Clinical Case Studies8(6) 417 –423© The Author(s) 2009

Clinical Case Studies
8(6) 417 –423
© The Author(s) 2009
Reprints and permission: http://www.
sagepub.com/journalsPermissions.nav
DOI: 10.1177/1534650109351930
http://ccs.sagepub.com
Psychotherapy of
Schizophrenia: A Brief History
and the Potential to Promote
Recovery
Paul H. Lysaker1 and Steven M. Silverstein2
Abstract
With growing awareness of the likelihood of recovery from
schizophrenia, interest has
arisen about the potential role of psychotherapy within
emerging treatment regimens. Could
psychotherapy uniquely promote recovery by addressing
symptoms, the achievement of
psychosocial milestones, and/or helping to enhance the extent to
which persons diagnosed with
schizophrenia experience themselves as meaningful agents in
the world? As an introduction to
a set of case studies of how psychotherapy can promote
recovery this article briefly reviews
the history of the psychotherapy of schizophrenia. In particular

the appearance and course
of psychoanalytically oriented treatments, as well as cognitively
and interpersonally based
treatments are detailed. Evidence supporting these approaches
and remaining questions for
research are discussed.
Keywords
schizophrenia, recovery, psychotherapy, psychosis
Recent reviews have suggested that contrary to long-standing
pessimistic views, most people with
schizophrenia do not experience lifelong dysfunction. Instead,
most with this condition move
meaningfully toward or achieve recovery over the course of
their lives (Bellack, 2006; Lysaker &
Buck, 2008; Silverstein, Spaulding, & Menditto, 2006). They
may not only experience improve-
ments with regard to symptoms or function, but also positive
changes in how persons think about
and experience themselves as individual human beings in the
world (Resnick, Rosenheck, &
Lehman, 2004; Roe, 2001; Silverstein & Bellack, 2008). As a
result of growing awareness of this
possibility, interest has arisen in whether some forms of
psychotherapy could play an important
role in treatment. Given literature suggesting psychotherapy
may help a wide range of people
without psychosis to develop both a richer sense of self and a
more adaptive self-concept
(Hermans & Dimaggio, 2005), it is now asked whether it could
do the same for many with schizo-
phrenia and thereby uniquely promote recovery (Lysaker &
Lysaker, 2008).

To explore this question and a wide range of related concerns,
this issue of Clinical Case Stud-
ies is devoted to case studies of the processes by which
individual psychotherapy can promote
recovery. Therapies which range from office to community
based and from existential to
1Indiana University School of Medicine
2University of Medicine and Dentistry of New Jersey,
Piscataway
Corresponding Author:
Paul H. Lysaker, 1481 West 10 street, Indiana University
School of Medicine, Indianapolis, IN 46202
Email: [email protected]
418 Clinical Case Studies 8(6)
metacognitive to cognitive behavioral are presented with the
unifying question of how they are
able to promote wellness. Before beginning with the first,
however, it seems important to note
that any advancement in this area should be considered in the
context of the long and controver-
sial past of the psychotherapy of schizophrenia, a past which,
almost as much as any, contains a
range of of conflicting scientific claims and emotional ladden
debates. To provide a framework
for considering how to think about contemporary developments
in schizophrenia, the current
article first offers a brief overview of the history of the
psychotherapy of schizophrenia and then
highlights some of the continuing points of contention.

The History of the Psychotherapy of Schizophrenia
Often overlooked is that one of the first clinicians to seriously
advocate for individual psycho-
therapy for people with schizophrenia was Jung (1907/1960).
Jung (1907/1960, 1939/1960,
1958) treated many hospitalized and significantly ill patients in
the early part of the 20th century
and contrary to the zeitgeist, argued that persons with
schizophrenia could accept and benefit
from a psychotherapy with certain modifications. Jung
suggested that even the most profoundly
disturbed aspects of illness were connected in some meaningful
way to the life history and self-
concept of the patient. As such Jung asserted that much of the
work of therapy necessarily
involved increasing the patient’s understanding of his or her
self-concept.
Initially though, Jung was alone in this pursuit, as Freud (1957)
had firmly announced that
psychoanalysis with people with schizophre nia was impossible
given that persons with schizo-
phrenia could not form a proper attachment to a therapist. And
psychotherapy for schizophrenia
briefly then vanished more or less once Jung left the Burghölzli
and with a few notable excep-
tions (Fierz, 1991; Perry, 2005), abandoned his interest in
schizophrenia.
In the 1930s and 40s, however, interest in the psychotherapy of
schizophrenia suddenly
appeared in a range of different settings. Psychoanalysts such as
Fromm-Reichmann (1954),
Hill (1957), Searles (1965), and Sullivan (1962) all produced
reports which contended that
meaningful intimate bonds with persons with schizophrenia

