (Suppl. 384): 67-70.
Orma, E. (1978). Unpublished presentation delivered at the meeting of the
Turku Psychotherapy Society, Turku.
Pao, P . - N . (1979). Schizophrenic Disorders. Theory and Treatment from a
Psychodynamic Point of View. N e w York: International Universities
Press.
 REFERENCES A N D B I B L I O G R A P H Y 283

Parland, O. (1991). Tieto ja elaytyminen. Esseitaja muistelmia [Knowledge

and Empathy. Essays and Memoirs; in Finnish], Juva: W S O Y .
Parloff, M . B., & Dies, R. R. (1977). Group psychotherapy outcome re­
search 1965-1975. International Journal of Group Psychotherapy, 27;
281-319.
Psychosocial Treatment of Chronic Mental
Paul, G . L . , & Lentz, R. J. (1977).
Patients: Milieu vs. Social-learning Programs. Cambridge M A : H a r v a r d
University Press.
Penis, C. (1992). Some aspects of the use of cognitive psychotherapy with
patients suffering from a schizophrenic disorder. In: A . Werbart & J.
Cullberg (Eds.), Psychotherapy of Schizophrenia. Facilitating and Ob­
structive Factors (pp. 131-144). Oslo: Scandinavian University Press.
Pietruszewski, K. (1991). Psychotic versus non-psychotic family d y n a m ­
ics during adolescents' in-patient treatment. In: Abstracts: Third World
Family Therapy Congress, 2-6 June, Jyvaskyla, Finland (p. 314). Jyvas­
kyla: University of Jyvaskyla.
Pines, M . (1992). " T h e world according to K o h u t . " Lecture delivered at
the meeting of the Finnish Psychoanalytical Society, Helsinki.
Pollin, W . , A l l e n , M . G . , Hoffer, A . , et al. (1969). Psychopathology in
15,909 pairs of veteran twins: evidence for a genetic factor i n the
pathogenesis of schizophrenia and its relative absence in psycho­
neurosis. American Journal of Psychiatry, 126: 597-610.
Portin, P., & Alanen, Y. O. (1997). A critical review of genetical studies of
schizophrenia. I. Epidemiological and brain studies. II. Molecular
genetic studies. Acta Psychiatrica Scandinavica, 95: 1-5, 73-80.
Pylkkanen, K. (1994). The Finnish National Schizophrenia Project
1982-1992: is a balanced and controlled demstirutionalisation pro­
cess possible? Psychiatria Fennica. Yearbook: 169-183. Helsinki: F o u n ­
dation for Psychiatric Research i n Finland.
Pylkkanen, K., & Eskola, J. (1984). Kokemuksia mielisairaanhoidon
uudistuksesta Italiassa [Experiences from the innovation of psychiat­
Suomen Ladkarilehti, 39: 1520-1522,
ric care in Italy; in Finnish].
Rakkolainen, V . (1977). Onset of Psychosis: A Clinical Study of 68 Cases.
Annales Universitatis Turkuensis, Ser. D, Vol. 7 (Turku, Finland).
Rakkolainen, V . , & Alanen, Y . O . (1982). O n the transactionality of defen­
sive processes. International Review of Psycho-Analysis, 9: 263-272.
Rakkolainen, V . , Lehtinen, K., & Alanen, Y . O. (1991). Need-adapted
treatment of schizophrenic processes: the essential role of family­
centred therapy meetings. Contemporary Family Therapy, 13: 573-582.
284 REFERENCES A N D B I B L I O G R A P H Y

Rakkolainen, V . , Salokangas, R., & Lehtinen, P. (1979), Protective con­

structions i n the course of psychosis. In: C Muller (Ed.), Psycho­
therapy of Schizophrenia (pp. 233-243). Amsterdam: Excerpta Medica.
Rakkolainen, V . , Vuorio, K . A . , Syvalahti, E . , et al. (1994). "Observations
of comprehensive psychotherapeutic treatment of new schizo­
phrenic patients without neuroleptic drugs i n Kupittaa hospital i n
1989-92." Paper read at the Eleventh International Symposium for
Psychotherapy of Schizophrenia, Washington, D C .
Raman, A . C , & M u r p h y , H . B. (1972). Failure of traditional prognostic
indications in A f r o - A s i a n psychotics: results of a long-term follow­
up survey. Journal of Nervous and Mental Diseases, 154: 238-247.
Rang, B. (1987). Wolfskinderen en de ontwikkeling van de mensweten­
schappen [When the social environment of a child approaches zero;
in Dutch]. Comenius, 27: 316-342.
Rapaport, M . , Hopkins, H . K., H a l l , K., et al. (1978). A r e there schizo­
phrenics for w h o m drugs may be unnecessary or contraindicated?
International Journal of Pharmacopsychiatry, 13:100-111,
Rechardt, E . (1971). Skitsofreniapotilaan kieli [The language of the
schizophrenic patient; in Finnish]. Duodecim, 87: 1591-1599.
Reiss, D . (1971). Varieties of consensual experience. III. Contrast between
families of normals, delinquents, and schizophrenics. Journal of Nerv­
ous and Mental Diseases, 152: 73-96.
Retzer, A . , Simon, F. B., Weber, G . , et al. (1991). A follow-up study of
manic-depressive and schizo-affective psychoses after systemic
family therapy. Family Process, 30:139-153.
Reveley, A . M . , Reveley, M . A . , Clifford, C . A . , & M u r r a y , R. M . (1982).
Cerebral ventricular size in twins discordant for schizophrenia. Lan­
cet, 1: 540-541.
Reveley, A . M . , Reveley, M . A . , & Murray, R. M . (1984). Cerebral ven­
tricular enlargement in non-genetic schizophrenia: a controlled twin
study. British Journal of Psychiatry, 144: 89-93.
Rice, D . P., Kelman, S., Miller, L. S., & Dunmeyer, S. (1990). The Economic
Costs of Alcohol and Drug Abuse and Mental Illness: 1985. Rockville
M D : National Institutes of Mental Health, D H H S Pub. N o ( A D M ) ,
90-1694.
Rieder, R. O . , M a n n , L . S., Weinberger, D . R., et al, (1983). C o m p u t e d
tomographic scans i n patients with schizophrenic, schizo-affective
and bipolar affective disorder. Archives of General Psychiatry, 40:
735-739.
 REFERENCES A N D B I B L I O G R A P H Y 285

Riskin, J. R., & Faunce, E . E . (1972). A n evaluative review of family

interaction research. Family Process, 11: 365-455.
Robbins, M . (1993). Experiences of Schizophrenia: An Integration of the Per­
sonal, Scientific, and Therapeutic. N e w York: Guilford Press.
Roberts, G . W . (1990). Schizophrenia: the cellular biology of a functional
psychosis. Trends of Neuroscience, 13: 207-211.
Robins, J. N . , Helzer, J. F., Weissman, M . M . , et al. (1984). Lifetime preva­
lence of specific psychiatric disorders in three sites. Archives of Gen­
eral Psychiatry, 41: 949-958.
Rosenfeld, H . A . (1987). Impasse and Interpretation. London: Tavistock.
Rosenthal, D . (1970). Genetic Theory and Abnormal Behaviour. N e w York:
McGraw-Hill.
Rosenthal, D . , Wender, P. H . , Kety, S. S., et al. (1968). Schizophrenic's
offspring reared i n adoptive homes. In D . Rosenthal & S. S. Kety
(Eds.), The Transmission of Schizophrenia (pp. 377-391). N e w York:
Pergamon Press.
Rosenthal, D „ Wender, P. H . , Kety, S. S., et al. (1971). The adopted-away
offspring of schizophrenics. American Journal of Psychiatry, 128:
307-311.
Rothstein, A . (1980). Towards a critique of the psychology of the self.
Psychoanalytic Quarterly, 49: 423-455.
R u n d , B. R. (1986). Communication deviances i n parents of schizophren­
ics. Family Process, 25:133-147.
Salokangas, R. K. R. (1977). The Psychosocial Prognosis of Schizophrenia [in
Finnish, with English summary]. Publications of the National Pen­
sion Institute, Series A L : 7. T u r k u , Finland: National Pension Insti­
tute.
Salokangas, R. K . R. (1983). Prognostic implication of the sex of schizo­
phrenic patients. British Journal of Psychiatry, 142: 145-151.
Salokangas, R. K . R. (1986). Psychosocial outcome i n schizophrenia and
psychotherapeutic orientation. Acta Psychiatrica Scandinavica, 74:
497-506.
Salokangas, R. K . R., Rakkolainen, V . , & Alanen, Y . O . (1989). Mainte­
nance of grip on life and goals of life: a valuable criterion for evalu­
ating outcome i n schizophrenia. Acta Psychiatrica Scandinavica, 80:
187-193.
Salokangas R. K. R., Stengard, E . , Rakkolainen, V . , et al. (1987). Uudet
skitsofreniapotilaat ja heidan perheensa. USP-projekti III [New
schizophrenic patients and their families: NSP-Project III; i n Finnish,
286 REFERENCES A N D B I B L I O G R A P H Y

with English summary], Psychiatria Fennica. Reports, N o . 78. Helsinki:

The Foundation for Psychiatric Research i n Finland.
Salokangas, R. K. R., Stengard, E . , Rakkolainen et al., V . (1991). Uusien
skitsofreniapotilaiden hoito ja ennuste. Viiden vuoden seuranta.
USP-projekti V [Treatment and prognosis of new schizophrenic p a ­
tients: a five-year follow-up. NSP-Project V ; i n Finnish, with English
summary]. Psychiatria Fennica. Reports, N o . 95. Helsinki: The Founda­
tion for Psychiatric Research in Finland.
Salonen, S. (1975). The hospital w a r d from the standpoint of the patient's
self-esteem. Psychiatria Fennica. Yearbook: 325-331. Helsinki: The Foun­
dation for Psychiatric Research in Finland. [Reprinted in: S. Salonen,
Psychotherapeutic Studies in Schizophrenia. Annates Universitatis Turku­
ensis, Ser. D, V o l . 12 (Turku, Finland).
Salonen, S. (1979). O n the metapsychology of schizophrenia. International
Journal of Psycho-Analysis, 60: 73-81, [Reprinted in: S. Salonen, Psy­
chotherapeutic Studies in Schizophrenia. Annales Universitatis Turkuen­
sis, Ser. D, V o l . 12 (Turku, Finland).
Sandin, B. (1992). Schizophrenic strategies for survival. In: A , Werbart, &
J. Cullberg (Eds.), Psychotherapy of Schizophrenia: Facilitating and Ob­
structive Factors (pp. 50-57). Oslo: Scandinavian University Press.
Schubart, C , K r u m m , B., Biehl, H . , & Schwarz, R. (1986). Measurement
of social disability i n a schizophrenic patients group: definition,
assessment, and outcome over 2 years in a cohort of schizophrenic
patients of recent onset. Social Psychiatry, 21:1-19.
Schulz, C G . (1975). A n individualized psychotherapeutic approach
with the schizophrenic patient. Schizophrenia Bulletin (Issue 13):
44-69.
Schulz, C. G . , & Kilgalen, R. K. (1969). Case Studies in Schizophrenia. N e w
York: Basic Books.
Schwarz, F. (1982). G r o u p analysis with schizophrenics. In: M . Pines & L .
Rafaelsen (Eds.), The Individual and the Group, V o l . 2 (pp. 239-249).
N e w York: Plenum Publications.
Scott, R. D . , & A l w y n , S. (1978). Patient-parent relationships and the
course and outcome of schizophrenia. British Journal of Medical Psy­
chology, 51: 343-355.
Scott, R. D., & Ashworth, P. L . (1967). " C l o s u r e " at the first schizophrenic
breakdown: a family study. British Journal of Medical Psychology, 40:
109-145.
Scott, R. D . , & Ashworth, P. L . (1969). The shadow of the ancestor: a
 REFERENCES A N D B I B L I O G R A P H Y 287

