Psychotherapy and Schizophrenia: The Mirror of Countertransference

The relationship between psychotherapy and schizophrenia has undergone pronounced changes over the last several decades. The advent of psychiatric medication led to remarkable breakthroughs that obscured the existential issues inseparably tied to the lived experience of illness and overshadowed the role of psychotherapy in the treatment of schizophrenia. Recent years have brought renewed scrutiny of the place of psychotherapy in the treatment of persons with major mental illness but much less attention has been shown to matters of countertransference. The complex legacy of loss and grief assumes a special dimension in the therapeutic relationship and touches the lives of client and clinician alike. Both travel a common path and share privileged moments. It is the intersection of these life experiences, and how their confluence shapes the course of therapy that is the focus of this essay.     

Memory and meaning in the psychotherapy of the long-term mentally ill

After a long period when the treatment of major mental illness was under the decisive influence of the biological revolution in psychiatry, there are now growing signs of a revival of the role of psychotherapy in understanding the lived experience of psychotic disorders. Despite increased attention to the subjective world of persons afflicted with severe mental illness, considerably less has been written about the devastating effects of a loss of reality on memory and meaning and about the especially complex ordeals facing therapists who enter into long-term relationships with clients cut off from the past and the future. The ensuing quest for meaning amid the breakdown of memory is the focus of this paper.     

Is it schizophrenia or spirit possession?

This paper addresses the question of whether spirit possession, a concept with a religious/spiritual base, is, in fact, more accurately defined as a major symptom of a mental disorder, such as schizophrenia, and according to the Eurocentric tradition, should be treated with psychotropic medication and psychotherapy. On the other hand, should this culturally determined phenomenon and such alternative curative interventions as spiritual healing be more seriously examined as viable ways of defining and treating mental illness? The way in which the self is defined and understood, within different cultural contexts, is employed to explore the differing ways in which psychotic symptoms are understood and ultimately treated.     

Moving toward recovery within clients' personal narratives: directions for a recovery-focused therapy

Recent literature emphasizes that recovery from schizophrenia involves recovery within one's own narrative of an integral sense of identity, agency, social connection, and worth. While this is intuitively appealing and consistent with a wide range of literature, it raises the issue of how to best help people do this in individual psychotherapy. In this article, we explore how psychotherapy might help people construct new narratives or storied understandings of their lives and thereby promote recovery from schizophrenia. Exemplified with two individual examples, we first discuss the barriers that challenge and the techniques that help psychotherapists seeking to enter into dialogue with people with severe mental illness. We also offer a theoretical model of how the revitalization of dialogues within therapy can be conceptualized as a process that promotes recovery and discuss the objective measurement of such outcomes.     

Time,Knowledge, and Power in Psychotherapy: A Comparison of Psychodynamic and Cognitive Behavioral Practices

Time has long been recognized as a marker of professional control and a tool for the organization of work. Yet we know less about how temporality intersects with experts’ epistemic goals. This article illustrates how the patterning of time in psychotherapy shapes the construction of knowledge about mental illness and how this relationship is mediated by patients’ own interventions. I focus on psychodynamic and cognitive behavioral therapeutic practices and draw on data from ethnographic observations in an outpatient psychiatry clinic and in-depth interviews with psychotherapists. The article details the constitutive relationship between two dimensions of temporality: first, clock time, namely the length of treatment, the length and frequency of sessions, and the flow of the therapy hour, and second, the temporal epistemics of illness, its construction as a phenomenon with a past, present, and future. Clinicians in the two orientations attempt to construct particular temporal landscapes by integrating these two facets of their work. Yet they must always do so in response to patients’ own temporal interventions. By attending both to the organization of professional work and the temporality of illness, this article brings together two largely distinct literatures within medical sociology, namely scholarship on the profession of medicine and social scientific understandings of the temporal dimensions of illness. It shows that temporality is constitutive of how knowledge and power are negotiated in expert work.     

