Ertr

Yrjö O.
Alanen
ISPS ISPS
Ann-Louise S. Silver
Manuel González de Chávez
Editors
AND AND
ITS SyMPOSIA ITS SyMPOSIA
FIFTY YEARS OF HUMANISTIC TREATMENT OF PSYCHOSES

FIFTY YEARS OF HUMANISTIC
TREATMENT OF PSYCHOSES
In Honour of the History of the International Society for the Psychological

Treatments of the Schizophrenias and Other Psychoses, 1956 - 2006.
Yrjö O. Alanen
Editors
TECHNICAL SECRETARIAT SCIENTIFIC SECRETARIAT

Carmen Benavent, ISPS Project Manager Manuel González de Chávez, Chairman
Psychiatric Service I
7535 0 primeras pgs_7535 000 indice 09/06/16 11:53 Página 1
AND

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First published in 2006, by Fundación para la Investigación

y Tratamiento de la Esquizofrenia y otras Psicosis, for its distribution during XV
Internacional ISPS Congreso , Madrid,12-16, June,2006.
www.ispsmadrid2006.com
Copyright 2006 ISPS & Fundación para la Investigación y Tratamiento de la Esquizofrenia y

otras Psicosis.
www.isps.org
www.cursoesquizofreniamadrid.com
Selection and Editorial matter, Yrjö Alanen, Ann Louise S.Silver and Manuel González de
Chávez. Individual chapters, the contributors.
All rights reserved. No part of this book may be reprinted or reproduced or utilised in any
form or by any electronic, mechanical, or other means, now known or hereafter invented,
including photocopying and recording, or in any information storage or retrieval system,
without permission in writing from the publishers.
Further information:
Dr.Manuel González de Chávez
Chief of Psychiatric Service
General University Hospital "Gregorio Marañón"
c/ Ibiza nº 43. 28009 MADRID
SPAIN
Phone +34 91 5868132
Fax +34 91 426 5110
[email protected]
Depósito legal: M-23892-2006

ISBN: 84-611-1029-3
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INDEX
List of Contributors .............................................................................. 7
1 Introduction
Yrjö O. Alanen, Ann-Louise S. Silver, Manuel González de Chávez . . . . . . . . . . . . . . . 11
Part I: HISTORY OF THE ISPS SYMPOSIA
2 Beginnings of the International Symposia for the Psychotherapy of Schizophrenia

Christian Müller . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
3 The First Three ISPS Symposia on the Psychotherapy of Schizophrenia in Cery
(Lausanne) and Brestenberg (near Zurich), 1956, 1959 and 1964
Gaetano Benedetti . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
4 The IVth ISPS Symposium In Turku, Finland in August 4 – 7, 1971
Yrjö O Alanen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
5 The Vth ISPS Symposium In Oslo, Norway, August 13 -17, 1975
Jarl Jørstad, Svein Haugsjerd, Bjorn Ostberg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
6 The VIth ISPS Symposium In Cery/Lausanne, Switzerland, September 28-30, 1978
Christian Müller . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
7 The VIIth ISPS Symposium In Heidelberg, Germany in 30.9-2.10 1981
Helm Stierlin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
8 The VIIIth ISPS Symposium In New Haven, Conn., U.S.A, in October 1984
Ann-Louise S. Silver and Stanley Possick . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
9 The IXth ISPS Symposium in Turin. Italy, in August 1988
Pier Maria Furlan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
10 The Xth ISPS Symposium In Stockholm, Sweden, in August 11-15 1991
Johan Cullberg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
3
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AND
11 The XIth ISPS Symposium June 12.-16.1994 in Washington, DC, U.S.A.

Stanley Possick and Ann-Louise S. Silver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
12 The XIIth ISPS Symposium in London, October 1997
Brian V. Martindale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
13 The XIIIth ISPS Symposium in Stavanger, Norway, on June 2000
Jan Olav Johannessen and Gerd Ragna Bloch Thorsen . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
14 The XIVth ISPS Symposium in Melbourne, Australia, in September 22.-24, 2003
Patrick Mc Gorry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
15 Planning of the ISPS Congress (Symposium XV) in Madrid 2006
Manuel González de Chávez . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
Part II: THE ISPS TODAY
The ISPS gets organized . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
16 The Establishment of the International Society for the Psychological Treatments

of Schizophrenia and Other Psychoses
Brian Martindale and Jan Olav Johannessen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233
17 Development of the ISPS newsletter, website and secretariat
Torleif Ruud . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
18 ISPS in the Age of the Internet
Chris Burford . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
Establishment of Local ISPS activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259

19 Europe
Brian Martindale and Jan-Olav Johannessen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
20.A United States of America

Ann-Louise S. Silver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273
20.B Australia
John Gleeson . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291
20.C New Zealand

John Read, Jim Burdett, Jim Geekie, Helen P. Hamer, Patte Randal,
Dale Rook, Melissa Taitimu . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295
20.D Eastern Asia: The Singapore Chapter
Lyn Chua . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297
4
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INDEX
Breaking the Covenant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301
21.A International schizophrenia research and the concept

of patient-centredness 1988 – 2004
Timothy Calton, Anna Cheetham, Karen D’Silva & Christine Glazebrook . . . . . 303
21.B Commentary on “Breaking the Covenant: International Schizophrenia Research

and the Concept of Patient-Centredness 1988-2004” by Timothy Calton, Anna
Cheetham, Karen D’Silva and Christine Glazebrook.
Brian Koehler . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321
Part III: VIEWS ON THE FUTURE DEVELOPMENT OF THE ISPS
22 My Views for the Future Development of the ISPS

Gaetano Benedetti . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327
23 The Understanding and Treatment of People with Schizophrenia
John S. Strauss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331
24 Towards a deeper integration of psychological and humanistic
values in the psychiatry of psychoses
Johan Cullberg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339
25 The Future of Psycho-Social Approaches to Schizophrenia:
Facing up to the Challenges Ahead
John Read . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343
PART IV: ANNEXES
I.- The ISPS Constitution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355
II.- History of ISPS Board members 1990-2006 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363
III.- ISPS Life Honorary Members. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365
Yrjö O. Alanen, Finland (1994- ) by Manuel González de Chávez . . . . . . . . . . . . . 367
Gaetano Benedetti, Switzerland (1994- ) by Brian Koehler . . . . . . . . . . . . . . . . . . . . 371
L. Bryce Boyer, U.S.A. (1994- 2000 ) by Sue von Baeyerer . . . . . . . . . . . . . . . . . . . . . 375
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AND
Johan Cullberg, Sweden (2003- ) by Sonja Levander . . . . . . . . . . . . . . . . . . . . . . . . . . . 379
Stephen Fleck, U.S.A. (1994-2003) by Ann-Louise S. Silver . . . . . . . . . . . . . . . . . . . . 383

Murray Jackson, U.K. (1994- ) by Brian Martindale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 387
Jarl Jørstad, Norway (1994- ) by Svein Haugsjerd . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 389
Julian Leff, U.K. (2003- ) by Brian Martindale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393
Theodore Lidz, U.S.A. (1994-2001) by Ann-Louise S. Silver . . . . . . . . . . . . . . . . . . . 397
Christian Müller, Switzerland (1994- ) by Luc Ciompi . . . . . . . . . . . . . . . . . . . . . . . . . . . 401
Barbro Sandin, Sweden (1997- ) by Kia Sjöström . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 403
Harold F. Searles, U.S.A. (2003- ) by Ann-Louise S. Silver . . . . . . . . . . . . . . . . . . . . . 407
Helm Stierlin, Germany (1997- ) by Michael Wirsching . . . . . . . . . . . . . . . . . . . . . . . . 411
John S. Strauss, U.S.A. (2003- ) by Ann-Louise S. Silver . . . . . . . . . . . . . . . . . . . . . . . 413
Endre Ugelstad, Norway (1994-1996) by Torleif Ruud . . . . . . . . . . . . . . . . . . . . . . . . . 417
Lyman C. Wynne, U.S.A. (1994- ) by Susan McDaniel . . . . . . . . . . . . . . . . . . . . . . . . . . . . 421
CONCLUDING WORDS
Manuel González de Chávez, Ann-Louise S. Silver, Yrjö O.Alanen . . . . . . . . . . . . . . . 423
NEXT BOOK! . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433
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List of Contributors
Yrjö O. Alanen, Professor of Psychiatry (Emeritus), University of Turku,
Finland
Gaetano Benedetti, Professor of Psychotherapy and Mental Hygiene,

University of Basel, Switzerland
Chris Burford, Consultant Psychiatrist, St Ann’s Hospital, London N15.
Tim Calton, Lecturer in Psychiatry, University of Nottingham, U.K.
Johan Cullberg, Professor of Psychiatry, Stockholm Center of Public

Health, Sweden
Pier Maria Furlan, Professor of Psychiatry, University of Turin, Italy
John Gleeson, Associate Professor, Department of Psychiatry, Melbourne,

Australia
Manuel González de Chávez Menendez, Professor of Psychiatry,

Complutense Madrid University, Chief of Psychiatric Service, University
Hospital “Gregorio Marañon”, Madrid, Spain
Svein Haugsgjerd, Professor, Psychiatrist, Psychoanalyst, Oslo, Norway
Jan Olav Johannessen, Professor, Chief Psychiatrist, Rogaland Psychiatric

Hospital, Stavanger, Norway
Jarl Jørstad, Psychiatrist, Psychoanalyst, Sandvika, Norway
Brian Koehler, Ph.D., Psychoanalyst, Professor of Postdoctoral Program in

Psychotherapy and Psychoanalysis .School of Social Work .New York
University. New York, N.Y., U.S.A.
Lyn Chua, Ph.D., Lyn Chua, PhD. Assistant Professor, Department of

Psychological Medicine, Yong Loo Lin School of Medicine, National
University of Singapore, Singapore
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AND
Brian Martindale, Consultant Psychiatrist, Psychoanalyst, South Tyne and

Wearside Mental Health NHS Trust, U.K.
Patrick McGorry, Professor of Psychiatry, University of Melbourne,

Australia
Christian Müller, Professor of Psychiatry (Emeritus), University of Bern,

Switzerland
Bjorn Ostberg, Psychiatrist, Oslo, Norway
Stanley,Possick, M.D., Associate Clinical Professor of Psychiatry, Yale

University School of Medicine, New Haven, CT, US and Faculty, Western
New England Institute for Psychoanalysis, New Haven, CT .
John Read , Professor, Department of Psychology, Auckland, New Zealand
Torleif. Ruud, Research Director, SINTEF Mental Health Services

Research, Oslo, Norway.
Ann-Louise Silver., Psychiatrist, Psychoanalyst, Columbia, MD, Professor

of Psychiatry, Uniformed Services University of the Health Sciences,
Bethesda, MD. U.S.A.
Helm Stierlin, Professor of Basic Psychoanalytic Research and Family

Therapy (Emeritus), Heidelberg, Germany
John S. Strauss, Professor of Psychiatry, Yale University School of

Medicine, New Haven, CT, U.S.A.
8
INTRODUCTION
CHAPT. 1 PHOTOGRAPHS
Yrjö O.Alanen
9
AND
Ann Silver
Dr. Manuel González de Chávez
10
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1. Introduction
Yrjö O. Alanen, Ann-Louise S. Silver, Manuel González de Chávez
The XVth ISPS congress in Madrid is taking place 50 years after the first
International Symposium for the Psychotherapy of Schizophrenia was held
in Lausanne, Switzerland, in 1956. This stimulated the chairman of the
Madrid organisational committee, Professor Manuel González de Chávez, to
effectuate a history of the ISPS (now The International Society for the
Psychological Treatments of the Schizophrenias and Other Psychoses). He
asked two colleagues who were actively participating in the ISPS activities to
be his co-workers, one from the U.S.A. (Dr. Silver), and the other from the
Northern Europe (Prof. Alanen), both areas known for their impressive role
in the development of psychotherapy of psychoses and the ISPS activities.
We shall first go to Central Europe, the actual birthplace of ISPS. At that time,
in the mid-1950s, two young Swiss psychiatrists, Christian Müller and the
Italian-born Gaetano Benedetti – both around thirty-five years old -
dissatisfied with the predominant ways of treating schizophrenia, decided to
gather together colleagues they knew through their interest and writings
dealing with psychoanalytically oriented treatment of schizophrenic patients.
We are very lucky to still have both of these “founding fathers” among us, in
good mental strength and able to describe for us vividly their memories of the
establishment as well as contents and discussions of the first ISPS symposia,
held in Switzerland in 1956, 1959 and 1964. The number of participants in
these first symposia was restricted (about 30 in each), most of them coming
from Switzerland, Germany and France. In accordance with this, the great
majority of the presentations were given in German or French. It is very
encouraging for us to read Benedetti’s and Müller’s descriptions, including
their continued faithfulness to their original ideas, emphasizing the
significance of the personal commitment of the therapist to his/her patient,
based on efforts to understand the origins of their problems – something
which both of them strongly express at the end of their contributions.
This book has been divided into two sections, the first one describing all the
ISPS symposia arranged until now. The second one, entitled “The ISPS
today,” deals with the establishment of the ISPS as a society in the 1990s and
with the local ISPS activities. To complete this section, we asked some
11
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AND
persons actively engaged in the ISPS activities, among them Professor

Benedetti, to present their views on the future of our association.
The fourth and fifth symposia were arranged in the Scandinavian area, in 1971
in Turku, Finland (chair: Yrjö Alanen) and in 1975 in Oslo, Norway (Jarl Jorstad
and Endre Ugelstad). The development of schizophrenia psychotherapy had
come to have new dimensions, still predominantly based on psychodynamic
understanding. This was very visible in the planning of the programme in
Turku: besides individual psychotherapy and on equal basis, family therapy
and therapeutic communities were included. Another change was the
invitation of several U.S. and British psychotherapists to contribute with their
presentations. The same orientation continued in the Oslo symposium, and a
welcome innovation there was the disappearance of the restriction regarding
the number of participants. In the Swiss symposia the organizers wanted an
intimate discussion atmosphere between the therapists; however, the new
regime also allowed younger and less experienced therapists the possibility to
participate. This had a great positive impetus for their future work.
The language used was now Englis h, very reasonable from the point of view
of the symposia’s larger yield and scope. A disadvantage was the diminished
interest of therapists from Central Europe in the ISPS activities. Despite the
fact that the next two very successful symposia were organised again in
Lausanne in 1978 (Christian Müller), and in 1981 in Heidelberg, Germany
(Helm Stierlin, Lyman C. Wynne and Michael Wirsching), this feature was not
permanently corrected, especially with regard to participants from France.
In Heidelberg different orientations of family research and therapy formed the

largest bulk of presentations, seconded by treatment settings and individual
psychotherapy. It was followed by the first symposium arranged in the U.S.A.
in 1984 in New Haven, Conn., likewise chaired by distinguished pioneers of
family studies on schizophrenia, Theodore Lidz and Stephen Fleck. In his
keynote address Lidz strongly deplored the neglect of psychosocial therapies
that were already visible in the development of American psychiatry. The
psychoanalytic tradition in the treatment of psychoses pioneered in the United
States was still strongly present in this symposium.
The next symposium was held in Turin, Italy, in 1988, organ ised by Pier Maria
Furlan, in cooperation with Benedetti. It became the largest one ISPS has
held to date, with 1300 participants. Four hundred of them came from Italy
and simultaneous interpretation of the presentations was arranged. The
12
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INTRODUCTION
symposium was the first one to have a subtitle defining the main goals of the
organizers: “Approaches to Psychosis: from the One-to-One Laboratory to
the Psychosocial Models.” The presentations gave a very vivid and many-
sided picture of the great interest in different psychotherapeutic activities
prevalent at the end of the 1980s, with emphasis on both psychodynamic and
larger psychosocial approaches.
In the symposia arranged during the 1990s, a gradual change from

psychodynamic approaches to a greater plurality was noticeable, even
arousing some controversies inside the ISPS membership circle. This also
included strivings - with varying success – for integrative contacts with
approaches based on other kinds of starting-points. The amount of
participants of symposia arranged in Europe remained rather high, between
700 and 1000 both in Stockholm, Sweden, 1991 (Johan Cullberg), London,
U.K., 1997 (Brian Martindale) and Stavanger, Norway, 2000 (Jan Olav
Johannessen). In Washington, D.C., U.S.A., 1994 (David Feinsilver) and
Melbourne, Australia, 2003 (Patrick McGorry) it was somewhat lower. The
tradition to give the symposium a subtitle was continued and especially those
of the Washington and London symposia were revealing: “Psychotherapy and
Comprehensive Treatment” (Washington), and “Building Bridges” (London).
In the Stockholm symposium one of the features enlarged on was the

attention to the cognitive-behavioural and educational methods besides those
with psychodynamic basis. This development was continued especially in
London and Melbourne, and new studies emphasizing the importance of early
treatment and preventive activities also came to the foreground. Some
biologically oriented researchers were invited to participate in the program in
Washington, D.C., as well as in Stavanger symposia. However, we experienced
that the endeavour to find integrative viewpoints with each other seemed –
despite our own controversies - to be greater among the psychotherapists
than among biologically oriente d researchers and clinicians. A more
integrated development between psychological and biological standpoints in
the study and understanding of schizophrenic psychoses apparently had to
wait for its time.
In several later ISPS symposia, representatives of the consumer associations

- people living with psychotic illness, as well as those of their relatives - have
been among the invited participants. In the Melbourne symposium, one of the
highlights was the plenary speech by Dr. Fred Frese. He represented the
National Alliance for the Mentally Ill in the U.S.A., and had, himself, recovered
13

AND
from schizophrenia. He is now the Director of Psychology in the clinical service

in which he once was a patient.
For a long time, the international symposia were the only function of the ISPS.
An informal executive committee was formed in the 1970s, its members
mostly coming from the chairmen of former symposia. The most important
function of this organ was to decide on the place of the next symposium, made
in a meeting during the preceding one. The organisation of the symposia was,
in practice, left to the local group, formed and led by a dedicated chairperson
joining the international executive committee.
Even if the symposia in this form had a very important stimulating effect, the
need for more regular and extended activities gradually became obvious.
The idea to develop a broader range of ISPS activities besides the symposia
was expressed by many long-time ISPS pioneers, especially by the perhaps
most dedicated among the members of the informal executive committee,
Endre Ugelstad from Norway, whose untimely death soon afflicted us with
grief.
Parallel with the extending plurality of the approaches, these thoughts

further strengthened, and the need to develop the activities of the ISPS in a
more organised setting became of current interest. In the Washington
symposium in 1994 the idea of developing the ISPS into a society was already
being discussed. The informal executive committee increased its meetings,
beginning to plan the constitution for the society to be established. A draft
for this purpose was prepared by Brian Martindale before the London
symposium and accepted there under his leadership. The established
community was named The International Society for the Psychological
Treatments of Schizophrenia and other Psychoses, thus emphasising the
broadening scope of the objectives and activities of the new society. A formal
executive committee was elected in a meeting open to all the symposium
participants. However, the letters ISPS were maintained as the emblem and
a shortened sign of the society, thus retaining the continuity and reminding
us of the roots of the society.
The most important part of the broadened functions soon became the
establishment of local ISPS branches in individual countries in different parts
of the world. As described in our book, the development of local activities has
varied greatly until now, being very active in some of the countries and hardly
begun in many others.
14
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INTRODUCTION
Looking at the present situation, the more comprehensive psychotherapeutic

approach, also including orientations outside of the original psychodynamic
starting-points, has been generally adopted by the ISPS. Together with the
development of more integrated therapeutic approaches, this seems very
reasonable. However, the study by Calton et al. on the distribution of the ISPS
symposium abstracts from 198 8 to 2003 to categories representing different
psychotherapeutic orientations, included in our book, is apt to give rise to
concern: are we going too far away from our original goals and convictions?
We should not forget the starting point of all genuine psychotherapeutic work
with schizophrenic and other psychotic patients – whether it is based on
psychoanalytic/dynamic or cognitive/educational approaches, or whether its
object is the individual patient or the interactional network around him: It
should be based on an empathic and understanding approach to the problems
of the people we are treating, and on endeavours to help their growth as
human beings and to increase their interpersonal and social capabilities.
The need to promote psychological and humanistic approaches, as opposed to

the still dominant way to restrict the treatment of psychoses one-sidedly to
drugs, was strongly expressed, in different forms, by the ISPS members whose
views for the future of the ISPS were asked for in our book: these being one of
our two “founding fathers,” Gaetano Benedetti, two dedicated representatives
of the older ISPS generation, John S. Strauss and Johan Cullberg (all of them
Life Honorary Members of the ISPS), and one very active representative of the
younger ISPS generation, John Read. Another common emphasis in their lucid
texts was the hope to develop the ISPS into an even more important and
influential global centre for the study of psychotherapeutic treatment
approaches to schizophrenia and other psychoses than what it is now, both in
theory and practise.
We hope that these views can guide us to work in the further strengthening
of the ISPS and its activities during the coming decades.
Yrjö O. Alanen, M.D.

Vähä Hämeenkatu 3 C 54
20500 Turku, Finland
E-mail: [email protected]
Manuel González de Chávez, M.D.