historical factor i n the transmission of schizophrenia. British Journal

of Medical Psychology, 42:13-31.
Scottish Schizophrenia Research Group (1987). The Scottish first episode
schizophrenia study. I. Patient identification and categorization. II.
Treatment: Pimozide versus flupenthixol. British Journal of Psychiatry,
150: 331-338.
Scottish Schizophrenia Research Group (1992). The Scottish first episode
schizophrenia study. VIII. Five-year follow-up: clinical and psycho­
social findings. British Journal of Psychiatry, 161: 496-500.
Searles, H . F. (1955). Dependency processes in the psychotherapy
of schizophrenia. Journal of American Psychoanalytic Association, 3:19­
66. [Also in: Collected Papers on Schizophrenia and Related Subjects (pp.
114-156). Madison, C T : International Universities Press, 1965; re­
printed London: Karnac Books, 1986.]
Searles, H . F. (1958). Positive feelings in the relationship between the
schizophrenic and his mother. International Journal of Psycho-Analysis,
39: 569-586. [Also in: Collected Papers on Schizophrenia and Related
Subjects (pp. 216-253). Madison, C T : International Universities Press,
1965; reprinted London: Karnac Books, 1986.]
Searles, H . F. (1961). Phases of patient-therapist interaction i n the psy­
chotherapy of chronic schizophrenia. British Journal of Medical Psy­
chology, 34: 169-193. [Also in: Collected Papers on Schizophrenia and
Related Subjects (pp. 521-559). Madison, C T : International Universi­
ties Press, 1965; reprinted London: Karnac Books, 1986.]
Searles H . F. (1965). Collected Papers on Schizophrenia and Related Subjects.
Madison, C T : International Universities Press [reprinted London:
Karnac Books, 1986].
Sechehaye, M . - A . (1955). Die symbolische Wunscherfullung [Symbolic re­
alization]. Darstellung einer neuen psychotherapeutischen Methode und
Tagebuch der Kranken. Bern: Hans Huber.
Sedvall, G . , & Farde, L . (1995). Chemical brain anatomy i n schizophre­
nia. Lancet, 346: 743-749.
Sedvall, G . C , & Wode-Helgodt, B. (1980). Aberrant monoamine metab­
olite levels i n C S F and family history of schizophrenia. Archives of
General Psychiatry, 37:1113-1116.
Seeman, P. (1993). Schizophrenia as a brain disease. The dopamine
receptor story. Archives of Neurology, 50: 1093-1095.
Seeman, P., G u a n , H . - C , & V a n T o l , H . H . M . (1993). Dopamine D 4
receptors elevated i n schizophrenia. Nature, 365: 441-445.
288 REFERENCES A N D B I B L I O G R A P H Y

Segal, H . (1973). Introduction to the Work of Melanie Klein. London: The

Hogarth Press, and the Institute of Psychoanalysis [reprinted L o n ­
don: Karnac Books, 1988].
Seikkula, J. (1991). The Family-Hospital Boundary System in the Social Net­
work [in Finnish, with English summary]. Jyvaskyla Studies in Educa­
tion, Psychology and Social Research, 80. Jyvaskyla, Finland.
Selvini Palazzoli, M , Boscolo, L . , Cecchin, G . , & Prata, G . (1978). Paradox
and Counterparadox. A New Model in the Therapy of Schizophrenic Trans­
action. N e w York: Jason Aronson.
Selvini Palazzoli, M . , Boscolo, L . , Cecchin, G . , & Prata, G . (1980).
Hypothesizing-circularity-neutrality: three guidelines for the con­
ductor of the session. Family Process, 19: 3-12.
Sesemann, V . (1927). Beitrage zur Erkenntnisproblem: iiber gegenstandliches
und ungegenstandliches Wissen. Kaunas: Lietuvos Universito H u m a n i ­
tarniu M o k s l u Fakulteto.
Shakow, D . (1962). Segmental set: a theory of the formal psychological
deficit i n schizophrenia. Archives of General Psychiatry, 6: 1-17.
Sham, P. C , O'Callaghan, E„ Takei, N . , et al. (1992). Schizophrenia fol­
lowing pre-natal exposure to influenza epidemic between 1939 and
1960. British Journal of Psychiatry, 160: 461-466.
Shepherd, M . , Watt, D . , Falloon, I., & Smeeton, N . (1989). The natural
history of schizophrenia: a five-year follow-up study of outcome and
prediction i n a representative sample of schizophrenics. Psychological
Medicine Monographs (Suppl. 15). Cambridge, U . K . : Cambridge U n i ­
versity Press.
Siirala, M . (1986). Unpublished presentation delivered at Kupittaa H o s ­
pital, T u r k u .
Simon, W . , & Wirt, R. D . (1961). Prognostic factors i n schizophrenia.
American Journal of Psychiatry, 117: 887-390.
Singer, M . T., & Wynne, L. C. (1963). Differentiation characteristics of the
parents of childhood schizophrenics, childhood neurotics, and young
adult schizophrenics. American Journal of Psychiatry, 120: 234r-243.
Singer, M . T . , & Wynne, L , C . (1965). Thought disorders and family
relations of schizophrenics. III-IV. Archives of General Psychiatry, 12:
187-212.
Singer, M . T . , Wynne, L . C , & Toohey, M . L . (1978). Communication
disorders and the families of schizophrenics. In: L . C . Wynne, R. L .
Cromwell, & S. Matthysse (Eds.), The Nature of Schizophrenia: New
Approaches to Research and Treatment (pp. 499-511). N e w York: John
Wiley & Sons.
 REFERENCES A N D BIBLIOGRAPHY 289

Sjostrom, R. (1985). Effects of psychotherapy in schizophrenia. Acta Psy­

chiatrica Scandinavica, 71:513-522.
Sjostrom, R. (1990). Psykoterapi v i d schizofreni—en prospektiv studie
[in Swedish]. Svenska Lakartidningen, 87: 3279-3282.
Slater, E . (1953). Psychotic and Neurotic Illnesses in Twins. Medical Re­
search Council, Special Report Series N o . 278. London: Her Majesty's
Stationery Office.
Sledge, W . H . , Tebes, J., Rakfeldt, J., et al. (1996). D a y hospital/crisis
respite care versus inpatient care. Part I. Clinical outcomes. Part II.
Service utilization and costs. American Journal of Psychiatry, 153:
1065-1083.
Snyder, S. H . (1981). Dopamine receptors, neuroleptics, and schizo­
phrenias. American Journal of Psychiatry, 138: 460-464.
Speijer, N . (1961). The Mentally Handicapped in the Sheltered Workshops.
The Hague: Ministry of Social Affairs and Public Health.
Spitzer, R. L . , Endicott, J., & Robins, E . (1975). Research Diagnostic Criteria.
N e w York: Biometric Research Division, N e w York State Psychiatric
Institute.
Stabenau, J. R., T u p i n , J., Werner, M . , & Pollin, W . (1965). A comparative
study of the families of schizophrenics, delinquents, and normals.
Psychiatry, 28: 45-59.
Stanton, A . H . , Gunderson, J. G . , Knapp, P. H . , et al. (1984). Effects of
psychotherapy in schizophrenia: I. Design and implementation of a
controlled study. Schizophrenia Bulletin, 10: 520-563.
Stanton, A . , & Schwarz, M . (1954). The Mental Hospital. N e w York: Basic
Books.
State Medical Board in Finland (1988). The Schizophrenia Project 1981-87.
Final Report of the National Programme of the Study, Treatment and
Rehabilitation of Schizophrenic Patients in Finland [in Finnish, with E n g ­
lish summary]. Series Handbooks N o 4. Helsinki: Valtion painatus­
keskus.
Stein, L . I. (1993). A system approach to reducing relapse i n schizophre­
nia. Journal of Clinical Psychiatry, 54 (Suppl. 3): 7-12.
Stein, L . L , & Test, M . A . (1980). Alternative to mental hospital treatment.
I. Conceptual model, treatment program, and clinical evaluation.
Archives of General Psychiatry, 37: 392-397.
Steinglass, P. (1987). Psychoeducational family therapy i n schizophrenia.
A review essay. Psychiatry, 50: 14r-23.
Stern, D . N . (1985). The Interpersonal World of the Infant. A View from
Psychoanalysis and Developmental Psychology. N e w York: Basic Books.
290 REFERENCES A N D BIBLIOGRAPHY

Stierlin, H . (1972). Family dynamics and separation patterns of potential

schizophrenics. In: D . Rubinstein & Y . O . Alanen (Eds.), Psycho­
therapy of Schizophrenia (pp. 169-179). Amsterdam: Excerpta Medica.
Stierlin, H . (1974). Separating Parents and Adolescents. A Perspective on
Running Away, Schizophrenia, and Waywardness. N e w York: Q u a d r a n ­
gle & The N e w York Times Book C o .
Stierlin, H . (1976). The dynamics of owning and disowning. Psychoana­
lytic and family perspectives. Family Process, 15: 277-288.
Stierlin, H . (1983). Reflections on the family therapy of schizo-present
families. In: H . Stierlin, L . C . Wynne, & M . W i r s d u n g (Eds.), Psycho­
social Intervention in Schizophrenia (pp. 191-198). Berlin & Heidelberg:
Springer-Verlag.
Stierlin, H . , Riicker-Embden, I., Wetzel, N . , & Wirsching, M . (1977). Das
erste Familiengesprach. Stuttgart: Ernst Klett.
Strauss, J. S., & Carpenter, W . T. (1972). The prediction of outcome of
schizophrenia: I. Characteristics of outcome. Archives of General Psy­
chiatry, 27: 739-746.
Strauss, J ,S., & Carpenter, W . T. (1974). The prediction of outcome in
schizophrenia, II. Relationships between predictor and outcome
variables. A report from the W H O International Pilot Study of
Schizophrenia. Archives of General Psychiatry, 31: 37-42.
Strauss, J. S., Rakfeldt, J., Harding, C . M . , & Lieberman, L . (1989). Psy­
chological and social aspects of negative symptoms. British Journal of
Psychiatry, 155 (Suppl. 7): 128-132.
Suddath, R. L . , Christison, G . W . , Goldberg, T. E . , et al. (1989). Temporal
lobe pathology i n schizophrenia. American Journal of Psychiatry, 146:
464-472.
Suddath, R. L . , Christison, C . W . , & Torrey, E . F. (1990). Anatomical
abnormalities i n the brains of monozygotic twins discordant for
schizophrenia. New England Journal of Medicine, 322: 789-794.
Sullivan, H . S. (1924). Schizophrenia: its conservative and malignant
features. American Journal of Psychiatry, 81: 77-91. [Also in: Schizo­
phrenia as a Human Process. N e w York: W . W . Norton, 1962.]
Sullivan, H . S. (1930). Socio-psychiatric research. Its implications for the
schizophrenia problem and for mental hygiene. American Journal of
Psychiatry, 87: 977-991. [Also in: Schizophrenia as a Human Process.
N e w York: W . W . Norton, 1962.]
Sullivan, H . S. (1931). The modified psychoanalytic treatment of schizo­
phrenia. American Journal of Psychiatry, 88: 519-540. [Also in: Schizo­
phrenia as a Human Process. N e w York: W . W . Norton, 1962.]
 REFERENCES A N D B I B L I O G R A P H Y 291

Sullivan, H . S. (1954). The Psychiatric Interview. N e w York: W . W . Norton.

