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VOL 6, NO. 4, 1980 Individual Psychotherapyof Schizophrenia

by Gaetano Benedetti Abstract

The work of the author and others inthe field of psychotherapy of schizo-phrenia is said to have demonstratedthat understanding the patient re-quires a special therapeutic relation-ship which is different from that inthe psychoanalysis of neurosisbecause it implies an intrapsychicprocess that can be described asfollows: Parts of the ill personalityare introjected by the psychotherapistand parts of his personality areadopted by the patient, as shown bythe fact that the^lreams^and the un-conscious fantasies and striving of thetherapist reflect the anxieties of thepatient, and the dreams of the latterare structured by the inner move-ments of the former, as if there werea partially shared identity betweenthem both. This phenomenon iscalled "identification." Thepsychotherapy of schizophreniareveals realms of existence in whichunderstanding is not only a functionof personality, but also a transforma-tion of personality by the act of beingnear the patient.

A sensitive understanding of a lifehistory which has led to schizo-phrenia does not constitute proof thatsome biological causes were not alsopresent. The recent work of Rosen-thai et al. (1968) has pointed to theexistence of a hereditary transmissionof the illness,1 which is an importantalternative to the etiologkal theoriesof psychological and family influ-ences. An intertwining of psycho-

1The importance of the hereditary fac-tor is, of course, controversial. Accordingto the most recent research of Tienari (inpress), the mental health of the adopted-away offspring of schizophrenics is largelydependent upon the mental health of theadoptive families.

logical influences with biologicalpredispositions has long beenpostulated by Manfred Bleuler (1954)to be at the roots of schizophrenia.2

At the beginning of this century,Eugen Bleuler (1911) theorized thatmany schizophrenic symptoms aredue to the psychological reaction ofthe personality to the unknown pro-cess of the disease. This was the firststep of psychodynamic thinking inmodem psychiatry. The second stepwas taken by Jung (1907), who, atBurgholzli, continued this line ofthought in his thesis that schizo-phrenic symptoms ean4>e-Gured-bypsychotherapy. He stressed the psy-chogenetic point of view. We havediscovered since then that the work-ing through of the psychological "sec-ondary" symptoms can also affect thevery basis of the disease, even its"primary" symptoms (Benedetti1975).

The third step was also taken inSwitzerland by Ludwig Binswanger(1957), who demonstrated that everypsychotic symptom is so connectedwith every other as to form aschizophrenic "world" of its own,which can be explored only by meansof psychological research. It seemsthat splitting and autism, as ManfredBleuler (1972) pointed out, lie at thevery core of the whole schizophrenicpsychopathology, and are its fun-damental symptoms. As the central

2I owe to Manfred Bleuler the conceptthat schizophrenia is an illness caused bythe continuous intertwining of psycho-traumatic life histories and biological pre-dispositions, and 1 am indebted to him forhis constant encouragement of my work.

Reprint requests should be sent to Pro-fessor Benedetti at Kantonsspital Basel,Universitatskliniken, PsychiatrischeUniversitatspoliklinik, Petersgraben 4,4031 Basel, Switzerland.

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events of schizophrenia are a multiplesplitting of the ego (Spaltung) and itsautistic retreat from the world,psychotherapy aims at the creation ofa therapeutic integration of the pa-tient, which does not work on thesocial level alone (as does socio-therapy and social rehabilitation) butgoes deep into the unconscious, sothat within the patient an intra-psychic synthesis can be fosteredthrough the mirror of what happensin the dual patient-therapist field(Benedetti 1975).

Such an integration is attempted bymeans of the capability of thetherapeutic person to enter into theworld of the schizophrenic, usingshared symbols of the patient, thetherapist's creative fantasies, as wellas ego-nourishing dynamic interpreta-tions, all of which stimulate fromwithin the psychotic world thenecessary psychosynthetic forces(Benedetti 1975).

Such psychotherapy is, therefore,that point of integration wherepsychoanalysis merges withpsychosynthesis, and where thedevelopment of the patient and theself-realization of his therapist aresymmetrical phenomena. Only if thepsychotherapist can himself take astep toward his own individualization(individuation, Jung), through the en-counter with his patient, is the latteralso able to construct his new saneworld within that of his therapeuticpartner (Benedetti 1975).