General University Hospital “Gregorio Maranón”
c/Ibiza 43, 28009 Madrid, Spain
15

AND
Ann-Louise S. Silver, M.D.

4966 Reedy Brook Lane
Columbia, MD 21044, U.S.A.
16
7535 1a parte 01_7535 001-08 01 09/06/16 11:52 Página 17
AND

In Honour of the History of the International Society for the Psychological Treatments of the
Schizophrenias and Other Psychoses, 1956 - 2006.
PART I:
HISTORY OF THE ISPS SYMPOSIA
7535 1a parte 01_7535 001-08 01 09/06/16 11:52 Página 18
 
CHAPT. 2 and 3 PHOTOGRAPHS
Gaetano Benedetti and

Christian Müller, during III
Symposium
Auditorium First Symposium

Laussane 1956
19
 
AND
Margarite Sechehaye
Symposium 1956
Christian Muller
(on the left) and
Gustav Bally
Symposium I
20
7535 1a parte 01_7535 001-08 01 09/06/16 11:52 Página 21
Book of II Symposium
21
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AND
Symposium 1956
Ludwig Binswanger speaking
Gaetano Benedetti
Symposium 1956
22
 
2. Beginnings of the
International Symposia for the
Psychotherapy of Schizophrenia
Christian Müller
[Originally in German. English translation by Philip Isenberg. This paper, as well the next one
by Benedetti, are reproduced, with the revisions made by the authors, from Gaetano Benedetti
und Christian Müller: Psychotherapie der Psychosen. Schriften der Blum-Zulliger-Stiftung
Bern zur Geschichte der Psychoanalyse, Nr 1, edited by K. Weber, 2001.]
The first of these Symposia took place in 1956 in Cery/Lausanne. When I

recalled that time and read the lectures of that colloquium, I was once again
immersed in the very special and enthusiastic atmosphere of that period,
including the years between 1945 and 1950, in which we participants
concluded our basic psychiatric education. What were our theoretical
positions, our interests and convictions?
We came from a time in which our predecessors in Switzerland had

developed methods of therapy that today would be called "biological” –
insulin therapy, electroshock,1 the sleeping cure. The two Bleulers, father
and son, were the undisputed masters of our profession. And I see a
particular quality of Switzerland in the fact that it was above all psychiatrists
with a psychodynamic concept who were interested in these treatments. I
will mention only two: Prof. Jakob Klaesi in Bern and my father, Professor
Max Müller. Even today, it seems to me that this connection of the two sides
was the expression of an openness toward everything that was interesting
and toward anything that might perhaps improve the tragic destiny of
schizophrenics who were herded together in the psychiatric hospitals of the
era. The existential analysis (Daseinanalyse) of Binswanger and Boss





23
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AND
interested us, even left its mark on us, but for the temperament of us young
psychiatrists, all of these theories were too philosophical and too far
removed from practice.
And how did things stand with psychoanalysis? It was of course always
current in Switzerland, more so than abroad, but it was condemned to a
nearly subversive and clandestine existence. I was not the only one of my
generation who had to do his training analysis in secret without the
knowledge of the chief. But this hiding was for us also a reason for
enthusiasm, and in a small way, it also belonged to realm of opposition
against fathers.2 What was taught back then? A psychopathology that was
strongly influenced by Jaspers, the differential diagnosis between organic
and functional psychoses. Psychopharmacology was at its beginning. Our
daily work was the examination and correct description of the patients, the
meticulous recording of clinical histories, the reports, then the injection of
the soporifics for the sleeping cures, and the special nutrition of patients
who refused to eat.
And the psychotherapy of psychoses? We had a vague idea about the

pioneering work at the beginning of the century under the influence of Eugen
Bleuler. People such as Alphonse Maeder, Sabine Spielrein, Karl Abraham,
Johann Jakob Honegger, and, above all, Carl Gustav Jung attempted, on the
basis of Freudian ideas, to see the sense in schizophrenic symptoms,
whether they were hallucinations, delusions, autism, or dissociation. We
hardly read the writings of these predecessors. They had disappeared from
our field of perception, for reasons that are easily recognizable: their
attempts to approach the psychoses did not have any ascertainable effect at
the practical level. They were intellectual efforts, to understand, to explain,
to interpret, without any great significance for the fate of the patients.
At the time of our training in Zurich and Lausanne, however, two authors
appeared whose publications immediately fascinated us and filled us with
enthusiasm. They were two Swiss women, Gertrud Schwing3 and Marguerite
Sechehaye,4 both of whom had worked in private practice as psychoanalysts







24
 
Beginnings of the International Symposia for the Psychotherapy of Schizophrenia
with schizophrenics, one in Vienna, the other in Geneva. That challenged us

to be active with our patients, not to lose heart if our interpretations did not
get to them, to dedicate a great deal of time to them. What emerged above
all from Ms. Sechehaye was the attempt to correct the deficiency from which
the patient was suffering through that which she called symbolic realization
(réalisation symbolique; Sechehaye, 1947).
A third bombshell shook up the tranquil sleep of the clinical psychiatrist who
was satisfied if his patients were calmed by the sleeping cure or insulin
therapy. That was the book by John Rosen (1953) about direct analysis. He
promoted an active – I would say virtually overwhelming – penetrating,
aggressive attitude, a battle with the patient, an active participation in the
drama of the psychosis, an identification of the therapist with that which the
patient projected in him, mother image, father image, and so on, and all of
that excited us and stimulated us to the highest degree. Of course, we would
later experience that the concepts of Ms. Sechehaye, like those of John
Rosen, were not flawless, and today we would no longer be able to blindly
accept them. But during the years 1952-56, in Zurich and Lausanne, we
tested these theories with eagerness without any difficulties being able to
deter us. In Burghölzli, in Zurich, colleagues were bubbling with enthusiasm
in their activity during sessions with one patient, they kept contact with him
under horrible conditions, accompanied by screaming, acts of violence,
stereotypies, rejection, and so forth with regard to the sometimes half-
naked, agitated, swearing, shrieking patient in a cell. To put it briefly, it was
a truly heroic atmosphere in which the attempt was made to maintain
contact with an autistic patient at any cost. I later attempted to portray the
results of these bold and fascinating endeavors in detail in an article (Müller,
1961). They sometimes ended with a spectacular improvement in the
condition of the patient.5
As a consequence of those experiences, the idea came to me to bring

together in discussion all those in Switzerland and abroad who were
interested in this new approach. My friend Benedetti, whom Manfred
Bleuler had sent to the USA for training with Rosen, was at once completely



25
 
AND
keen on the undertaking, and together we began to organize these

Symposia. That was in 1955-56. Benedetti was working at the time in Basel,
and I was a senior physician under Steck in Lausanne. With regard to the
situation from which we started out, Benedetti wrote in 1991, “We were
dissatisfied with the predominantly organicistic orientation of European
psychiatry and had sought the aid of psychoanalysis... First and foremost, it
was necessary for us to clear two misunderstandings out of the way. The
first of these was that the psychotherapy of schizophrenia was nothing
more than an intensification of the habitual contact between doctor and
patient, made up if compassion, benevolence and conscious responsibility,
and not a commitment which requires from the therapist a serious and
complex preparation, both theoretical and practical. The second
misunderstanding was that psychotherapy was just one of many methods to
which one can recourse when the others have to be unsatisfactory.”
(Benedetti, 1992).
If today, nearly sixty years later, I take the documents and correspondence
in hand, I cannot help but feel a certain pride for my courage and
enthusiasm. Organizing an international conference with the participation of
colleagues from Germany, France, and England was something new both for
myself and for psychiatry in Lausanne. What nerve, for a thirty-four year-old
whippersnapper to turn directly to the greats of European psychotherapy
and invite them to Lausanne! I organized and wrote invitations to Racamier,
de Saussure, Lebovici, Mitscherlich, Binswanger, and others, all the while
keeping up my duties as the senior physician who was responsible for half of
the hospital, the men’s section (at that time, the patients’ sections were still
divided by sex). It was a great help that Benedetti and I formed a
homogeneous duo whereby with time, he dedicated more time to theory
while I was more occupied with the organization. In a letter of October 4,
1956, he wrote to me, among other things, “Dear Christian, the entire weight
of this symposium rests upon your shoulders while I’m having a fine and
relaxing time in Sicily. But I hope to be able to make good again next time,
because I greatly hope that this gathering will be the first of an entire
series.”
Benedetti was right, the Symposia would continue to this very day. The
response was very favorable, the publication by Karger was a success, and
three years later, in 1959, we met in the German-speaking part of
Switzerland, in Brestenberg, and in 1964 again in Cery. Each time, the
number of participants increased, and soon the problem no longer consisted
26
 
of finding lecturers, but rather having to hurt feelings by rejections.

Symposia then followed abroad: in Turku, Finland and in Oslo, Norway, then
back to Cery for the third time in 1978.
As at any conference, they included enthusiasm and disappointments,

rivalries and jealousy, and numerous memories of particular episodes
remain. For instance, when the grande dame of Freudian psychoanalysis,
Frau Kestemberg, came into conflict with the grande dame of family therapy,
Frau Selvini, in the lecture hall at Cery. Frau Kestemberg asked Frau Selvini
why she always wanted to be right. “Because I am right,” was the response.
Another episode occurred in Heidelberg, where my friend Helm Stierlin had

organized the Symposium. I had been invited to give the introductory lecture in
the great historical hall of the university. While I was speaking, someone
suddenly stood up, pushed his way through the rows to me, and began to speak
in a delusional manner. It was a schizophrenic who had mixed in with the public.
Stierlin and I attempted to convince him that he should not interrupt the
meeting. That was one very lively and direct encounter with our topic.
On the same occasion in Heidelberg, Stierlin spoke of the twenty-five years

that had elapsed since the first Symposium in Cery. He said that the child
had grown up and its character had changed, it had learned English and had
become more capable of traveling. “I don’t know whether this child has
developed in accordance with the wishes and expectations of its fathers.
Without a doubt, this Symposium has for many become something
respectable and attractive.” In actuality, the ISPS (The International Society
for the Psychological Treatments of the Schizophrenias and Other
Psychoses) which today organizes the Symposium for the Psychotherapy of
Psychoses, has members throughout the entire world, sections in many
countries, and everything that belongs to a modern institution; even the
website is not lacking. In the beginning, it was the forty of us; that has now
turned into several hundred.
And I, the father, have become the grandfather or even the great-
grandfather. We founders have been named as honorary members and have
received medals. If someone gets medals, though, does that mean that the
act is over, the curtain falls, and one is ready for the daisies?
How do I feel about this development, am I proud of it? Yes or no? Yes,
because with the predominance of “biological” psychiatry, it is important
27
 
AND
that an international organization actively maintains and defends the

psychodynamic point of view. No, because precisely that ideal which
Benedetti and I pursued at that time no longer has the same meaning as it
did back then. Let us understand each other correctly when we speak of
psychodynamic thinking. I do not want to simply refer to the writings and
ideas of Freud, but rather to an attitude. I would like to characterize this
attitude as follows: it is about not just describing the phenomena of the
illness, but rather understanding its sense, its meaning for the patient. In my
instruction, I have also always tried to arouse inquisitiveness about what this
“loss of the sense of reality” means, what the emergence of “madness” (and
I use this old word intentionally) means in the life of the patient, because I
am most deeply convinced that only the tireless efforts for understanding
also give us the possibility to create lively human contact with the patient. It
is not sufficient to organize that which today is called “community-based”
sociotherapy so that the patient can be integrated or can remain in a social
network. No, that is really not enough for me. Furthermore, I think that what
is essential in the process of a therapy with the schizophrenic is the
unconditional personal commitment of a therapist who, starting from that
which he has understood about his patient, attempts to deal with him in a
different manner than what he has experienced up to that point. It can be
called “correcting experience,” which seemed to me to be a very essential
thing during the entire period of my work. This type of personal
commitment, that is my “credo,” the flag that I will hold up as long as my
strength allows.
References:
Benedetti, G. (1992). From the first to tenth international symposium for the psy-
chotherapy of schizophrenia. In Psychotherapy of Schizophrenia: Facilitating and
Obstructive factors (ed. by A. Werbart and J. Cullberg), pp.15-27. Oslo:
Scandinavian University Press.
Müller, C. (1955). Über Psychotherapie bei einem chronischen Schizophrenen.

Psyche 9:350-369.
Müller, C. (1961). Die Psychotherapie Schizophrener an der Zürcher Klinik. Versuch

einer vorläufigen katamnestischen Übersicht. Nervenarzt 32:354-368.
Rosen, J. N. (1953). Direct Analysis. New York: Grune & Stratton.
28
 
Sechehaye, M.A. (1947). La réalisation symbolique. Nouvelle méthode de psy-

chothérapie appliquée á un cas de schizophrénie. In: Revue suisse de psychol. e
de la psychol. appliquée, supp. 12. Bern : Huber. (In english: Symbolic Realization
A new method applied to a case of schizophrenia. New York: Internat. Univ. Press,
1951).
Christian Müller, M.D.

Herrengasse 23
3011 Bern, Switzerland
29
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3. The First Three ISPS Symposia

on the Psychotherapy of
Schizophrenia in Cery
(Lausanne) and Brestenberg
(near Zurich), 1956, 1959 and
1964
Gaetano Benedetti
(Original in German. English translation Philip Isenberg)
The history of the International Symposium on the Psychotherapy of

Schizophrenia began during the early 1950s. An important impetus was the
collaboration with my friend and colleague, Christian Müller, in Burghölzli,
the internationally renowned university psychiatric clinic in Zurich.
Encouraged by the benevolent support of Manfred Bleuler, then medical
director of the clinic, we undertook the first psychotherapeutic attempts in
this difficult field which, at that time, was so controversial.
What was opening up there was a fruitful and encouraging time of

collaboration all the more so considering that the pharmacological therapy
was still very much at its beginning and the pioneers of a psychotherapeutic
approach to schizophrenia could with complete justification refer to a purely
biologically oriented psychiatry as being impotent.
At that time, we established a dialogue with young, open, non-dogmatic

psychiatrists from different countries who were capable of demonstrating
enthusiasm. We wanted to exchange our experiences and to mutually
provide each other with stimuli and inspiration.
In the wake of the relocation to Lausanne of Christian Müller, who became

an important representative of our matter of concern in French Switzerland,
it seemed to us that the time had come for a first symposium. The results
were reflected in the number of interested participants and in the high
quality of the discussions, and thus the groundwork was laid for two
31
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AND
additional symposia in subsequent years which took place in Brestenberg,

Switzerland and then again in Lausanne.
In the attempt to bring alive old memories of the collaboration with you, I
looked through the journals of the first three symposia which Müller and I
edited between 1956 and 1964. They reflect that time back when our
Symposium was always held in Switzerland, either at Cery (in Lausanne) or
in Brestenberg (near Zurich) and was based upon relationships that were
still personal or would soon become so.
A photo album which I kept at that time helped me to recall the faces of
friends and acquaintances. In the intervening period, many of them have
passed away or, like Christian and I, have gotten older.
If I were now to attempt first of all to indicate what it was that first and
foremost radiated from those Symposia, then I would begin with two
impressions: firstly, what struck me upon rereading was the enthusiasm
that Christian knew how to arouse in all of us, an enthusiasm that resulted
not just from the main speakers, but also from the discussions that were
also printed. This enthusiasm, which never ceased to be critical,
nevertheless had a quality that was youthful, fresh, and persuasive – as if it
were possessed by people who understood themselves to be innovators – yet
also seized the older participants.
Let us turn, for example, to the words of the venerated Ludwig Binswanger
(Photo) with which he inaugurated the discussion at the 2nd Symposium:
For me, the penetration of the psychotherapy of schizophrenia into

psychiatry signified the second great event in my more than fifty years of
collaboration on the history of psychiatry. The first, of which the current
situation vividly reminds me, was the onset of Freud’s psychoanalysis. (L.
Binswanger, 2nd Symposium, p. 25.)
As early as the First Symposium, a remark from Helmut Bach of Berlin

placed similar emphasis:
If I now extend my comparison to the measures for treatment, then I may

well begin with the idea that today, Freud would probably have long ago
departed from his thesis of the therapeutic inaccessibility of narcissistic
illnesses.
32
 
The First Three ISPS Symposia
The hope of having found in the psychotherapy of schizophrenia a key to the

healing was so great that there was no lack of voices that wanted to avoid a
pharmacologically induced remission of the psychosis before the
psychological healing. In that regard, I turn to the words of one of the great
psychotherapists, Adelheid Fuchs-Kamp, whom I visited many years later
along with my wife in a Berlin old age home and who then, even in the last
years of her life, radiated such a human aura that her neighbor at the table,
as she told me, always wanted to eat a bite from her plate. Here is her
remark (Fuchs-Kamp, Volume 2, p. 157):
With regard to this therapeutic goal, I had to direct my efforts from the
very beginning at avoiding a remission under all circumstances, which in
this case to which I essentially wish to refer would not have been easy to
achieve. The remission loomed as a possibility even worryingly soon
during the first days of the stay in the clinic. The fact that such an objective
poses particular challenges is something that you will be able to
appreciate since in psychiatric clinics in general, a remission is looked
upon as an optimal result, to be viewed virtually as a cure of a psychotic
episode. A true cure, for which I strove for A., was only to be hoped for if I
were to be successful under all circumstances in keeping up the drive to
live that had first chaotically broken down in the psychosis, in order to be
able to use it fruitfully with the patient.
But in this regard, the wise voice of Walter Bräutigam (3rd Symposium, pp.
185-86) certainly makes a more critical emphasis:
The question appears to be whether one can still accept the responsibility
today of not actively and somatically treating an acute psychotic. For the
patient, the period in the psychosis is in any case a time of great fear,
unproductive strain, and a time with thoroughly humiliating experiences
for his self-consciousness.
The second prominent feature of the Symposia was the disclosure of a new
image of the schizophrenic person, the disclosure of a deeper relationship to
the patient which – although it was indeed prepared by Bleulerian psychiatry
which emphasized that which is human and by Daseinanalyse (existential
analysis, which was the first to speak of a “world” of the schizophrenic
person) – was also understood in this context in psychoanalytical terms.
Freud and Jung, Bleuler and Binswanger, all of them, each on his own level
of thought, viewed schizophrenia in psychological terms; none of them,
33
 
AND
however, had placed the relationship to the patient in the focus of attention
to such a degree and made such demands as was now occurring.
Whether it was “symbolic realization” or “relatedness” that was spoken of,
whether “basic trust” or the “constancy and reliability of the relationship”, a
new wind was blowing everywhere.
At this point, I will let some of the advocates of this “great change” speak:
(Silvano Arieti, 2nd Symposium, p. 9) [English in original]:
I could say that it is a communication with “the naked and native dignity of
man.” The patient must acquire a feeling of reliance and trust. In normal
development the mother-child relation engenders what has been called
basic trust: a complex, interpersonal feeling which consists of the
expectation, on the part of the child, that the mother will be there to give
and love; and of the taken for granted idea, on the part of the mother, that
the child will grow up to be a normal and worthy and loving person.
In the therapeutic situation the patient must experience something

reminiscent of this basic trust, as perhaps he never experienced. This
trust must be conferred by the simplicity, strength and forwardness of the
therapist, not by his solicitous benevolence. In some cases the patient
needs to lean and cling, to be talked to for hours and hours. The therapist
has the feeling he has to perform almost a psychological blood
transfusion. The needs of the patient may be so great, as to be indeed
impossible to satisfy if we adhere to our schedule or to the conventional
ways of private practice.
And already at the first Symposium, Marguerite Sechehaye stated [French

in original]:
I have always regretted having entitled my book Réalisation symbolique

[Sechehaye 1947, engl. Symbolic Realization, 1951], because the apples
that I gave to Renée were not a symbol of mother’s milk but rather the
mother’s milk itself. It was not a symbol, but rather a “magical, pre-
symbolic participation.”
P. C. Racamier, however, presents a slightly differentiated opinion (1st

Symposium, p. 130) [French in original]:
34
 
I also think that in the relationship with the schizophrenic, the dialectic of
the gift and of the frustration is a fundamental given. Genetic studies show
us that the child succeeds in grabbing hold of the object – that is, reality –
and the make-up of his person only through an alternating series of
gratifications and frustrations that are literally founders of reality.
Systematically frustrating the schizophrenic or systematically gratifying
and satisfying him are two perfect ways of pushing him into his alienation.
The slightly differentiated opinion of Gustav Bally also places a similar

emphasis (Bally, 2nd Symposium, p. 219) (Photo):
In that regard, too little consideration is paid to the fact that the patient is
not just, nor even first and foremost, a little child or an infant, but rather
at the same time an adult who throughout his life had constantly been
confronted with situations with which he could not cope. For that reason,
the sole granting of infantile satisfactions seems to me to be unbalanced.
If it is not supplemented, it provides the patient with too little support.
Without a doubt, included in this support is reliable care that corresponds
to the care that may be expected from a devoted mother. But, as Stierlin
correctly emphasizes, “non-yielding solidarity” includes not just the
willingness to soothe the patient, but also a certain restraint. For the
schizophrenic patient, the analyst must present a pattern of behavior; that
is, with his behavior show real possibilities of association. He can only do
this by means of a steady, steadfast constancy.
Indeed, here the clear boundaries are shown between, on one hand,
therapists who placed the fulfillment of impulses in the forefront with
regressed schizophrenics and, on the other hand, those who also
considered the grown-up person of the patient and did not idealize the
countertransference.
The first group includes Marguerite Sechehaye whom, as a result of her

prominent role in all of the Symposia, I quote once again (Sechehaye, 1st
The more regressive the schizophrenic, the greater the importance of

these paraverbal factors. By means of these, the therapist achieves his
first objective, which is to move the patient from the autistic state he is in
to a symbiotic state with his analyst. Or, as Biswanger would say, “moving
the patient out of the world of solitude and abandonment into the dual
35
 
