[Page 168]

SCHIZOPHRENIA: PROBLEMS AND METHODS OF PSYCHOTHERAPY [*]

EUGENE T. GENDLIN, Chicago, Illinois [**]

I

Later in this paper, I will state five principles for psychotherapy with schizophrenics. First, I want to discuss several problems which schizophrenics, in particular, pose for the therapist. It is really more true to say that these were problems for us, as a group of therapist, in working with schizophrenics. Looking back, we see now that the same problems arise also with parents with children, and with people who do not have a well worked out sense of what therapy is. They arise also with the externalized, defensive, non-inward-looking client who isn't ready to sit down and engage in therapy. In the last analysis, the same problems arise with everyone. Still, I will term these "special challenges in working with schizophrenics."

First, silence. Over and over again we met hours of silence. This was not the kind of silence that we like and are used to in therapy: the kind of silence in which the individual deeply, inwardly explores himself, or feels something relevant and important. That kind of silence is not only easy to stand; it seems important and valuable to us. If the individual talks all the time, then he is not deeply engaged in therapy. Only when he stops to let something "sift down" or "seep in" (whatever you choose to call this inward process), he is really doing therapy.

The silence we met in working with schizophrenics was a different kind. It was a silence of emptiness, of resistance. Sometimes the patient did not know what this—to us a therapy relationship—was. It was an unwilling, not knowing what to do in, kind of silence. Sometimes it stretched for twenty or thirty interviews. There would, perhaps, be one hour in which something did happen, and then, next time, silence again.

Second, whether silent or not, these patients did not develop a sense for the exploration process of therapy. They were not set to ask questions of themselves, to inquire into themselves, work on themselves, come to know themselves, or struggle through what was bothering them. The assumption (which we have not yet formulated well) [Page 169] that is usually shared between the therapist and the client—"I have a problem," or "I have lots of problems," or "I don't like my life," or "I'm not happy with me . . . what can we do about it?"—was missing with these patients. If, for a little while, it seemed as if the patient was talking about something of importance to him in the direction of understanding, or exploring, or improving, or struggling with his person, a little while later that would be gone again. It would be as if it had never happened. There was no continuing exploration set.

Third, the self-propelled process that we were used to did not occur with these patients. Usually this process arises after a certain initial period. At first, I have a sense that I, as the therapist, am "pulling" the process. It is my responses that are bringing the client's attention to his feelings, to something relevant. Then, after a while, as I respond repeatedly to the level of felt meanings or feelings, it moves. The client finds that he is now looking at a new feeling, and he says, "Oh, there is this other aspect." He finds arising in him something that he has always felt, yet never really looked at before. Soon both he and I are following whatever feeling comes up next. When that process stops temporarily, he "scans inwardly," or "sifts inwardly" for a while, and then says, "Oh, and another thing is. . . ." The process becomes self-propelled. It pulls both of us. This, too, did not occur with these patients.

Fourth—and this was a phenomena that happened with great regularity—the patient would reject the therapist. The rejection was not just the give-and-take of interview encounter as we are used to it from therapy. Rather, it was a total rejection of the whole prospect of a relationship with this therapist, seeing this therapist, coming to interviews. It was a more or less total "go away and leave me alone" from the patient, pointed both at the therapist and at the idea of continuing interviews. If these patients had not been hospitalized, and if it had not been possible (and in a sense required) for the therapists to force themselves on the patients, in most cases therapy would have stopped at one time or another.

I was the first therapist in this group to take a patient, and the first to be rejected. I was not, at least then, accustomed to seeing someone who did not want to see me. It had always been the other person's need that was my excuse for being there, for living, for working. He needed me and I had nothing to do with it. Even my specific responses, what I said in therapy, occurred because of what he just said. I was quite used to (and quite spoiled by, as I see it now) the fact that my foundation was always provided by his need. But here was a person who said, "Leave me alone. Go away. I don't want to talk. I talk to some people, but I don't want to talk to you. Aren't there other [Page 170] patients you can see?" Here was a person who did not even want to enter an office with me, let alone have some tense, mysterious, and probably phony thing called "therapy" or "let me help you."