The PsychotherapeuticRelationship in the IndividualTreatment of Schizophrenia

Individual psychotherapy of theschizophrenic patient begins with the"entrance" of the psychotherapist intothe actual situation and into theworld of his partner. "Entrance" is

something that all psychotherapists ofthe schizophrenic ill have experiencedand described, although with dif-ferent words, as something fun-damental. They speak of participa-tion (Sullivan 1962), therapeutic love(Rosen 1953), relatedness (Arieti1955), therapeutic symbiosis (Searles1964), intentionality (Schultz-Hencke1952), identification (Benedetti 1975a,1975b, 1978, 1979),etc. I believe thatsuch a relation is not only symbolic,as is transference, but also symboliz-ing, as is reality itself. Only in thisway can the relationship create a dualworld of experience which goes farbeyond what can be clinicallygrasped, and which also contributesto the "individuation" of thepsychotherapist himself. Entranceinto the actual situation and into theworld of the ill is experienced by thepsychotherapist as a gift given to himby the patient himself and by his ownunconscious, but it can also betrained and stimulated by our medita-tion. This situation of entrance, onceit has arisen, reveals itself on dif-ferent levels, which can all eithercoexist simultaneously or appearsingly.

I shall describe only three of them:1. Therapeutic dreams arise and

show us our unconscious concernwith the patient, as has recently beenso beautifully illustrated by Isotti(1978). They lack the classicaldichotomy between latent andmanifest content, postulated by Freud(1925) for all dreams because theyserve therapeutic communication andcan therefore be used to reinforce it.

The two following examples mayillustrate this:

A patient feared the eyes of histherapist. He felt that he was beinghypnotized and killed by them. Thefollowing night the therapist dreamedthat he saw the eyes of his patient,

which were staring at him. They wereenormous and terrible, as thetherapist's eyes had been in the pa-tient's experience. The therapisttrembled with anxiety, but couldwithstand the look because it seemedto him, in his dream, to be that ofeternity itself. We see here a reversalof the death experience of the patientinto a fearful, but grandiose life ex-perience of the therapist.

Another therapist dreamed:

I found myself together with an in-curable schizophrenic in a gloomy,lonely, and cheerless room. Onlyfew words were spoken. Suddenlyit was as if a curtain lifted; a sec-ond level of reality appeared (thepsychotherapeutic transformationof the phenomenon of a splittingbetween a first and a second levelof symbolization). In a vision ofeternity the patient appeared to meas a hero, as leader of many shin-ing knights charging into infinity.Astonished, I looked at this pic-ture, and I suddenly knew thatboth levels, that of the psychoticreality and that of the transcenden-tal vision were complementary inC. G. Jung's sense of the word.

2. Some negative feelings of thepatient, of which he is not aware andcannot verbalize, are perceived by thetherapist as his own. In this way heexperiences the patient's unconsciousby sensing it within his own being.For example, it can happen that thepatient can realize his own latent ag-gressivity only after his therapist,who has not yet discovered it,wonders about his own aggressivemood, which seems to him to bewithout any cause. In one supervisionI controlled a problematic counter-transference of a therapist, who feltdisgusted by her patient, without,however, finding any reason for it. Iguessed that such a feeling could bethe manifest sign of her capability tocome in touch with some "disgusting"parts of the patient's unconscious.


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After the therapist could, with thehelp of my interpretation, overcomeher anxious countertransference, thepatient (a girl) became conscious of asexual problem, which disgusted her(and no longer the therapist). She(the patient) then dreamed of aloathesome man, whose featuresbecame more and more gross andrepulsive, and who urinated into theglasses of people at the table. At thispoint it became possible to workthrough the patient's sexual distur-bance. But this problem only came tolight through the transient therapeutic"appersonation" (appersonierung)which was no rejection of thepatient's sexuality, but the sign thatthe therapist's unconscious hadmerged with that of the patient, inorder to structure it.

We see also that a psycho-pathological phenomenon becomes,in the therapeutic identification withthe patient, a way of "taking over"his existence. 'Taking over" heremeans that the patient's unconsciousis not discovered by the interpreta-tion of verbal signals, as in thepsychoanalyses of neurosis, but itmust be carried mutually by both thepatient and his therapist in order tobecome articulated. Whereas, inclassical psychoanalysis, transferenceis an alternation of actual reality andmust be shown as such to the patient,mutual identification is the groundfor a dual reality in psychotic autism.It sometimes seems that even theschizophrenic unconscious is disinte-grated, as Freud (1925) himself sur-mised when he spoke of the loss ofintrapsychic images in the psychoticunconscious. This must therefore notonly become discovered, but first beborn as a structure out of the act of aprimary duality which lies at the veryroots of psychic life.