could emerge in therapy. They
noted patients with this condition were often eager for treatment
and could utilize the bonds that
formed with therapists as the basis of a movement toward
health. These and other authors pro-
duced a wealth of compelling anecdotal reports suggesting that
persons with schizophrenia
could accept and embrace psychotherapy as a means to make
sense of their lives in a holistic
manner they otherwise could not. Psychotherapy thus emerged
as a treatment that might thereby
help them develop both a healthier sense of themselves as
beings in the world and richer experi-
ences of daily life. As an illustration here is a quote from a
person with schizophrenia about
their experience of psychotherapy offered by Hayward and
Taylor (1956):
Meeting you made me feel like a traveler who’s been lost in a
land where no speaks his
language. Worst of all, the traveler doesn’t even know where he
should be going. He feels
completely lost and helpless and alone. Then suddenly he meets
a stranger who can speak
English. . . it feels so much better to be able to share the
problem. . . If you are not alone
you don’t feel hopeless any more. Somehow it gives you life
and a willingness to fight
again. (p. 221)
While this literature produced a series of interesting though
sometimes fantastic theories of
the subjective experience of psychosis and its antecedents, there
was little scientific evidence
supporting its efficacy. As reviewed in a range of sources,
controlled trials failed to find

significant benefits for psychoanalytic psychotherapy (Drake &
Sederer, 1986). For instance, in
what was referred to as the Boston Psychotherapy Study, more
than 160 adults with schizophrenia
Lysaker and Silverstein 419
were randomly assigned to receive exploratory insight oriented
therapy or a reality based
supportive psychotherapy (Gunderson et al., 1984). Extensive
efforts were devoted to the
training of therapists, the selection of appropriate participants,
assessment procedures and
methods. Nevertheless, the most notable result was a drop rate
of just more than 40% six months
after assigned to treatment and a drop rate of nearly 70% two
years following that. More detailed
analyses of the results of those who remained in the study
revealed some improvements in
insight as well as improvements in negative symptoms among
participants assigned to the more
skilled therapists (Glass et al., 1989; Gunderson et al., 1984).
Beyond the findings of the Boston psychotherapy study, another
blow was simultaneously
dealt to the credibility of at least some psychoanalytic
treatments for schizophrenia. In particular,
a range of approaches to the psychotherapy were based on the
idea that schizophrenia is primar-
ily caused by pathological family dynamics (e.g., Karon 2003).
Psychotherapy, according to this
view was the treatment of choice as it alone could repair the
damage done by caretakers to their
children by too great, too little, or too confusing levels of

involvement. Research, however, indi-
cated that schizophrenia was instead a genetically influenced,
neurobiological brain disorder
involving distortion of basic human experience, one that could
well develop regardless of family
dynamics. Beyond pointing to the reality that families had been
generically blamed without any
basis, the issue here was raised of whether there was anything at
all psychotherapy could offer,
that is, beyond general human support. Drake and Sederer
(1986), for instance likened some
psychotherapies of schizophrenia to the pouring of burning oil
over wounds, a medical practice
that went for centuries without any medical basis. Nevertheless,
when surveyed, 60% of men-
tally ill persons and their families indicated that they were
interested in psychotherapy, a rate that
possibly echoes the finding that three in five participants
remained in the Boston study at 6
months (Coursey, Keller, & Farrell, 1995; Hatfield, Gearon, &
Coursey, 1996).
Following this, and concurrent with the recognition of recovery
as a likely outcome of schizo-
phrenia, a range of new possible rationales for psychotherapy
for schizophrenia have been raised
as well as empirical support for the efficacy of psychotherapy.
Perhaps most prominent among
these involve cognitive behavior therapy (CBT). Originally
created to address depression, the
use of CBT has steadily expanded to address schizophrenia and
other psychotic disorders (Rector
& Beck, 2002). Treatment from this perspective has stressed
that the neurobiological processes
of schizophrenia interact with social, developmental, and
psychological factors resulting in mal-