Yet he was our first research patient. He was of the right age, sex, social class and degree of disturbance, and had been matched with a control on all of these points. The whole research would be skewed if we began dropping people who were not cooperative. We would have a group of only those patients who wanted therapy and were outgoing and cooperative. Our findings would mean very little. As a result, when the patient did not want to see me I felt and surely conveyed a great deal of pressure. He had to see me. I very much felt the need to tell him somehow that there was no choice—neither he nor I had any choice. The research design had selected us for each other. There was no way out. But I wasn't used to this. Both as a therapist and as a person, I did not then have any ability to force myself into a situation where I was not welcome.

I slowly learned that there is another reason why I might go to to see someone. It might not be because he needs me, which makes it very easy. Instead, it might be because I want to, because I decide to. The space I take up is in some sense mine, and I can say that I am here because I decided to be here. I know you don't want me to be here, but you stand there, I stand here. This space I take up because I want to. It took me a while to learn that. During this period I would go to see him for just a few minutes, just as much as I could bear—I could bear—and then I would leave again.

This happened repeatedly to almost every one of the therapists. And it is invariably a painful experience. It isn't just that you blame yourself for things you did that may have brought it about. The patient is ill, afraid, and withdrawing. You know that, but it's still painful—particularly painful not to be able to reach out to him for such a long period, when you want to (and not to be able to give up either). And it is painful in another sense: I find that I have a great deal of warmth for the person I am trying to make contact with, and the warmth gets turned back by this rejection. It then has to accumulate again and overcome this feeling.

A fifth special characteristic of these patients is that they are isolated, or disconnected, or out of interaction in a way that is worth talking about separately. It isn't just that they have "this problem" or "that personality content," or "this conflict," or "that difficulty." They are somehow as people cut off. I am becoming increasingly convinced that we should approach this kind of patient from the beginning with a thrust to reconnect him. I now say, at the beginning, something like, "I will get you out of here." "I will do something about this." "There [Page 171] can be a job for you after a while. You'll work here and then we'll get you a job on the outside. You don't have to go back where you came from." I know that where he came from is where he got sick, and the people he lived with are the people he got sick with and became isolated from. I want to bring this message—even though I know it can't be heard completely at the beginning (I think it is heard on some level). The message is: I'll reconnect you to the world and to me, and in a different way than you were before because that failed—there you were isolated. [1]

I think it is characteristic of these people that there is not only this or that specific difficulty. It is not only what the trouble is. As whole persons they have become isolated, cut off, dampened, shut in, silent inside, dulled, and separated from living. Some kind of reconnecting them to us and to the world is needed. For this reason, I think that all our efforts to define schizophrenia—to classify it as a disease entity—will probably fail. Schizophrenia is something that isn't. Interaction isn't. Being alive toward other people inside isn't. Certainly there must be all kinds of chemical imbalances and organismic reactions as a result of this. If we can find chemical means to alleviate these, the individual may be more able to become reconnected. I doubt, however, that there can be a chemical or any other kind of cure without interaction. I think the not being, the absence, the cutoffness of interaction constitutes what we call schizophrenia.

In summary, the special characteristics I mentioned were: a long and empty kind of silence, the absence of an exploration process and the absence of a set towards exploration, the absence of a self-propelled therapeutic process, the rejection of the therapist, and the disconnectedness.

II

In the face of these challenges, a typical therapist reaction would be to try just about everything. Preconceptions and favorite methods that don't work are very quickly discarded. This, more than anything else, has moved us away from a concern with technique, a concern with being "client-centered" or being any other particular way—even from being "therapeutic," to the extent that the word implies a particular method. We have shifted from talking about the optimal response [Page 172] behavior to much more basic and global factors: the attitudes of the therapist, the approach that as one person he takes toward the other person, how to make interaction happen where it isn't. We now see these as much more fundamental variables.