AND
world of love and warmth.” To do so, it is essential that the schizophrenic

perceives, right from the outset, that his psychotherapist is coming to him
with the boundless devotion and love of a mother for her ailing child.
But S. Lebovici should also be mentioned at this juncture (Lebovici, 2nd

When countertransference is underpinned by a profoundly positive

attitude, when the psychotherapist’s insight enables the introduction of
valid psychodramatic counter-attitudes, it seems to us that the
psychotherapy is moving in the most favorable direction for these
patients. It is gratifying, without catering to the patients’ masochistic
demands. Such therapy is simultaneously direct, gratifying, and fulfilling.
We believe it must be studied as an original tool.
The giving manner is formulated with “love”, with loving care (F. W. Beese,
3rd Symposium, p. 132):
We would like to assume, although as a totally preliminary impression,

that what is actually effective in individual psychotherapy is the
completely general loving care for the patient; however, we can only
make this understandable and accessible to him by our understanding
his language by our including ourselves under the circumstances in his
psychosis.
But what is therapeutic love? In that regard, let us listen to the words of
Martti Siirala (Siirala , 1st Symposium, page 309):
With regard to the problem of love in therapy, I wonder whether this term
has not again and again been hypostatized by different ideals that we have
and whether love is not actually something that does not flow from us to
the patients but rather consists of the fact that we remain loyal and steady
in the situation with the patient. All of our ideas about love fall apart again
and again and we experience something completely different than we
expect, and we discover that in the occurrences between the patient and
ourselves, hatred and bitterness horn their way in over and over again.
And furthermore from Fritz Meerwein (Meerwein, 1st Symposium, p. 153):
Precisely by the therapist not demanding any healing from the patient, he
provides him, without speaking of it, with the trust that the possibilities for
36
 
healing lie within him, the patient, himself, and thus only then will he take
him seriously.
An essential aspect of the general tendency consists of the fact that the
illness is not so much divided according to nosological criteria, as classical
psychopathology has done, but rather much more considers the affect of the
patient and his transformation into this affect.
Thus, even a colleague who is competent for schizophrenic defective states,

such as Raoul Schindler, can say (Schindler, 2nd Symposium, p. 281):
If your experiences up until now agree with mine, if the defect

represents an image of transformation of the total personality that can
only be specified with difficulty, and if variations occur not only in a
downward direction but also, so to speak, upward, then, ladies and
gentlemen, we actually no longer have any justification in adhering to
the term “defect”, even if only through our silence. We can only
understand it historically as an unfortunate attempt to reduce the
schizophrenic illness to the conceptual range of a psychology of
elementary functions.
The significance of the affectivity of the patient, which makes communication

possible, was emphasized in nearly all of the lectures and discussions
precisely as a contrast to the old teaching of the inability to empathize. Thus,
we hear from Marta Eicke (Eicke, 3rd Symposium, p. 80):
Whatever leads a patient to accusation, dramatic delusions, silence, or

verbal incomprehensibility, I attempt to elicit from these statements the
affect content, I attempt to test the statement for its communicative
quality... I thus offer him what I have experienced from patients without a
particular statement on my part. The patient thus no longer then
introjects something foreign or a reaction of his partner which would lead
him to further depersonalizations, but rather he only still introjects that
which he himself already is and which thus for a moment becomes
identical with himself. By virtue of the fact that I do not ascribe any
interpretations beyond the content of that which has been verbalized, I
also draw from the doctor-patient dialog the dangerous possibility that
unconscious emotions on my part that influence such interpretations
could then be introjected by the patient.
37
 
AND
All of this was not just a plain theorizing way of thinking. In a series of
impressive case histories, for instance from Winkler, Fuchskamp,
Bister, Herner, Neumann, and others, the healing significance of the
intense relationship to individual patients is presented in a documentary
fashion.
Of course, a fertile polarity appears between the rather philosophically
thinking psychiatrists who, like Siirala or Storch, regarded schizophrenic
illness within the framework of a split in existence or who used this illness
as an opportunity for a view of the societal psychopathology, and other, more
clinically oriented colleagues who, like Bräutigam or Schindler, brought out
the specific disease character of the illness.
Siirala, for instance, said:

The splits therefore appear to pervade our entire coexistence, indeed, the
communal body. They are the same splits that we find in our
schizophrenically afflicted fellow men and yet they affect us differently. They
are, as it were, more difficult to combat, because even in our task of healing,
no agreement prevails with regard to the existence of such a collective
illness – and otherwise, very, very few people seem to have any idea about it.
Or the same author once again (Siirala, 2nd Symposium, p. 217):

For me, schizophrenic psychosis – to put it briefly – is a “challenge” to a
new reception – after an unsuccessful attempt at an existential solution.
It shatters the order of the state of existence that was in effect thus far for
those who could not accept any more room for development in that state.
Existence sounds itself out anew. That which was threatened by
petrification calls for a battle. What, then, is crucial in that situation?
Protective boundaries must oppose the chaotic, autism must be met with
warmth and spontaneity, the defenses must be met with understanding,
respect, and the careful reconciliation of absolute opposites. That which is
hidden and that which is offensive require tolerance, gentleness, and
above all a vigilant sense of the search for contact that is manifest therein.
Regressive behavior leads to the warmth of the nest and the instinctive
feel for a genuine childhood that is suitable for the adult.
Or from Wilheln Kütemeyer (Kütemeyer, Volume 2, p. 87):
The view has, however, irrefutably been of an illness of society that is not
just called this way metaphorically but is real, if the usual relationship of
38
 
the mentally ill person and the doctor, of the patient and those around him
at all becomes reversed: from behind the failure of the schizophrenic, an
intellectual capacity and sensitivity emerges, greater than that which is
“normal”, and out of the mental immaturity of the patient, a cosmopolitan
attitude surfaces – with respect to a deeper and higher world than that of
the usual reality – in which the patient becomes the master of coping with
existence for the “healthy.” In that context, we must judge whether it is
really our movement and our action, whether it is our receptiveness which
makes this gradation of the depth of the phenomena visible for us which
gives rise to this development and change for us.
Schindler, however, expresses a different opinion (Schindler, Volume 3,

p.133):
“Schizophrenia, then, is alas not a strange way of life, however, but rather
an illness, that is, an onset that can be described of changing occurrences
in a personality that up to that point had been experienced as integrated.
It is also not a neurosis which, through elaborate circumventions or
supplements of the ego, grants to the fulfillment of desires an illusory
satisfaction that is continuous in meaning, but rather a change in the
totality and structure of the ego itself, as the relatives correspondingly
attest with their observation of a personality change that has occurred and
which even expresses the Bleulerian term of schizophrenia, as Stierlin,
for his part, has impressed upon us.
The fact, though, that the schizophrenic, in the language of his disease,
expresses our own even existential conflicts and symbolically speaks our
language was recognized, for example, by A. Storch (Storch, Volume 1,
p.231):
There are final human questions which, even where the patient does not
actually ask them, are nevertheless expressed in the symptoms of his
illness: questions about human existence in this world, about life, death,
and the hereafter; about the proto-opposites of good and evil, of God and
the devil. They are the fundamental questions of all religions,
philosophies, and poetry which in the end are certainly unanswerable. It is
also not about theoretical answers, but rather about showing the patient
who is disarranged or deranged from our world paths that make possible
for him the acceptance of the world and of his own being. Everything
depends upon answering genuinely and truthfully to the patient who, in
39
 
AND
distress, poses such questions. Only then do we fulfill the task that has
been assigned to us as psychotherapists.
An important modification of the psychoanalytical technique in the treatment

of schizophrenic patients emerged in numerous lectures and discussions in
the 1950s. While many authors – it seems to me to be a minority – still
worked closely with interpretations, others recognized that the symbolic
game, the psychodrama, the gesture, the so-called “latent therapeutic
response” (Hull) played a role in the therapy that was not inconsequential, if
not often downright decisive.
It was above all Herbert A. Rosenfeld, representing in this context the entire
Melanie Klein school, who worked with interpretations similarly to my
former teacher, John Rosen. At the 3rd Symposium, he stated (Rosenfeld,
Volume 2, p. 202):
Through the interpretation of the negative transference and the ideal
transference, the relationship to the analyst becomes more real, that is,
less psychotic. With this, I do not mean that the psychotic transference
stops absolutely, but rather that a connection is formed between patient
and analyst where outside of the psychotic transference, a non-psychotic
one exists. This non-psychotic “line of understanding” between the
analyst and schizophrenic patients is sometimes narrow and uncertain.
But it is important to recognize this opportunity of understanding between
the patient and the analyst and to make use of it. This is especially
important for the analysis of acute schizophrenias.
Christian Müller replied (Müller, Volume 2, p. 218:
Dr. Rosenfeld has again and again drawn attention to the great
importance of interpreting and, in so doing, used the term “interpreting”
in evident connection with the spoken word. I nevertheless wonder
whether the term “interpretation” ought not to undergo a broadening
within the framework of the psychotherapy of schizophrenics, namely, in
the sense that it no longer be restricted to verbal communication. We
have heard from Lebovici how important the gesture is for clarification,
for symbolization, and how often an essential fact becomes accessible to
the schizophrenic only in the carrying out of a miming motion. I
consequently believe that an exquisitely interpretive function can be
inherent even in the gesture. It has indeed already been very correctly
stated that it is often difficult to decide whether the schizophrenic
40
 
understands and hears the same thing in the word that we pronounce as
we have in mind. And the gesture is of course subject to the danger of a
false interpretation by the patient. But practical experience shows that
it is possible to express that which is specific somewhat more by acting,
which is not to be immediately equated with acting in the
psychoanalytical sense or with symbolic wish fulfillment.
Racamier likewise expressed his opinion (Racamier, Volume 1, p. 145)

[French in original]:
Every analyst since Freud has wanted his or her patients to express,
rather than suffer from, their conflicts and their torments in ordinary
analysis. The ritual of the therapy promotes verbal expression and
prohibits action. With a schizophrenic, this ritual is impossible and would
be harmful, and the prohibition of action, if it is to be obeyed, must be
more active and stricter. With the schizophrenic, it is not enough to
interpret; it is necessary to act, but obviously to act in a comprehensive
manner.
At this point, I will cease with the reminiscences and quotes. The three
Symposium volumes, edited by Christian Müller and myself, with their
articles have transported us to a time in the past that was filled with
fascinating new beginnings, and I must repeat how much this early
collaboration shaped my thinking. But how could I better bring my remarks
to a close than with a leap into the present where, more than forty years
later, I described the psychotherapeutic position in the matter of
schizophrenia upon receiving the Margrit Egner Award in Zurich in 1999?
My words show how much of those earlier beginnings has remained in my

life’s work.
This is now both the old and the young Benedetti who is speaking to you. In the
attempt to represent the valid therapeutic position in the psychotherapy of
psychoses thus far, I would like to briefly formulate three dimensions:
1. The manner of understanding

2. The affective closeness
3. The positive distance
These three keywords shall be further explained below.
41
 
AND
1. The manner of understanding is multilayered. It corresponds first of all to

the therapeutic need to understand every behavior of the patient in its hidden
motivation and to check the causal chain of its conditions. It requires
patience in view of the motivation of the patient that is deeply unconscious
and only decipherable in several attempts at understanding. It also requires
curiosity in the inexhaustible exploration of the unconscious, as well as the
courage to venture one’s own psychodynamic hypotheses in order to clearly
see a completely sensible clinical picture.
Creative therapeutic ideas and projections of one’s own symbols do not

distort the objective form of the illness because they increase this
intersubjectively and the dual dimension of existence even opens up in the
psychopathology. The manner of understanding means the readiness of the
therapist to introject defended and separated feelings of the patient in order
to consciously experience them in substitution and to return them,
transformed by his own experience, to the patient. Within this context, it also
means the ability to track down the patient’s possibilities for development
that lie hidden in his psychopathology, to shed light upon them, and to
support them against any possible resistance. Finally, I would like to
mention the “cognitive respect” for the psychosis. Nothing is so incapable of
empathy in its language that it would not also be unique and individually
stimulating to us, and no hour of therapy is so boring in its recidivism that it
cannot every time offer something as new and unexpected as life itself.
2.The affective closeness to the psychotic patient, which Arieti calls

“relatedness”, has already been represented for many years by
psychoanalysis, even in the treatment of the severely neurotic patient, as a
partial possibility. Along with Cremerius, I cite the “principle of emotional
experience.”
I myself see the affective closeness above all else in that capability of the
therapist for partial identification with certain sides of the psychotic person
that do not seldom appear in the manner in which we dream about our
patients and which makes it possible for us to go through the situations of
dangers in symbol, fantasy, and dream, situations which the patients are at
the mercy of, without our being threatened by such closeness.
If the therapist is not threatened by the affective closeness and the partial
identification that results from it, but rather is only “existentially
challenged”, then he can create progressive representations of coping out of
the negative images of the psychosis and can convey them to the patient.
42
 
Affective closeness is consequently a source of imagination and the

formation of symbols. It is the origin of that “double nature” of the
therapeutic imagination that, on one hand, follows the metaphorical
language of the patients, thus accepting it seriously and without
adulteration, and, on the other hand, brings about a positive change through
its own symbols.
Affective closeness is in conflict only in dialectical terms with rationalizatin,

with conceptually articulated interpretation, with expansive reflection.
3. The Positive Distance

Every person, admittedly including the psychotherapist, has his problems
and conflicts. Does he know them? Has he dealt with them? In the first place,
the therapist’s conflicts that have existed and been dealt with create that
special sensitivity which is important for the deeper understanding of the
psychosis and which I also would like to designate as a “positive affinity” for
the illness. In the second place, on the other hand, they weigh upon the
relationship, especially if they remain unconscious to the therapist without
supervision. Then the patients are faced with those introjections (for
example, the unconscious therapeutic aggressivity) that are not experienced
by him as such but rather as his own impulses (Searles). Thus in every case,
that attentive and constant self-examination and self-consciousness which
Sulllivan has already emphasized is necessary with the therapist. It works in
the inverse direction of closeness, it creates that intersubjective distance
which protects the encounter from any danger of mutual entanglement and
lends it rather the expansive breadth of reflection. This fundamentally holds
true for any psychotherapy, but especially for the treatment of psychotic
people whose “ego boundary” is fragile (Federn) and whose symbiotic
potential is high in spite of all autism.
Positive distance correspondingly means that the therapist learns to work

“free of countertransference” in certain situations. Freud expressed early on
that the best analyst is the one who can work without countertransference.
Today, on the other hand, we know that countertransference is an important
engine of the relationship. If, however, it is understood in the more narrow
original meaning as a projection of earlier unconscious experiences upon
the patient, and if such experiences are of the negative variety, then they can
weigh upon the therapeutic relationship. Let us think, for instance, of the
feelings of helplessness or of boredom which may exist in the face of
stubborn psychotic resistance with the therapist if he himself has to deal
43
 
AND
with a depressive fund of his own life. His self-knowledge and self-
meditation, however, are capable of producing once again that agreeable
attitude of the calm distance that resolves any mutual mixing of the
problems.
An attitude of positive distance also means that the therapist controls the
manner and the degree of the affective closeness that connects him with his
patient according to the latter’s needs and can often be adapted to the
patient’s fear. For example, should a therapeutic dream that does indeed
shed light upon a problem and spread optimism be communicated or be kept
silent? In a certain situation, can a decisive statement be ventured? Behind
the “technical problems” which are then to be discussed hovers the attitude
of the therapist which is a cause of the fact that sometimes, interpretations
that may appear similar can have different results, depending upon the
character of the therapist.
I would like to close here. The first three Symposia were the point of
departure for a pioneering development in psychiatry and made me decide
to remain loyal to the project of the psychotherapy of schizophrenic people
for half a century and to dedicate the majority of my therapeutic and
scientific energy to it.
44
 
References
The literature of all of the lectures cited in the text is contained in the three cited
Symposium volumes, edited by G. Benedetti and C. Müller. In addition to these, I
would also like to mention additional works by Peciccia, Navratil, Searles, and
Sullivan.
Benedetti, G. and Müller, C. (eds.): Internationales Symposium über die

Psychotherapie der Schizophrenie. Vorträge und Diskussionen. Lausanne, Oktober
1956. Basel: Karger Verlag.
Benedetti, G. and Müller, C. (eds.): 2. Internationales Symposium über die

Psychotherapie der Schizophrenie. Vorträge und Diskussionen. Zürich 1959. Basel:
Karger Verlag.
Benedetti, G. and Müller, C. (eds.): 3. Internationales Symposium über die

Psychotherapie der Schizophrenie. Vorträge. Lausanne, 23. - 26. April 1964. Basel:
Karger Verlag.
Navratil, L.: Von der Kunsttheräpie zum Künstler. Lecture on November 8, 2001 on the
occasion of the awarding of the Margrit Egner Award.
Peciccia, M.: Bildgestaltende Psychotherapie, Benedetti, G.: Psychotherapie als exis-

tentielle Herausforderung. Göttingen: Vandenhoeck & Ruprecht, 1992.
Searles, H.F.: Collected Papers on Schizophrenia. London: The Hogarth Press, 1965.
Sechehaye, M.A.: “La réalisation symbolique. ‘Nouvelle méthode de psychotherapie

appliquée à un cas de schizophrénie’” in Revue suisse de psychol. et de la psychol.
appliquée, suppl. 12. Bern: Huber, 1947.
Sullivan, H.S.: Schizophrenia as a Human Process. New York: Norton, 1962.
G. Benedetti, M .D.
Inzlingerstrasse 21
4125 Riehen, Switzerland
45
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Yrjö Alanen,
Chairman of
Turku Symposium
Book of Turku Symposium 1971
47
 
AND
Otto Will,
Symposium Turku 1971
48
 
4. The IVth ISPS Symposium

In Turku, Finland in
August 4 – 7, 1971
Yrjö O. Alanen
Preparations
Five years had elapsed in 1969 without any new plans for further gatherings
since the first three ISPS symposia. This may have been influenced by a
certain amount of frustration due to partly unrealistic expectations invested
in long-time psychoanalytic psychotherapies of schizophrenic patients -
sometimes began with rather “heroic” starting-points. At the same time, the
position of neuroleptic drugs as the general treatment mode of this disorder
was confirmed. Christian Müller dealt with these matters in his Turku
presentation to which I will return later. However, the interest was by no
means extinguished and also new ways of psychotherapeutic treatment had
been developed.
In this situation, I received a telephone call from my close friend and

colleague Kauko Kaila, one of the Finnish psychiatrists who had received
psychotherapy training in Switzerland during the 1950s and taken a
continued interest in the care of schizophrenic patients. Kaila as well as his
colleagues Martti Siirala and Allan Johansson also participated in the earlier
ISPS symposia. Kaila had communicated with Müller whom I also knew well
after his visit in Finland a few years earlier. Being aware of the interest those
of us at the Turku University Department of Psychiatry had in the
psychotherapy of schizophrenia, they suggested that the symposium be held
here. As a young and newly appointed head of this department, I regarded
this proposal both as an honour and as a great pleasure. An international
organizing committee of ten members as well as a smaller local organizing
group (besides myself, Dr. Viljo Räkköläinen, Dr. Simo Salonen, Mrs. Aira
Laine, psychologist and Mrs. Outi Kangas, secretary) was promptly
established and the preparatory work for the symposium began.
The inquiries I sent to well-known schizophrenia psychotherapists from