Without a therapeutic "receiver,"the patient's sensations are so far

disorganized, fragmented, deper-sonalized, and derealized that theycan never be transformed into struc-tured ego experiences. They are notsimply repressed as fantasies or af-fects, as in neurosis, but theydisintegrate into parts of sentences, tovoices, and abstruse meanings in thepsychotic world.

3. The autistic schizophrenic sym-bols become, in the language of thetherapist, dualized symbols of insightand communication. They are stillthe old ones, but they are filled withnew life, the identity of the therapist-patient. For instance, a patient whofelt influenced by everything saysnow, in the psychotherapy, that sheis "thrown around" by the therapist'swordsthese are now the "influenc-ing machine" (Tausk 1919), which,however, have a new role, do notpersecute, but protect the patient.

The counteridentification of thepatient with his therapeutic parts bymeans of the acceptance of thetherapist's interpretations appears tobe possible only to the same degreethat the therapist, on his part, iden-tifies with the introjected fragmentedexperiences of his patient. In thepsychotherapy of schizophrenia, thepatient learns to distinguish betweenobject and self, to sense his surround-ings, and to organize his fragmentedego functions by means of thetherapist's allowing himself to be usedas symbiotic object. The recovery orthe improvement of the patient doesnot occur only on the level of adap-tion to social norms by overcomingresistances toward them, but ratheras a change in the therapist himself,in the adapting of the therapist to thepatient and the potential humanity ofhis existence.

The range of psychopathologicalfacts is narrowed by this discovery,as many things, which at first seemto be meaningless in psychosis, ac-

quire significance in that special areaof reality which is formed by themutual introjection and projectionprocesses of the patient and histherapist, as if there were a thirdreality between the healthy one of thedetached observer and the psychotic,irrational one of the patient.

The concept of what is reality,psychodynamically seen, in the dualexperience of therapy defies logicaldefinitions. The point, however, isthat the classical psychopathologicprocesses of appersonation and tran-sitivism become, ultimately, the veryforces of separation between the selfand the world, in that they are usedin the therapeutic symbiosis. But weshould not forget that the verytherapeutic "weapon" of the iden-tification grows out of the knowledgethat therapeutic countertransferencecan also be very harmful, if it doesnot serve the interests of the patient.It has been shown that in the therapyof schizophrenia, the unconsciouscountertransference of the therapistcan be the unconscious cause ofmany behavior patterns of the patient(Searles 1964). This broadens the con-cept of schizophrenia as pure trans-mission or introjection of irrational-ity. Not only the family (Lidz 1968)or society (Basaglia 1968) but alsoour psychiatric unconscious plays arole here. Schizophrenia can also beconsidered as the intemalization ofthe irrationality of all existence.

It is one central paradox of thepsychotherapy of psychosis that ituses the same autistic symbols whichform the basis of the schizophrenicpsychopathology in order to create ameans of communication with the pa-tient. The paradox is also that wepsychotherapists must give up our"delusional possession of reality"(Siirala 1972), our clinical demandsand expectancies, our hierarchicalprivileges of normality, our tenden-


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cies to exercise a cognitive powerover the ill, and our needs to adaptthe patients to ourselvesin order toshare with them the great symbols ofthe psychosis and the desperate at-tempts of the ill towardself-realization.

Therapeutic entrance into the ac-tual situation is in psychosis more im-portant than is the reconstruction ofthe past in the psychoanalysis ofneurosis; it is the therapist's messageto the patient. I must discuss now anobjection to such a personal thera-peutic approach which has beenraised by many authors. Laing (1959)for example speaks of the danger ofan "implosion," that is, the dissolvingof the schizophrenic ego when con-fronted with our emotions. FriedaFromm-Reichmann (1950) also tells usthat any offer of love or friendshipto the mentally ill should be avoided.I agree, of course, with these authorsinsofar as they warn against a super-ficial emotional approach to the pa-tient, which can only be sensed byhim as a demand from us. The matteris different, however, if "therapeuticlove" means our readiness to be withthe patient in his world of death. Ourmessages to the patient convey thatwe do not expect anything from him,that we want only to be with him inhis dreams, fantasies, and terrifyingexperiences.