This trend began even before we began working with schizophrenics. Rogers presented a theory of basic "conditions" or therapist attitudes some years ago. Conceptually, this was what I have just described: Rogers proposed that the personal attitudes of the therapist toward the client are basic, rather than "reflection of feeling," or "interpretation," or some other method. But for some years, despite this theory, we continued discussing and practicing quite definite kinds of behaviors. For example, whatever the client said, I would try to sense the felt meaning of what he said and I would respond to that. We held theoretically that there might be any number of other behaviors which would manifest understanding, but in practice we remained within this fairly narrow band of response behavior. Working with schizophrenics taught us a much wider vocabulary of behavior, a much wider range of what one might do, what one might be pushed into doing by one's own feelings and own needs, in order to reach a person not being reached.

I think, and will try to show, that the basic principles are the same as they were. If you look, not at the specific technique or behavior that we earlier asserted, but at why that technique seemed so important, the why is the same for the different behaviors today as it was then.

For example, we felt then that the therapist should not add interpretations, extraneous material, or expressions of his own feelings. Why? Because these are likely to get the client off his track. It is, after all, his process of experiencing, working through, and focusing on himself that makes therapy. Opinions and extraneous deductions distract the client from his inward attention, and, as a result, therapy will not move. For this reason, such responses did not seem to fit into therapy.

However, here is a client who is not on any therapeutic track. In order to make something happen, a therapist can use not only what the client is expressing and going through, but also what he himself, as a therapist, as a person in this moment, is going through, While the client may give me very little to go on, I have all the events going on in me to use in order to make something happen. As I will discuss in more detail later, I still also have the important responsibility to respond to him, especially once I do make something happen.

We also felt that it was not good to answer questions. If a client asked a question, it was typical for the client-centered therapist not [Page 173] to answer it, but instead to pay attention to why he was asking it or to try to reflect the feeling that underlay the asking. Why? Because very often a question would be only indirectly related to what the individual was concerned about. Answering the question would shut off the process before the real point of the question could appear. For example, a client who did not feel understood by the therapist in some important way might ask, "How old are you?" This was relevant only in the sense that it meant: "How can a young person like you understand me, particularly as you just didn't?" If the therapist answered the question, he often shut off the important process which develops from this underlying concern. For the same reason we did not express opinions. The therapist's opinion would get in the way of the further process which often leads to quite different concerns than appear at first.

With these patients, however, I find that I want to and need to bring myself in much more. I need to show the patient where I am. I don't want subverbal cues alone to determine his imagination of what I might be thinking. My tendency now is flatly to answer all questions, showing what is going on inside me, and then very quickly I add, "But why are you asking?" or "Are you asking because of this?" This may seem like the opposite behavior, but the basic principle in both is to bring out his track, to enable him to express where he is. Similarly, I now very often express quite flatly what my opinion is. I then make sure I say after that, "But I don't really know, and besides, I have a feeling that you think something entirely different, and what I just said doesn't fit." I tell him why I think that the opinion I have just presented is probably miles away from what he is concerned about and perhaps must be concerned about before anything else will fit or be pertinent or helpful. I sometimes flatly ask, "Now tell me, why doesn't that fit?" As a result, we then attend to where his concern is and why my opinion doesn't fit. Again, the principle of getting to his process, or enabling him to express his perceptions and work with his feelings, stays the same.

We used to wait for the client. We did this because the client's ongoing process is well worth waiting for. For example, even if I know he will have to talk about a sexual difficulty which he has hinted at, I can wait, because the process is moving. What he is working on now is next; that is what be is now feeling and is now up against. When that is resolved, something else will be next, and then something else. Soon he may be where I have guessed he has to go, and it is now the next step in his process.