“Let’s Talk About Children” resource: A parallel mixed method evaluation

Psycho-education interventions for families affected by parental mental illness have been found to be effective. This study aimed to assess the feasibility of a psycho-educational resource for parents, designed to initiate family discussions about parental mental illness and educate parents about the impact of their illness on children. In a mixed methods design, 19 parents read the “Let’s Talk About Children” psycho-educational resource and completed pre-and-post questionnaires measuring their perspectives of mental illness and awareness of the impact of mental illness on their children and family. 18 of these participated in a follow-up, one hour, individual interview to obtain further feedback on the resource. After viewing the resource, changes in parents’ attitudes and/or behavior in relation to mental illness and parenting were recorded. Interview findings indicate that the resource gave parents an awareness of the skills and knowledge needed for initiating family discussions about parental mental illness. The results of this study can be used to inform future interventions targeting parents who experience mental illness.     

A Self-Psychological Perspective on Chronic Illness

It is becoming increasingly common to encounter patients seeking psychotherapy for symptoms resulting from chronic illness. Regardless of the specific diagnosis, chronic illness is a phenomenon with deep implications for disruption of self-states and narcissistic injuries. Working with chronically ill patients presents many challenges to the patient and the therapist, ranging from acute grief and loss to a reworking of unresolved developmental issues. This paper explores the use of a self-psychological perspective in the treatment of chronic and terminal illness. Approaching treatment from a self-psychological perspective, psychoanalytic psychotherapy can be successfully utilized in conjunction with supportive therapy.     

Another face of health care disparity: stigma of mental illness

In many everyday situations, individuals with mental illness face stigma that leads to discrimination. A growing body of evidence suggests that those with mental illness experience disparities in health care and that their medical needs are often overlooked. The purpose of this article is to increase awareness to this problem. Fictional vignettes in which individuals with mental illness seek medical care are presented, followed by discussion on the role discrimination may play in the level of care these patients received. To help alleviate disparities, nurses are encouraged to advocate and speak out when they suspect discrimination is affecting the quality of care of those with mental illness.     

Mental illness etiology beliefs among African American men with serious mental illness and their social support networks

Semi-structured qualitative interviews were conducted with 26 African American men with serious mental illness who were consumers of community mental health services and 26 members of their social support networks. All participants were asked what they believed had caused the consumers’ mental illness. Consumer participants most commonly identified chronic life stressors as a causal factor, while social supports most often identified intrinsic factors such as genetics or biology as causes of mental illness. Some support participants believed that unintentional drug use had precipitated the onset of mental illness or had no causal theories. The fact that some support participants could not identify a causal explanation may indicate failure on the part of mental health care systems to engage with consumers’ social support networks and provide education about mental illness and its causes. The implications of etiology beliefs on mental health service utilization are discussed.     

MENTAL ILLNESS AND THE DEMAND FOR ALCOHOL, COCAINE, AND CIGARETTES

This article estimates the effect of mental illness on demand for addictive substances, allowing for structural endogeneity and simultaneity between mental illness and addictive consumption. Results show that individuals with a history of mental illness are 26% more likely to consume alcohol, 66% more likely to consume cocaine, and 89% more likely to consume cigarettes. This high-participation group is also price-responsive, although their price elasticities differ somewhat from those without mental illness. The results provide added justification for higher taxes and supply reduction activities. Furthermore, subsidizing the treatment of mental illness can reduce addictive consumption.(JEL I1 )     

Expert views of children's knowledge needs regarding parental mental illness

Children of parents with a mental illness are at significant risk of developing a mental illness. This risk may be reduced if appropriate interventions are provided that include information and knowledge about mental illness. While there are some interventions for children of parents with a mental illness, research is lacking about the type of mental health information children need and why they need that knowledge. This study presents the perspectives of a purposive sample of international research experts in the field of parental mental illness about the kind of mental health literacy information children with parents with a mental illness need. Twenty-three participants completed a self-constructed short answer questionnaire about the knowledge needs of children of parents with a mental illness. The qualitative data indicates that ‘identifying information’, ‘making sense of parents behaviour’, ‘coping better’ and ‘respecting safety’ are key knowledge needs of children. Given the views presented, these findings suggest that health care professionals should advocate for policies that support individual-, peer-, and family-focused programs driven by strong evaluation and rigorous research. If this is done, children of parents with mental illness may experience ‘myth busting’ of incorrect information about mental illness.     