Sullivan, H . S. (1956). Clinical Studies in Psychiatry. N e w York: W . W .
Norton.
Sullivan, H . S. (1962). Schizophrenia as a Human Process. N e w York: W . W .
Norton.
Syvalahti, E . K. G . (1994). Biological factors i n schizophrenia. Structural
and functional aspects. British Journal of Psychiatry, 164 (Suppl. 23):
9-14.
Szasz, T. (1961). The Myth of Mental Illness. N e w York: R a n d o m House.
Tahka, V . (1984). Psychoanalytic treatment as a developmental con­
tinuum: considerations of disturbed structuralization and its phase­
specific encounter. Scandinavian Psychoanalytic Review, 7:133-160.
Tahka, V . (1993). Mind and Its Treatment: Psychoanalytic Approach. N e w
York: International Universities Press.
Tarrier, N . , Barrowclough, C , Vaughn, C . , et al. (1989). C o m m u n i t y
management of schizophrenia: a two-year follow-up of behavioural
intervention with families. British Journal of Psychiatry, 154: 625-628.
Tienari, P. (1963). Psychiatric Illnesses in Identical Twins. Acta Psychiatrica
Scandinavica, 39 (Suppl. 171).
Tienari, P. (1975). Schizophrenia i n Finnish male twins. In: M . H . Lader
(Ed.), Studies of Schizophrenia. British Journal of Psychiatry Special Pub­
lication No 10 (pp. 29-35).
Tienari, P. (1992). Interaction between genetic vulnerability and rearing
environment. In: A . Werbart & J. Cullberg (Eds.), Psychotherapy of
Schizophrenia: Facilitating and Obstructive Factors (pp. 154-172). Oslo:
Scandinavian University Press.
Tienari, P., Sorri, A . , Lahti, I., et aL (1987). Genetic and psychosocial
factors in schizophrenia: the Finnish adoptive family study. Schizo­
phrenia Bulletin, 13: 477-484.
Tienari, P., Wynne, L . C , M o r i n g , J., et al. (1993). Genetic vulnerability or
family environment? Implications from the Finnish adoptive family
study of schizophrenia. Psychiatria Fennica. Yearbook: 23-41. Helsinki:
The Foundation for Psychiatric Research i n Finland.
Tienari, P., Wynne, L . C , M o r i n g , J., et al. (1994). The Finnish adoptive
family study of schizophrenia. Implications for family research. Brit­
ish Journal of Psychiatry, 164 (Suppl. 23): 20-26.
Torrey, E . F. (1983). Surviving Schizophrenia. A Family Manual. N e w York:
Harper & Row.
Torrey, E , F., M c G u i r e , M . , O'Hare, A . , et al. (1984). Endemic psychosis
in western Ireland. American Journal of Psychiatry, 141: 966-970.
292 REFERENCES A N D B I B L I O G R A P H Y

Torrey, E . R , Taylor, E . H . , Bracha, H . S., et a l (1994). Prenatal origin of

schizophrenia i n a subgroup of discordant monozygotic twins.
Schizophrenia Bulletin, 20: 423-432.
Tsuang, M . T . , Woolson, R. R , & Fleming, J. A . (1979). Long-term out­
come of major psychoses: I. Schizophrenia and affective disorders
compared with psychiatrically symptom-free surgical conditions.
Archives of General Psychiatry, 39:1295-1301.
Tuori, T. (1987). The Systemic Family Therapy of Married Schizophrenic
Patients [in Finnish, with English summary]. Annates Universitatus
Turkuensis, Ser. C, V o l . 62 (Turku, Finland).
Tuori, T . , Lehtinen, V . , Hakkarainen, A . , et al. (1997). T h e Finnish N a ­
tional Schizophrenia Project 1981-1987: 10-year evaluation of its
results. Acta Psychiatrica Scandinavica.
Ugelstad, E . (1978). Psykotiske langtidspasienter i psykiatriske sykehus—Nye
behandlingsforsok [in Norwegian]. Oslo: Universitetsforlaget.
Ugelstad, E . (1979). Possibilities of organizing psychotherapeutically ori­
ented treatment programs for schizophrenia within sectorized psy­
chiatric service. In: C Muller (Ed.), Psychotherapy of Schizophrenia (pp.
253-258). Amsterdam: Excerpta Medica.
Uttal, W . R. (1997). D o theoretical bridges exist between perceptual expe­
rience and neurophysiology? Perspectives in Biology and Medicine, 40:
280-301.
V a n Putten, T., Marshall, B. D . , Liberman, R., et al. (1993). Systematic
dosage reduction i n treatment-resistant schizophrenic patients. Psy­
chopharmacological Bulletin, 29:315-320.
V a n T o l , H . H . M . , Bunzow, J. R., G u a n , H . C., et al. (1991). Cloning of a
human dopamine D 4 receptor gene with high affinity for the anti­
psychotic clozapine. Nature, 350: 614-619.
V a r v i n , S. (1991). A retrospective follow-up investigation of a group of
schizophrenic patients treated in a psychotherapeutic unit: the Kast­
anjebakken study. Psychopathology, 24: 335-344.
Vaughn, C . E . , & Leff, J. P. (1976). The influence of family and social
factors o n the course of psychiatric illness. British Journal of Psychia­
try, 129:125-137.
V i n n i , K . (1987). The costs of schizophrenia to the society [in Finnish],
Skitsofrenian hoito, konsensuskokous, 26-28 October. Suomen Akat­
emian julkaisuja, 6.
Virtanen, H . (1991). Family- and Environment-centred Geropsychiatric Treat­
ment [in Finnish, with English summary]. Annates Universitatis Turku­
ensis, Ser. C, V o l . 85 (Turku, Finland).
 REFERENCES A N D B I B L I O G R A P H Y 293

V o l k a n , V . D . (1981). Transference and countertransference: an examina­

tion from the point of view of internalized object relations. In: S.
Tuthman, C . Kaye, & M . Zimmerman (Eds.), Object and Self: A Devel­
opmental Approach (pp. 429-451). N e w York: International Universi­
ties Press.
Volkan, V . D . (1987). Six Steps in the Treatment of Borderline Personality
Organization. Northvale, N J : Jason Aronson.
V o l k a n , V . D . (1990), The psychoanalytic psychotherapy of schizophre­
nia. In: L . B. Boyer & P. Giovacchini (Eds.), Master Clinicians on Treat­
ing the Regressed Patient (pp. 245-270). Northvale, N J : Jason Aronson.
V o l k a n , V . D . (1994). Identification with the therapist's functions a n d
ego-building i n the treatment of schizophrenia. British Journal of Psy­
chiatry, 164 (Suppl. 23): 77^82.
Volkan, V . D . (1995). The Infantile Psychotic Self and Its Fates. Understand­
ing and Treating Schizophrenics and Other Difficult Patients. Northvale,
N J : Jason Aronson.
V u o r i o , K. A . , Rakkolainen, V . , Syvalahti, E . , et al. (1993). Integrated
treatment of acute psychosis [in Finnish]. Suomen Ldakdrilehti, 48:
466-471, 582-588, 689-693.
Watt, D . G , Katz, K . , & Shepherd, M . (1983). The natural history of
schizophrenia: a 5-year prospective follow-up of a representative
sample of schizophrenics b y means of a standardized clinical and
social assessment. Psychological Medicine, 13: 663-670.
Waxier, N . E . (1979). Is outcome of schizophrenia better i n non-industrial
societies? The case of Sri Lanka. Journal of Nervous and Mental Dis­
eases, 167: 144-158.
Weinberger, D . R. (1987). Implications of normal brain development for
the pathogenesis of schizophrenia. Archives of General Psychiatry, 44:
660-669.
Weinberger, D . R. (1995). F r o m neuropathology to neurodevelopment.
Lancet, 346: 552-557.
Weinberger, D . R., Berman, K. F . , Suddath, R., & Torrey, E . F. (1992).
Evidence of dysfunction of a prefrontal-limbic network i n schizo­
phrenia: a magnetic resonance imaging and regional cerebral blood
flow study of discordant monozygotic twins. American Journal of Psy­
chiatry, 149: 890-897.
Weinberger, D . R., Torrey, E . F., Neophytides, S. N . , & Wyatt, R. J. (1979).
Lateral cerebral ventricular enlargement i n chronic schizophrenia.
Archives of General Psychiatry, 36: 735-739.
Weller, M . P. I. (1989). Mental illness—who cares? Nature, 339: 249-252.
294 REFERENCES A N D B I B L I O G R A P H Y

Wender, P. H . , Rosenthal D . , & Kety, S. S. (1968). A psychiatric assess­

ment of the adoptive parents of schizophrenics. In: D . Rosenthal & S.
S. Kety (Eds.), The Transmission of Schizophrenia (pp. 235-250). N e w
York: Pergamon Press.
Werner, H . (1948). Comparative Psychology ofMental Development. Chicago:
Follett.
Whitehorn, J. C , & Betz, B. (1960). Further studies of the doctor as the
crucial variable in the outcome of treatment with schizophrenic p a ­
tients. American Journal of Psychiatry, 117: 215-222.
Wiesel, F . - A . (1994). Neuroleptic treatment of patients with schizophre­
nia. Mechanisms of action and clinical significance. British Journal of
Psychiatry, 164 (Suppl. 23): 65-70.
W i l l , O . A . , Jr. (1961). Process, psychotherapy and schizophrenia. In: A .
Burton (Ed.), Psychotherapy of Psychoses (pp. 10-42). N e w York: Basic
Books.
Williams, J . , Spurlock, G . , McGuffin, P., et al. (1996). Association be­
tween schizophrenia a n d T 102C polymorphism of the 5-hydroxy­
rryptamine type 2a receptor gene. Lancet, 347:1294-1296.
Winefield, FL R., & Harvey, E . J. (1994). Needs of family caregivers i n
chronic schizophrenia. Schizophrenia Bulletin, 20: 557-566.
W i n g , J. K . (1960). A pilot experiment of long hospitalized male schizo­
phrenic patients. British Journal of Preventive and Social Medicine, 14:
173-180.
W i n g , J. K., & Fryers, T. (1976). Psychiatric Services in Camberwell and
Salford. London: M R C Social Psychiatry Unit.
Winnicott, D . W . (1960). The theory of the parent-infant relationship.
International Journal of Psycho-Analysis, 41: 585-595. [Also in: The
Maturational Processes and the Facilitating Environment (pp. 37-55).
London: Hogarth Press & The Institute of Psychoanalysis, 1965; re­
printed London: Karnac Books, 1990.]
Wolkowitz, O . M . , & Pickar, D . (1991). Benzodiazepines in the treatment
of schizophrenia: a review and reappraisal. American Journal of Psy­
chiatry, 148: 714-726.
W o n g , D . F., Wagner, H . M . , Tune, L . E . , et al. (1986). Positron emission
tomography reveals elevated D2 dopamine receptors i n drug-naive
schizophrenics. Science, 234: 1558-1563.
W o r l d Health Organization (1979). Schizophrenia—An International Fol­
low-up Study. Chichester: John Wiley.
Wynne, L . C . (1965). Some indications and contraindications for explora­
tory family therapy. In: I. Boszormenyi-Nagy &: J. L . Framo (Eds.),
 REFERENCES A N D B I B L I O G R A P H Y 295