With these people, however, it did not work that way. So often there is no ongoing process of this sort. The patient's hints are quite [Page 174] often desperate beggings that someone help him talk about "this thing." If, in the middle of an incoherent jumble, a patient says to me, "I feel like a prostitute," I will respond to that. If I don't respond to it at that moment because I'm not able to or don't want to, I'll come back to it. I need not wait for the patient to raise it again. I will respond not only to this one phrase but to a whole problem area it implies. What I make of it is, of course, my own construction, and I'll tell him that. I might say, "I imagine that you have some kind of important sexual mess there that you're afraid to talk about and that you don't like yourself for. That's what I imagine. I don't really know because you didn't tell me very much. But I wish you would. And if not today, then some other time." And I will bring it up again.

What is the principle of this? Earlier, as now, the principle is: even though I intellectually conclude that he must soon talk about sex, that does not mean that bringing it up now, while he's working on something else, will enable him to deal genuinely with the sexual matter. What will happen? We won't really be working on anything. He will cognitively discuss the correctness of my guess, and eventually we will have to go back to what he was genuinely working upon and work there again. But it is quite different when someone half-helplessly asks please to be responded to on this, which he can hardly stand to talk about, but which, nevertheless, is there for him. It does not hurt such a person to talk about it openly. It is not as though you have "dredged it up" and it might harm him because he is not yet ready to hear it. He already has it. It is not true that he would not have to deal with it had you left it alone. Nor will he deal with it only intellectually. He is dealing with it, and in an intensely painful and lonely way. The question is: will you leave him to deal with it alone, or will you respond to him on it?

Finally, as an underlying client-centered principle (this is only one of the many ways of stating it): we have always wanted to respond to the felt meaning. (I term it the "felt meaning." More commonly it is called "the feeling," though we do not only mean any emotion such as "You're angry" or "You're afraid." Rogers termed it the felt concrete "personal meaning" implicit in what an individual says.) For example, someone may tell you a story about what happened to him. He is working in some sense on himself. This situation that happened is important, and upsetting, and that is all he knows clearly. He tells the whole situation in great detail: "He said this . . . and I said this . . . and then this happened . . . and how could that happen?" Then you respond. What do you respond to? Not to all the details of the situation, but to what that whole situation is for him—what it amounts to for him, how he is in it, what the personal implicit felt thing he is [Page 175] struggling with is—in so far as you get that. Your words point to that, whether you are accurate or inaccurate. You may say, "You felt helpless in that situation, and yet you wanted very much for it to be all right, but you couldn't convince yourself or something." He may say, "No, it's not quite that. It's more like this. . . ." He is focusing his attention on how that feels.

Contrast this with a deductive response. Instead of trying to grasp the individual's felt sense of the reported situation, you use it to deduce what you can about him. From his description of himself or the situation you can tell that he is a given kind of person, and that, under different circumstances, he would react in various given ways. He has deducible general traits. You can correctly deduce many generalized traits of this sort.

I draw this distinction as a horizontal and a vertical axis. Horizontally, from what the individual now says, you can deduce many things he is not now saying (is not now concerned with). Such things are true in general of people who say the kind of thing he is saying. Vertically, the dimension is the depth with which you can point to the felt sense of what he is now looking at. This model may fit any type of therapy, though it would not necessarily be expressed in these terms. Psychoanalysts would say that the interpretation for which the patient is ready, the proper interpretation for now, is one which helps what is just now under the surface, about to "break through." Any other interpretation may be correct, but the patient is "not ready for it" now. Though we use different ways to describe it, we all try to respond to the felt, now ongoing, concrete, momentary process of experiencing. The present implicit felt meanings can thereby be spoken and interacted with.

Again, this principle has stayed the same. However, often with these clients this type of process is not now ongoing. The therapist has to do something to make it happen.

