Schizophrenia is a chronic terror syndrome
Bertram Karon, Ph.D.
Dr. Karon has been a professor of psychology at Michigan State since 1962. His CV is below.Dr. Bertram Karon’s illuminating article about the necessity of psychotherapy for schizophrenia patients and the harms of treatment with drugs is reproduced here and a pdf version can be viewed or downloaded here. The present content was delivered as a speech upon receiving the first Lifetime Empathic Therapy Award. If you prefer to watch rather than read, the opportunity to do so is on YouTube.
The first 300 pages of my book, Psychotherapy of Schizophrenia: The Treatment of Choice, describes what we know about schizophrenia and how best to treat its symptoms. The last hundred pages describes a controlled random assignment blind evaluation study comparing 70 sessions of psychoanalytic therapy with medication. The finding was that the optimal treatment was psychotherapy without using medication, if the patient, the therapist, and the setting permit. Next best was psychotherapy with initial medication that was withdrawn as rapidly as the patients could tolerate. Psychotherapy plus medication was better than medication alone, but not as good as withdrawing the medication.
Schizophrenia is a chronic terror syndrome. All of the symptoms of schizophrenia are either manifestations of the terror or defenses against it. Chronic terror blanches out most other emotions, which led Eugen Bleuler to the erroneous conclusion that schizophrenics have no affect. Many patients are helped by being told in the first or second session that you will not let anyone kill them.
Schizophrenia is not genetic. 85% of patients do not have a first-order relative who has the diagnosis. Schizophrenia is not primarily a physiological disorder, the disordered physiology is the result of the chronic terror. The physiological changes are the same that everyone experiences when we are terrified. Of course there are also physiological changes which are the effect, usually destructive, of the psychiatric medications.
It is now known that schizophrenics typically have suffered multiple traumas, as well as lesser bad experiences. Most of the traumatic experiences do not get in to the hospital record, but if you listen to the patients you will eventually learn about them. I have never treated a schizophrenic patient whose life as experienced by the patient would not have driven me, or anyone I could conceive of, crazy. People do not get sick because life has been good to them.
Long-term follow-up studies now show that 30% of schizophrenics will get better in the long run, within 25 years, with no treatment, but continued medication will prevent that 30% from ever having a full recovery. Of course, meaningful psychotherapy (and there are a number of ways to do meaningful psychotherapy, not just the way I work) produces much better results. Most patients get better, at least 80%, but it often takes a lot of work.
In 2008 I published a case study in the online journal, Pragmatic Case Studies in Psychotherapy, which is available without charge, of a man diagnosed as a hopeless schizophrenic by all the psychiatrists who medicated him. They insisted that ECT was his only hope, although it probably wouldn’t help him. His wife had the courage to say no, get him out of the hospital, and bring into my office. He was continuously hallucinating, not eating, and not sleeping. After taking him off all medications, and providing psychoanalytic therapy, the patient improved to the point of being able to work at an intellectually demanding job within six months. He continued in therapy to achieve his own life goals of being a first-rate college professor, a first-rate creative intellectual, a first-rate husband, and a first-rate father. I published the case to correct the myth that such patients are untreatable and never get better.
Hallucinations are basically waking dreams, and can be readily understood with Freud’s theory of dreams, with minor alterations. There are no universal symbols but there are frequently used symbols. Schizophrenic hallucinations may occur in any sensory modality, but auditory hallucinations are most frequent because schizophrenia is an interpersonal disorder, and speech is a communication between people. As with dreams, if the patient associates to the hallucination, the two of you will eventually figure out what the hallucination is about. Patients don’t like being told they hallucinate, but they readily discuss voices and other experiences.
Delusions are distorted beliefs. All of us have a more or less organized understanding of ourselves and of our world. You don’t believe that I’m psychotic, and I don’t believe that you are psychotic, because we have the same general understandings, and if we disagree we can explain the basis for our disagreement. If you think the world is flat, you are normal if the year is 1400, you are at least suspect in 2011. The belief is the same; all that has changed is what other people believe. Schizophrenics have had strange experiences. Their symptoms are strange experiences. Their real lives include strange experiences. They do the best they can to understand themselves and their world. They are as realistic as their anxieties permit.