Intensive Family Therapy: Theoretical and Practical Aspects (pp. 289­

322). N e w York: Hoeber Medical Division, Harper & Row.
W y n n e , L . C . (1978). Family relationships and communication. C o n c l u d ­
ing comments. In: L . C . Wynne, R. L . Cromwell, & S. Matthysse
(Eds.), The Nature of Schizophrenia. New Approaches to Research and
Treatment (pp. 534-542). N e w York: John Wiley & Sons.
W y n n e , L . C , McDaniel, S., & Weber, T. (1986). Systems Consultation: A
New Perspective for Family Therapy. N e w York: Guilford Press.
W y n n e , L . C , Ryckoff, I. M . , Day, J., & Hirsch, S. (1958). Pseudomutu­
ality in the family relations of schizophrenics. Psychiatry, 21: 205-220.
W y n n e , L . C , & Singer, M . T . (1963), Thought disorder and family rela­
tions i n schizophrenia. I—II. Archives of General Psychiatry, 9: 191-206.
W y n n e , L . C , Singer, M , T., Bartko, J. J., & Toohey, M . L . (1977). Schizo­
phrenics and their families: research o n parental communication. In:
J. M . Tanner (Ed.), Developments in Psychiatric Research (pp. 254-286).
London: H o d d e r & Stoughton.
Wynne, L . C , Singer, M . T., & Toohey, M . L . (1976). Communication of
the adoptive parents of schizophrenics. In: J. Jorstad & E . Ugelstad
(Eds.), Schizophrenia, 75. Psychotherapy, Family Studies, Research (pp.
413-451). Oslo: Universitetsforlaget.
Z u b i n , J., & Spring, B. J. (1977). Vulnerability—a new view of schizo­
phrenia. Journal of Abnormal Psychology, 86: 103-126.
 INDEX

A a k u , T., 147,193
A l v i r , J . M . J . , 116

A a l t o , I., 2 1 6
A l w y n , S., 7 1 , 7 7 , 8 6 , 1 2 6

A a l t o n e n , J . , 1 2 5 , 1 3 0 , 1 3 8 , 1 4 9 , 1 7 0 ,
A l z h e i m e r ' s disease, 48

253
A m e r i c a n Psychiatric Association,

A b r a h a m , K 59, 76, 78

v
30, 31, 3 2 , 1 6 2

Achte, K , A . , 38,142
A n d e r s o n , C . M , 128, 201

a c u t e p s y c h o s i s t e a m s , 1 7 6 , 1 8 9 , 243
A n d r S , G . , 138

i m p o r t a n c e a n d f u n c t i o n s of,
A n d r e a s e n , N . C , 29, 47, 49

244-246
annihilation anxiety, 97

a c u t e p s y c h o s i s w a r d c o m m u n i t i e s ,
A n t h o n y , E . J 79

195
Anttinen, E . E . , 132,133,136,185,

A d a m s s o n , C , 31
192, 249, 250

a d h e s i v e identification, 63
anxiety, c o n c r e t i z a t i o n of, 10

a d o l e s c e n c e , 25, 60, 70, 81, 83, 90,

A r i e t i , S., 2 6 , 2 7

96, 9 8 , 1 0 4 , 106, 208

A r l o w , J., 63

d e v e l o p m e n t a l c h a l l e n g e s of, 9 3
A r m e l i u s , B.-A, 3 1 , 1 2 5 , 1 6 7 , 1 6 9 ,

i m p o r t a n c e o f p e r i o d of, 9 3 - 9 5
242

a d o p t i v e c h i l d r e n , s t u d i e s of, 5 2 - 5 6 ,
a r t i s t s , s c h i z o p h r e n i c , 2 9

252
affective style ( A S ) , 72

a d u l t characteristics, a t t e n t i o n to
A s h w o r t h , P. L . , 7 1 , 7 7 , 1 2 6 , 1 7 6

a n d s u p p o r t for, 208
Australia, 240

affective e x t i n c t i o n , 28
a u t i s m , 83, 8 9 , 1 5 2 , 203

affective style ( A S ) , 72
d e v e l o p m e n t of, 2 8

after-care, p l a n n i n g for, 180

e a r l y infantile, 31, 74

aggression:
as s e c o n d a r y o r r e l a t i v e

destructive, 66
p h e n o m e n o n , 29

i n a b i l i t y t o n e u t r a l i z e , 63, 107
s y m b i o t i c t e n d e n c i e s i n , 182

a g g r e s s i v e n e s s , 17, 8 1 , 1 0 7 , 2 2 3
s y m p t o m s , 29

A l a n e n , Y O . , 3, 4, 6 - 8 , 2 3 , 3 1 , 3 4 ,
w i t h d r a w n , 82

3 9 , 5 6 , 70, 7 5 , 7 8 , 8 0 - 9 0 , 1 0 2 ,
a u t i s t i c - s c h i z o i d t e n d e n c y , 8 9

118, 1 2 4 - 1 2 6 , 1 4 4 - 1 5 2 , 1 5 6 ,
a v e r a g e s c h i z o p h r e n i c b r a i n , 49

158, 1 5 9 , 1 6 5 , 1 6 7 , 1 6 9 - 1 7 1 ,

175, 179, 187, 1 9 3 , 1 9 6 , 212,

B a l d e s s a r i n i , R . , 115

213, 241, 244, 245

Barnes, T. R. E . , 29

A l l e b e c k , P., 3 1 , 9 6
B a r r , C . L., 5 6

297
298 INDEX

B a r t k o , J . J . , 79
B r e n n e r , C , 6 3

Basamania, B. W . , 69
brief psychotic disorder, 31

B a t e s o n , G . , 68, 69, 71
British Object Relations School, 60

B e n e d e t t i , G . , 7, 7 4 , 1 1 2 , 1 1 9 , 1 7 2 ,
Brodey, W . M . , 69

184, 202, 2 0 4
B r o w n , G . W . , 36, 7 2

b e n z o d i a z e p i n e d e r i v a t i v e s , 116
Buchanan, R. W., 48

Beres, D . , 7 7
B u r g h o l z l i H o s p i t a l , 1 2 0

Berggren, B.-M., 47
B u r n h a m , D . L . , 2 9 , 8 9

Bergman, A . , 63

B e r m a n , K . E , 4 9
Caldwell, C . B., 29

Bertalanffy, L . v o n , 71
Camarillo Hospital, California, 120

Bertelsen, A . , 52
C a m e r o n , N . , 26

Betz, B., 40,190

C a n a d a , 34, 36,129

Biehl, H . , 165,168
cannabis, 96

Bigelow, L . B., 48
C a n n o n , T . D . , 4 8 , 5 7

b i o m e d i c a l approach, preference of,

Carlsson, A . , 46,101,115

113-114
Carlsson, M , 46,101

B i o n , W . R., 62, 255

Carpenter, W .T., 116,117,153,154,

b i o p s y c h i a t r i c research, 87,88, 105,

158,167

256
case m a n a g e m e n t teams, 201, 245

B i r c h w o o d , M . , 125, 138
case studies, 1-2,27-28, 81, 91-93,

Birley, J. L . T., 72
94-95, 96, 98, 99-100,

B l a n d , H . C , 36
177-178, 206, 207-208

B l a t t , S . , 5 3
Catherine, 117, 2 1 6 - 2 2 8 , 2 3 5

B l e u l e r , E . , 11, 2 6 , 3 0 , 3 3
Eric, 8 - 1 4 , 2 7 , 2 0 5

Bleuler, M . , 36
John, 2 2 8 - 2 3 5

B l o c h , S., 2 3 8
Marjorie, 214-216

Bone, M . , 36
Paula, 1 5 - 2 3 , 1 2 6 , 1 9 7 , 2 0 6

Bonett, D . , 49
Sarah, 3 - 7 , 7 2

borderline schizophrenia, 31, 33,

c a s t r a t i o n a n x i e t y , 9 7

152, 182
catatonic schizophrenia, 30, 80,152

Borri, R , 124
catatonic states, 9 1 , 1 0 1

B o r u s , J. E , 238
Cawley, R., 132

Boscolo, L . , 71
C D , see c o m m u n i c a t i o n d e v i a n c e s

B o s t o n State H o s p i t a l , 121
C e c c h i n , G . , 7 1

B o s z o r m e n y i - N a g y , L , 71, 126
C h a n g , M. Y , 3 8

B o w e n , M . ,69, 71, 77,126

"chaotic" a n d "rigid" families, 70,

Bowlby, J., 74
86, 1 0 6

Boyer, L . B., 112,119,172, 184,194,

Chestnut L o d g e Hospital, 120,192

202, 205, 206

childhood family environments, 67

b r a i n , s t r u c t u r a l a b n o r m a l i t i e s , a n d
c h l o r p r o m a z i n e , 111, 1 1 7 , 1 2 0 , 1 2 1

predisposition to
Christison, G . W . , 48

s c h i z o p h r e n i a , 47-50, 88
C i o m p i , L . , 36, 39, 57,102, 107,109,

Breier, A . , 48
134,195, 242

Bremner, J. D . , 49
C l a g h o r n , J. L . , 131

 INDEX 299

Cleghorn, J. M., 47
Dalison, B., 36

Clifford, C. A., 48
Dane County Project, Wisconsin,

cognitive-analytical approach, 125

136,137

cognitive-behavioural approach,
Davis, A. E., 136

125
Davis, J. M., 114

Cohen, B. M , 115
Davis, O. R., 48

Cole, J. O., 114

Day, J., 69

Colombia, 37
day hospitals, 137, 179,180, 218,

communication deviances (CDs), of

242

parents, 69-71, 86
day-and-night hospitals, 136

community-based psychiatric
Dean, C , 137

developments, 134-138
death, psychological, 28, 97

death instinct, 61

concretization, 10, 11, 27, 206, 213

conflict theory, 63
dedifferentiation anxiety, 97

conjoint therapies of families of

defence mechanisms:

origin, 182
parental, 80

Conran, M. B., 133

transactional, 80

contact with family, importance of

deficiency theory, 63

to treatment, 177
dehumanization, 239, 255, 257

Coon, H., 56
Dein, E., 89

Cooper, J. E., 33
Delay, J., 70, 111

Cornelison, A. R., 16, 67

DeLisi, L. E., 57

couch, use of, 202

delusions, 25-30

countertransference, 7, 74,119,172,
effect of neuroleptics on, 114

184,193,195, 202, 207, 209,

of reference, 10

210, 222, 227, 233

parental psychotic, 79

couple therapy, 23,147,155,

physical, 27,152

182-184, 196, 197, 201, 219,

projective, 12

221,222
psychological, 152

Cramer, G., 52
psychotic, 13,16, 32,96, 212

Deniker, P., 70, 111

creative interests, benefit of, 209

crisis centres, 136,137

Denmark, 37, 89, 167

crisis intervention, 128,150,155,

dependence, illness-induced, 171

175, 177,181,182,187
Der, G., 35

De Sisto, M. J., 136

crisis situations, and contact with

therapist, 210-211, 248

Dies, R. R., 131

crisis team, 138; see also acute

Dingemans, P. M., 31

psychosis team
Dinitz, S., 136

Croatia, 34
disintegration anxiety, 28

Crow, T. J., 49,105

Dixon, W. J., 120

Cullberg, J., 105,205, 256

dizygotic twins, 88

Czechoslovakia, 37
Doane, J. A., 70, 72,128

Domarus, E. von, 26

Daily Living Programme (London),

Donaldson, S. R., 115

137
Done, D. J., 48

300 INDEX

dopamine, 102,105,115,116
explorative, insight-oriented (EIO)

h y p e r a c t i v i t y t h e o r y , 101
psychotherapy, 122,123

receptors, 46,101
expressed emotion measurement

d o u b l e b i n d , 68, 69, 94, 9 9 , 1 9 5

(EE), 7 1 - 7 2 , 1 2 9 , 213

d r i v e gratification, 107

d r u g a n d / o r a l c o h o l , a b u s e , 31, 96,
F a l l o o n , I., 3 4 , 7 2 , 1 2 8 , 1 2 9 , 1 3 7 , 1 3 8 ,

159, 215, 221, 240, 254

240, 253

D S M d i a g n o s t i c s y s t e m , 30, 3 2 - 3 3
f a m i l i e s , s c h i s m a t i c , 16

- I I I - R , 32, 34, 3 7 , 1 1 9 , 1 3 8 , 1 4 2 ,
family background,

151-153,157,167
p s y c h o d y n a m i c s of, 2 1 0

- I V , 30-32, 90
family therapeutic relationship,

D u n m e y e r , S., 2 4 0
e m p a t h i c , 82

D y s i n g e r , R. H . , 69
f a m i l y therapy, 125-130,195, 202

c o n j o i n t , 15

E a r l y , D . C , 135
c o m b i n e d w i t h i n d i v i d u a l therapy,

E a t o n , W . W . , 33
185-195

E E , see e x p r e s s e d e m o t i o n
c o n t i n u i n g , 145

measurement
i n c l u d i n g c h i l d r e n i n , 183

ego defences, a n d interactional

a n d i n d i v i d u a l therapy, integrated,

relations, 80-82
15

ego functions:
pioneering research in, 68-71

d i s i n t e g r a t i o n of, 3 0
psychodynamically oriented,

r e g r e s s i o n of, 2 6 - 2 7
126-127,196

ego-psychological psychoanalytic
psychoeducational, 112,127-130

r e s e a r c h , 78
r e s i s t a n c e t o as l a b e l , 1 8 2

E l o r a n t a , K . J . , 136
system-oriented approach, 71-72

E m d e , R . , 78
t r i a l s , c o n t r o l l e d , 128

empathy, 11-12,192
t r a i n i n g for, 1 4 8 - 1 5 1

i n therapeutic relationship, 7,15,

see also f a m i l y t h e r a p y ; n e e d ­
2 9 , 1 8 4 , 2 0 3 , 2 0 6 , 211
adapted treatment; systemic

E n d i c o t t , J., 1 6 2
family therapy; therapy

E n g s t r o m , A . , 31

E n o c h a n d S h e p p a r d Pratt Hospital,
f a m i l y - d y n a m i c research, 23, 56, 58,

M a r y l a n d , 132
73, 75, 8 1 , 1 0 7 , 215

epidemiological data, international,

f a m i l y - o r i e n t e d interventions, 167

34
c r u c i a l s i g n i f i c a n c e of, 1 6 9 - 1 7 0

E r n s t , K . , 70
f a n t a s i e s , p s y c h o t i c , 11

erotic impulses, a n d course of

Farde, L., 47,101,115

p s y c h o s i s , 102
f a t h e r , p e r s o n a l i t y of, 8 6

e r o t i c i z e d transference, 208, 234

F a u n c e , E . E . , 71

E s k o l a , J., 1 3 7
F e d e r n , P., 5 9 , 6 3 , 1 1 2 , 1 2 6

E s t e r s o n , A . , 70
Fenichel, O . , 5

e u g e n i c s , 238
F e n t o n , F. R . , 136

E w a l t , J „ 121
fertility, 52

 INDEX 301

Finland, 1, 7, 8, 15, 34, 35, 38, 70,

Glass, L. L., 123

112,118,130,132,135,
Goffman, E . , 42

139-235,237,239, 241, 244,

Goldberg, D., 240

247, 248, 252-254

Goldstein, J. M . , 39,159

Finnish Mental Health Association,

Goldstein, K., 27

148
Goldstein, M . J., 72,128,129

Finnish National Schizophrenia

Gonzalez de Chaves Men&idez, M . ,

Project, 38,159-166,167,176,
131

178,187,188, 212, 244, 252

Gottesman, I. L, 29,52

comparison of prognostic findings,

Green, A . , 70

165-166
Greenspan, S. L , 87

follow-up studies, 162-166

Grigsby, J., 106

goals of, 161

Grinspoon, L . , 121

patient sample, 162-164

Gross, G., 36

first-admissions, 36,117,118,120,
Grotstein, J. S., 63

130,174,176,178,179, 214,
Group for the Advancement of

216
Psychiatry, 253

improved outcome for, 188

group therapy, 130-134

first-episode schizophrenic patients,

Gunderson, J. G . , 122,124, 190

138, 165-166, 170

Guntem, G., 130

Fischer, M . , 52
Gupta, S., 35

Fleck, S., xv-xvi, 15,16,67, 68,106,

239
Haakenasen, K., 123

Fleming, J. A . , 36
Habermas, J., 40, 255

Flomenhaft, K., 128,150 .

Hafner, H . , 39

Forssen, A . , 37
Hakkarainen, A . , 113

Framo, J. L . , 71,126
Haley, J., 68

Freud, S 58, 59, 60, 61, 62, 65, 76,

v
Halldin, C , 115

78, 82, 85, 86, 87, 97

hallucinations, 6, 7, 25-30, 32,114,

Frith, C. D., 48
208, 228, 234

Fromm-Reichmann, E , 7, 60,112
Hanlon, T. E . , 117

Fryers, T., 34
Harding, C M . , 37,105,135

Furlan, P. M . , 124
Harl, J. M 111

Harlow, H . E , 46

Garcia-Ordas Alvarez, A . , 131

Harlow, M . K., 46

Gath, D., 38
Harris, A . , 36

Gaustad Hospital, Oslo, 123

Hartmann, H . , 63, 78, 87,108

Gelder, M . , 38
Harvard University, 121

Gelenberg, A . J., 115

Harvey, E . J., 126

gender, 158
Haug,J. O., 47

Germany, 112,165, 238

Haugsgjerd, S., 238

Gibson, R. W., 29
Hauser, P., 48,105

Gilbert, S., 193, 209, 256

hebephrenic form of schizophrenia,

Gladstone, A . I., 29
28, 30, 80, 91,152,157

302 INDEX
H e g a r t y J . D . , 37
see also f a m i l y t h e r a p y ; n e e d ­
H e i k k i l i i , J . , 228, 230
adapted treatment; therapy

H e i n r i c h s , D . W . , 117
i n d i v i d u a t i o n , 81, 82, 88, 9 3 , 1 0 6 ,

H e s t o n , L . L . , 78
1 0 7 , 1 8 1 , 1 8 4 , 211, 216, 230,

H i e t a l a , J . , 101
235, 253

H i l l , G R , 30
see also s e p a r a t i o n

H i n d m a r s h , T., 47
i n f l u e n z a , m a t e r n a l , 49, 57, 252

H i r s c h , S „ 69, 7 0 , 7 1
initial examination, therapeutic

H j o r t , R , 31, 96
i m p o r t a n c e of, 1 7 5 - 1 7 8

H o g a r t y , G . E . , 1 2 8 , 1 2 9 , 214
institutionalization:

H o l d e r l i n , E , 29
a v o i d i n g r i s k of, 179

h o l d i n g , 203
c o n s e q u e n c e s of, 3 0

H o l s t e i n , C , 49
i n t e g r a t i v e a p p r o a c h , n e c e s s i t y of,

h o m e o s t a s i s , family, 21, 22, 7 1 , 1 8 3 ,

45-46

198
Inter-Scandinavian C o m m u n i t y

h o m i c i d a l acts, 29
P s y c h i a t r i c N I P S P r o j e c t , 118,

h o m o s e x u a l p a n i c , 100
139, 1 5 7 , 1 6 5 , 1 6 7 - 1 7 0 , 1 8 8 ,

hospitalization:
189,193, 209, 213, 245

a v o i d a n c e of, 1 2 8
follow-up findings, 167-170

d u r a t i o n of, 179
g o a l s of, 167

i n d i c a t i o n s for, 1 7 9
therapeutic orientations in, 167

hostels, 185, 240, 242

interactional relationships, 40

H o u l t , J., 113,136
as c r u c i a l p r e d i s p o s i n g f a c t o r , 1 0 7

H s i a , C Y , 38
e a r l y , 58, 6 3 , 73, 74, 77, 8 0 , 84, 8 8

H u b e r , G . , 36, 47
a n d involvement of ego defences,

H u t t u n e n , M . O . , 49
81-82

s i g n i f i c a n c e of, 4 5 - 4 6

I d a n p a a n - H e i k k i l a , J . , 116
w i t h therapist, 203

Illowsky, B . , 48
i n t h e r a p y m e e t i n g , 175

i m p u l s e control, 90
International Classification of

w e a k e n i n g of, 2 9
D i a g n o s e s ( I C D 8), 1 4 2

I n d i a , 34, 37
I n t e r n a t i o n a l P i l o t S t u d y , 35

i n d i v i d u a l therapy, 23,118-125,
interpersonal structures, protective,

200-212
98

d e v e l o p m e n t of, 1 4 6 - 1 4 8
" i n t e r p r e t a t i o n u p w a r d s " , 12, 2 0 5 ,

d y a d i c r e l a t i o n s h i p s i n , 74
206

f r e q u e n c y of, 2 1 1 - 2 1 2
interpretations, t i m i n g of giving,

a n d g r o u p t h e r a p y , c o m b i n e d , 131
205-207

i n d i c a t i o n s for, 184
intrafamilial communication:

long-term psychodynamic
d i s o r d e r s , 107

s u p p o r t i v e , 167
d i s t u r b e d , 55

p s y c h o d y n a m i c , 146-148, 248
intrafamilial disturbances,

shift to, as treatment progresses,

c o n t i n u i t y of, 75

1 7 3 - 1 7 5 , 184
intrafamilial environment,

s i g n i f i c a n c e of, 8 - 1 4
s i g n i f i c a n c e of, 8 6 - 8 9

 INDEX 303

intrafamilial relations, 22, 23, 76,

K i l l i n g m o , B . , 255

103,189, 253
K i n n u n e n , P., 23, 8 7 , 1 0 0 , 1 9 6

a n d pathogenesis of schizophrenia, K l e i n , M , 60, 61, 62, 63, 8 1 , 1 1 2

6
K l e i n m a n , A . M . , 38

introjection, 206
K n i g h t , E . , 66

irrationality, t r a n s m i s s i o n of, 6 7
K o h u t , H . , 6 5 , 6 6 , 7 5 , 8 3 , 85, 9 7 , 1 0 7 ,