III

With this emphasis on the therapist's use of his own experiencing, some rules or principles are necessary. I will state some of these, though we have not yet formulated enough such rules. We need to differentiate, define, and make much more explicit what we do as therapists, so that we can discuss it, institute research and train people in it. We do not have enough defined words with which to talk about what we do as therapists. Thus the differentiations I will draw are in an area we know well but in which we have no socially standard words.

First, I will describe three levels on which I might respond to another person. I might respond, as I have just discussed, to the very [Page 176] specific felt meaning implied in what he just now says. This is the narrowest level on which I might respond: what he just now says or indicates is going on in him. (If he says nothing, I may still respond to what I sense might be occurring just now.)

On a broader level, I can ask myself, "What is all this about? Where are we? What is this?" (I might mean by "all this" what has happened in the last few minutes, the whole hour, or even the last several interviews.) I can respond to all of this that has happened or that he has been trying to do.

There is a third and even wider source of response, and that is I. I can ask, "What is my response, as a person, to this other person?" We are taught to look least at ourselves, to look least at our personal response to this person in this moment. Usually, our own personal response must be quite strong before we feel it at all. By then it has usually become something upsetting or wrong: "How can I get across?" or "Why doesn't he talk about something important?" or "Why doesn't he talk?" or "Why are we stuck?" At such a well advanced stage of trouble I first become aware of riot going on in me. Otherwise, as long as he is doing something therapeutically relevant, my attention is comfortably settled on him.

To illustrate these three levels: here is a person saying something to which my response might be, "You feel all alone." This is a response on the first level: a response to what he is just now saying, what is now occurring in him. Then I have a sudden realization that, "Oh, yes, that seems to be the point of all of this. He's been sitting there the whole hour, isolated, alone, looking away, talking in his own autistic space, as if I weren't even here, yet in some way reaching out for someone to come and pick him up and take him, touch him, or be with him." That is the second level. Finally, on the third level, there is my reaction of wanting to take him by the shoulders and make him aware that I am here, my wanting to take him out of this autism in some way. I find that these three response levels are always available.

A second principle: there is almost always a positive way of responding to another person's troublesome behavior. In the world the given behavior is self-defeating. It pushes people away, makes them angry, and defeats what he is trying to do. Yet there is a way of looking at the behavior such that there appears in it the implicit positive attempt to live, to reach another person, to express a feeling, to be real, to be a warm, enjoyed person, to satisfy needs. I may not be able to see it that way at first, but I can assume it is there. I can assume that this person who is now pushing me away is, in some sense, reaching for someone. This may seem like my stubborn assumption, but it [Page 177] is a helpful one. I find at the next moment that I can respond to the fear of me that is involved in his pushing me away. Or I may find that I can respond to a way in which we are related which is implicit in this angry pushing me away. Perhaps he is angry at me because I will not stay longer. The hour is over. Initially, it bothers me that he is angry at me. I don't like it when people are angry at me. Now the whole hour seems spoiled. He can't stand limits and refuses to accept my need to go. With a few seconds of attention, however, I can see, in addition to this, that his anger means we have the kind of relationship in which it is important that I stay. It suddenly strikes me that his anger is also an expression of closeness toward me. I now have a very different reaction than my initial one: "I am glad that you very much want me to stay!" I find this powerful reaction only a few seconds later. This kind of reaction fits the patient's experiencing process in a way which carries it forward as a successful interaction.

I do not mean by positive "good" or "nice" (in my example it was anger). Rather, I mean completed as an interaction between two human beings. A great many things these people do (as well as a great many things we all do) are not successful as efforts to interact as persons. However, there is (probably always) the possibility of responding to these behaviors so as to make a completed interaction. Only sometimes do I find this response. Yet, it is extremely powerful when I am occasionally able to make a successful interaction out of one of these self-defeating relationship moves.