A therapist, for example, listens toa patient who feels surrounded byscreaming devils; he tells the patientthat he, too, is there; and, by leapinginto the demonic circle, forces the pa-tient to perceive his presence in thevery core of his psychotic world.Another patient relates a frighteninghallucination in which he is over-whelmed by a flood of water. Thetherapist "sees" the deluge, 'la creuxde la vague" (in French also the termfor impending catastrophe), and hebraces himself to withstand this vi-sion. In another case the therapist

relates to his suicidal patient his owndream, in which the latter throwshimself out of the window; in an at-tempt to save her, the therapist runsto the window and can hold her inthe air with his eyes. The patientsaid, after hearing this dream, thatshe was then no longer able to killherself.

I do not deny that even this mutualdwelling in death can be rejected bythe patient. But in my experience thepatient longs for nothing as much ashe does the object of his resistance,his therapist. Only then can the deathwhich has been taken over by thetherapist be overcome by the patient.The patient asks fearfully whether thetherapist is still alive, whether he eatsand sleeps well, whether he still ex-ists, for if the therapist exists, so,too, can he.

My point here is that the therapistdoes not first try to rationalize thesymptoms of the psychotic patient,but wants to be together with himwithin his symptoms. The first stepof the psychotherapy is this dualizedpsychopathology. This was well ex-pressed by a patient who, during herpsychosis, had a terror of the worldas if it were a train bearing downupon her. During psychotherapy shedeveloped a "therapeutic hallucina-tion" in which she heard the therapisttell her to lie between the rails. Sheasked, frightened, how she could dothis. The hallucinated therapistanswered that he would lie betweenthe rails with her.

I call this mutual process "identifi-cation" and "counteridentification,"and I mean that the fragmented pa-tient's ego finds its own identity byidentification with the integrated egoof the therapist.

At the end of this process, thepsychopathological phenomenon of"transitivism" is transformed into anact of psychotherapeutic mutuality.This is shown by the following dream

of a patient, in which an animal laybound in a stall, dying of hunger andthirst. "What good fortune that youhave come to save me in the lastminute," cried the animal to the pa-tient, as she began to cut its ropes. Inthis dream the patient had assumedthe role of the therapist, as it was asif she herself had cut the ropes tosave herself. This identification wasonly possible because the therapisthad often identified with the sufferingof the patient and had thereby ex-perienced himself as the boundanimal.

Interpretation and ResistanceIn the Psychotherapy ofSchizophrenia

Another fundamental point concernsthe problem of psychodynamic inter-pretation. We can reach the core ofthe question by asking ourselves,how we can distinguish betweentherapeutic interpretations inschizophrenia and in neurosis.

1. Interpretations in thepsychotherapy of schizophrenia canhardly grasp the connections of an in-dividual psychogenesis in such an ex-haustive manner that they couldreally explain why conflicts must becarried out by the patient in aschizophrenic way. Interpretationsare, therefore, "operational" innature, in that they do not discover aspecificity of psychodynamics at theroots of schizophrenia. They giverather pictures of the dynamic andexistential situations between the pa-tient and his therapist. They can alsobe formed by therapeutic fantasieswithout, therefore, being untrue,because they unfold in this way thetherapeutic relationship. Interpreta-tions translate schizophrenic processesinto psychogenetic events in order togive to the patient the key to thestructuring of his psychotic ex-


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periences, as they are mirrored backto him by the therapist.

2. Interpretations.are concernednot only with drives and instinctualneeds of the patients, as in neurosis,but also with what I would call"structural needs" of the schizo-phrenic ego. I mean by these theneeds of the patients to distinguishbetween egoic and alien, to grasp thefrontiers of their own egos, to struc-ture associations in time and space,to find an intrapsychic coherence,and so on. To understand such con-ditions demands a new level of psy-chodynamics which does not exist inneurosis, and which must be reachedby the psychotherapist by being withthe patient in the depth of his abnor-mal psychology.

3. The psychotherapy of psychosisis different from the psychoanalysisof neurosis because of the differentemphasis put on the resistances of thepatients.

Freud taught us that we can oftenovercome neurotic resistances bydescribing them to the patient. Thispresupposes a healthy part of the egowhich can work with us and look onthe sick part of itself. Only those fewschizophrenics who are similar toneurotics are able to do this.

Most schizophrenics are so depen-dent upon their own autistic, delu-sional, aggressive, paranoid behavior,that their clinging to their systemsand symptoms is more than aresistance; it seems to be an attemptat survival by means of organizing alast psychotic identity in the vacuumof their "nonexistence."