adaptive beliefs about the self, and tendencies to attr ibute
malicious intentions to others in an
overly rigid manner. CBT thus helps to correct those beliefs
through a systematic, collaborative
process of belief examination and prediction of the
consequences of behaviors and events. Evi-
dence supporting its efficacy includes controlled trials showing
that persons with schizophrenia
are willing to attend CBT and that CBT can reduce
dysfunctional cognitions, leading to reduc-
tions in positive and negative symptoms, and improvements in
psychosocial function (Drury,
Birchwood, Cochrane, & MacMillian, 1996; Gumley et al.,
2003; Lysaker, Davis, Bryson, &
Bell, 2009; Pilling et al., 2002; Sensky et al., 2000).
Diverging slightly from this line of thought, Chadwick (2006)
developed Person-Based
Cognitive Therapy for distressing psychosis, in an effort to
move from a symptom-focused to
a person-focused therapy. Person-Based Cognitive Therapy is an
integrative form of treatment
which draws on cognitive theory, mindfulness, client centered
principles, and a social–
developmental perspective which understands language as a
socially available tool which
persons use to make meaning of their daily activities. This
approach uses cognitive and expe-
riential techniques for working with pervasively negative self
schemata and promoting
self-acceptance and self-awareness. In parallel, case studies by
other authors, have also sug-
gested cognitive behavior therapy for psychosis can address the
personal meaning of symptoms
and psychosocial dilemmas (Davis & Lysaker, 2005;
Silverstein, 2007).

Interest has also increased in using a modified form of
psychoanalytic therapy for people with
schizophrenia. Bachmann, Resch, and Mundt (2003), has
suggested that psychoanalytic psycho-
therapy for people with schizophrenia may beneficially foster
an experience of the self and the
therapist as two separate people that share a relationship,
leading to the stabilization of a sense
of personal identity, and the integration of the psychotic
experience. Some evidence suggests that
such an approach can be helpful, at least for people who are
more clinically stable at the outset
of treatment (Hauff et al., 2002). Rosenbaum et al. (2005) have
also indicated that among more
than 560 first episode patients, those who received supportive
individual psychodynamic psy-
chotherapy or an integrated treatment had better overall
functional outcomes after 1 year of
treatment than those who received treatment as usual.
At perhaps an even larger holistic level, attention has turned to
whether psychotherapy might
promote recovery by helping some with schizophrenia develop a
richer sense of personal identity
as embedded with that person’s unique personal history or
narrative (France & Uhlin, 2006;
Lysaker, Buck, & Roe 2007; Silverstein et al., 2006). Beyond
exploring the validity of a particu-
lar conclusion or response to a particular symptom,
psychotherapy has been suggested as
something that could, as it does for many others (Adler,

Skalina, & McAdams, 2008; Neimeyer
& Raskin, 2000), represent a place where persons develop richer
and more layered stories about
who they are in the present, the person they have been across
the course of their life and what is
possible in the future for them. A deepened personal narrative
might then naturally be an oppor-
tunity for experience of oneself as an active agent who prevails
in the face of adversity. Providing
some support for this possibility are case studies suggesting that
improvements in the richness of
personal narratives may result during the course of individual
psychotherapy of persons with
schizophrenia and may be linked with other indicators of
recovery (Lysaker, Davis, Jones,
Strasburger, & Hunter, 2007; Lysaker et al., 2005), that self
concept is a meaningful predictor of
outcome in both first episode (Harder, 2006) and more advanced
phases of illness (Lysaker,
Buck, Hammoud, Taylor, & Roe, 2006). Finally, in the face of
evidence that many with schizo-
phrenia experience difficulties with metacognition, or thinking
about thinking (Brune, 2005;
Lafargue & Frank, 2009; McGlade et al., 2008; Stratta et al.,
2007), others have suggested that
psychotherapy could promote recovery by helping persons to
develop metacognitive capacity
(Lysaker, Buck, & Ringer, 2007). Just as psychotherapy has
been found to promote metacogni-
tion in persons who do not suffer from psychosis (Bateman &
Fonegy, 2001; Choi-Kain &
Gunderson, 2008; Dimaggio, Semerari, Carcione, Nicolò, &
Procacci, 2007), could it be tailored
to help persons with schizophrenia make better sense of their
own mental states and the mental
states of others and thereby evolve a complex storied