Europe and America showed that the interest towards this kind of
49
 
AND
symposium had grown greatly. Compared with the earlier symposia, two
changes were made. While the participants of Swiss symposia were, with a
few exceptions, residing in Central European countries, I also made contacts
with many American psychotherapists, most of them I already knew from my
earlier study year in the United States. This also led to the result that the
main language of the symposium became English, instead of the earlier
German and French. The other change was the extension of the programme
to include not only individual psychotherapy and theoretical issues related to
it, but also family therapy and research, as well as experiences of
therapeutic communities established for the treatment of schizophrenic
patients. However, we continued - even if somewhat extended - the
restriction of the amount of participants, familiar from the symposia held in
Switzerland in order to maintain a rather intimate atmosphere. The amount
of participants was fixed at 60, 15 of them being from the host country.
While asking for the views expressed by the members of the International
Organizing Committee, I still had a rather free hand in the planning of the
symposium. For the invitation of the speakers, we received several small
grants from various (in total, 12) pharmacological companies – a fact which
exposes the financial dependence of the medical field, including the
university departments, to this kind of support. A congress on psychotherapy
was not, of course, their first selection, but was still regarded as a part of
their public relations activities about which we expressed our gratitude.
I invited several well-known psychotherapists from the U.S., then the leading
country in the field, beginning with my earlier teacher Theodore Lidz from
Yale University. I also contacted the Psychotherapy Section of the World
Psychiatric Association. David Rubinstein, a family therapist and the
secretary and treasurer of the section, appeared to have a very active
interest in the symposium. Together with Rubinstein and facilitated by his
contacts, we afterwards edited a book including all symposium presentations,
published by Excerpta Fennica (Rubinstein and Alanen, 1972) – according to
my opinion, printed even in a too elegant and expensive way. Cuban-born
David came to Turku with his own family – a luxuriant Mrs. Rubinstein,
impressing all the symposium participants by her manifold necklaces and
rings, and four kids.
Dr. Denis Leigh from Great Britain, Secretary General of the WPA, also
showed his keen interest in the symposium, encouraging us through his
appearance in Turku. Other British participants included, among others,
50
 
The IVth ISPS Symposium
some colleagues familiar to me from my recent visit there. I also wrote to

Ronald D. Laing inviting him to come to Turku but received a refusal (as far
as I remember, the only one!): Laing wrote to me that he could not promise
to come to Turku in 1971 because he did not know where he would that year.
Later I heard that he had been in a Buddhist Monastery in Thailand.
From the Central Europe, the “founding fathers” Gaetano Benedetti and
Christian Müller were self-evident lecturers. A group of German
psychiatrists, who had participated in earlier symposia, also came to Turku
to give presentations. This led us to the establishment of a German-speaking
sector in the programme. The situation was worse with regard to the French
participants: there were only two of them, and they did not have
presentations in the symposium. We found it reasonable to translate the
German presentations into English for the symposium book. However, the
diminishing amount of Central European participants was also a problem in
the later symposia, except for those held on their own soil.
The Scandinavian and Finnish therapists were naturally well represented,

even if I had the unpleasant role to refuse many requests here. I was glad
that the restriction of the amount of participants did not continue in the
following symposium, held in Oslo.
The geographical distribution of the participants covered an area from

Budapest, Hungary to Lima, Peru. Dr. Leigh told me that we should have also
invited some African colleague to join our group. Maybe he was right.
Anyway, we, as the members of the local organizing group, were very
pleased by the activity and enthusiasm of the symposium participants and,
even helped by weather warmer than the average during the Finnish
summer, we were left with very pleasant remembrances of this event.
Preparations
The presentations in the symposium – as well as in our proceedings book -
were divided in four parts: I. Basic and Theoretical Issues; II. Individual
Psychotherapy; III. Family Psychotherapy and Research; and IV.
Psychotherapeutic Community and Related Subjects. The book also includes
my introductory address and a verbatim report on the panel discussion
concluding our programme.
51
 
AND
I will begin with my introduction. Entitled “The Place of Psychotherapy in the

Psychiatric Approach to Schizophrenia,” it dealt with the problem why
psychotherapy not only occupies a rather peripheral place but is actually subject
to rejection in the treatment of schizophrenia. For the therapists, participating in
the symposium, psychodynamic approach to schizophrenic patients is an
empirical fact, verified in our practice. In the schizophrenic withdrawal and
disorganization of the personality we see an attempt by the patient to preserve
a minimum of security and need satisfaction in an environment that has become
excessively frightening to him – “an individual who is perhaps more vulnerable
than the average and who has in any case grown up amidst anxiety-producing
modes of human interrelationships.” We are able to help schizophrenic patients,
or at least a part of them, to improve or recover. I found a complicated
conglomeration of causes of the situation:
• our scientific-medical tradition, such great victories in the investigation and

treatment of numerous other illnesses. The psychotherapeutic ways of thought
are often difficult to comprehend and even experienced as “unmedical;”
• unconscious defences, both individual and collective, adding to the

difficulty to integrate the knowledge about man gained through
psychodynamic study with biological knowledge and to examine the
interrelationship between these two;
• connected with this, a tendency to isolate these patients, not totally from
society as often previously, but psychologically, by emphasizing the
dissimilarity between them and other people, including ourselves;
• reliance on the drug treatment to avoid encountering the schizophrenic
patients’ deep-rooted problems;
• the high number of schizophrenic patients.
I also referred to a larger resistance factor, supposedly the most

fundamental of all: the denial of our common guilt, springing from the
responsibility we all have for another - the most important reason why the
obvious influence exerted by parent-child relationships on the child’s
development and the part played by them in the genesis of various mental
disorders are so difficult to perceive and the knowledge of them so difficult
to be adopted.
The same kind of problems – even more critical today than thirty years ago
- were dealt with by some other speakers, in an especially concrete way by
52
 
Christian Müller. In his treatise “The problem of resistance to psychotherapy

of schizophrenic patients,” Müller examined the reasons why the number of
schizophrenic patients receiving individual psychotherapy or analytically
oriented group therapy has diminished in Europe. He turned toward the
unconscious motivations and resistances of the therapists themselves. The
key-word he found was narcissism, not only by the patient but especially by
the mobilisation of claims to omnipotence engendered within the analyst by
the patient. Such claims serve in the service of the physician’s primary
narcissism and the unconscious fantasies satellite to this. According to
Müller, the current caution in the application of psychoanalytic methods in
schizophrenia may have its roots here: in the fear of frustrations which the
therapist has not overcome in himself; his fear of uncontrolled aggressivity
as a reaction to narcissistic insults; i.e., in the therapist’s
countertransference problems leading them to protect themselves of such
experiences through new duties and avoidance of new therapeutic
endeavours with schizophrenic patents.
Müller also referred to the influence of rebellion against powerful father

figures personified by the representatives of the old Kraepelinian psychiatry.
He also showed understanding for the problems of these psychiatrists: “Let
us imagine what it would mean (for them) were we able to furnish an
absolute proof that schizophrenia would be determined solely on the basis
of biographical factors!” The shock would be calamitous: many measures
that were in use over the course of years would reveal themselves as
horrible mistakes. They would react according to the principle: what may not
be, cannot be. Müller also criticized the fashionable opposite trend to deny
the disease character of schizophrenia and the easy solutions of the problem
of madness achieved through such fancies. Referring to his teacher Ernst
Blum, he emphasized “the counter-magic of organic” as well as “the
counter-magic of political”, both of them serving as defensive pseudo-
solutions to the problems of schizophrenia and its treatment. At the end of
his presentation he reminded us all (including himself), “not to close our
eyes against the forces governing within each of us, and within the scope of
our continuing self-analysis, constantly to test as well our relationship and
encounters with the schizophrenic”.
The other central presentations in Part I. were those by Theodore Lidz

(“Schizophrenic disorders: the influence of conceptualizations on therapy”)
and Otto. A. Will Jr. (“Psychotherapy and schizophrenia: implications for
human living”). Two characteristics were common for both of them: a
53
 
AND
humanistic spirit and the emphasis on technical problems of the therapeutic

relationship, differing from the therapy of neurotic patients through its more
interaction-marked character. Lidz repeated the family findings of his
research group (Lidz et al., 1965), their inference being that “the cardinal
therapeutic task with schizophrenic patients lies in releasing the patient
from the bondage of completing a parents’ life, or in bridging the schism
between his parents, to enable him to become a person of his own right,
investing his energies in his own development and his future rather than in
coping with the problems of the preceding generation.” He warned against
an early and forceful use of interpretations, because the major focus of
therapy lies in individuation and reliance upon the self. He also expressed his
doubt that conjoint family therapy – as useful as it may be by preparing the
patient’s way for the revaluation and intrapsychic reorganization of the
parental introjects - could by itself undo the intrapsychic distortions. For
this, individual therapeutic relationship is needed. However, Lidz also
emphasized the significance of residential treatment and questioned the
adequacy of individual psychotherapy without provision of social, emotional,
and cognitive educational or re-educational therapy, particularly in those
patients whose difficulties are more developmental than regressive in
nature. He also concluded that the diminishing interest in the psychotherapy
of schizophrenic disorders is at least partially due to discouragements
stemming from following faulty directives.
Will told us of his first contacts with schizophrenia patients, then named as
cases of dementia praecox with its implications of organic deficit, disease
and deterioration. Gradually he became interested in the patients as human
beings: “I shall never forget what it meant to me personally as well as
professionally to discover that ‘everyone is much more simply human than
otherwise,” as expressed in the well-known thesis of the great teacher,
Harry Stack Sullivan (1953). There is now, Will emphasized, evidence to
support “the view that schizophrenia is a paradigm of fundamental aspects
of human living, and that psychotherapy is not only a treatment procedure,
but is a method for the study of those fundamentals displayed in distorted
form – and yet in startling clarity – in schizophrenic behavior.” Will then
examined comprehensively phenomenological, etiological and therapeutic
questions connected with schizophrenia, illustrated by the treatment of a
female patient. He especially emphasized the topics of the sense of self, of
relatedness, and of hope. “I hold to the view that the human relationship is
the essential ingredient of human survival, growth, development, and
continued existence,” Will concluded, summing up his speech: “The
54
 
interpersonal is not all of man’s life but we ignore its importance to our peril
… Our task is not to decide that psychotherapy or human relatedness are
necessarily or useful – or not – but to determine how these may be used to
further the realization of a human being’s growth.”
Other presentations in Part I included those by Claus B. Bahnson (U.S.A.),

Torsten Herner (Sweden), Esther Bloom (Denmark), and Thomas Freeman
(Northern Ireland, U.K.). I was impressed by presentations of two younger
psychoanalysts - even if schizophrenia may not have been the most central
topic in them. Michael A. Woodbury (U.S.A.) had as his topic “The Abraham
complex: of filicide, war and psychosis:” “War can be considered a social
institution which among other things keeps under control filicidal and
reactive patricidal impulses” (even by the “contract:” let us not kill our sons
but one another’s: let us spare our own sons to that they can defend us
against other men’s sons!). Matti Tuovinen (Finland), working in the field of
forensic psychiatry, examined the topic “Schizophrenia and the basic
crimes;” the basic crimes being murder, incest, and cannibalism (the last
one, however, was left outside of the presentation “because of the lack of
opportunity to study a case”). According to Tuovinen, murder often has also
a certain ”constructive” aspect, from the point of the murderer’s ego, as an
attempt to intrapsychic adaptation used, e.g., to avoid a mental illness.
Part II, dealing with individual psychotherapy, was begun by Gaetano

Benedetti (“Psychosynthetic countertransference in individual psychotherapy
of schizophrenia”). His main emphasis was the importance of the
countertransference, a topic which also played a central role in many of
Benedetti’s later presentations and writings. Psychotherapy with
schizophrenics is a combination of two methodological approaches: 1) A
psychoanalytic technique modified, in contrast with the analysis of the
neuroses, and 2) an attempt at a psychosynthesis. “He is in us and we are in
him”, Benedetti pointed out and raised the synthetic function based on the
interactional relationship as the central agent in the development of the
schizophrenic patient’s personality. He also draw our attention to the dreams
of the psychotherapist: they may be an important indicator of the unconscious
countertransferential processes.
Silvano Arieti’s lecture (“Psychodynamic search of common values with the

schizophrenic”) relied greatly on the experiences of Frieda Fromm-
Rechmann and other therapists of the “Washington school,” leading then to
critical examinations of extremist views on the nature of schizophrenia.
55
 
AND
Arieti pointed out, e.g., that the etiological factors are not restricted to the
influence of a very unfavourable early family environment; the patients also
have a special propensity for responding strongly only to the adverse aspects
of environment. He especially criticized Laing’s opinions. “We must thus
conclude that the schizophrenic psychosis is not a normal reaction to an
abnormal situation, as some authors, for instance Laing, imply. It is an
abnormal way of dealing with an abnormal situation (italics by Arieti).”
Two younger Scandinavian therapists, Britta Hegethorn (Sweden) and Pirkko

Siltala (Finland), as well as G. Ammon (Germany) concentrated in case
histories. Ammon’s technique had influences deriving from Rosen’s “direct
analysis.” Siltala told us of a long and successful therapeutic relationship
with an especially ill male patient. I admired her ability to preserve her
therapeutic role and attitude even while allowing herself to expand the
therapeutic sphere by contacting the patient’s mother – originally hostile
towards the therapist – as well as to continue the therapy hours during her
maternity leave at her home and allowing the patient to realize his hopes to
see the therapist’s baby boy with whom he in part unconsciously identified
himself. This is an example of the exemptions from usual restrictions
sometimes beneficial in schizophrenia psychotherapy – Benedetti told in his
presentation of a therapist, supervised by him, who once with good result
suggested to his patient a psychodrama, wherein they would temporarily
exchange roles: the patient was to sit on his chair, his on hers. Part II was
concluded by Martti Siirala’s philosophical treatise the essential aspiration of
which was expressed in its title: “Psychotherapy of schizophrenia as a basic
human experience, as a ferment for a metamorphosis in the conception of
knowledge and the image of man.” From his ethical starting-points Siirala
pointed out that insight into individual schizophrenia needs enlargement to
comprise the collective isomorphic phenomena: “Whenever a human
dilemma does not meet any center of common responsibility … it is bound to
move into direction of vicarious responsibility, devoid of the solidarity of any
common network.”
Part III of the symposium, Family Psychotherapy and Research, was,

according to my opinion, especially interesting, bringing to our knowledge
findings of the psychodynamic family research strongly emerged during the
preceding ten to fifteen years. This concerns, above all, two investigators,
closely related to each other, Helm Stierlin and Lyman C. Wynne (both of them
then working at the National Institute of Mental Health near Washington).
Their presentations (Stierlin: “Family dynamics and separations patterns of
56
 
potential schizophrenics;” Wynne: “The injection and the concealment of

meaning in the family relationships and psychotherapy of schizophrenics”)
combined both theoretical and clinical viewpoints.
In the beginning of his discourse, Stierlin stated that there are two more or
less integrated etiological pathways leading the potential schizophrenic to
his final breakdown: the pathway of calamity and inept parenting, and the
pathway of psychological exploitation. He then focused on the latter and
presented – as I understand, for the first time - his concept of transactional
modes which dominate a family life during given periods, all of them, when
operating in excess, implying a traumatization and/or psychological
exploitation of the child. The transactional modes are the modes of binding,
delegating, and expelling. The binding may operate on three levels which can
be formulated and named also with terms closely connected with the
psychoanalytic structural model: id-binding (infantilizing the child by
offering undue regressive gratification), ego-binding (the parent substitutes
his own – distorted as well as distorting – ego for that of the child), and
superego-binding (the child is trained to experience any betrayal of loyalty –
as exemplified in his wish to separate – as a crime against the parent). The
mode of delegating gives more space to the child, who still is held “on a long
leash:” it combines the two meanings of the Latin word, de-legare: to send
out, and to entrust with a mission. The mode of expelling means an enduring
neglect and rejection of the child. The modes were also illustrated by a case
history.
As a psychoanalyst and family researcher, I found – and still find – these

transactional modes, more detailed examined in Stierlin’s accompanying
works (Stierlin, 1974) very instructive and useful in understanding the
interactional dynamics in the families of many schizophrenics, and in my
mind I have even somewhat deplored that they seem to have fallen more into
background in his later work. Consider, e.g., the role of the mode of
delegation in the fate of the Australian pianist David Helfgott, described in
the well-known film “Shine!”
Wynne’s description of the injection and concealment of meaning can be

seen, as it were, as illustrations of the attribution dynamics included in
Stierlin’s mode of ego-binding, with many clinical examples. Wynne also
refers to Schatzman’s (1971) study of the painful ways developed by the
father of Dr. Daniel Paul Schreber, the object of Freud’s famous treatise, to
control the behaviour of his children (even more thoroughly described by
57
 
AND
Niederland, 1984), thus illustrating the links between the intrapsychic

dynamics, as examined by Freud, and the family dynamics. In his concluding
discussion of implications for psychotherapy, Wynne especially emphasized
the complementary roles within the families, thus paving the way for
systemic approaches to family therapy. “The first task of parents and
therapists alike is to help establish a trustworthy relationship within which
there can be reciprocal interchange, verbal and non-verbal.”
David Rubinstein’s presentation (“Clinical issues in family therapy of

schizophrenia”) gave to us a description of his own way as a psychotherapist
of schizophrenic patients, begun as a pupil of Rosen, selecting a chronically
ill young schizophrenic to live in his family and experiencing the most
difficult impact this kind of patient may have on the family life, and
developing to a systemically oriented family therapist. In my own
presentation, I spoke about the benefits of family therapy in hebephrenic
schizophrenia, illustrated by a case history; Heimo Salminen (Finland) also
had a case report dealing with the family therapy of a schizophrenic patient;
Michael B. Conran (United Kingdom) dealt with the relationship between
blame and hope, based on his experiences from Villa 21 in Shenley Hospital
near London (cf. later); and Helmut Bach (Germany) with the preference for
analytical family therapy of a juvenile psychotic patient. Michael A Woodbury
(U.S.A.), working in the field of community psychiatry, examined more
complex socio-cultural processes and transitional concepts linking
individual, family and community dynamics in an interesting way.
This section also included two expressly research-centred presentations.

R.D. Scott and A. Montanez (U.K.), from Napsbury hospital, operating under
the National Health Service, had compared with each other the parents’ view
of themselves and the patients’ view of their parents in a “community
centred” group of schizophrenics, spending less than 70 % of the 2 years
after first admission in hospital, and in a “hospital-centred” group in which
the patients spent more than 70 % of the two years after first admission in
the hospital. It appeared that in the community centred group patients
confirmed the parents’ view of themselves (“tenable patient-parent
relationships”) while there typically was a difference between the parents’
view of themselves and the patients’ view of their parents (“untenable
patient-parent relationships”) in the hospital-centred group. In the latter
group, there was a heightened danger of continuing hospitalisation based on
psychological rejection from the part of the family members (the “closure” as
aptly described by Scott and Ashworth, 1967). The implication for therapy was
58
 
that active family-centred treatment should be directed to the hospital-

centred group. “We reserve what resources we have for those who certainly
require them, the hospital-centred patient and his parents.” Stein Bastiansen
and Einar Kringlen (Norway) gave a preliminary report of their study of
children of two psychotic parents; the sampling of parents being based on
the Norwegian Psychosis Register and information of the children - besides
various official records - on personal investigation. The result was that, even
with age correction, the frequency of psychotic subjects among the children
did not exceed 25 %. There was no significant difference between various
diagnostic combinations of psychosis in the parents. Besides psychotic
children, a great variability of normal (more than one third), neurotic and
“psychopathic” offsprings were found.
Part IV, Psychotherapeutic Community and Related Subjects, may be

characterized as probably the most “virginal” area in the symposium. During
the panel discussion concluding our programme it was stated that despite a
general interest very few studies of the results of the work in therapeutic
communities had been published.
The section was begun by Loren R. Mosher (U.S.A.), the emerging pioneer in
the establishment of therapeutic communities outside the system of medical
organizations. He presented – as far as I know, for the first time – the
principles and research design of the Soteria project, recently began by
Leonard Goveia, Alma Menn, and Mosher. Mosher told us that the project will
test the developmental crisis orientation to an initial episode of
schizophrenia. The therapy will be given “by indigenous, non-professional,
specially trained personnel (‘guides’) to a group of schizophrenic patients
living with staff, in a comfortable 16-room home in the community, which we
call Soteria house.” Mosher emphasized that the disruptive schizophrenic
episode is also believed to have unique potential for reintegration-
reconstitution if it is not prematurely aborted or forced into some
psychologically ‘strait-jacketing’ compromise. The personnel is selected
from persons who seem to have the potential ability to ‘tune in’ the patient’s
altered state of consciousness, without no “procrustean” theory of
schizophrenia. In the study, much emphasis will be placed on the self-report
of the patients. The patients will be followed for two years after discharge,
and a control group is formed from a psychiatric ward in a local general
hospital. - As far as I remember, the first reactions to Mosher’s plan were
somewhat confused; the Soteria project was not mentioned in the
concluding panel discussion.
59
 
AND
Problems and difficulties inherent in the establishment and activities of

therapeutic communities in the frames of hospital environment were a
topic recurring in many presentations, including those by A.A. Fischer (the
Netherlands), C. Roccella (Italy), J. Füredi and M. Kun (Hungary), and Kauko
Kaila (Finland). The rigidity of the organization, often in the form of
authoritarian attitude of the leading officials (sometimes physicians,
sometimes not), resistance based on the difficulty to understand a
therapeutic approach deviating from the usual medical model were
among the factors mentioned, as well as intrigues both outside and within
the ward community. Fischer, working at the H. C. Ruemke Clinic
connected with the University of Utrecht, dealt with conditions, personal
and organizational, which he had found crucial for success or failure of a
therapeutic community, emphasizing, e.g., the need for a constant,
optimal tension which should remain between social and real
relationships and therapeutic relationships. His conclusions were rather
pessimistic with regard to the possibilities to make a therapeutic
community succeed as a part of a bigger institution like a mental hospital.
The therapeutic community “must be outside a medical system of
organization, consequently outside a hospital”, and it “must develop in a
situation that compares maximally with normal living conditions,” Fischer
inferred.
Simo Salonen (Finland), working at our Turku clinic, had a more optimistic
tone. Unconsciously, he had seen the therapeutic community as a means of
realizing his own omnipotence fantasies, or as an extension of himself, as it
were. In connection of the following panel discussion Salonen brought
forward his interesting observations of the patients’ fragmented
transferences manifesting themselves in their relationships with different
members of therapeutic community. An internal integrative process of the
therapeutic community may then lead to a situation where the patient’s
fragmentary and obscure transference processes begin to appear more
integrated. In their presentation “On the taking of a medicine” Michael B.
Conran and S. T. Hayward gave us a psychoanalytically oriented ”snapshot” of
the interrelational work of the staff in Villa 21 at Shenley hospital near
London, in which Conran had developed a therapeutic community which
consciously followed the family structure. W. Bister (Germany) told us of
results of psycho- and sociotherapy with schizophrenics in a night clinical
ward in Berlin, and another German therapist, M. Pohlen described his study
dealing with a new organizational mode for short-term psychoanalytic group
analysis in a clinical setting.
60
 
The discussion of the activities and problems of therapeutic communities

continued in the Panel discussion, chaired by Otto A. Will. Experiences were
further described by, e.g., Jarl Jørstad who, together with Endre Ugelstad,
organized the next ISPS symposium. He described the work at the Dikemark
Hospital in Oslo, Norway, opposing Fischer’s exacerbated view of the
impossibility to make a therapeutic community succeed as a part of a
hospital. Christian Müller said that he did not believe that the principle of
therapeutic community has a real specific action, a view opposed by Fischer
and Salonen. The discussion then went on to the question of how to define
the term therapeutic community. Will, himself Director of Psychotherapy at
Chestnut Lodge sanatorium in which many patients stayed for years6,
mentioned examples of the very varied use of this term: he had even visited
a ward, “like an old-fashioned railway station,” in which the median stay of
patients was less than 7 days. The psychiatrist in charge still called his ward
“therapeutic community.” Stuart C. Miller, from the Austen Riggs Center,
U.S.A. said that the goals of the community they have – also with long-time
patients in intensive individual psychotherapy - would probably be better
described as anti-antitherapeutic than as therapeutic. I had the opportunity
to introduce the use of the term “psychotherapeutic community” adopted at
our Turku clinic, to make a difference from a therapeutic community of
Maxwell Jones’ type, in which the main emphasis was not put on
psychotherapeutic relationships. Mosher provoked panel members by
asking if anyone can show him a study that therapeutic community, however
defined, does anything for schizophrenics that cannot be done without one?
He himself knew only two studies in which results of therapeutic
communities were compared with those of more traditional hospital ward,
both of them unsatisfactory in their design.
A ladies’ committee (Mrs. Hanni Alanen. Mrs. Kaija Kaila and Mrs. Varpu
Siirala) planned the social program of the symposium together with the
organizing group, the absolute draw of which was a cruise in the beautiful
Turku archipelago, with hundreds of islands, to the island of Seili, in which
the eldest mental hospital in Finland had been situated (now changed to the
Institute for Archipelagic Research of the University of Turku). The weather



61
 
AND
was kindly disposed to us. The warm August evening, gradually getting
dimmer, as well as the old wooden Seili church impressed many of the
participants. The enchanted Mrs. Adele Wynne – having American-Swedish
background – experienced herself to have been brought in the middle of an
Ingvar Bergman film.
Afterthoughts
How to describe the influence of the symposium? It certainly increased the
interest in and respect for psychotherapeutic activities with schizophrenic
patients in Finland and in other Northern European countries, even if the
restriction of the amount of participants may have somewhat diminished
this. At our department, we have got a place, at least preliminary, in the
“world map” of schizophrenia investigation and therapy, and the
comprehensive psychotherapeutically oriented Turku Schizophrenia Project,
began a couple of years earlier, received a strong stimulus for its further
work. After the symposium, Otto A.Will led a psychotherapy seminar at our
department, followed by Helm Stierlin the next year and after them many
other well-known therapists and researchers.
It was also obvious that the international community of schizophrenia

psychotherapists greatly enjoyed this opportunity to discuss their
experiences with each other and strengthen their mutual relationships. The
diminished interest, referred to at the beginning of this account, was not
perceptible in the atmosphere of the symposium. This was also confirmed by
the decision to continue the series of symposia in the future at three years’
regular intervals.
Compared with earlier ISPS symposia, there was a somewhat more critical
tone with regard to questions dealing with individual psychotherapy.
However, Lidz, Will and Benedetti examined therapeutic relationships with
schizophrenic patients and the techniques suitable for them in a very
constructive and deepening way. The section dealing with family therapy was
– at least for me - the most innovative part of the symposium while the study
of therapeutic communities appeared to be in its early phase, including
Mosher’s initial presentation of the courageous Soteria plan. Regretfully,
resistance factors referred to above have later greatly hindered the family-
centred work based on psychodynamic understanding, so promising thirty or
62
 
forty years ago. One can understand the opposite reaction on the part of,
e.g., parents’ associations, supported by psychiatrists with restrictive
neurobiological views, to the family findings – at least with a superficial
acquaintance with them. However, one should notice that the purpose of
psychodynamically oriented family investigators has always been to help
both the patients and their families. Later, the systemic point of view has led
to a more balanced view to the family interrelationships: that all interactions
among different members in the family are two-way processes, and at the
same time a part of the dynamics of the larger family circle. Parents
influence their children, and children, with their different innate inclinations,
influence their parents. In addition the importance of genetic vulnerability,
besides the problems of disordered environments of growth, was referred to
in several symposium presentations. This is certainly a wider view to
vulnerability factors in schizophrenia than the views of many neurobiological
investigators of today for whom the word “environment” only refers to
physical factors in work during the mother’s pregnancy or childbirth.
References
The proceedings of the IV. International Symposium on Psychotherapy of
Schizophrenia were published in the book
Psychotherapy of Schizophrenia, edited by David Rubinstein and Yrjö O. Alanen,

Amsterdam: Excerpta Medica, 1972 (347 pages).
Other references in the text:
Lidz, T., Fleck, S. and Cornelison, A. (1965). Schizophrenia and the Family.
International Univ. Press, New York.
Niederland, W.G. (1984). The Schreber Case (expanded edition). Hillsdale N.J.: The
Analytic Press.
Schatzman, M. (1971). Paranoia and persecution: the case of Schreber. Family

Process 10:177-207.
Scott, R.D. & Ashworth, P.L. (1967). ‘Closure’ at the first schizophrenic breakdown:
a family study. Brit. J. med. Psychol. 40:109-145.
63
 
AND
Stanton, A., & Schwarz. M. (1954). The Mental Hospital. New York: Basic Books.
Stierlin, H. (1974). Separating Parents and Adolescents. A Perspective on Running

Away, Schizophrenia, and Waywardness. New York: Quadrangle & The New York
Times Book Co.
Sullivan, H.S. (1953) The Interpersonal Theory of Psychiatry. New York: W.W.
Norton & Co.

64
 
GALLERY PHOTOGRAPHS
Chairmen and
book of Oslo
Symposium 1975
Photo from Oslo

Symposium 1975.- From
left to right, Jarl Jørstad,
Yrjö Alanen,
Helm Stierlin,
Theodore Lidz and
Endre Ugelstad
All of them ISPS
Honorary Members.
65
 
AND
Oslo Symposium 1975

Esko Orma, Heta Orma, YrjoAlanen,
Hanni Alanen, Pekka Tienari
66
 
5. The Vth ISPS Symposium

In Oslo, Norway,
August 13 -17, 1975
Jarl Jörstad, Svein Haugsgjerd and Bjørn Østberg
Background
The development within the Norwegian psychiatry over the last few years
has served as a background for this 5th International Symposium On
Psychotherapy of Schizophrenia in Oslo. Interest in learning more about
psychotherapy was increased and created demands from younger and
younger residents and psychiatrists for better teaching and training. This
resulted in a dramatic change in residency training in psychiatry where the
Psychotherapy Committee in the Norwegian Psychiatric Association
formulated the new demands: Every psychiatric resident had to have 100
hours supervision, once a week in the therapist-patient relationship and the
basic principles of psychodynamic psychotherapy. The supervisors should
have a psychodynamic or psychoanalytic background, including their own
psychotherapy/psychoanalysis. These demands provoked strong resistances
from many of the professors who were chairmen in the teaching
committees, but they could not stop the development and new committees
were constituted.
At that time, most residents were working in mental hospitals, most treating
severely disturbed patients, many of them schizophrenics. The need to learn
more about how to treat these difficult and challenging patients was one
background for the symposium. Another contributing factor was the
arrangement of two to three seminars on psychotherapy once a year. Eighty
to 100 participants from all over Norway met some of the pioneers in
psychotherapy from other countries, particularly Switzerland, Great Britain
and the USA.
Some of us also had been able to study at some of the best teaching centers
abroad and to come into contact with outstanding psychotherapists, some of
whom we could invite to the Symposium in Oslo.
67
 
AND
The Norwegian arrangement committee of the Symposium in Oslo was:

Endre Ugelstad, chairman; Jarl Jørstad, co-chairman; Svein Haugsgjerd,
secretary; Willy Jensen, treasurer; Bjørn Østberg, postsymposium seminars;
Oddbjørg Jørstad, social program, and Nils Retterstøl, Helge Waal, Einar
Kringlen.
More than 100 participants from 15 different countries attended the

Symposium - all active in psychotherapeutic work and research. In addition
to lectures and discussions in plenum and in sections, a great deal of work
and exchange of experience took place in a number of workshops during the
afternoons.
Compared with former symposia in 1956, 1959, 1964 and 1971, this
symposium found that the quest for a clearer comprehension of factors
operative in intensive psychotherapy of schizophrenia was continuing.
However, there were also new tendencies within the scope of
psychotherapeutic and social treatment of schizophrenia. Our insight was
deepened through family studies and the development of different forms of
family therapy. We also gained experience from milieu-work in institutions
and through social-psychiatric viewpoints.
The different aspects of the Symposium were concentrated in three parts:
I Basic issues and psychotherapeutic experiences in different settings.

The contributors were: Gaetano Benedetti, Beatrize Foster, Ruth and Ted Lidz,
Donald Melzer, Christian Müller, E. M. Podwoll, Viljo Räkköläinen, Simo
Salonen, Clarence G. Schulz, John Strauss et al. and The Arezzo Group.
II Family studies: Implications for treatment.
The contributors were: Yrjö Alanen, M. A. Bremer-Schulte, Michael Conran,
Stephen Fleck, Luc Kaufman, David Rubinstein, R. D. Scott, Maria Palazzoli
Selvini and Helm Stierlin.
III Research projects.
The contributors were: John G. Gunderson, Edgar Heim and Enar Johnsen with
co-workers, Maria Orwid et al., Alma Z. Menn and Loren R. Mosher, Clarence G.
Schulz, Endre Ugelstad, Lyman Wynne and Margaret Singer.
Abstracts of some of the central presentations are mentioned here:
I Basic issues and psychotherapeutic experiences in different settings.
68
 
The Vth ISPS Symposium
Gaetano Benedetti, whom we knew from previous seminars in Norway,

started with: Curative factors in psychotherapy with schizophrenic patients. He
felt this was the very scientific core of psychotherapy. Curative factors are
those that make a new openness of communication between patient and
therapist possible. He considered four points of central importance: 1. The
dynamics of the therapist’s unconscious as shown by some of his dreams.
2. The therapist’s fantasies. 3. The mirror phenomenon, which moves in
both directions. 4. The integration of love and aggression in the patient and
in the therapist. Benedetti illustrated these four points with a couple of
dreams of the therapists and vignettes from therapies. It is not the dream
itself which is the curative factor but the attitude of the therapist which is
surely more than love. It is also symbiosis and service to the patient. They
also convey to the patient how much the therapist is involved with him/her.
Secondly, the patient experiences through dreams that he/she is being
meshed and confused with an alien other world, which, however, is
substituted through the unconscious symbiosis with the non-alien
therapist. The curative effects rest upon the capacity of the therapist, first
to share truly and sincerely the images of the patient and second to
transform them slowly by the ferment of the therapist’s presence, to
permeate them with his/her own fantasies.
An example of the mirror phenomenon is a patient who says: “When

dancing, I need someone looking at me in order to be sure that I really exist.”
Integration also occurs in psychotherapy by showing the patient his/her

destructive impulses, unusually concealed in his/her projections onto the
outer world, in his/her delusions of persecution. Healing is not so much the
patient’s cognitive realization of his/her own aggressive impulses but the
integration in a positive frame of reference. This partly happens through the
loving attitude of the therapist and through pointing out to the patient how
many positive aspects of him/herself are destroyed by his/her destructive
impulses. The integration of the destructive impulses within the many
psychological factors and experiences of the past, which determined them,
is also important. Aggressive impulses will regularly be transferred to the
therapeutic relationship. The tranquility of the therapist in encountering
such fantasies, directed against him/herself appeared to be the first support
of the patient and the aggressive impulses slowly become less and less
dissociated. Fusion of love and aggression in the patient occur, first of all,
through the therapeutic fusions of such feelings in the countertransference.
69
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AND
Ruth W. Lidz and Theodore Lidz made some comments on the supervision of
the psychotherapy of the schizophrenic patients. Both authors had been
supervising advanced residents in long term psychotherapy of schizophrenic
patients at Yale University, New Haven for many years. They pointed to the
importance and quality of the supervision. Difficulties in communication,
sharp and sudden reversals in the patient’s attitudes towards the therapist,
unexpected regressions into fragrant psychosis and the patient’s inordinate
demands can dishearten the therapist and lead him/her to decide that drugs
are the only answer or that he/she may leave the field to those who are more
masochistically inclined. Considerable thought and effort must go to
supporting the therapist and examining his/her blocks and
countertransference problems. Using classical analytic techniques can be
detrimental. The therapist should not be aloof and distant and present
him/herself as a passive screen against which the patient can react. A
schizophrenic patient responds only to a real person who is interested in
him/her as an individual. Openness and directness is also the therapist’s
major projection against being included in a patient’s delusional system.
Delusions are rarely, if ever, overcome by uncovering their unconscious
meaning. The therapist should talk about things that are meaningful to the
patient. Information should also be obtained from relatives.
Many patients have a desperate need for closeness and, at the same time,
an extreme fear of it, and become panicky over fears of fusion, engulfment
and loss of the self. Just when the patient seems to be forming an
attachment to the therapist, the patient often flees, sometimes from the
treatment, sometimes back into a more regressed condition.
Not all psychiatrists can learn to work effectively with schizophrenic

patients. A therapist must have firm boundaries between him/herself and
others as well as between fantasy and reality. Supervision can help a person
to work with schizophrenic patients, but it cannot make him/her into a
person who can do so.
Donald Meltzer: The role of narcissistic organization in the communication

difficulties of the schizophrenic.
Psychotic functioning calls for a model for narcissistic organization that is

more flexible than Freud’s operational description. Meltzer finds a model
more concrete in its structural dimensions and more qualitative in its
approach to the economic mind in Melanie Klein’s work from her paper on
70
 
schizoid mechanisms, 1946. This model is basically a view of the unconscious

as structured by different infantile parts and their internal objects.
In this paper, Meltzer describes material from the psychoanalytic treatment

of three different schizophrenic patients, each case illustrating different
problems in communication. All three patients demonstrate the importance
of posing the question: “Who is talking? To whom?”
Charles was in treatment more or less continually from age 15 until he

entered analysis at 31. He was no longer hallucinated, deluded and catatonic
as he had been before. But he was disheveled, avoided eye contact, talked in
a muttering and fragmented way. After three years of analysis, he improved
socially, took up work, resumed schooling, improved his relations with the
family. But when tender feelings and depressive pains began to emerge in
the transference situation, he reacted with a hasty retreat. He developed a
habit of trying to chase women, who most often were scared of him. He also
took pleasure in suspecting the analyst, teachers, bosses and classmates of
homosexuality. When the analyst tried to break his refusal of
communication, he attacked his words with mockery, punning, caricature,
fragmenting and twisting of logic. His schizophrenia was replaced with
blatant psychopathic behavior.
Philippa, 16, suffered from a delusional system: a rich man with the same
name as the therapist had bought her from her parents to perform a huge
research project on schizophrenia to appear in a movie. She developed the habit
of commenting on the analyst’s every movement: crossing of legs, scratching
of an itch and so on. “You cannot seem to control yourself, Dr. Meltzer.” As a
result of this controlling on the part of the patient, the analyst’s interpretative
activity became more and more repetitive, and the patient turned to miming
instead of talking. Eventually she developed a pattern of staring and blinking.
After several months, the analyst interpreted that she was making a photo of
the analyst with her eye-camera, in order to recover the object in calm later.
The patient answered: “Pictures are just as good as people.”
Jonathan, 20, had been in a deep catatonic state for five years and looked like
a sad clown or a rag doll, his only verbal responses were almost tic-like. In
the fourth year of analysis, his repetitive “dunno, dunno” and “yeah, yeah” had
given way to song lines, movie titles and some fragments of life history and
culminated in starting to use his own name instead of his alias, “Boris.” His
absolute despair had given way to hope. Separation reactions became severe.
71
 
AND
These cases give us a glimpse of two dimensions in the evolution of speech. The
first dimension, verbalization, means that the person is able to introject a
speaking - or rather a singing - object, and can repeat it, at first mechanically,
later with increasing rhythm and modulation. The second dimension,
vocalization, corresponds to the small child’s play with sounds as if they are
objects in the mouth. That part of the personality which has become
schizophrenic is that part which has departed so far into the realm of narcissism
that it is beyond the “gravitational” attraction of good objects, and therefore of
beauty, truth and goodness. That means that the capacity to communicate
states of mind with an object with parental qualities has been attacked.
Containment of the illness, and possibly some degree of recovery, can be

hoped for if the avenues of communication are kept open. The investigation
of the actual process of communication therefore takes first priority in the
consulting room. We must expect, however, that the patient will openly join
in ridicule and mocking, gradually to move to the sidelines to watch the
struggle between trust and cynicism.
Viljo Räkköläinen: Psychodynamic and interpersonal aspects of the onset of

psychosis. Räkköläinen’s paper was based on a thorough interviewing with 68
patients, 50 of them psychotic and 18 rediagnosed as borderlines, age 15 to 45,
consecutively admitted to the Department of Psychiatry, University of Turku,
1969. Based on this material, he suggests that the reality factor precipitating
a psychotic breakdown is qualitatively a narcissistic injury (in Kohut’s sense).
He also suggests that the onset of the psychosis is a “replica” of the problems
of early separation-individual phase (as described by Stierlin).
The onset situation is studied in relation to three important life issues:

1. Separation from the primary family.
2. Progress into a stable position in working life.
3. Stability or change in adult relationships.
A general conclusion was that these patients suffering a psychotic

breakdown showed
• narcissistic vulnerability in their early life history
• demands for autonomy in the onset situation
• precipitating adverse life events having a narcissistic significance.
Freud’s and Sullivan’s two-phase model for the psychotic breakdown can be
satisfactorily described in terms of the separation-individuation process.
72
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Failure in early separation-individuation leaves the person in extreme need

for protective symbiotic dependence. The first stage in the psychotic process
is a failure to achieve symbiotic unions, which leads the person to desperate,
omnipotent and non-functional attempts at identity. The final stage is
reached when this attempted identity is crushed by unavoidable adaptive
tasks of normal life, or by loss of the last vital symbiotic object.
Simo Salonen: On the Technique of the Psychotherapy of Schizophrenia.