I s o h a n n i , M , 191
192, 2 0 3 , 2 0 4 , 2 5 5

Italy, 1 1 2 , 1 2 4 , 1 3 7
K o p e i k i n , H . S., 1 2 9

K r i n g l e n , E . , 32, 52, 88

Jablensky, A . , 35, 37
K r i s , E . , 78

Jackson, D . D . , 21, 68, 7 1 , 1 2 6

K r u m m , B . , 165

J a c k s o n , M , x v i i - x i x , 132, 208
K u i p e r s , L . , 126

J a c o b , T . , 71
Kupittaa Mental Hospital, 140,142,

Jacoby, C . G . , 47
146,151, 217

Jarvi, R 125

v
Project, 117-118

Jefferies, J. J . , 129
K u u s i , K , 38

J e n k i n s , J. H . , 72

Johansson, A . , 8,119,126
Laakso, J., 39,124,125

Johnstone, E . C , 47, 48
labelling, 38, 42, 8 6 , 1 3 4 , 1 4 9 , 1 7 8 ,

Jones, M . , 131,132, 144,191

235

J o n e s , P., 90
Laing, R. D . , 70,133

Josephson, E 30
v
L a m b o , T. A . , 35

J o u k a m a a , M . , 34
Langfeidt, G 31,142
v

Juliano, D . M . , 48
Langsley, D . G . , 128,150, 240

J u n g , C G . , 112
L a p i n l a h t i , 3 , 8, 1 6

"justifiable o p t i m i s m " , 192

Larmo, A . , 81,103

L a r s e n , T . K . , 138

Kaila, M . , 3
L a z e l l , E . , 130

K a l j o n e n , A . , 39
Leff, J., 70, 71, 7 2 , 1 2 8 , 1 2 9 , 201, 213

K a l l m a n n , E J., 50
Lehtinen, K , 31,125,144,148,149,

K a n a s , N . , 131
150, 1 5 2 , 1 5 3 , 1 5 6 , 1 5 7 , 1 7 3 ,
K a r n o , M , 72
189, 199, 201, 245

K a r o n , B . P., 1 2 1 , 1 2 2
L e h t i n e n , P., 98

K a s a n i n , J., 31, 66
Lehtinen, V , 34,113,118, 230

K a t z , K . , 165
L e n i o r , M . E . , 31

K a u f m a n n , L . , 126
L e n t z , R . J 132

K a v a n a g h , D . J . , 72
L e v a n d e r , S., 2 0 5

K e i n a n e n , E . , 78
L e v e n e , J. E . , 129

K e i t h , S. J . , 3 7 , 1 3 1
L e w i s , S., 4 7

K e l m a n , S., 240
libido theory, 76

K e n d l e r , K . S 152

v
L i d z , R . W . , 67, 211, 239

K e r a n e n , J 130

v
L i d z , T., 1 5 , 1 6 , 42, 46, 53, 67, 68, 70,

K e r n b e r g , O . E , 62, 63, 8 0 , 1 1 8
7 7 , 7 8 , 7 9 , 8 2 , 8 6 , 9 4 , 211

K e t y , S. S . , 5 2 , 5 3
L i e b e r m a n , J . A . , 116

K i l g a l e n , R . K , 132
L i e b e r m a n , L . , 105

304 INDEX

L i n , K . - M . , 38
M e d n i c k , S., 4 8 , 4 9 , 8 9

L i n d b e r g , D 131

v M e n n , A . Z . , 133

Lindqvist, M . , 101,115
Meyer, A . , 60,112

L i n k e r , I., 3 6
M i c h i g a n S t a t e U n i v e r s i t y , 121

L i n s z e n , D . H . , 31, 96
M i k l o w i t z , D . J . , 72

L i n z , M . , 36
M i l e s , C , 29

L i s t , S. J . , 4 7
M i l l e r , L . S., 2 4 0

L o e w e n s t e i n , R . M . , 78
M i n i - F i n l a n d Project, 34

L o n d o n , N . J., 63
M i s h l e r , E . G . , 73

L o n n q v i s t , J . , 38
M o i s e s , H . W . , 56

l o s s , e x p e r i e n c e s of, 98
m o l e c u l a r genetic studies, 56

m o n o z y g o t i c t w i n s , 48, 88

M a c F a r l a n e , J . , 74
M o r t e n s e n , P. B . , 3 5

M a c h o n , R . , 49
Mosher, L . R., 37,131,133

Machotka, R, 128,150
m o t h e r - c h i l d relationship, 75, 77,

M a c L e a n Hospital, Massachusetts,
78, 86, 93

122,190
M u i j e n , M . , 137

M a c m i l l a n , E , 138
Miiller, C , 36,112,120

M a h l e r , M . S., 6 3 , 6 5 , 8 2 , 8 3 , 8 7 , 1 0 2
M u n k - J o r g e n s e n , P., 35

M a i n , T. E , 131,132
M u r p h y , H . B . , 34, 38

M a l k i e w i c z - B o r k o w s k a , M . , 130
M u r r a y , R . M . , 3 5 , 4 8 , 5 7 , 90

M a l m , U . , 131
M y e r s , J . K., 3 4

M a l m i v a a r a , K . , 78

M a l s o n , L . , 46
N a m y s l o w s k a , I., 1 3 0

M a n n e r h e i m , M . , 98
narcissism, primary, 58-59

M a r d e r , R . S., 115
narcissistic disorders, 204

M a r m o t , M . , 90
narcissistic traumas, 97

M a r s h , L . C , 130
N a s r a l l a h , H . A . , 47, 48

M a r t i n o t , J . - L . , 101
N a t i o n a l Institutes of M e n t a l H e a l t h

Massachusetts Mental Health

( N M I H ) , 15, 6 9 , 1 1 4

C e n t e r , 121
N a t i o n a l Institutes of H e a l t h

M a t t e - B i a n c o , I., 2 5 5
Research Center (NIH),

M a x P l a n c k I n s t i t u t e , M u n i c h , 131
116-117

M a y , P. R . A . , 1 2 0 , 1 2 2
N a t i o n a l S c h i z o p h r e n i a Project,

M a y o u , R . , 38
F i n l a n d , 239

M c C a l l e y - W h i t t e r s , M . , 47
n e e d - a d a p t e d t r e a t m e n t , 117,

M c G h i e , A . , 70
139-190, 191-235, 249, 256

M c G l a s h a n , T. H 116,120

v
acute psychosis teams, 244

M c G o r r y , P. D . , 9 0
case excerpts, 214-235

M c N e i l , T . E , 49
catchment area m o d e l , 241-243

medication:
c o n c e p t a n d p r i n c i p l e s of, 1 7 0 ­
p o s t p o n e m e n t o f i n t r o d u c t i o n of,
186

178
as c o n t i n u o u s i n t e r a c t i o n a l

q u e s t i o n o f n e c e s s i t y for, 1 1 6 - 1 1 8
process, 172

see also n e u r o l e p t i c s
d e v e l o p m e n t a l n e e d s of, 2 4 1 - 2 5 2

 INDEX 305

family and individual therapy

C o m m u n i t y Psychiatric N I P S

c o m b i n e d , 185-186
Project

a n d family therapy, 196-202

N i s k a n e n , P., 38

f o l l o w - u p , n e c e s s i t y of, 173
N o r r i s , V , 36

a n d g r o u p t h e r a p y , 185
N o r t h e r n S a v o Project, 244

h e r m e n e u t i c a p p r o a c h of, 1 7 0
N o r w a y , 3 5 , 1 1 2 , 1 3 8 , 1 6 7 , 244

h u m a n i z i n g e f f e c t of, 188
N S P ( N e w S c h i z o p h r e n i c Patients),

a n d individual psychotherapy,
see F i n n i s h N a t i o n a l

202-212
Schizophrenia Project

i n t e g r a t e d a p p r o a c h e s i n , 172
n u r s e t h e r a p i s t , 190, 233, 234

m o d e s o f t r e a t m e n t , w e i g h t i n g of,
N y b a c k , R , 47

173

p r i m a r y t h e r a p e u t i c c o n c e r n , 173
O b e r s , S. J . , 7 7

and psychopharmacological
object relations, 58, 60, 74, 93

treatment, 212-214
e v o l u t i o n of, 74

a n d psychotherapeutic
influences o n , 80

c o m m u n i t i e s , 191
i n t e r n a l i z e d , 103

qualitative resources, 243-244

l o n g - t e r m , 78

rehabilitative activities in, 249­ s t u d y of, 8 2

252
O ' B r i e n , C B „ 131

a n d therapy of family of origin,

o b s t e t r i c c o m p l i c a t i o n s , 48

182
O ' C a l l a g h a n , E . , 57

therapy meetings in, 173,175

o e d i p a l s i t u a t i o n , 62, 82, 9 4 , 9 5 , 9 7 ,

n e e d - f e a r d i l e m m a , 29
224, 226

N e o p h y t i d e s , S. N . , 4 7
O g d e n , T . H . , 81

N e u m a n n , B . , 119
Ojanen, M . , 34,133

neuroleptics, 36-38,129,158,
O l s e n , S. A . , 2 9

164-170,178, 255
O l s o n , D . K , 231

a c t i o n of, 101
o n e - p a r e n t families, 197

a t t i t u d e o f p s y c h i a t r i s t s t o , 116
O n s t a d , S., 5 2 , 8 8

d e c r e a s e i n n e e d for, 1 3 1 , 1 8 8
o r a l d r i v e g r a t i f i c a t i o n , 76

e f f e c t i v e m e c h a n i s m of, 115
o r g a n i c b r a i n d i s o r d e r s , 25, 29, 45,

i n need-adapted treatment,
48,105, 138,152

212-214
" o r g a n i s m i c p a n i c " , 102

p o p u l a r i t y of, 11
o r g a n i z a t i o n - a f f i n i t y , 88

p r e d o m i n a n t e f f e c t of, 2 9
l e a d i n g to a v e r s i o n o f contact, 87

psychopharmacological
O r m a , E . , 193

treatment, 114-118
O r n , H . , 36

r e s t r i c t e d u s e of, 134
outpatient treatment, significance of

N e w m a n , E , 129
for s e l f - e s t e e m , 179

N i e d e r l a n d , W . G . , 86

N i g e r i a , 35, 37
P a l o A l t o , C a l i f o r n i a , 68

N I M H , see N a t i o n a l I n s t i t u t e s o f
panic, 102,103,107

Mental Health
h o m o s e x u a l , 231

N I P S P r o j e c t , see I n t e r - S c a n d i n a v i a n
anxiety, 49

306 INDEX

P a o , P.-N., 6 3 , 1 0 2 , 1 0 3
P i n e , R , 6 3

p a r a d o x i c a l interpretations, 198
P i n e s , M . , 8 3

paranoid character disorders, 53

Pittman, R S 128,150
v

p a r a n o i d disintegration, 234
Pollin, W . , 78

p a r a n o i d psychoses, of parent, 80
P o r t i n , P., 5 6

p a r a n o i d s c h i z o p h r e n i a , 3 0 , 3 2 , 5 8 ,
positive connotations, 198

157,159,173,189
post-operative psychoses, 96

classical treatise o n , 86
p o s t t r a u m a t i c stress d i s o r d e r

p a r a n o i d - s c h i z o i d p o s i t i o n , 2 3 , 6 1 ,
(PTSD), 49

62,63
Prata, G . , 71

p a r e n t a l personality, significance of,

p r e o e d i p a l p r o b l e m s , d i s o r d e r s

78-80
d e r i v i n g from, 82

p a r e n t - c h i l d relationships, a n d
prepsychotic personality:

personality development,
d e s c r i p t i o n of, 8 9 - 9 0

73-74
development, 89-95

parents:
Preston, M , 125

autistic, c h i l d r e n of, 80
p r i m a r y narcissism, 59, 76

l a c k o f e m p a t h y , of, 8 5
p r i m a r y process, 26, 30,184

paranoid, 197
progesterone, 39

P a r k e r , J . H . , 3 6
prognosis, 33, 57, 9 8 , 1 0 4 , 1 0 5 , 1 0 6 ,

P a r l a n d , O . , 255
120,129,145-148,153,164,
Parloff, M . B . , 131
188,199, 225, 235, 251, 2 5 6