understanding of one’s life? Evidence of
this possibility includes some case studies (Lysaker et al., 2007)
suggesting that psychotherapy
interventions can be used to target metacognitive capacity as
well as empirical studies suggesting
that metacognitive deficits indeed limit personal narrative
beyond the effects of other aspects of
psychopathology and social factors such as stigma (Corcoran &
Frith, 2003; Lysaker, Buck,
Taylor, & Roe, 2008).
Summary and Questions
In summary, the history of the psychotherapy of schizophrenia
contains a series of different
epochs. Most recently we have observed a rise in possi ble
rationales for how psychotherapy
could promote recovery. These include approaches which
address a wide array of phenomenon,
some at the level of symptoms and others at the level of
personal narrative and the quality of
self-experience. Many questions however, remain. Whereas the
efficacy of symptom-focused
approaches are supported in part by randomized trials, more
holistic approaches are still develop-
ing and awaiting more rigorous testing. Beyond that it remains
to be articulated to what extent
the emerging cognitive, dynamic, interpersonal, and
phenomenological approaches differ from
one another. Are there key principles which might unite these in
some ways? Do they approach
the issue of recovery in fundamentall y different ways? Is it

possible that each may be appropriate
for some but not all with schizophrenia? We hope that in the
following set of case studies the
detailed descriptions of the psychotherapy processes may
provide some partial answers to these
questions and push further the development of interventions
which assist persons with schizo-
phrenia to achieve and sustain recovery.
Declaration of Conflicting Interests
The authors declared that they had no conflicts of interests with
respect to their authorship or the publica-
tion of this article.
Funding
The authors received no financial support for the research
and/or authorship of this article.
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Bio
Paul H. Lysaker is a clinical psychologist at the Roudebush VA
Medical Center and Associate Professor of
Clinical Psychology at the Indiana University School of
Medicine. His ongoing research concerns the role
of metacognitive deficits in schizophrenia and
psychotherapeutic interventions aimed at improving func-
tion among persons with severe mental illness.
Nursing research is used to study a dilemma or a problem in
nursing. Examine a problem you have seen in nursing. Provide
an overview of the problem and discuss why the problem should
be studied. Provide rational and support for your answer.
Wk 3 Team - Schizophrenia Case Conceptualization and
Treatment Plan Presentation
Assignment Content
Top of Form
Imagine your team has been asked to present to a group of
counseling interns at a psychiatric hospital to teach them about
the intricacies of schizophrenia spectrum disorder.
Create a case scenario for a client with schizophrenia.
Review the Psychotherapy of Schizophrenia: A Brief History
and the Potential to Promote Recovery article, located on this

week's Electronic Reserve Readings page.
Create a 12- to 15-slide Microsoft® PowerPoint® presentation
to teach the counseling interns treatment strategies for the client
in your case scenario. Include the following:
· Provide a summary of the client's case scenario.
Sarah is a 12-year-old girl who is currently in middle school.
Her parents came into the office to receive assistance due to
having concerns for the client's behaviors and being unable to
identify what is causing her behaviors. Parents state that the
client hears voices and sees things that are not present. Clients
parents tell the counselor that the client states that she sees her
grandfather and great-grandmother who have passed away years
ago. They also allow the counselor to know that the client will
do different things and tell others that someone told her to do it.
Upon meeting with the client, the client allows the counselor to
know that she does see her grandfather, great-grandmother, and
that voices do tell her to do different things. During the session,
the client would look into the distance at times and she
appeared to be focusing on something else or not paying
attention to what was going on around her. When spoken to, the
client was unable to provide information on what was being
discussed.
· Outline the behavioral symptoms the client is exhibiting. 1
slide with speaker notes
· Describe how the behavioral symptoms of the client fit into
diagnostic criteria for each disorder. 2 slide with speaker notes
· Describe possible assessment instruments that may be used
with each client, and explain why this instrument should be
used.
· Describe therapeutic interventions for treating this client.
· Provide a differential diagnosis for explaining why this client
has schizophrenia spectrum disorder and not another psychotic
disorder.

Cite a minimum of three sources.
Format any citations in your presentation consistent with
appropriate course-level APA guidelines.
Bottom of Form

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Clinical Case Studies8(6) 417 –423© The Author(s) 2009