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Letter to the Editor   |    
Specific Techniques for the Psychotherapy of Schizophrenic Patients
David Ray, M.D.
Psychiatric Services 1998; doi:
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by Andrew Lotterman, M.D.; Madison, Connecticut, International Universities Press, 1996, 224 pages, $35

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Dr. Lotterman, who is on the faculty of the Columbia University Center for Psychoanalytic Training and Research, has written a timely book on a difficult subject. As pressures mount for us to see our patients as lists of symptoms that should be specifically medicated away, we, like patients with schizophrenia, are in the process of "deconceptualizing.” In our case, because of time constraints, we are losing the ability to think symbolically about our patients. That is, we are in danger of focusing only on patients' biology gone awry rather than on patients' symptoms and behaviors as the only means they have to tell us their story. Dr. Lotterman skillfully and successfully helps us reconceptualize our understanding of the schizophrenic process using concepts from neurobiology, infant and child development, and psychoanalytic theory.

The book discusses both biological and psychological factors that contribute to the schizophrenic process. Unlike patients with character or neurotic disorders, schizophrenic patients lose the capacity for using symbolic language to describe and reflect on their experience. Schizophrenic patients have difficulty processing sensory, cognitive, and emotional experiences. This difficulty leads to states in which they tend to manage immediate experience by primitive defenses aimed at protecting the vulnerable self from being overwhelmed.

To help clinicians understand the phenomenology of what they experience with schizophrenic patients, Dr. Lotterman reviews and condenses the theories of psychoanalytic writers such as Freud, Klein, Boyer, Giovacchini, Semrad, Segal, and Rosenfeld. He then proposes his understanding of the meaning of the myriad of symptoms, transferences, and countertransference a therapist may come across. He describes the need to help patients relearn how to verbalize their thoughts and feelings and how the therapist can use the countertransference to help patients name their experiences.

After presenting his theoretical framework in the first two chapters, Dr. Lotterman uses chapter 3 to describe the structure of therapy, such as helping a patient to make a commitment to taking medication or to put thoughts and feelings into words rather than act out destructively. Clinical vignettes illustrate the author's points. Chapter 4 addresses the nature of the psychic structure of the schizophrenic patient. Here and in chapter 6, Dr. Lotterman describes the phenomenology of disturbances in attachment, affect regulation, loss of boundaries between the inner and outer world, loss of the capacity to think symbolically, and loss of reality testing. He describes the breakdown of patients' use of symbols into bizarre somatic, perceptual, and sensory experiences.

In chapter 5 he addresses specific therapeutic techniques for working with the patient's loss of boundaries, hallucinations, delusions, pressured speech, ideas of reference, and paranoia. Actual transcripts of sessions are used to illustrate the suggested techniques. In chapter 7 the author writes about the benefits of psychotherapy with schizophrenic patients. They include the ability to put thoughts into words rather than actions, better affect regulation, and changes in object relations.

Parts of Dr. Lotterman's book try to correlate research in neuroscience with psychoanalytic theories and observations. Future research will be necessary to bear out these correlations. However, this is a valuable book for clinicians who work with schizophrenic patients and want to understand the process of this complicated disorder. It is a helpful guide to making thoughtful and appropriate therapeutic interventions. Through Dr. Lotterman's reconceptualization of schizophrenia, we can rediscover the heart and soul of a person suffering from a very difficult illness.

Dr. Ray is assistant professor of psychiatry at the University of Massachusetts Medical Center in Worcester.

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