P a r n a s , J., 48
e n v i r o n m e n t a l f a c t o r s , effect o f , 3 9

" p a r t - o b j e c t " r e l a t i o n s h i p , 6 0 , 2 0 4
a n d gender, 39,159

P a s a m a n i c k , B., 136
good, 37,101,117,119,135,

passivity, 2 9 , 87, 88, 94,115

147-148,165,169,184, 248

P a u l , G . L . , 1 3 2
e x p l a n a t i o n s for, 158

P e r r i s , C , 1 2 5
factors predictive of, 38

personal nurse, 145,177,178,

of schizoaffective p s y c h o s e s , 31

192-194, 209,218, 219, 222,

a n d labelling, 42

230, 231, 232, 2 3 3

a n d p s y c h o s o c i a l factors, 38

personal psychoanalysis,
a n d treatability, factors affecting,

i m p o r t a n c e o f therapist's, 8
158-159

personality development, early

projection, 206

p h a s e s of, 63-65
p r o j e c t i v e i d e n t i f i c a t i o n , 1 5 , 6 1 , 6 2 ,

personality disorders, parental, 67

70, 75, 81, 8 4 , 1 0 7 , 204, 2 1 5 ,

personality functions,
223, 2 2 5

disintegration of, 26
pseudohostility, 69

personality of the therapist,

p s e u d o m u t u a l i t y , 69, 86

i m p o r t a n c e o f i n
psychiatric h o m e care, 136

psychotherapy, 8
psychiatric treatment a n d research,

Picasso, P , 2
future of, 2 5 4 - 2 5 7

P i c k a r , D . , 116
p s y c h o a n a l y t i c a n d f a m i l y - d y n a m i c

P i e t r u s z e w s k i , K . , 130
a p p r o a c h e s , i n t e g r a t i o n of,

Piirtola, O . , 38
73-89

 INDEX 307

psychoanalytic studies, 58-66

R a k k o l a i n e n , V , 34, 39, 62, 79-81,

psychoanalytically oriented
97, 9 8 , 1 1 7 , 1 1 8 , 1 2 4 , 1 2 5 , 1 4 8 ,

(psychodynamic)
1 4 9 , 1 5 9 , 1 6 1 , 1 7 0 , 1 7 5 , 214,

p s y c h o t h e r a p y , 111-113, 256
216

family, 119,196,197
R a m a n , A . C , 38

g o a l of, 2 0 3
R a n g , B . , 46

i n d i v i d u a l t h e r a p y , 146
R a p a p o r t , M . , 117

p s y c h o d y n a m i c family research,
R A S , 122,123

66-77
Rasimus, R., 39,125,147,148

psychoeducational family therapy,

reactive p s y c h o s e s , 32

1 1 2 , 1 1 3 , 1 2 7 , 201
of parent, 80

p s y c h o l o g i c a l b o u n d a r i e s , 26
reality t e s t i n g , l o s s of, 2 5 - 2 6 , 2 2 7

psychopathology, intergenerational,
reality-adaptive, supportive ( R A S )

211
psychotherapy, 122,123

p s y c h o p h a r m a c o l o g i c a l treatment,
Rechardt, E . , 11,12

114-118, 212-214
R e d d a w a y , R , 238

psychosis:
regression, o p t i m a l w a r d

d r u g related, 96
c o m m u n i t y attitude to,

factors precipitating, 95-100

194-195

general, 32
regressive p s y c h o t i c state, r e c o v e r y

m a r g i n a l o r atypical, 32
from, through family-centred

o n s e t of, 6 2 , 9 1 , 9 5 , 9 6 , 9 7 , 1 0 1 - 1 0 4 ,
treatment, 157

109
rehabilitation, 4 2 , 1 2 4 , 1 7 8 , 238, 241,

p a r e n t a l , 103
245

p s y c h o d y n a m i c s of, 5 8 - 5 9
financial savings through, 240

therapies, long-term, 207

p r o g r a m m e s , 34, 3 7 , 1 3 2 , 139

psychotherapeutically oriented
psychosocial, 170,185

w a r d c o m m u n i t i e s , see w a r d
team, 243

c o m m u n i t y
rehabilitative activities,

psychotherapy:
d e v e l o p m e n t of, 1 1 3 , 2 4 4 ,

d u r a t i o n of, 9
249-252

of psychotic disorders,
Reiss, D . , 72,128

combination of approaches in,

R e k o l a , J. K . , 70

8
Retzer, A . , 127

training, 247-249
Reveley, A . M , 48, 57, 88

t r i a l s , l i m i t a t i o n s of, 124
Reveley, M . A . , 48, 57

see also t h e r a p y
R i c e , D . P., 2 4 0

p s y c h o t i c delusions, parental, 79
Rieder, R. O . , 48,105

p u b e r t y , 89, 94, 9 5 , 1 0 6
R i s k i n , J. R , 71

a n d increased drive pressure, 97

r i s p e r i d o n e , 116

P y l k k a n e n , K . , 34,137, 239
R o b b i n s , M , 63, 65, 78, 87, 8 8 , 1 1 2 ,

119,126

Q u a r t e s a n , R . , 124
Roberts, G . W . , 49

R o b i n s , E 162

Rakfeldt, J v
105
R o b i n s , J. N . , 34

308 INDEX

R o d g e r s , B . , 90
early initial intervention,

Rosenbaum, B., 31,167

effectiveness of, 157

R o s e n t h a l , D . , 5 2 , 5 3 , 95
and employment, 38,135,165,

Rothstein, A . , 204
170

R i i c k e r - E m b d e n , I., 71
e n v i r o n m e n t a l f a c t o r s , r o l e of, 4 7 ,

R u n d , B . R , 70
52, 5 3 , 5 6 , 8 7

R u s s e l l , C S., 231
e p i s o d e s , p r e v e n t i o n of, 137-138

R y c k o f f , I. M , 6 9
e s t i m a t e d c o s t s of, 2 3 9 - 2 4 1

R y d b e r g , U . , 31
h e r e d i t a r y factors, 47, 5 0 - 5 7

i l l n e s s m o d e l s of, 3 9 - 4 3

S a a r e l m a , M . , 78
i n c i d e n c e a n d p r e v a l e n c e rates of,

Sage, R , 66
33-35

S a l o k a n g a s , R . , 34, 39, 9 8 , 1 4 3 , 1 4 5 ,
individual psychological a n d

146,159,161,162,164
interactional, 40-42

S a l o n e n , S., 63, 1 3 2 , 1 9 2 , 1 9 3
in industrialized a n d in

S a n d i n , B . , 119,123, 205
d e v e l o p i n g countries, 35, 37

S a t e r H o s p i t a l , S w e d e n , 119
influence of political factors o n

S c a n d i n a v i a , 3 1 , 1 3 2 , 1 4 2 , 237, 241
t r e a t m e n t of, 238

Scandinavian Multicentre
i n t e g r a t e d m o d e l of, 4 1 , 4 3

P s y c h o t h e r a p y Project, 31
i n t e g r a t e d t r e a t m e n t of, 170

S c h a d e r , R . , 121
l o n g - t e r m p r o g n o s i s of, 3 6 - 3 9

schismatic families, 69,197

morbidity, 34-35, 39

s c h i s m a t i c m a r i t a l relationships, 67,
m u l t i f a c t o r i a l c a u s e s of, 1 0 4 - 1 0 9

86
o n s e t a n d c o u r s e of, 1 0 , 2 7 , 3 0 , 4 8 ,

schizophrenia:
72, 9 1 , 9 8 , 1 0 9 , 1 5 2 , 1 6 4 , 1 8 4 ,

acute onset, 38
221,256

age limits for the risk of

p a r a n o i d , 30

d e v e l o p i n g , 31
p a t h o g e n e s i s a n d n a t u r e of, 4 5 ­
a n d ambivalence, mother's, 84-85
109

b e l i e f i n o r g a n i c n a t u r e of, 1 1 3 , 1 2 7 ,
p o s s i b i l i t y o f p r e v e n t i o n of,

138
252-254

b i o m e d i c a l m o d e l of, 4 0
p r e c i p i t a t i n g factors:

c a t e g o r i z a t i o n of, difference
physical, 95-96

b e t w e e n A m e r i c a a n d Britain,
psychological, 96-100

33
p r e d i s p o s i t i o n t o , 73-^89

catatonic, 30, 98
biological factors, 4 7 - 5 7

c h i l d h o o d , 31
p s y c h o s o c i a l factors, 58-73

d e c l i n e i n i n c i d e n c e of, 3 5 , 2 5 4
- p r o n e i n d i v i d u a l , d e v e l o p m e n t of,

d e v e l o p m e n t a n d c o u r s e of, 108
91

d i f f i c u l t y o f d e f i n i n g l i m i t s of,
from a public health perspective,

33-35
33-35

e a r l i e s t o n s e t of, 3 0
r e g a r d e d as o r g a n i c disorder, 45

early frustrations, a n d
r e l a t i o n s h i p o f t o d i s t u r b a n c e s of,

d e v e l o p m e n t of, 7 6 - 7 8
46

 INDEX 309

role of transmitter substances, 47

s e l f - e s t e e m , 11, 60, 66, 94, 9 7 , 1 0 0 ,

s o c i a l a n d e c o l o g i c a l m o d e l of, 4 2
104,105,108, 131,177,179,

s u b g r o u p s of, 3 0 - 3 2
199

s y m p t o m s of, 2 5 - 3 0
significance of outpatient

schizoaffective psychoses, 31,152,

t r e a t m e n t for, 179

162
self-object theory, 204

schizophrenia-spectrum personality
self-objects, 65, 66, 75, 9 4 , 9 7 , 98,

d i s o r d e r s , 52, 53, 72
107-109, 203, 210

schizophrenic and
n e e d for, 8 2 - 8 5

schizophreniform disorders,
relationships, early, 90-93

d i s c u s s i o n of, 3 2 - 3 3
f o r m a t i o n of, 88

schizophrenics:
Selvini Palazzoli, M , 71,127,128,

borderline, 8
198

i m p r o v e d o u t c o m e for, 189
s e p a r a t i o n , 80, 85, 91, 93, 98, 9 9 , 1 0 6 ,

m a r r i e d , 130
1 8 1 , 1 9 8 , 211, 235

schizophreniform disorder, 31-33,

- i n d i v i d u a t i o n , 81, 82, 8 8 , 1 8 4

118,152,153,218
separations, i n therapy, 210

s c h i z o p h r e n i f o r m p s y c h o s i s , 31, 96,
Sesemann, V., 255

157,162,169, 227
S h a k o w , D., 2 6

schizophreniform puerperal
S h a m , P. C , 4 9

psychosis, 96
S h e n l e y H o s p i t a l , 133

" s c h i z o p h r e n o g e n i c m o t h e r " , 86
S h e p h e r d , M . , 34, 3 6 , 1 6 5 , 1 6 8

s c h i z o t y p a l personality disorder, 33
Siirala, M , 175

S c h n e i d e r , J . L., 1 0 6
S i m o n , W 38

S c h r e b e r , D. P . , 5 8 , 8 6
Singer, M T . , 53, 69, 70, 72, 7 9 , 1 0 7

S c h u b a r t , C , 165
Sjostrdm, R., 31,119,123,167,205

S c h u l s i n g e r , R , 48, 89
s k e w e d families, 197

Schulz, C . G . , 132,193
s k e w e d m a r i t a l relationships, 67, 86

Schuttler, R 36
v
S k r e , L , 52, 88

S c h w a r z , E , 131
Sledge, W . H . , 113,137

S c h w a r z , M . , 132
Smeeton, N . , 34

S c h w a r z , R . , 165
S n y d e r , S. H . , 1 0 1 , 1 1 5

S c o t l a n d , 90, 1 3 2 , 1 6 5 , 168
social e n v i r o n m e n t , i n f l u e n c e of, 37