The patient, for instance, who hasbecome disintegrated by the intra-psychic presence of a "bad object,"projects this upon his therapist byfeeling persecuted by him. In thisway he tries to get rid of the "badobject" in order to experience himselfas a unity. A second autistic patientrefuses a surrounding world which

dissolves him, in order to slip into asafe protected corner of himself. Athird patient, who cannot developany loving connection to the worldand to himself, tries to compensatethis lack with the delusion of love.

It would be naive to assume that itcould be of use to the ill to be con-fronted with the psychodynamics ofsuch phenomena as the knowledge ofthem would be for him only a tinyreality that could not fill the terriblevacuum within himself.

We may, however, reach the pa-tient if we convey to him, throughour interpretations, the feeling thatwe accept and understand his resis-tances as necessary expressions ofhimself which permit us to know hisworld and so to relate to it. We donot merely wish to reduce his resis-tance to psychological mechanisms.

In this connection I remember a pa-tient who idealized me as Godhimself. It was of no use to reducethis delusional transference to the lossof her beloved mother duringchildhood. She maintained that theorigin of her feelings toward me wasthe actual dual reality. The patientwas, however, impressed by my in-terpretation that I felt myself to befor her the mirror of a radiatingmetaphysical sun, which could reachher through me in order to become,later, a part of herself. If such inter-pretations are aimed at putting our-selves into the psychotic world of thepatient, then this psychotic worldmust become valuable to us as amessage of a human longing for per-sonal existence.

The Psychotic Relevance ofThis Work

The essential significance of this workdoes not lie, of course, on a statisticallevel. One is faced with the fact thatin individual treatment of psychosis,

from 2 to 8 hours weekly are needed,so that only a small number of casescan be benefited. We are then con-fronted with the dilemma that either,as in some cases, the clinical resultsof the great therapeutic engagementdo not go far beyond what one couldreasonably expect from the normalcourse of the sickness, or else themedical satisfaction for the healing ofchronic patients, who otherwiseseemed incurable, is counteracted bythe objection that our successful casesbelong to a small privileged group ofpatients, compared with the majorityof schizophrenics.

Of course, suffering people allbelong to the most discriminatedagainst human beings. How can one,however, justify the great efforts ofthe individual psychotherapy of thefew when thousands are excluded?We must realize that the socialbenefits of this work do lie onanother level.

1. The psychiatrist with experiencefrom the individual psychotherapy ofpsychosis develops a sensitivity whichalso enables him to better masterother psychotherapeutic tasks of hisdaily activities, such as short treat-ments, long-term counseling, grouppsychotherapies, single consultations,etc. It has been my experience thatthe knowledge acquired from in-dividual psychotherapy can permeatemany fields of psychiatry, insofar asthey are ready for such influence.

2. A second point lies in the factthat this work with a few patientscan tell us more, from the dynamicpoint of view, about the essence ofschizophrenia than the more descrip-tive form of observing thousands ofcases in a psychiatric institute.

3. Lastly, I would like to mentiona point which goes beyond specificpsychiatric interest. Individual treat-ment is a human challenge to us, andpermits a personal view of the suffer-ing individual, which belongs to the


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great experiences of what the humanbeing is.

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Wechselbeziehung zwischen Patientund Therapeut bei der Psychotherapieder chronischen SchizophrenicPsyche, 18:494-531. 1964.Sechehaye, M.A. Introduction a unepsychothkrapie des schizophrenes.Paris: Presses Univ. de France, 1954.Siirala, M. Psychotherapy of schizo-phrenia as a basic human experience,as a ferment for a metamorphosis inthe conception of knowledge and theimage of man. In: Rubinstein, D.,and Alanen, Y.O., eds. Psychother-apy of Schizophrenia. Amsterdam:Excerpta Medica, 1972. pp. 130-155.Sullivan, H.S. Schizophrenia as aHuman Process. New York: W.W.Norton and Company, 1962.Tausk, V. Ober die Entstehung desBeinflussungsapparates in derSchizophrenic Intern. Zeitschrift furPsychoanalyse, 5:1-33, 1919.Tienari, P.; Lahti, I.; Naarala, M.;Sorri, A.; and Vaisanen, E.Schizophrenics offspring reared inadoptive homes: A family-dynamicstudy. In: Muller, C , ed. Psychother-apy of Schizophrenia. Amsterdam:Excerpta Medica, 1979.

The Author

Gaetano Benedetti is Professor ofPsychotherapy and Mental Health atthe University of Basel, Basel,Switzerland.


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