Mental Illness as a Barrier to Marriage Among Unmarried Mothers

This study explores how mental illness shapes transitions to marriage among unwed mothers using augmented data from the Fragile Families and Child Wellbeing study (N= 2,351). We estimate proportional hazard models to assess the effects of mental illness on the likelihood of marriage over a 5‐year period following a nonmarital birth. Diagnosed mental illness was obtained from the survey respondents’ prenatal medical records. We find that mothers with mental illness are about two thirds as likely as mothers without mental illness to marry, even after controlling for demographic characteristics, and that human capital, relationship quality, partner selection, and substance abuse appear to explain only a small proportion of the effect of mental illness on marriage.     

A Sociological Alternative to the Psychiatric Conceptualization of Mental Suffering

Uncovering both the structural causes and experiences of suffering is a central sociological endeavor. Sociologists study many different kinds of suffering; after all, strife is experienced both physically and emotionally, because of internal factors such as illness, due to external factors such as trauma, and as a result of economic, political or natural environments. In this paper, I address one form of suffering: mental suffering. In particular, I describe the medicalization of mental suffering in biological psychiatry, which focuses on the genetic factors of illness and equates mental suffering with mental illness. The psychiatric concept of mental illness highlights the continuing, crucial role for sociology in both understanding the experience and identifying the structural roots of suffering. Since the dominant conceptualization of mental suffering is as a medical concept, it is vital for sociology to offer alternative explanations and contribute to a multidimensional analysis. The roots of mental suffering are much more than biological; social comparison, social inequality, and other social stressors are equally important etiological considerations. Therefore, a true understanding of mental suffering requires multiple perspectives, and sociological constructs guard against a total medicalization of mental suffering.     

Mental illness, supported education, employment and recovery: Ben's story

Supported education programs aim to facilitate the successful return to higher education for people living with mental illness who may have experienced educational interruptions due to their illness. This article shares the story of Ben who lives with mental illness and his experience of participating in an Australian supported education course. The two authors draw on a qualitative life history approach as they reflected on Ben's experiences of mental illness, educational disruption and returning to education and employment. The losses associated with educational disruption and the positive and empowering experience of becoming a student again are described as positively impacting recovery. Ben's story is shared in anticipation that other people living with mental illness, their family and carers, or workers supporting those people, may draw from his determination and success, in their own journeys of recovery.     

Freedom and struggling openly in psychotherapy: A qualitative inquiry with LGBQ young adults from religious families

Lesbian, gay, bisexual, and queer (LGBQ) young people from religious families are at increased risk of family rejection, poor mental health outcomes, and are overrepresented in mental health services. This article describes a two‐part qualitative study aimed at exploring the experiences of LGBQ young adults from religious families in psychotherapy, identifying positive and negative psychotherapy experiences, and understanding the influence of family and religion on the psychotherapy experience. Data were collected through a web‐based survey (n = 77) and interviews (n = 7) with LGBQ young adults (ages 18–25) from religious families. The study followed an interpretative phenomenological approach. Integrated results found often invisible, relational therapy processes, and religious discourses as significant to LGBQ young people who seek psychotherapy. Implications for future research, effective systemic family therapy practices with LGBQ young people from religious families, and a critique on ethical and legal limits of confidentiality with policy implications are outlined.     