Scott, R . U , 71, 77, 8 6 , 1 2 6 , 1 7 6

s o c i o d e m o g r a p h i c predictors, 90

Scottish Schizophrenia Research

Sopimusvuori therapeutic

G r o u p , 165,168
communities, 132,133,135,

Searles, H . E , 7 , 1 2 , 1 5 , 60, 65, 78, 93,

249, 251

172, 202, 2 0 3
"Soteria Berne", 134,195, 242

Sechehaye, M . - A . , 76,112,119
Soteria h o m e , California, 133,134

Sedvall, G . , 47,57,115
Soviet U n i o n , 37, 238

S e e m a n , P., 1 0 1 , 1 1 6
Speijer, N . , 135

Segal, H . , 60
S p i t z e r , R. L . , 1 5 2 , 1 6 2

S e i k k u l a , J., 130
s p l i t t i n g , 6 1 , 6 2 , 81

self p s y c h o l o g y , 65-66, 7 5 , 1 0 7
S p r e n k l e , D. H . , 2 3 1

310 INDEX

S p r i n g , B . J., 9 5
systems-oriented a p p r o a c h , 71, 73

S r i L a n k a , 34, 38
S y v a l a h t i , E 47, 48

S t a b e n a u , J. R . , 7 8
Szasz, T., 42

Stanton, A . , 122,132

State M e d i c a l B o a r d , F i n l a n d , 34,
T a h k a , V , 76, 83, 97

159
T a k a l a , K . , 70

S t e i n , L . I., 1 1 3 , 1 3 6
Tarrier, N . , 129

Steinglass, R , 113,127
T e i c h e r , M . H . , 115

S t e n g a r d , E . , 161
T e r r y , D . , 16, 6 7

Stenij, R , 136
Tessier, L . , 136

S t e r n , D . N . , 74, 76, 8 3 , 1 0 6
Test, M . A . , 1 1 3 , 1 3 6

S t e w a r t , J., 13
therapeutic communities, 131-134,

S t e w e n , A . , 70
170,179, 244

S t i e r l i n , H . , 71, 77, 81, 8 2 , 1 2 6 , 1 2 7 ,

d e v e l o p m e n t of, 1 4 4 - 1 4 6

181,196
s i z e of, 2 4 2

S t r a u s s , J. S 1 0 5 , 1 1 6 , 1 5 3 , 1 5 4 , 1 5 8 ,

v
treatment, 189

167
therapeutic relationship,

S t r i n d b e r g , A . , 30
g u a r a n t e e i n g c o n t i n u i t y of,

S t r u e n i n g , E . L . , 136
180

S u d d a t h , R , 4 7 , 4 8 , 4 9 , 5 7 , 88
therapist:

s u i c i d a l b e h a v i o u r , 6, 2 9 , 1 1 9 , 1 6 2 ,
as " c o n t a i n e r " , 2 0 4

210, 224
g e n d e r of, 2 0 4 - 2 0 5

S u l l i v a n , H . S., 6 0 , 6 9 , 9 4 , 1 0 3 , 1 0 4 ,
as i d e a l i z e d i n t e r n a l o b j e c t , 2 0 4

1 0 5 , 1 1 2 , 1 3 2 , 172
p e r s o n a l f e e l i n g s of, 1 5 , 1 6

s u p e r v i s i o n of therapist, 121,140,
as s e l f - o b j e c t f o r t h e p a t i e n t ,

144-147,172,188,190,193,
203-205

202, 235, 243, 248

s i g n i f i c a n c e o f p e r s o n a l i t y of, 2 0 4

Swank, G . E . , 128,150
therapy:

S w e d e n , 3 5 , 1 1 2 , 1 1 9 , 1 3 8 , 1 6 7 , 214,
d u r a t i o n of, 2 3

215, 216, 242, 244

f a v o u r a b l e r e s p o n s e to, 9 - 1 4

symbiotic dependence, 82-85

f a m i l y , b e n e f i t s of, 1 4 9

m u t u a l , 198
of the f a m i l y of o r i g i n / p r o c r e a t i o n ,

symbiotic needs:
182-184

g r a t i f i c a t i o n of, 192
individual a n d family, c o m b i n e d ,

p e r s i s t e n c e of, 7 5
23

s y m b i o t i c r e l a t i o n , 93
outcomes, 119-125

s y s t e m i c cycle, 89
recent regressive d e v e l o p m e n t s i n ,

systemic family therapy, 71,130,

239

148, 149
s u c c e s s f u l , 9 - 1 4 , 212

and psychodynamic individual

see also f a m i l y t h e r a p y ; n e e d ­
therapy, combining, 185-186
adapted treatment

systemic networks of interpersonal

t h e r a p y m e e t i n g s , 170, 1 7 5 - 1 7 8 , 187,

r e l a t i o n s h i p s , 85
189

s y s t e m i c - s t r a t e g i c t h e r a p y , 127, 129,
avoidance of hospitalization

1 9 5 - 1 9 9 , 201, 246, 248

t h r o u g h , 177

 INDEX 311

first, 181
twins, studies of, 50-52, 88

functions of, 175-176

Tyson, M., 231

Tienari, P., 53, 86, 88, 252

Toohey, M. L., 53,70, 79

Ugelstad, E., 31, 96, 123,167, 193,

Torgersen, S., 52, 88

209, 249, 256

Torrey, E. E, 34,47,48,49,57, 72
undifferentiated schizophrenia, 30

training, for psychotherapy,

unemployment, 161

247-249
United Kingdom, 36, 37, 112,127,

transference, 59, 74, 75, 78, 83,119,

135, 240

180, 193-195, 202-210,

United States, 9,13,15, 33, 36, 37,

221-227, 233, 234

52, 59, 60, 63, 66,70,112,114,

transference psychosis, 6, 7
117,120,127,132,136,178,

transmitter activities, 46, 57,106,

201,239, 240, 253

115,116, 255
University of California at Los

"transmuting internalization", 204

Angeles, 72

treatment organization,
University of Turku, 23, 248

development needs of,

241-252
Van Putten, T., 115

Tsuang, M. T, 36, 39,159

Van Tol, H. H. M 116
v

Tuma, A. H., 120

VandenBos, G. R 121,122
v

Tuori, T, 113,130, 159, 166, 244

Varvin, S., 124

Tuovinen, M., 70
Vaughn, C. E., 72

Tupin, J., 78
Vermont project, 37,135-136

Turku Clinic of Psychiatry, 24,124,

Vinni, K., 239, 240

139,140,142, 177,180,187,
Virtanen, H., 148,149

191,192
Voikan, V. D., 8, 63, 74, 82,103,112,

Turku Mental Health Office, 140,

184, 202, 203

142
vulnerability to schizophrenia,

Turku Schizophrenia Project,

psychodynamic factors, 75

140-159, 187, 192

vulnerability-stress hypothesis, 138

admission clinic, 150

Vuorio, K, 117, 214

development of family therapy,

148-151
Wales, 90

development of individual
ward community, 132,133, 190-195

therapy, 146-148
activities of, 185

goals of, 140-142

passive resistance on, 194

outcome findings, 151-157

as re-created early self-obect

patient cohorts in, 142-144

environment, 192

and prognosis and treatability,

structure of, 144-145, 192

158-159
Washington School, 60,112

psychotherapeutic community in,

Watt, D., 34,165

144-146
Waxier, N., 38, 73

therapy meetings, benefits of, 149

Weakland, J. R , 68,126

Turku University Central Hospital,

Wecksell, J. J., 29

142
Weinberger, D. R 47, 48, 49

312 INDEX

W e l l e r , M P. L , 2 3 8
W i r s c h i n g , M . , 71

W e n d e r , P. H . , 5 3
W i r t , R . D . , 38

Werner, R , 2
Wode-Helgodt, B., 57

W e r n e r , M . , 78
W o l k o w i t z , O . M . , 116

W e s t e r n L a p l a n d Project, 130,138,
W o n g , D . R , 101

253
W o o l s o n , R . R , 36

W e t z e l , N . , 71
W o r l d H e a l t h O r g a n i z a t i o n , 35, 37,

W h i t e h o r n , J. C , 40,190
135, 251

W H O , see W o r l d H e a l t h
Wyatt, R. J., 47

Organization
W y n n e , L . C , 15, 53, 69, 70, 71, 72,

Wiesel,E-A., 47,114,115
77, 79, 8 6 , 1 0 7 , 1 2 6 , 1 8 2 , 246

W i l l , O . A . , Jr., 6 0 , 1 1 9 , 1 9 2

Williams, J., 56,132,152,208

Yale U n i v e r s i t y , 15, 67

W i n e f i e l d , H . R . , 126

W i n g , J. K . , 34, 3 6 , 7 2 , 1 3 5
Zipurski, R. B., 47

Winnicott, D . W . , 203
Z u b i n , J., 95

 Schizophrenia
Its Origins and Need-Adapted Treatment
b y Yrjo O . A l a n e n
With a Foreword by Stephen Fleck and an
Introduction by M u r r a y Jackson

Professor Alanen's book may be the most comprehensive treatise o n

schizophrenia in 25 years.
Stephen Fleck, M.D.

G i v e n increasing and often counterproductive pressure for a 'quick fix' of

psychiatric conditions, Yrjo Alanen's Schizophrenia: Its Origins and Need-
Adapted Treatment is a timely and important contribution. In contrast to the
world-wide trend for simple solutions to complex psychological disorders,
the author opposes reductionist and dehumanizing approaches to patients.

A l a n e n masterfully integrates knowledge on schizophrenia whether it

derives from psychodynamic or biological studies. H e then proceeds to
illustrate h o w this integrated knowledge is the foundation of a 'need­
adapted' method designed to treat psychotic individuals. T h e beauty of
this method, which is predominantly psychotherapeutic and includes family
meetings, is that it can be utilized within public health care systems.

Alanen's clarity of thought in explaining his approach to his patients is

matched with his empathic understanding of his patients' inner worlds
and their familial a n d societal problems. This book includes memorable
case vignettes along with research findings. I recommend this book not only
for clinicians, students and teachers of mental health but also for those i n
public policy who are charged to design effective treatment methods.

Vamik D. Volkan, M.D.

The appearance [in English] of this important book will be welcomed by

all those struggling to deepen their understanding of psychotic mental illness.

Murray Jackson

Karnac Books, Cover illustration

58, Gloucester Road, by anonymous patient
London SW7 4QY Cover design by
M a l c o l m Smith
http: / / www.karnacbooks.com ISBN 1 85575 156 9