Third, I find that it is necessary to go through a few steps of looking at and differentiating my own feelings. At first I may have only a painful, stuck, embarrassed, frustrated feeling that something is wrong. That, by itself, gives me very little with which I can do anything. When I look at it, however, I find in the next second that: "Oh, yes. Why isn't he talking more about something important? That's really what is bothering me." With another moment of attention I then find: "I wish he would." At the first moment I was simply tense and frustrated, and I had nothing to say. A moment later I could have said, "Why don't you ever say anything you really feel? Why do you give me only this junk?" At the third instant, however, I can say, "Why don't you let me hear more from you? I have a strong wish to hear from you. I feel like inviting you to come in much further than you have been doing." It is really the same feeling at all three points, but a few seconds of attention are needed to allow it to unfold. When I can allow myself to attend to the stuck, embarrassed feeling of: "I don't know how to do anything useful here with you," I almost always find in it a whole reservoir of responses, most of them towards the other person.

[Page 178]

A fourth principle, and I think this should be a formal rule: It Is Permissable For Me To Be Foolish. I have discovered that there is only one person in the world who really deeply and strongly cares whether I am very effective and marvelous or whether I am foolish, and that person is I. It does not matter so much to anyone else. Therefore, I do not really need to care so much about it either. I can risk not doing well, or seeming as though I am not doing well. I can afford to take this kind of chance.

This specific rule involves a broader principle: I find it helpful to separate my concern for the other person from my concerns and fears for myself. Once I realize, for example, that I am afraid I will do the wrong thing and be an incompetent therapist, then I can see that I also care for him quite separately from this. My care for him has a different quality. My fear for me constricts me. My care for him is an expansive, freeing feeling. Thus when I find myself hurt, stuck, and constricted, I know I am concerned for me, and I spend a few seconds untangling my own concerns. If I allow these room, I then find: "Oh, yes. He's still there and he's important to me." He is another person. We are not "grown together" in such a way that he has to get well so I can be comfortable with myself. That, it is true, is my concern, but above and beyond that, there he is, a separate person.

Especially in a situation where you are rejected and where, no matter what you do, you sometimes feel foolish or incompetent, it is quite important to let the separateness of the patient emerge in this way. It is a freeing discovery that, because he is separate, I don't really have to get him well. All these felt pressures are really just for me.

I admit these pressures which, I realize, I feel for me. They do not drop away. But, when I realize they are for me, they lose their seemingly great importance. As long as my fears for me and my concern for him are mixed together, the mixture carries all the importance and worth of my professional and personal concern for this human being. I feel I must give such concerns weight. They are my indicators of when I do a responsible job. I am not easily careless or foolish with other people's lives. When I realize the part of my felt pressure which is for me, that part loses its importance. I can afford to play with it, to incur it, to be foolish. Above and beyond these pressures there is left my concern for him. How what I do will affect him, that is important, that isn't something I can be careless about—but, as usually happens, my concern for him doesn't feel constricting and pressured. It feels expansive and freeing. He suddenly emerges as a separate person and I can really care for him.

For these reasons, I think, it is a very important principle to try to distinguish between the feelings and concerns I have for me, and those [Page 179] I have for him. It is this distinction which allows me to be or seem foolish as only my self-image is at stake.

Finally, I want to state a rough formula to summarize all these considerations. By being more expressive, by bringing more of ourselves, we can be even less imposing than we were before. Years ago the principle that we did not want to impose led us to keep ourselves secret. However, we did impose assumptions, pressures, expectations, and preconceptions which we left unstated. The client remained in a half-lonely condition, while we, also in a half-lonely way, kept to ourselves what was going on in us.

The principle of non-imposition still stands. We try to keep separate what is he and what is I. If I can sense something happening in him, a statement of what I feel is going on in him is still the most powerful response. But just as I try to say what is occurring in him, without imposing on it my own feelings and interpretations, so also can I say what is in me separately, without confusing it with him or forcing it on him. I can say it clearly as me, as a statement about myself. I may not be at all sure what he feels. I leave that space empty for him to fill purely as him. By not imposing on his space, I can also say what I feel as me, in my space.