Nursing home admissions and long-stay conversions among persons with and without serious mental illness

The appropriateness of nursing homes for individuals with serious mental illness remains a controversial issue in long-term care policy more than a decade since the landmark U.S. Supreme Court Olmstead decision in 1999 , which affirmed the rights of persons with disabilities to live in their communities. Using national nursing home Minimum Data Set assessments from 2005, the authors compared the demographic, clinical, and functional characteristics of persons with and without serious mental illness newly admitted to nursing homes. They found that newly admitted people with serious mental illness were younger and more likely to become long-stay residents than those admitted with other conditions, despite a higher proportion of residents with serious mental illness, including the elderly, classified as low-care status. The most substantial and clinically significant difference for rates of low-care status 90 days after initial admission are for persons younger than 65 with serious mental illness versus those younger than 65 without serious mental illness (33% vs. 8.5%, or 3.9 times greater). There is a notable difference in low-care status between persons aged 65 and older with serious mental illness and those aged 65 and older without serious mental illness (14% vs. 6.6%, or 2.1 times greater). These results suggest that a substantial number of adults with serious mental illness residing in nursing homes may have the functional capacity to live in less restrictive environments.     

The impact of mental illness on employment: consumers' perspectives

This paper is based on a qualitative study of employment for people with mental illness. Forty-one consumers of mental health services were interviewed to obtain their perspectives on employment. One of the major issues they discussed was the ways in which mental illness affected their employment experiences. These effects were complex and interrelated and varied between individuals depending on their unique characteristics and circumstances. Participants described effects relating to the need to maintain mental health, difficulties with work performance, and work confidence and work goals. Understanding consumers' perspectives on how mental illness affects employment is necessary for practitioners and researchers seeking to explain or improve consumers' employment outcomes.     

Maximizing potential: innovative collaborative strategies between one-stops and mental health systems of care

Barriers to seamless service delivery between workforce development and mental health systems of care have kept both entities from maximizing their potential in regards to employment for job seekers with mental illness who are capable of work and seeking employment. Using a multiple case study design, this study examined the nature of collaboration between workforce development and mental health systems to understand the policies and practices in place to assist individuals with mental illness to find and keep work. The paper presents innovative strategies that involved staff from both workforce development and mental health agencies. Findings from this research identified the following collaborative strategies: (a) the creation of liaison positions and collaborative teams; (b) staff training on mental health and workforce issues; and (c) multi-level involvement of individuals with mental illness. Implications for workforce professionals are offered as a way to stimulate implementation of such strategies.     

Enabling careers, autonomy, and prosperity: Using community organizing and building approaches to improve the educational outcomes of people with mental illness

Objectives: The objective of this regional initiative was to develop access to educational opportunities for people with mental illness with a view to ultimately advancing their career prospects. Participants: The initiative engaged a broad range of community stakeholders including people with mental illness, their families, educators, mental health service providers and, policy analysts. Methods: The initiative used community organizing and development strategies to develop solutions to problems related to access to education. Results: The initiative was successful in mobilizing community participation, identifying priorities, and translating these priorities into action plans. Working groups of community stakeholders engaged in initiatives related to improving access to resources to support education, developing training for teachers in secondary schools, creating peer support systems, and developing a pilot supported education program as a partnership between a college and mental health service. Conclusion: Organized community building provided a foundation for a broad range of initiatives meant to improve access to educational opportunities for people with mental illness. Evaluation efforts will need to focus on the extent to which these initiatives ultimately ledto positive changes in the careers of people with mental illness.     

Mental Illness and Criminal Behavior

The tragic events in Aurora, CO and Newtown, CT have renewed public perception of mentally persons as ‘dangerous’ and ‘criminal.’ Unfortunately, this perception is based more on conjecture and fear than research. The following essay takes stock of the empirical research on mental illness and criminal behavior. Three noteworthy trends emerge from this literature. First, the prevalence of mental illness is substantially higher among individuals who have come in contact with the criminal justice system relative to the general population. Second, individuals with psychotic and externalizing behavioral disorders, particularly those who also abuse drugs and alcohol, tend to engage in higher levels of violence than individuals with other forms of mental illness. Third, mental illness does not determine whether someone will break the law; rather, it is but one of many criminogenic risk factors that interact in complex ways to influence individual behavior.