Salonen starts with the discussion concerning two competing models for
psychosis, both based on Freud’s writings. One is what was later called a
conflict model, advocated by Jacob Arlow and Charles Brenner, the other
what is later called a defect model, advocated by Nathanael London. From
the observation that drive cathexes are never completely withdrawn,
representations never completely absent, he follows Veikko Tähkä in
affirming that new structures may emerge during the psychotherapy
process. The psychotherapy opens up for a phase-specific interaction
process, corresponding in time with the origination of the disorder in early
childhood. The therapist is recruited as an object for this process according
to the patient’s developmental needs, as described by Bryce Boyer and Peter
Giovacchini.
Because of the massive destruction of cathected representations, drive

energies are seeking their discharge on an almost physiological level, an
observation first made by Edith Jacobson. This fact makes the therapist’s
capacity of “holding function” (Winnicott) all the more important.
Salonen describes two cases of psychoanalytic psychotherapy with psychotic

patients, where a holding and containing analytic attitude has prevailed.
Separation experiences and separation anxieties have been interpreted and
worked through. Gaps in the patients’ narcissistic protective organization
(narcissism as Kohut’s defines) have been repaired and formerly de-
cathected representations have been re-cathected and vitalized.
John S. Strauss and Marc A. Frader:

Justifying intensive psychotherapy for schizophrenia in a community treatment
center.
The authors stated that serious criticism had been raised against the use of
intensive psychotherapy for treating schizophrenics with the increasing
desire and pressure to provide psychiatric treatment for all who need it.
73
 
AND
Such treatment may serve no useful purpose and even if it did, it would not
be feasible because of the scarcity of treatment resources. They also said
that the justification of such treatment was complicated further by a dualism
basic to psychiatry. On the one hand, the individual, his or her humanity and
personal growth are considered as central. On the other hand, assessment,
classification and treatment techniques focusing on large numbers of
patients are needed to care for all those needing help and to increase our
knowledge through controlled studies. The authors asked: Given these
problems, can intensive psychotherapy for schizophrenics being treated in a
community treatment center be justified? To evaluate this, the authors
examined four issues: (1) Possible advantages of psychotherapy as a
treatment modality for schizophrenics; (2) Limitations of psychotherapy
resources available in a community treatment center; (3) Increasing the
number of therapists and maximizing the effectiveness of therapeutic
resources by modifying techniques, and (4) Developing methods for
allocating psychotherapy resources.
The authors discussed these issues extensively and stated, among other
things:
(1) The personal meaning and interpersonal implications of symptoms and

disordered behavior can be dealt with in psychotherapy. Without such
intervention, the messages these symptoms have regarding adjustment and
growth problems are lost forever. Individual psychotherapy can have an
important role in helping the individual to deal with his/her psychosis,
difficulties in relating to others and with possible precipitants for the
psychosis, including difficult family relationships or other stresses. If
intensive psychotherapy does have useful functions for treatment, training
and advancing our knowledge, the question is whether such a treatment is
logistically feasible in a community treatment center.
(2) Information was collected from two communities for the report presented
to provide a more concrete estimate of the severity of resource limitation. If
these two communities were more staffed with potential psychotherapists
than most (in the USA), how is it possible to consider individual
psychotherapy as a practical approach to the treatment of schizophrenia in
such settings?
(3) Because of the large populations of schizophrenic patients who come to

community mental health centers for treatment, those facilities should also
74
 
be used as training centers for psychiatric residents and other mental health
professionals who wish to learn about psychotherapy with schizophrenics.
An important approach is to maximize the effectiveness of the limited
psychotherapy time available, for example, exploration of the patient-
therapist relationship during treatment and helping schizophrenic
individuals cope with and adapt to everyday social and interpersonal events;
promote the patient’s continuing existence in society and minimize the need
for hospitalization and, if hospitalization cannot be avoided, try to develop as
much liaison with the impatient ward as possible.
(4) The crucial issue in considering allocation of scarce treatment resources

is what level of functioning and happiness can be expected in a person with
a given treatment in contrast to how he will be if the treatment is not
provided. The harsh reality of limited resources requires consideration of
how to allocate these resources to provide the most benefit - “triage” may be
needed. Certain key principles and procedures are necessary to develop a
focus and specific goal of effective triage: (a) to use psychotherapy resources
for those patients with whom these resources would make the greatest
difference between a full and successful life and a vegetative or miserable
one; (b) clearly defining and evaluating reliably dimensions of outcome
function covering several aspects of living: at least symptoms, interpersonal
function, and work function; (c) improved systems for classifying patients:
systems of multi-axial diagnosis using several “axes” or dimensions on
which to evaluate patients, for example: symptom picture, course of
disorder, premorbid social function, premorbid work function, and the
nature of any precipitating events related to the onset of his/her symptoms.
In the conclusion, the authors said: Through specifically defined research,

we might be able to provide considerable help to the therapists in the
community setting who need to use their resources as efficiently as
possible.
The Arezzo Group1: Schizophrenia and psychotherapy in the light of the class
struggle and democratic psychiatry. Italy became a nation as late as 1861. The


75
 
AND
economic development and accompanying social transformation took place

slowly and in a period when England, France and the United States were
modern, industrialized societies. The Catholic Church was more influential
than in most other countries, as an unconditionally anti-liberal factor.
Liberal democratic institutions were not well developed, and the mentality in
the ruling classes were still pre-modern when Mussolini came to power in
1922, a fascist dictatorship that lasted until 1944. During this period, a
strongly repressive atmosphere prevailed in all the institutions dealing with
marginalized people, like prisons, mental hospitals, reform schools,
orphanages, homes for the elderly and so on.
After World War II, the Italian society was modernized economically with US
economic investments and aid. The labor unions and political parties voicing
the interests of the working classes continued to be repressed. The
communist party had been banned during the Mussolini era and had grown
into a formidable political force during the war. During the period called the
Cold War, Italy more than other Western countries became the battleground
between rightist and leftist forces.
During the 1960’s, more and more people saw the need for democratic
reforms in both national and regional institutions, including psychiatric
hospitals. Franco Basaglia and his coworkers in Gorizia had started to
develop ideas for mental health care reforms from 1961, and his book
“L’instituzione negata” (1968) became a manifesto for the movement called
Psichiatria democratica, which was founded in 1975. Centers for this
movement were Trieste, Ferrara, Reggio Emilia and Arezzo in Tuscany.2 The
ideology behind the psychiatric reform was from the therapeutic community
model (Maxwell Jones) and psychotherapy principles from Sullivan, Fromm-
Reichmann, Benedetti, Müller and others. The working methods were group
meetings, home visits, network meetings and all other activities known from
the therapeutic community, but applied to the local setting and
neighborhood, town or city.


76
 
II Family studies: implications for treatment
Yrjo O. Alanen presented some of the results and experiences he and his co-
workers made through a research project with 30 odd schizophrenic patients
and their parents in Helsinki and Turku between 1966 and 1972, including a
follow-up 1972/73: On background and goals in the family therapy of young
schizophrenic patients and their parents.
Psychodynamically oriented conjoint sessions with the patient and his/her

parents formed the predominant therapeutic approach. In 17 cases, the
family therapy was combined with the patient’s individual psychotherapy
following the family therapy, particularly in cases when the patient had
disengaged him/herself sufficiently from his/her family and interests and
object relations had become outside the family.
One of the most important indications for family therapy was mutual
dependency problems, and pathological emotional ties between parents and
child. They often found a striking lack of empathy for the child in the parents.
They unconsciously “utilized” the child for their own narcissistic purposes.
This explained why changes in and recovery of the child could constitute a
threat to the parent’s own psychic equilibrium. Manifestations of aggression
were more or less forbidden in many of these families. In favorable cases,
the patients experienced the improvement of their parent’s mutual
relationships as a factor enhancing their own integration and bringing them
relief.
Emphasis was on the treatment of the patient’s parents and another on the
treatment of the patient him/herself. The common goal was to relieve the
disturbances of the family environment and to weaken the mutual
dependency ties, to promote the patient’s individuation and psychological
separation from the family and, at the same time, help the parents endure
this. It was highly important for the parents to experience the therapist as an
empathic and support-giving person so that they could transfer their own
dependency needs to him/her. One of the therapist’s central tasks was to
“translate” the patient’s communication into a form that would be easier to
understand.
In the follow-up study, four patients were completely free from psychotic
features and two had also benefited very considerably from the family
therapy. Eleven had other positive experiences. Alanen concluded that the
77
 
AND
duration of the family therapy ought to be two to four years and one session
a week in order to be adequate.
Stephen Fleck presented: A general system view of families of

schizophrenics. He used the general system approach as a framework to
study and assess families and to bring some measure of order into the
chaotic world of family pathology. Like any other open system, a family can
be examined and evaluated in terms of its central functions and goals,
leadership, boundary integrity and management among system
components and between the group as a whole and the outside,
managerial links and affective bondage within it, effectiveness and
relevancy of communication inside the system and between it and the
outside world. The human family is a special group because of biosocial
and cultural givens, which require that the family nurtures and humanizes
the young by teaching them not only about themselves and how to live
within a family but also about the mores, cultural values and
instrumentalities of the society. The family is the keystone of society and
must fulfill the aforementioned system functions. The family must also
introduce children into society in school and in peer relations and
familiarize them with the tools and values of their society. If it
malfunctions, this may burden and handicap offspring severely,
particularly so in the process of emancipation from the family, to become
a full-fledged adult member in society.
Fleck demonstrates how failures in several of these areas are typical for
families with schizophrenic offspring in three clinical illustrations. The
examples showed the parents as severely disturbed, rendering the
formation on an effective parental coalition and leadership impossible. In the
parent-patient triads, they saw global task deficiencies in all evolutionary
phases. There were boundary violations, inconstant emotionally bonds,
probably incestuous and anxiety laden. Communication was ineffective,
bizarre and fragmented. The clinical data so far suggest that the number of
severity of system defects may determine pathological outcomes rather than
any particular defect in and of itself.
Fleck concluded that schizophrenia is a deficiency disease of family

functioning and task performance.
M. Selvini Palazolli, L. Boscolo, G. Cecchin and G. Prata, working in a private

outpatient center in Milan, presented what was probably a provoking new
78
 
model for many of the participants: Therapy of the family in schizophrenic

transaction: paradox and counterparadox. One heterosexual couple of
therapists worked with the family, one other couple remained behind a one-
way mirror in an observation room. They could intervene in the session at
any time to call one of the therapists into the observation room in order to
make observations and give advice. The family was always informed of their
work method. After the interview with the family, the team meets together
to discuss the possible conclusion of the session and then the two active
therapists rejoin the family and make the final intervention, which is always
crystallized to a few sentences.
Inspired by the works of Bateson, Haley and Watzlawik, the team learned to
think in an entirely new way, to conceive reality not in a linear but rather in
a circular manner, where the concept of function is central. They abandoned
the verb to be and substituted it with the verb to show, which enabled them
to understand the interplay in the family game. This interplay in the family of
schizophrenic transaction is based on the prohibition or taboo of defining the
relation. Paradoxical communication is an outstanding tool in the service of
this taboo. Schizophrenia becomes a crazy collective game with demanding
and relentless rules, which impose moves and countermoves upon all the
members of the family in the service of an endless game.
The experiences of this team had constantly demonstrated that a counter-

paradox, which strikes home, could trigger a great change in the system.
The team wanted to go beyond the barrier of rational dichotomies as
reasonable - unreasonable, normal - abnormal, real - unreal, bringing the
game to the absurd, until they reached the point in which the continuation of
the game is rendered impossible. Since the family always tries to disqualify
the therapists, the only possible disqualification left to them is the change of
the game. Thus, from session to session, the crazy game brakes down, and
the crazy behaviors lose their logic.
1. The basic contribution of the team was:

2. The positive connotation: In all observed behaviors, the therapists
declared themselves to be allied to the homeostatic ideal of the family.
3. The systemic paradoxical prescription to the entire family.
4. The concept of variable time in family therapy.
Because the paradoxical intervention needs a certain time span for the
reorganization of the system, they found that the most opportune time span
79
 
AND
between the sessions was one month, and not beyond a total number of 20
sessions (one to two years of therapy).
Helm Stierlin, in his presentation: Perspectives on the individual and family

therapy of schizophrenic patients, started with the paradoxical clinical
experiences from different therapists: A first proposition stating that mere
“individual therapy of schizophrenic patients does work,” and a second one
stating that “it does not work.” Evidence of the first is published by a number
of pioneer therapists. Other clinical evidence, no less impressive, appears to
challenge this notion. These researchers conceptualized the homeostatic
and system forces, keeping the schizophrenic locked into his family ghetto.
Double bind, pseudo-mutuality and pseudo-hostility, rubber fence, blurring
of intergenerational and other boundaries, consensus sensitivity,
undifferentiated family ego mass, inter-subjective fusion and cognitive and
affective binding, capture many schizophrenic patients maddingly tight with
his/her family. These forces can only be dealt with by including the patient’s
family in the treatment.
In a number of cases, however, a family’s involvement becomes unnecessary

because there is no longer a meaningful involvement between the parents
and child generations. This may occur under the expelling mode, where the
patient had been pushed out prematurely, left to his/her own devices. But
even in some of these families, there are hidden ties that connect as well as
disconnect many parents and their hospitalized offspring. They came to be
perceived as “ill, mad, beyond human influence or concern.” He/she was
condemned to a living death in a mental hospital. But this “dead” patient
retains the power to fill the parents’ lives with never ending terror, concern
and guilt.
An individual approach that focuses on a sick patient may free parents from
blame and guilt of ruining their child’s life. In other instances, while
supporting an individual psychotherapy, parents may feel they can do
something for the child after having suffered long periods of helplessness
and despair.
Stierlin describes the id-binding mode where the parents manipulate and
exploit the child’s dependency needs, for example by affording massive,
regressive gratification, sexually over-stimulating or frustrating them. In the
ego-binding mode, the parents intrusively substitute their own for the child’s
ego and these families are characterized by an undifferentiated ego -mass,
80
 
a consensus sensitivity, a cognitive chaos and their penchant to disqualify

and blur anything and everything. In super-ego binding, they foster a deep
loyalty, which causes the child to reel under brake-away guilt, should he/she
ever in thought or action, try to individuate or separate. The patients very
likely undo any therapeutic gain they made in individual therapy and thus
sabotage themselves, act out and signal to their parents and therapists that
psychotherapy is useless for them. These families should be included in the
treatment as soon as possible. Some patients are delegates of their parent,
they are sent out and entrusted with impossible missions, i.e. to embody and
actualize a parent’s grandiose, unfulfilled ego-ideal, or serve his/her
parent’s self-observation by embodying and enacting their own disowned
madness.
Research projects
John G. Gunderson: Recent research on psychosocial treatments for
schizophrenia.
John Gunderson’s presentation reviewed recent research, which re-

examines the effects of psychosocial treatments and their interactions with
drugs. He based his review on the four basic types of controlled research
design which are utilized to evaluate the effects of treatment in
schizophrenia and also other studies relevant to the evaluation of
psychosocial treatments: those where one treatment program is compared
with another without efforts to control specific drug or psychosocial
treatments within the program and those studies which attempt to isolate
the therapeutic ingredients within a given psychosocial treatment. He
reviewed studies that tried to shed light on the following issues:
psychosocial therapies and drugs; drug non-responders; are drugs
contraindicated?; milieu therapy; group therapy; family therapy; and
individual psychotherapy.
Implications for research: Since the effectiveness of drugs seems to depend

both on the sample of patients and the psychosocial treatment context,
researchers must redouble their effort to make these variables well-defined
and whenever possible controlled. The impact of milieu therapy seems
sufficiently large that studies should not consider this a “no treatment”
control. There is clear need for better refined and more reliable instruments
and usage of common assessment instruments - for example: subtyping of
81
 
AND
patients, subgroups of non-responders to drug treatment, instruments

characterizing different treatments (nature, attitudes and goals of therapy),
outcome measures (with some specificity for the type of treatment being
evaluated), the need for measurements of interpersonal closeness and
subjective comfort - in addition to widely accepted symptom measures.
Longer follow-up is required. There is the need to assess the effect which
the researcher’s own motives and expectations have upon the results.
Implications for clinical practice: The question of whether psychosocial

treatment of schizophrenia adds anything to drugs has been uniformly and
convincingly answered in the affirmative. There is certainly little justification
for the exclusive reliance on drugs as the “single most important treatment
for schizophrenia.” If anything, milieu therapy would seem most able to
justify this claim. The impact of psychosocial treatments on chronic patients
is perhaps more surprising than the results for the acute patients. Several
studies suggest that relatively non-intensive and inexpensive interpersonal
therapies can significantly add to the effectiveness of drugs in aftercare.
Other studies are needed to test whether more expensive and more intensive
therapy would further improve outcome results. The results also suggest
that an enthusiastic and highly motivated staff is more important than the
specific treatment models around which the therapeutic milieu is organized.
The exception may be the use of a behavioral modification model in the
treatment of highly chronic schizophrenics.
These implications provide a convincing rejoinder to recent efforts to write

off the importance of human intervention in the treatment of schizophrenia
for economic, ethical or ideological reasons.
Edgar Heim and Einar Johnsen with co-workers presented an explorative

study from the psychiatric clinic “Schlössli” in Oetwill, Zurich with 400
beds, developed through different phases of milieu-therapy, therapeutic
communities both in the different wards and in the hospital as a whole.
One goal was to find certain indications regarding the process and context
of the milieu therapy in Schlössli. A second goal was to clarify the position
of the schizophrenic patient within the therapeutic community: Application
of the principles of the therapeutic community with the participation of
schizophrenics.
Heim first presented the method and the principles they planned to follow in
the study:
82
 
1. Retrospective, historical descriptions of the hospital development.
2. Sociometric procedures registering certain interactional processes by

means of existing scales.
3. Explorative interviews with participants in a given social field.
4. Action research, which, however, was difficult to implement in a

psychiatric institution.
5. Participant observation, which they found particularly useful for

determining the most important forms of interaction and group processes
in a therapeutic community. The observations must, however, ensue
systematically. These observers were assigned to three different wards,
each observer working in each ward for one week.
Heim then mentioned the main principles of the therapeutic community:

Advance adequate communication. Create opportunities for social learning.
Advance social and group processes. Reduce hierarchical structures in
order to advance sharing responsibilities.
The general impression of the schizophrenic patients showed no

homogeneity. However, they found two different groups of these patients.
One group, (A) = active, showed more than average involvement in the events
reported in both the ward meetings and the group therapies. They were
actively represented in decision making during the ward meetings, however,
in the group meetings, their affective presence was hardly felt at all. This
group of schizophrenics is marked by a communicative, active, emotionally
highly-strung and vulnerable nature, while at the same time being endowed
with an excessive sense of justice. They seemed to derive considerable
benefit from the principles of the therapeutic community.
In contrast with this group, they found another group of schizophrenics, (P)
= passive, usually sitting around apathetically, quiet and withdrawn. This
group of schizophrenics are lost in the group processes and in the active
programs of the ward. They were easily overtaxed by the demands made on
them in the culture of a therapeutic community. But even this group showed
some profits. The medication could be reduced, isolation of a patient was
only rarely called for, and clearly structured activities, reality oriented action
and intensification of external contacts was steadily increasing.
83
 
AND
As conclusion, Heim clearly stated that particularly schizophrenics respond

to different milieu concepts. The future milieu therapy must therefore aim at
differentiating relations with patients, particularly with schizophrenics.
These patients need a therapeutic treatment, which includes the level of
behavior (e.g. symptom healing by means of medication), social interaction
(by means of milieu therapy) and insight (by means of psychotherapy).
Endre Ugelstad: Psychosocial treatment alternatives for long-stay

schizophrenic patients
Ugelstad, Norwegian pioneer in the psychotherapeutic approach to psychotic

patients, presented the results of treatment outcome study performed at
Gaustad Hospital, Norway in the period 1972-74. Thirty male in-patients with
schizophrenia, age 25-45 (average 33) with a long history of hospitalization
(average 6 years +) were distributed into four different treatment programs:
• extramural rehabilitation situation
• intensive treatment in a small milieu therapy ward
• intensive treatment individual psychotherapy while staying in a traditional

ward
• treatment as usual in active milieu treatment ward.
Preliminary results showed that a majority of the patients in the two

intensive treatment groups had achieved considerable improvement,
compared to the patients in the two other groups (extramural rehabilitation
and intramural treatment as usual). Among the six patients who made up
the intensive milieu treatment group, three managed to start and keep work
outside the hospital during the 15 month program, and two (one in the
working subgroup) managed to move out of the hospital and live outside.
Only two patients were unchanged. Among the six patients who made up the
intensive individual therapy group, three, all with paranoid symptomatology,
obtained a significant degree of insight in their family conflict history leading
up to the breakdown. Two of these were discharged during the treatment
period. A fourth patient resumed schooling while still living in the hospital.
A fifth one, a very withdrawn man, committed suicide unexpectedly during
the treatment period while the sixth, a young hebephrenic man, remained
unchanged.
84
 
Ugelstad’s study was the first in a series of intensive psychosocial treatment

programs both in Gaustad Hospital and in other Norwegian mental hospitals
during the 1970’s and 1980’s. Many of these subsequent programs were
studied and evaluated greatly under the umbrella projected called Nordic
Investigation of Psychotherapy for New Schizophrenic Patients (NIP), which
consisted of groups led by Endre Ugelstad, Norway, Rolf Sjöström, Sweden,
Yrjö Alanen and Klaus Lehtinen, Finland and Bent Rosenbaum, Denmark.
Lyman C. Wynne, Margaret Thaler Singer, and Margaret L. Toohey:

Communication of the adoptive parents of schizophrenics. This report brought
two approaches together for the first time that heretofore only had been
applied separately in research on schizophrenia: (1) the study of the adoptive
parents of schizophrenics and (2) the study of deviant parental
communication. Ten families with index adoptive schizophrenic offspring were
studied. Two comparison groups were selected to match the adoptive
schizophrenic cases as closely as possible: (1) families with schizophrenic
offspring reared by their biological parents and (2) families with adoptive non-
schizophrenics. All three groups of parents were interviewed with a semi-
structured interview schedule covered topics intended to evaluate each
parent’s psychological functioning and psychiatric status. Conjoint interviews
with each pair of parents elicited a current assessment and developmental
history of the offspring. The parents were each given a battery of psychological
tests (Rorschach, TAT, MMPI, WAIS, and others). The Rorschachs were tape-
recorded and transcribed verbatim. Analysis and scoring of the Rorschach
typescripts were done under scrupulously blind conditions. The paper
presented the results of assessing these blind assessments with their manual
for scoring communication deviances. The findings supported both a genetic
hypothesis and a psychosocial hypothesis. The authors stated that the results
were complementary rather than contradictory. Parental psychopathology and
parental communication deviances are derived from different but compatible
conceptual frames of reference: (a) the concept of direct, individual genetic
transmission and (b) the concept of multidirectional psychosocial influences
manifest in communication patterns that have unfolded overtime. Their
formulation of the family as a transactional social system inco rporates and
builds upon genetic and biologic characteristics and the personality features
of family members, which “fit” together - or fail to do so, during the multiple
tasks of individual and family development. The findings also strongly
suggested that some characteristics of late adolescent and young adult
schizophrenics are linked by non-genetic psychosocial processes to the
communication patterns of rearing parents.
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AND
Most psychiatric researchers assume that behavioral traits and symptoms,

including those called schizophrenic, are the results of interaction
between genes and environment, rather than either acting independently.
This report represented a collaborative effort to tap both genetic and
psychosocial processes in the same strategically selected sample of
adoptive subjects.
The symposium ended with a panel discussion: Essential factors and future
prospects in the relation between schizophrenic persons and their
psychotherapists.
Otto Allan Will pointed to three essential problem areas in schizophrenic

patients: attachment, regression and separation. But these are problems of
human living, which everybody has to deal with. David Rubinstein agreed that
the problem of psychotherapy of schizophrenics is probably closely ingrained
with the whole problem of human living. He also mentioned the social and
political aspects of the care of patients who are called schizophrenic.
Christian Müller mentioned that our knowledge has grown and that new
dimensions like the family dynamics entered the scene. The ideal model may
be the combination of an intensive psychoanalytical oriented individual
psychotherapy and the organization of the setting, the contact to the family,
to walk with the family. Gaetano Benedetti’s message underlined the efforts
of the therapist to separate him/herself from the aggressive phantasms of
the patient and to offer the patient a good object, which merges with
gratifying phantasies but, in spite of its relatedness or identification with the
internal phantasm, never disrupts the patient’s integrity. If the patient
succeeds in perceiving the therapist as a good object, he becomes ready to
discover the good object within him/herself. Again and again, he found that
the readiness of the psychotherapist to speak to the patient within his/her
own world, through his/her images, is a first step towards reaching him/her.
Clarence Schulz said that psychotherapists will gradually be working with
newer concepts and newer contributions and he mentioned the valuable
contributions from Otto Kernberg and Heinz Kohut and their concepts. Helm
Stierlin stated that this had been a most comforting conference of the
friendliness of finding oneself in the same boat in this difficult work. As a
conclusion of the Symposium David Rubinstein experienced that this
conference had a feeling of warmth, attachment, necessity to exchange
views, to fertilize each other and then let go, so we then can come back
again.
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After the termination of the Symposium, nine of the participants conducted

seminars in various parts of Norway, arranged in cooperation with the
Psychotherapy Committee of the Norwegian Psychiatric Association:
Gaetano Benedetti in Stavanger, Helm Stierlin in Bergen, John S. Strauss in
Tromsø, Beatriz Foster at Blakstad Hospital in Asker, Theodore Lidz in
Hamar, Otto Allan Will in Trondheim and Mara Palazolli Selvini had a special
seminar on family therapy in Oslo.
Jarl Jørstad. M.D.

Thommessensvei 14
1338 Sandvika, Norway
Svein Haugsgjerd, M.D.

Bjørn Østberg, M.D.

Anton Schjöthsg. 8
0454 Oslo
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Book of Lausanne Symposium.

1978
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AND
From left to right Helm

Stierlin, Harold Searles and
Lyman C. Wynne in
Lausanne Symposium 1978
Christian Müller and

Endre Ugelstad,
Lausanne 1978
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6. The VIth ISPS Symposium

In Cery/Lausanne,
Switzerland,
September 28-30, 1978
Christian Müller
If I call to mind the course of this symposium and go through the list of
participants and publications, what results from it is the recognition that this
symposium, like those of 1956 and 1964 which likewise took place in
Lausanne, is closely connected not only with the history of the Psychiatric
Clinic in Lausanne but also with the history of Swiss psychiatry as a whole.
In 1956, I went forward almost daringly, or so it now seems, afterwards. As a

young, thirty-five year old senior physician, I had the cheek to write to the
leading therapists of the era. Those who came included Mitscherlich,
Binswanger, Blum, Racamier, and others. The situation for the mentally ill in
that hospital at the time was still rather catastrophic. Although it was indeed a
clinic affiliated with the university, it was at the same time the regional hospital
for a canton with around half a million inhabitants. There were overfilled
waiting rooms and insufficient hygienic facilities, adequate occupational
possibilities were lacking, there were meager provisions, underpaid doctors
and nurses. I wanted to take action against this desperate insufficiency. That
is why I was able to convince my friend, Benedetti, that together, we could take
a bold step. That was already described in previous chapters.
In 1978, however, the situation was completely different. Psychoanalysis had

gained a foothold in the medical world of Lausanne; we were no longer
fighting single-handedly, rather, we formed an entire group. As can be
deduced from the program of 1978, success had once again been achieved in
winning over top-quality lecturers, some of whom were the same that we
had already brought together in 1956, 1959, and 1964.
Once again, I was able to count on the self-sacrificing help of my secretaries,

especially Ms. Marianne Junod. And we also had to struggle with the same
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AND
problem that Alanen describes for the Fourth Symposium in 1971 in Turku,
Finland, namely, there were numerous requests for the possibility of
participating, requests that we had to reject because of reasons of space,
which often brought harsh criticism down upon us.
In the more than twenty years since 1956, the face of the Lausanne clinic had
changed dramatically. Although the sexes continued to be separated, the
new building with its comfortable triple rooms, recreation rooms, the highly
developed occupational studio, the family care, the systematic training of the
assistants in analytic psychotherapy, and so on, all of this contributed to our
not only being able to offer our guests a comfortable conference setting but
also being able to point to that which had been achieved.
If the list of lecturers is scrutinized, then what is surprisingly revealed is that

in spite of the location – namely, Lausanne – the majority of the speakers
came from the USA or Scandinavia. Thanks to the aforementioned
renovations and new buildings in the University Psychiatric Clinic in
Lausanne, we could distribute the events well, alternating between main
lectures and group events.
I will never forget how elegantly Endre Ugelstad, who sadly passed away early
on, presided over the first session. Harold F. Searles, who had caused a
sensation with his uncompromising suggestions for long-term analytical
psychotherapies with schizophrenics, was there and spoke on identity.
Thomas Freeman, one of the few European psychoanalysts who had spent
his entire life in psychiatric institutions, discussed clinical and theoretical
considerations in detail. If one looks over the lectures which were held in the
various language groups, then names surface again and again that carry
international significance even today: Raoul Schindler, Paul Matussek, Martti
Siirala, Yrjö Alanen. That which Alanen reported for the Symposium that he
organized in 1971 in Turku also held true for us in 1978, namely, the growing
interest in family therapy interventions and system theory considerations in
the nature of schizophrenia. What has also particularly remained in my
memory is the wonderful lecture by P. C. Racamier on ambivalence and
paradoxicality in the treatment of schizophrenics. He, too, is one of the
psychoanalysts who spent a lifetime in the institution and in the analytical
treatment of schizophrenics.
The family therapy approach was represented above all by Helm Stierlin and
Lyman C. Wynne. They both spoke in English. In the meantime, at my clinic
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The VIth ISPS Symposium
in Lausanne, the group had consolidated around Luc Kaufmann, and out of
the first timid attempts for the introduction of family therapy at that time, the
institute for family therapy in Lausanne later came into existence and was
directed by Kaufmann. Mention should also be made of other prominent
names: Stephen Fleck, Theodore Lidz, and Loren S. Mosher, the latter of
whom spoke about his Soteria project. It is generally recognized that he
triggered a worldwide echo, and it should also be noted here that Luc Ciompi
later built up a similar therapeutic center in Bern.
On the evening of the first day, we attempted to have as many colleagues

from abroad invited into the Lausanne psychiatric circles, which apparently
was quite successful. On Friday evening, we set out for Romainmôtier, a
town with a fabulously beautiful Romanesque church and a priory where we
dined.
I now think that the course of the Symposium was satisfying, although I
would like to draw one distinction here: our First Symposium in 1956 was
characterized by a pioneer-like approach, a daring endeavor, while at the
Sixth International Symposium in Lausanne in 1978, a certain routine was
already present. It was no longer necessary to unfurl a new flag or, as the
venerable Ludwig Binswanger had encouragingly called for us to do in 1956,
to bring about a new psychiatric revolution; rather, it was necessary to
consolidate and strengthen that which existed, that which was known, and
that which could be exchanged.
In retrospect, it also seems remarkable to me that with all of these

Symposia including the one in 1978, they were not about lectures and
publications with regard to career possibilities while keeping one eye on
impact factors. They were not about the handing out of university chairs,
but rather all about a genuine, pioneering matter of concern to move the
psychodynamic view of schizophrenia and its treatment into the foreground.
What also still strikes me at this juncture is the fact that out of all of the
participants at that time, no one to my knowledge has renounced the
psychodynamic view and categorically migrated over into the camp of the
pharmacotherapists. And of course there was also reason for fanaticism;
during those years, we psychoanalysts never presented the view that a
schizophrenic could not also be comforted by medicines. Even my patient
Pierre, about whom I reported in 1956 in Psyche and who was one of the
people for whose sake I brought these Symposia into being, indeed even he
received neuroleptics.
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AND
The difference between our first two Symposia in Lausanne and that of 1978
also becomes clear if one takes the program of 1978 in hand. It was refined,
beautifully printed, it was a stark contrast to the humble, rather helpless
typewritten text that we sent out into the psychiatric world in 1956.
The fact, though, that the Symposium for the Psychotherapy of

Schizophrenia would turn into a worldwide organization as it appears today
was something that Benedetti and I could never have dreamed of at that
time. We were already very pleased at the simple idea that the University of
Lausanne supported our efforts, that the hospital made the facilities
available, that the hospital kitchen provided us with lunch, and that all of the
medical and non-medical employees of the clinic joined in with enthusiasm.
References
C. Müller (editor): Psychotherapy of Schizophrenia. Proceedings of the 6th
International Symposium on Psychotherapy of Schizophrenia. Amsterdam-
Oxford. Excerpta Medica International Congress series No 464, 1979.
Christian Müller, M.D.

Herrengasse 23
3011 Bern, Switzerland
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AND
Book of ISPS VII Heidelberg

Symposium 1981
Helm Stierlin and his

wife Satuila
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7. The VIIth ISPS Symposium

In Heidelberg,
Germany in 30.9-2.10 1981
Helm Stierlin
A quarter of a century has gone by since the symposium took place. That is
a long time when it comes to remembering things, so that in the following, I
had to rely on my fading memory, on my diary and on the papers presented
in the congress volume: “Psychosocial Interventions in Schizophrenia,”
edited by Helm Stierlin. Lyman C. Wynne, and Michael Wirsching in 1983
(Springer Verlag, Berlin-Heidelberg).
Approximately 250 colleagues from Europe and the United States participated
in the symposium organized by my team mates at the Abteilung für
psychoanalytische Grundlagenforschung und Familientherapie at Heidelberg
University. Their enthusiasm infected both many others and me and I
continue to be full of appreciation for all they did.
I vividly remember the introductory public address by Christian Müller with

the title “Die Begegnung mit dem Schizophrenen und seiner Familie” (The
Encounter with the Schizophrenic and his Family) whose pleasant, almost
poetic flow and philosophical tone were interrupted by the shouting of a
schizophrenic in the audience, apparently driven to make his own
contribution to the symposium. The lecture took place in the Alte Aula of
Heidelberg University, a stately lecture hall in which such distinguished
scientists and thinkers as Georg Wilhelm Friedrich Hegel, Max Weber and
Karl Jaspers had captivated their audiences in previous times.
In our introduction to the earlier mentioned congress volume, we three

editors spoke of “a salutary confusion” regarding the etiology and therapy of
schizophrenia as the possible most striking characteristic of the symposium.
And it seems to me after rereading his text that Christian Müller’s opening
lecture, albeit in itself not confusing, highlighted this characteristic. He
implicitly or explicitly referred to the often confusing diversity of
experiences, of basic assumptions, of treatment approaches and treatment
experiences that were presented at the symposium. This diversity made me,
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AND
in this brief chapter, have to repeatedly shift my observing lenses, to be

selective, to reduce complexity and yet to try to convey what I considered to
be essential.
What this task implied was highlighted by one term that Christian Müller
repeatedly used in his introductory speech: the term, “the schizophrenic.”
This is because it could suggest that there is a consensus among
researchers and therapists as to what the schizophrenic is and what
happens in his/her inner life. But that is not the case as the symposium so
strikingly showed. To be sure, we now have several diagnostic manuals to
guide us in making the schizophrenia diagnosis. However, the label
“schizophrenia” continues to cover a wide variety of clinical manifestations,
of inner experiences, of possible life courses, of prospects for complete or
incomplete recovery and hence also for special treatments that may be
indicated. So, with the above in mind, let me first turn to the topic of individual
therapies as these were presented at the symposium.
One of the presentations of these therapies stands out because it was

enriched by impressive material from a patient: the therapy presented by
Gaetano Benedetti.
Benedetti’s lecture was titled “Possibilities and Limits of Individual

Psychotherapy of Schizophrenic Patients.” In order to illuminate such
possibilities and limits, he reported on the first three years of his treatment
of a patient who showed a remarkable ability to express herself in verses and
in painting done by herself. Benedetti started his lecture by reciting a lengthy
poem in which she described the inner hell she had been experiencing. The
last lines of the poem read as follows:
Fear is hanging
Like a giant drop
Encompassing the world
And the monstrous depths
Of nothingness
Into which I am falling
On the way down
Accompanied by multicolored rage
And the loss of solidity
And the decay into undefined gravel.
Always and again this hated presence
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The VIIth ISPS Symposium
While the rage

Like a transparent bomb
Ticks on.
This rage, hypostatized as a transparent bomb, was continuously unleashed

against the therapist who “attempted to take this embittered and malignant
violence into himself with benevolent calm, which sprang from his
connection with the inexpressible human substance of the psychotic
person.” Benedetti characterized his work as a “dualization which expresses
a process that makes psychotherapy possible, but also transcends it
dialectically,” a process highlighting a drama during which the therapist
“has stepped into the contradiction of opposites, for example, the
contradiction between objective countertransference and subjective
identification with the patient’s suffering.” This drama was also revealed in
strikingly colorful paintings done by the patient during various phases of her
therapy and reproduced in the congress volume. However, at the end of this
case presentation, Benedetti warned us that several factors might mitigate
against the feasibility of this kind of individual therapy such as lack of
motivation on the part of the patient and possibly also the attitudes of family
members who, instead of supporting such individual therapy, might
sabotage it overtly or covertly.
John Kafka and Clarence Schulz - two colleagues with whom I had become
friends during my years at the staff of the Chestnut Lodge Sanatarium in
Rockville, MD - belonged to those participants who also reported or
commented on their individual psychotherapeutic work with schizophrenic
patients. This work was guided by a psychoanalytic model that required
working through the patient’s deep seated inner conflicts and traumas in a
lengthy process of transference and countertransference. At this Lodge, this
process was thought to require typically several years. Frieda Fromm-
Reichmann, Otto Will and Harold Searles, all of them associated with the
Lodge, were some of the pioneers in applying psychoanalytic principles to
the psychotherapy of schizophrenia and I, at the symposium, again and again
believed I could feel their presence.
The work which Paul Matussek and his co-workers presented at the
symposium also largely unfolded in the framework of classical
psychoanalytic theory. Thus, it could be seen as the German equivalent of the
work carried out at Chestnut Lodge. Matussek was then heading the
Research Institute for Psychopathology and Psychotherapy of the German
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AND
Max Planck Society. By the time the symposium took place, he and his 18 co-
workers had been treating nearly 100 schizophrenics with individual
psychotherapy.
Matussek emphasized the changes this therapy had undergone since its
beginnings in the fifties. At that earlier time pioneering therapists such as
Sechehaye and Rosen had tended to foster a patient’s regressive
gratification by, for example, feeding him or her with apples. Such an
approach now seemed ridiculous to Matussek. Rather, he stressed the
importance of a stably established transference “In view of the present state
of our analysis,” he stated, “I can already say this much: the success of the
psychotherapy of psychoses - independently of their duration and symptoms
- depends, above all, on the successful establishment of transference.”
However, there were also voices heard at the symposium which, in one way
or the other, were apt to cast doubt on psychoanalysis as the royal road to
the treatment of psychotic patients. One such voice was that of Robert Cancro
who titled his presentation “Some Preliminary Thoughts on the
Psychotherapy of Schizophrenics.” Even though Cancro paid tribute to
pioneers in the field such as Federn, Sechehaye, Schwing, Fromm-
Reichmann, Sullivan and Hill, he pointed to factors which, in the treatment
of schizophrenic patients, could cause us to doubt the leading role of
individual psychotherapy in general and of psychoanalysis in particular.
“Psychotherapeutic approaches to schizophrenic patients,” he stated, “differ
greatly and this variability contributes significantly to the methodologic
problems inherent in their evaluation. The search for the common factors in
the different but successful psychotherapies is essential for adequate
evaluation research.” Accordingly, he reminded us: “The therapist must have
an excellent tolerance of uncertainty if not an actual ability to enjoy it” and
“If tolerance of uncertainty is important, tolerance of error is essential.”
Uncertainty as to the feasibility and efficacy of a long lasting individual

psychoanalytically-oriented psychotherapy of schizophrenic patients could
also be gleaned from the comments of other contributors. As I remember it,
Theodore Lidz and Thomas McGlashan belonged to this group. They referred
in particular to the individual psychotherapies conducted at the Lodge. I
remember Lidz questioning the value of a hospital setting which fostered the
patients’ regressive gratification, kept them (more or less) away from their
families and made it difficult for them to return to, or start anew, an active
professional life. McGlashan, a staff member at Chestnut Lodge before his
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move to Yale University was, as I remember it, then mentioning a follow-up

study on a considerable number of Lodge patients he and his co-workers at
Yale had started and which was subsequently published in the Archives of
General Psychiatry (McGlashan, 1984). What he had found out so far was
apparently not of the kind to make him feel hopeful about the benefits of a
long term individual psychotherapy of schizophrenic patients in a hospital
setting. (When I paid a visit to the Lodge some time later I was told that he
had even recommended electroshock treatment for one or more of his
schizophrenic patients).
There were other contributions which tended to question or at least to

relativize the value of mere individual psychotherapy for schizophrenic
patients. These were the contributions by Daniel P. Schwartz, by Loren R.
Mosher and Alma Z. Menn and by Paolo Tranchina and Paolo Serra. They all
focused on the therapeutic or contra-therapeutic impact of a given hospital
and/or social setting in which the therapy - be this an individual or other
form of therapy - was to take place.
Schwartz elaborated how an experience of limits is essential for individual

growth and identity formation and is most essential for schizophrenic
patients whose identity is brittle. He reported on a number of cases in which
the setting of limits in a closed psychiatric hospital appeared mandatory as
well as helpful. But he also reported on cases in which the setting of limits
was overdone, as it were, turning it into sadistic aggression against, and
humiliation of, the patient. He further mentioned that the demands of a
society needing to protect its members from the psychotic’s destructive
outbursts on the one hand and therapeutic concerns for his or her growth on
the other will often clash and then confront therapists with contradictory
mandates and typical dilemmas. These dilemmas differ in closed and open
psychiatric hospitals. Schwartz reflected in particular on the chances for,
and problems of, providing adequate limits in an open hospital such as the
Austin Riggs Center in Stockbridge/Mass. in which he was working as an
analytically oriented therapist. This hospital provided - and, as far as I know
- still provides, intensive, individual psychotherapy of four or more hours
each week with an experienced therapist, a very special activities program
using sculptors, poets and theater directors as teachers, the presence and
focus of nurse-clinicians, community programs and much more. All patients
admitted themselves voluntarily and therefore had to learn to develop and
trust their inner limits rather than rely on outer limits which the hospital
might provide. These and other factors made Austin Riggs a unique place
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AND
comparable to the Lodge, but also made it accessible for only a small group
of privileged private patients whose growth became the staff’s overriding
concern.
But the most incisive criticism of long term individual therapy came, no
doubt, from Paul Watzlawick when he elaborated on the brief therapy of
schizophrenia. He supported his position with case descriptions, a
comparative analysis of various studies, consideration of the “Here-and-
now-communication in schizo-present families” and in his final comments
pointed to two epistemologies - one heavily relying on linear causality to
grasp intrapsychic processes, the other acknowledging the “fantastic
complexity of interactions” - which, in his view, were clashing at the
symposium.
In their presentation with the title “Scientific Evidence and System change:
The Soteria Experience” Loren R. Mosher and Alma Z. Menn compared two
residential settings for the treatment of schizophrenic patients: The so-
called Soteria House and an American Community Mental Health Center. But
they were less concerned with the question of how either setting could
support an ongoing individual psychotherapy but rather with how the given
setting, in and by itself, could become the main force in promoting the
residents’ growth, development and learning.
From this vantage the presenters gave an account of the insights they had
gained from the Soteria project which they had started a number of years
ago. In essence, this project relied on the democratization of a small
community of schizophrenic residents and their helpers who, as a rule, had
no significant professional training. This was considered an advantage in
their attempts to counteract the residents’ medicalization and their
becoming pathologized, as would have been the case in a typical psychiatric
hospital. Despite criticism from the psychiatric establishment and lack of
funds Mosher and Menn could report considerable successes. They also
evidently inspired Luc Ciompi, another contributor to the symposium, to start
the “Soteria project Bern” which Ciompi described for an appreciative
audience of about 3500 people at the EFTA meeting held in Berlin about a
quarter of century later (cf. Ciompi, 2001).
An even farther reaching project counteracting the trend to medicalize and

