The principles of direct confrontation: Psychotherapy with the schizophrenic patient

A new approach to the use of psychotherapy in the treatment of schizophrenia is offered which challenges many basic assumptions about how best to treat this difficult illness. A clinical consultation conducted by the senior author in Sweden with a 32-year-old woman (Stephanie) with a 28-year history of psychosis is used to illustrate the rationale behind the principles used. Although the consistent character of schizophrenia across cultures is a compelling argument for a biologic basis for the disorder, this should never justify the assumption that the interpersonal behaviors that interfere with the patient's ability to function are so intractable that psychotherapy is useless. The belief that the schizophrenic cannot be helped through psychotherapy is more often tied to the resistance and reluctance of the mental health professional to learn how to use interventions that will be effective in reaching the patient. Most important, the therapist must assume responsibility for change, and, as a result, must do, and endure, whatever is necessary to ensure that change takes place. This principle is crucial when working with schizophrenic patients whose very illness often prevents them from voluntarily entering into a meaningful treatment relationship. The verbatim descriptions of the interventions used by Rosberg in the consultation, accompanied by the analysis of the rationale behind them, illustrates how even the most intractable patient can be successfully influenced by psychotherapy when psychotherapists can overcome their resistance to the treatment process.