A non-humiliating non-threatening therapist who encourages them to describe their understandings in as much detail as possible will help them discover the meaning of their delusions. Patients do not like the word delusions, but they will abandon them when they discover inconsistencies and better understandings with the help of their therapist, without ever using the word delusion.
Delusions have four major bases. The most common is transference to the world at large of experiences and feelings from earlier in their life, often in symbolic form.
The second is defenses against pseudo-homosexual anxiety, that is, the fear that something means that they are homosexual, even though that is rarely its true meaning. Freud has talked about this. The patient feels withdrawn from human contacts and has a wish to be close to others. In growing up we felt comfortable with peers of the same sex before we became comfortable with the opposite sex, so when we feel withdrawn from everybody, we have an urge to be close to someone of the same sex. The patient wrongly concludes this is a homosexual urge, setting off the delusional defenses. They need to be told that everybody needs friends of both sexes, and this is not a homosexual urge.
The third basis is that some families teach strange meanings of concepts or strange concepts. The patient believes everyone thinks this way, and only in therapy do they usually learn that that is not true.
The fourth basis is the need to have an organized view of oneself and one’s world, as previously described. The brighter patients are apt to have a better organized view and therefore to get diagnosed as paranoid or paranoid schizophrenic.
When you treat any seriously disturbed patient, you will feel scared, because they are scared. You will be confused, because they are confused. In addition they do not trust you enough to tell you even what they do understand. You may also feel angry, depressed, ashamed, or any other bad feeling the patient has.
But if you can tolerate being confused, and if you can tolerate bad feelings, the patients will learn that they can tolerate being confused, and they can tolerate bad feelings.
And if you continue long enough, things will make sense and you will be helpful. The patients will not be turned off because you do not understand everything, but they will be impressed if you understand anything and are helpful with anything, because most of the mental health professionals they have seen have not been helpful.
With every new seriously disturbed patient, I have felt “Who am I to treat this person? I don’t know enough. I have hangups. The patient needs someone who knows more than me. The patient needs someone with no hangups.” But no one knows enough, and there are no therapists without hangups. But if we can tolerate these feelings, and do our best, patients almost always get better. They don’t need perfect therapists, they just need decent human beings, and it is my pleasure to be talking to a group of you.
My wife Mary died in February. She made possible everything good I have ever done, and she did a great deal more that I could not do. It is an extraordinary honor to be recognized by people whom you value and respect. Of all the professional groups with which we were involved, this is the one that she most valued and respected. She did not like professionals who were more interested in impressing their colleagues, or helping themselves professionally or financially than in providing real help to people who need it. All of you are here because you believe in and are furthering treatments that actually help people. She was proud of all of you. So am I.
Thank you for this extraordinary honor.
CV from https://www.msu.edu/user/karon/ (sourced 12/18/2015)
Bertram P. Karon
- Ph. D. 1957 Princeton University
- Research Interests:
- Effectiveness of psychotherapy with schizophrenics
- Effects of discrimination
- Phone: (517) 355-2159
- Office: 108 Psychology Research Bldg
- e-mail: firstname.lastname@example.org
- Professional Employment:
- Research Fellow in Psychometrics, Educational Testing Service, 1952-55
- Intern in Direct Analysis, John M. Rosen, M.D., 1952-56
- U.S.P.H.S. Pre-doctoral Fellow, Princeton University, 1956-57
- Senior Clinical Psychologist, Annandale (NJ) Reformatory, 1958
- Research Psychologist, Philadelphia Psychiatric Hospital, 1958-59
- U.S.P.H.S. Post-doctoral Fellow, Philadelphia Psychiatric Hosptial, 1959-61
- Private Practice, Philadelphia, PA, 1961-62
- Assistant Professor, Michigan State University, 1962-63
- Associate Professor, Michigan State University, 1963-68
- Professor, Michigan State University, 1968-present
- Project Director, Michigan State Psychotherapy Research Project, 1966-1981
My research focuses on the effectiveness of psychotherapy with schizophrenics, pathogenesis (unconscious destructiveness to those who depend on us), and the effects of discrimination. Some general interests include psychodynamics, psychoanalytic theory and therapy, and schizophrenia.
The published work of Bertram P. Karon spans over 40 years. For an chronological listing of his work, click on the following: