Faculty Bibliography

Psychotherapy has gained wide acceptance as a primary treatment for nonpsychotic psychological disorders but has yet to find the same acceptance in the treatment of psychosis. One reason for this is the idea that schizophrenia is a genetically determined brain disease unlikely to respond to psychological treatments. A second reason is the difficulty most people have in relating the symptoms of psychosis such as hallucinations and delusions to their own mental processes. This paper relates the manifestations of psychosis to ordinary mental life, and describes how psychotic symptoms arise as meaningful expressions of unbearable psychological pain in the aftermath of adverse life events.

This report consists of the personal reflections of seven frontline clinicians who participated in a formal training program for the psychotherapy of psychosis implemented in a large public clinic setting. The training was part of a quality improvement initiative, consisting of 12 hours of didactic presentation followed by 30 hours of weekly peer-group supervision. The clinicians comment on ways of working with patients prior to the training, and how their views and techniques changed as a result of the training. The reflections of frontline staff provide proof of the concept that psychotherapy for psychosis techniques can be added to existing clinical skills, and that it is possible to implement a program in psychotherapy for psychosis in a busy public clinic.

Objective: The purpose of this study was to determine if persons with a diagnosis of schizophrenia lack insight into their illness because cognitive deficits prevent them from applying an internal schema of mental illness to themselves. The study examines the ability of subjects to "insightfully" classify a series of short, fictional vignettes from a third-person perspective. Method: Investigators wrote 20 one-to three-sentence stories, 11 illustrating subtypes of psychotic symptoms, 3 illustrating non-psychotic psychiatric diagnoses, 3 indicating medical problems, and 3 no illness. The investigators read these stories to a sample of inpatients with a diagnosis of schizophrenia and a random community sample control group, and asked if subjects considered the person in each story to be mentally ill. Results: Subjects and controls were able to make accurate, fine distinctions among medical illness, no illness, and psychiatric illness categories. Conclusions: Patients did not demonstrate a deficit in the cognitive processing of illness schema, yet still failed to relate their own illness schema to themselves. This would encourage further study of the relationship between insight, denial, the mental representation of the self, and the meaning of the "mental illness" label to persons with psychosis

Some clinicians regard psychodynamic psychotherapy (PP) and cognitive behavioral therapy of psychosis (CBTp) as treatments with little in common. An integrated model is presented in which PP and CBTp fit together, with each modality playing an essential role in different ways at different points over the course of treatment. This model is developed by examining a core symptom in psychosis. Psychotic individuals seemingly perceive events in the outside world which are actually reflections of internal mental processes. Instead of experiencing thoughts or feelings, a person "sees" or "hears" things which appear to be occurring outside the self, a " thing presentation" of mental life. Before the unconscious meaning of psychotic symptoms can be psychodynamically interpreted to a person, " thing presentations" of mental life must first be returned within the boundary of the self. CBTp provides the technical means to do this. Once CBTp has helped re-establish connections between psychotic experience and internal emotional life, a psychodynamic perspective becomes increasingly important. In this model treatment begins with CBTp practiced in a psychodynamic frame, followed by a second phase of treatment in which PP bears empathic witness to a person's mental life, nourishing self experience