pathologize schizophrenic patients was reported by Paolo Tranchina and
Paolo Serra from Italy in their contribution with the title “Community Work
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and Participation in the New Italian Psychiatric Legislation.” In fact, I do not

know of any other events which so massively changed the lives of so many
schizophrenic individuals and their relatives as the social and political
reforms and their consequences about which Tranchina and Serra reported.
These reforms had taken place largely thanks to the efforts of Franco
Basaglia who had prematurely died several years before the date of the
Heidelberg symposium. Basaglia’s efforts and those of the so-called Arezzo
Group had led to a new psychiatric legislation in Italy in 1978 that aimed at
the progressive elimination of traditional psychiatric hospitals. Instead, all
newly diagnosed psychiatric patients had to be accommodated in general
hospitals. At the same time, outpatient community services were to be
enlarged and strengthened. In the first year of enforcement of the new law,
there had been a decrease of about 17% of the population of the psychiatric
hospitals in Italy; this population fell from 52,305 inmates to 43,526.
Compulsory admissions had decreased by 63%, declining from 33,287 to
12,244. For Tranchina and Serra, this proved that many of the compulsory
admissions carried out in the past had been completely arbitrary.
In their contributions to the symposium the two authors highlighted the

many new vistas and chances opened up by the new legislation. In particular,
they stressed how the patients’ relatives had become much more prone and
motivated to cooperate in the treatment. But they also pointed to the many
difficulties and bureaucratic delays which had so far hindered or even
prevented the implementation of the new law, not the least because of
increased efforts of the pharma industry to push their products into the
psychiatric market. All of this - the new vistas and the snarls hindering their
practical putting into effect - was in evidence when I, a short time later,
visited some psychiatric colleagues in Italy. I vividly remember the old style
psychiatric hospitals now empty and looking like deserted barracks. And I
also recall the mixture of relief and concern my colleagues conveyed to me.
In retrospect, this concern seems justified as Italy has also subsequently
been affected by the world-wide upsurge of neuro-biologic psychiatry.
Let me finally turn to the topic which possibly more than any other has made
for excitement and salutary (as well as not so salutary) confusion at the
symposium: The topic of family research and family therapy in schizophrenia.
This topic had been on the agenda of previous symposia. This time we were
fortunate in that the participants could again learn first hand about the most
recent findings and experiences of some of the most innovative researchers
and therapists in the field.
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AND
Forming a part of these were Lyman Wynne and Margaret Singer who, in
particular with their research on communication deviances, had laid the
ground for many subsequent projects carried out by themselves and others.
One of these projects was the Rochester Risk Research Program which
Lyman Wynne and Robert E. Cole presented at the symposium. Its perhaps
most interesting and important finding was the elucidation of family
relationship variables that promote health in families with children at risk
despite the expectable adverse effects which serious parental disorders can
be assumed to have on these children. The findings then obtained and the
questions then raised by the authors continue to be relevant for what has
come to be known “resilience research” in schizophrenia.
Michael J. Golstein - he worked in close cooperation with Wynne and Singer

- also contributed to the elucidation of family factors related to the onset and
course of schizophrenia. In his presentation with the title “Family
Interaction. Patterns Predictive of the Onset and Course of Schizophrenia,”
he also elaborated on the importance of communication deviances.
Furthermore, he applied the work on expressed emotion (EE) as carried out
by Vaughn and Leff (1976) with the Camberwell Family Interview (CFI). In
addition, he reported on his own work with the Affective Style (AS) measure.
He evaluated the validity of these constructs from a number of vantage
points and finally concentrated on the usefulness of the affective style
construct. He concluded: “Families in which significant others, usually
parents, express strongly critical and/or emotional overinvolved (intrusive)
attitudes are at a higher risk for onset and relapse for schizophrenia.”
However, his data also indicate “that these affective attitudes predict
schizophrenia only when associated with high levels of communication
deviance.”
The work of Pekka Tienari and his associates from Finland also gave evidence
of the importance of communication deviances in child rearing parents as
one major risk factor predicting a child’s later development of a
schizophrenic (or schizophrenic spectrum) disorder. I know of no other
research in the field of psychiatry comparable to it in scope, length of time
invested, methodologic stringency and number of variables examined. In his
presentation with the title “The Finnish Adoptive Study: Adopted-Away
Offspring of Schizophrenic Mothers”, Tienari and his associates reported on
the progress of the field work. By then, a national sample of 274 Finnish,
adopted away offspring of schizophrenic mothers had been identified. One
hundred fifty three of these offsprings of 134 mothers had been placed in an
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unrelated family during their first 4 years of life and were at age of risk for
schizophrenia when the symposium took place. The main finding was that
the index and control groups did not differ if they had been brought up in
relatively undisturbed adoptive families; but if the rearing family was more
disturbed, the index adoptees were clearly more disturbed than the control
adoptees.
Let me turn from the research on families with a schizophrenic offspring to

the experiences made with the therapy of such families as these were
reported at the symposium. Three approaches stood out here, all markedly
differing from each other.
The first approach, presented by Mara Selvini-Palazzoli and Giuliana Prata,

has since come to be known as the “Invariant Prescription.” This
intervention typically comes as a surprise to the family members as it
requires that only the parents and not their schizophrenic offspring come to
the next session. This prescription, the authors stated, “seemed to break the
ongoing game (in the family) without it being necessary for the therapist to
first understand what game has been going on.” By the time the symposium
took place, the authors had applied the prescription to 19 families.
The second approach was presented by Norman L. Paul in his contribution

with the title “The Unconscious Transmission of Hidden Images and the
Schizophrenic Process.” This approach is based on a transgenerational
perspective of the genesis of a schizophrenic process which Paul
exemplified by one particular family. It was guided by the hypothesis “that
the repressed mourning responses in family members (usually parents) are
related to a fixity in family structure or equilibrium which precludes the
formation of adequate ego boundaries on the part of family members.”
The third approach was presented by Carol M. Anderson from Pittsburgh

University. She called it “A Psychoeducational Model of Family Treatment for
Schizophrenia” and gave an overview of the - in her view very promising -
results obtained with it in the first three years of its application. This
approach, Carol Anderson pointed out, can be applied in diverse ways and
diverse settings. Yet it does require a particular kind of training that often
flies in the face of clinical instincts and learned therapeutic roles. That
notwithstanding, it has been this approach which in hindsight appears to
have developed further and to have established itself most strongly in the
mainstream of the international family therapy movement. Yet when taken
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AND
together, all three approaches just mentioned could, in their diversity, hardly
be seen as reducing the confusion, be it salutary or not salutary, reigning at
the symposium.
I conclude my report with two contributions, which, in contrast to the above,

can be seen as attempts to integrate and/or reconcile different forms of
treatment as well as the different theoretical positions underlying these
treatments. These are the contributions made by Yrjö Alanen and his Finnish
co-workers and those of our team in Heidelberg as I presented these at the
symposium.
Alanen’s and his team member’s work was presented under the heading
“Psychotherapy of Schizophrenia in Community Psychiatry: 2-Year Follow-
Up Findings and the Influence of Selective Processes on Psychotherapeutic
Treatments.” This work then included the psychiatric and psychological
investigators of 100 patients, aged 16-45, who during the preceding one and
a half years had entered treatment for the first time for a disorder included
in the group of schizophrenias. The treatment took place in an inpatient
and/or outpatient unit. In 90 out of 100 cases, these patient’s closest family
members were also interviewed. The treatments included individual
therapies, family therapies and, no less important, the active participation
and cooperation of the psychiatric staff, the patients and close family
members who were affected. Thus, one can speak of a treatment setting and
context which tried to do justice to what, up to that time, had appeared to be
(more or less) separate if not incompatible approaches to the understanding
and treatment of schizophrenia: The individual approach, the family
approach and the community approach. As it turned out, these were just the
beginnings of a study which, with respect to its findings as well as to the
questions it raised and still raises, continues to be unique, as can also be
ascertained from Alanen’s book “Schizophrenia - Its Origins and Need-
Adapted Treatment.” (Karnac Books, London, 1997).
In addition, the efforts of our Heidelberg group, presented under the heading
“Reflections on the Family Therapy of Schizo-Present Families” could - and
still can - be seen as attempts to embed a given treatment, in this case
predominantly family therapy, in a theoretical perspective which, in addition
to family factors, takes into account both individual as well as societal
factors which may either promote or interfere with a person’s growth and
survival. And I, too, tend to see the work then presented as a beginning which
has since branched out in various directions as is, for example, exemplified
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in my most recent book “The Democratization of Psychotherapy” (so far

published in German only) and which also can be seen as perpetuating the
confusion generated by the 1981 symposium - a confusion which, I believe,
was salutory after all, not the least because of the excitement, the warm
feelings, the mutual respect and the humor engendered again and again.
References
The proceedings of the symposium were published as the book
Psychosocial Intervention in Schizophrenia, an International View, edited by
H. Steirlin, L.C. Wynee and M. Wirsching, Berlin Heidelberg: Springer-Verlag,
1983. This book was also published at the same time as a German edition.
Other references in the text:
Alanen, Y.O. (1997). Schizophrenia - Its Origins and Need-Adapted Treatment.

London: Karnac.
Ciompi, L. et al. (2001). Wie wirkt Soteria? Bern:Huber.
McGlashan, T.H. (1984). The Chestnut Lodge Follow-up Study. I. Follow-up method-
ology and study sample. II. Long-term outcome of schizophrenia and affective
disorders. Archives of General Psychiatry 41:573-601.
Stierlin, H. (2003). Demokratisierung der Psychotherapie - Anstösse und

Herausforderungen. Stuttgart: Klett-Cotta Verlag.
Vaughn, C.E. & Leff, J.P. (1976). The influence of family and social factors on the
course of psychiatric illness. British Journal of Psychiatry, 129:126-137.
Helm Stierlin, MD, PhD.

Kapellenweg 19
D-69121 Heidelberg, Germany
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AND
Lidz and Fleck, Chairmen of New

Haven Symposium. 1984
Works of 1984 New Haven Symposium were

published in two issues of The Yale Journal
of Biology and Medicine.
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8. The VIIIth ISPS Symposium

In New Haven, Conn.,
U.S.A, in October 1984
Ann-Louise S. Silver and Stanley Possick
The VIIIth International Symposium on Psychotherapy of Schizophrenia was

held in New Haven, Connecticut in October, 1984. Under the leadership of
Stephen Fleck, M.D. and Theodore Lidz, M.D., it was the first of these
symposia to take place in the United States. Fleck commented, “…interest in
the psychotherapy of schizophrenics is rather low in the United States
compared with Europe, a reversal in orientation and research in the two areas
over the last quarter-century.” (p. 207) Three hundred participants from
throughout the world convened in New Haven to learn about and discuss the
central theme of the conference, new approaches to psychosocial
interventions in the treatment of schizophrenia. Ninety of the participants
presented, co-presented or discussed papers or case presentations. They are
listed at the end of the two-issue set of papers issuing from the meeting,
many of whom continue as major contributors to our field. Given the waning
interest in, and support for, individual psychotherapy of schizophrenia in the
United States at the time, coupled with declining research funding in the area,
this Symposium provided an important venue for national and international
leaders in the field to illustrate and document the efficacy of various
psychosocial interventions in the treatment of schizophrenic individuals.
Presenters raised fundamental questions about developmental and
psychosocial factors in the etiology and course of schizophrenia, leading to
productive discussion.
Nineteen of the approximately eighty manuscripts presented at the

conference were selected for publication in two successive issues of The Yale
Journal of Biology and Medicine, volume 58, numbers 3 and 4, published in
May-June, 1985 and July-August, 1985 respectively. The first issue focuses
on theoretical and epidemiological topics. The second issue addresses
treatment issues and program evaluations. The Symposium’s Editorial and
Program Committee and the Editorial Board of the Journal selected the
papers to be published, and Stephen Fleck, M.D. served as the guest editor
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AND
for these two issues of the Journal. The Editorial and Program Committee,
which also selected the main theme for the Symposium and decided on its
format and manuscripts to be presented, consisted of: Drs. Yrjö Alanen
(Turku, Finland), Stephen Fleck (New Haven, Connecticut), John Gunderson
(Boston, Massachusetts), Jarl Jørstad (Oslo, Norway), Ira Levine (New
Haven, Connecticut), Daniel P. Schwartz (Stockbridge, Massachusetts),
Helm Stierlin (Heidelberg, Germany), Pekka Tienari (Oulu, Finland), Endre
Ugelstad (Oslo, Norway) and Lyman Wynne (Rochester, New York).
The Symposium could not have taken place without the support and
assistance of the Yale University School of Medicine, its Department of
Psychiatry, which was chaired by Morton Reiser, M.D., and the Yale
Psychiatric Institute. All of the plenary lectures, case presentations, panels
and paper presentations were held at various facilities at the medical school.
The work of the local arrangements committee played a crucial role in the
success of the Symposium. This committee consisted of: Mr. Lawrence
Berger, Ms. Mady Chalk, Drs. Stephen Fleck, Charles W. Gardner, Ira Levine,
Theodore Lidz, Stanley Possick and Robert Rosenheck. This group took
responsibility for the moment-to-moment operations of the Symposium, and
also organized the social activities associated with the conference. The
members of this committee wanted to stimulate as much dialogue and
interaction as possible among the Symposium participants and the local
mental health practitioners and scholars. The fact that nearly a third of the
attendees presented at the Symposium facilitated this process. Those of us,
who had participated in previous I.S.P.S. symposia and who had been
welcomed as guests into the homes of our hosts, had found these to have
been warm and meaningful experiences. Many of this committee’s
members and several of our senior colleagues had dinners at their homes
for as many of the participants as possible. We tried to include a mixture of
local mental health professionals, who had an interest in work with
schizophrenia, with out-of-town and international guests at each of the
dinners. The dinner parties took place the night before a gala dinner dance
at the New Haven Lawn Club, and were a highlight of the Symposia.
The presentation of five case reports, each followed by a panel discussion, was
one of the organizing principles of the conference. The case material
illustrated how clinicians in various countries utilized different psychosocial
interventions, e.g. individual, group, family and milieu therapies in the
treatment of schizophrenia. The clinical cases brought the work we do to
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The VIIIth ISPS Symposium
life, and the subsequent panel discussions allowed one to link clinical
techniques with theory. One of the clinical presentations consisted of a
simulated family therapy session, which was then discussed. Christopher
Keats, M.D., of Chestnut Lodge, played the role of the patient. Over the years,
he has often commented on how easy it was for him to “become” the patient,
and how he really lived the part in the moment. He clearly enjoyed the
experience and enjoyed recalling it.
The breadth of the paper topics presented at the conference is captured by

the wide variety subjects noted in the titles of the Symposium’s published
manuscripts. These include: individual, family, group, milieu and combined
pharmacologic and group or individual therapy, the Schreber Case, the
Finnish Adoptive Family Study of Schizophrenia, and two other important
follow-up studies: the effects of supportive versus insight-oriented
psychotherapy of schizophrenia and the development of a global
psychotherapeutic approach to schizophrenia. At least three of these papers
have been associated with research that has had a major impact on the field
during the past twenty years. Together, these representative papers convey
the richness and diversity of the meeting’s formal offerings. Even though we
have no published record of the case presentations, the papers that were
published are rich in vivid case presentations and vignettes. We will review
the published articles since the journals themselves may be very difficult to
locate.
Theodore Lidz delivered the keynote address, a message still vitally current
twenty years later: “The address considers the regression that has taken
place in American psychiatry during the second half of this century, one
which has resulted from attempts to locate the origins of many psychiatric
disorders in the brain, and particularly from the misguided attempt to
revitalize the nineteenth-century conviction that schizophrenia is a clear-cut
disease entity that is chronic and incurable. The orientation has again
become self-fulfilling because of the relative neglect of psychosocial
therapies.” (p. 209) He saw the reason for the regression as “a
misunderstanding of the nature of human adaptation that rests greatly on
the capacities for language.” Children need to acculturate, and the
responsibility for this rests with the parents; failures in this project lead to
“escape into a fantasy life” and the resultant clinical picture we call
schizophrenia. Lidz decried the over-reliance on medication and the closure
of hospitals, with the result that homeless mentally ill then filled the cities
of the U.S. He refuted the earlier adoption studies, emphasizing the very low
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AND
rate of schizophrenia in adopted-away children of schizophrenic mothers.

He yearned for a return to the orientation taught by Adolf Meyer, who
emphasized the central role of life history. He gave case vignettes
illustrating recoveries from this so-called incurable condition. He quoted
Leon Eisenberg, “Our field has changed from a brainless psychiatry to a
mindless psychiatry. ”He then launched into the body of his talk, developing
the notion that human brains differ from other primates in that we use and
develop tools, the most important being the word – language. We can
consider past, present, future, and can communicate our thoughts; we can
adapt to our environments, but we must adapt to our own cultures to survive,
and we need our families to accomplish this. Lidz detailed his professional
path to working with families of schizophrenic patients, and his finding that
all had one very egocentric parent. He himself was routinely confused in
their presence. ”The fault is more likely to be in the programming than in the
hardware.” (p. 216).
David Adler (1985) presented “A framework for the analysis of psychotherapeutic

approaches to schizophrenia.” He describes the four major tasks of psychiatry
and then demonstrates how these tasks overlap and interdigitate. They include
a) the medical perspective: diagnosing, curing and limiting illness; b) the
rehabilitative perspective, reducing defect and its impact; c) the educative-
developmental perspective, fostering growth and competence, and d) the
societal-legal perspective, controlling socially deviant behavior. “…a
comprehensive approach to the psychotherapy of schizophrenic individuals
must take into account the many ways in which the schizophrenias are at the
same time a disease state, a defect, a cluster of behaviors labeled as deviant,
and a developmental impairment.” (p. 219) “Physician/patient relationships
often reflect a benign paternalism.” (p. 220) “One emphasis of this paper has
been that technique does not define an area of psychotherapeutic work even or
especially with schizophrenic patients. For example, if the focus of treatment is
on disturbed functioning, then the work is more often rehabilitative, whether the
techniques used are exploratory or supportive. Restoring the individual to an
adaptive equilibrium, maintaining control, alleviating symptoms, as well as
strengthening existing defenses, are goals of treatment. The relationship
between therapist and patient is utilized to promote functional improvement.”
(p. 225)
Pekka Tienari et al (1985) presented on the early phase of their famous

“Finnish adoptive family study of schizophrenia: “A nationwide Finnish
sample of schizophrenic mothers’ offspring given up for adoption has been
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compared blindly with matched controls; i.e., adopted-away offspring of

non-schizophrenic biologic parents. The families have been investigated
thoroughly by joint and individual interviews and psychological tests. In the
91 pairs where both the index and control families have already been
investigated and rated, the total number of severe diagnoses (psychosis,
borderline, character disorder) is 28.6 percent (26/91) in the index group and
16.5 percent (15/91) in the matched control group. Of the seven psychotic
cases, six are offspring of schizophrenics and only one is a control offspring.
However, no seriously disturbed offspring has been found in a healthy or
mildly disturbed adoptive family, and those offsprings who were psychotic
and seriously disturbed were nearly all reared in disturbed adoptive families.
This combination of findings supports the hypothesis that a possible genetic
vulnerability has interacted with the adoptive rearing environment.” They
underscored the possible interaction between genetic vulnerability to
schizophrenia and adoptive rearing environments in adopted-away offspring
of schizophrenic mothers. They list (p. 236) three alternative interpretations
of the findings: 1) “Genetically transmitted vulnerability may be a necessary
precondition for schizophrenia, but a disturbing rearing environment may
also be necessary to transform the vulnerability into clinically overt
schizophrenia.” 2) Healthy family rearing is a protective factor. 3) “Another
possibility is that the genetic vulnerability of the offspring manifests itself in
a way that is disturbing to the adoptive family.” However, there were just
about as many disturbed families adopting a vulnerable child as there were
disturbed families adopting a child not at risk. They reported that a major
subset of their group had not grown to an age when schizophrenia usually
manifests itself. They promised, and have since delivered, much rich
research material.
“Intensive psychotherapy of schizophrenia,” presented by Christopher Keats

and Thomas McGlashan was a prelude to their book, Schizophrenia:
Treatment Process and Outcome. “This work is part of a larger study in
which we are searching for clues as to what elements in the process of
treatment might contribute to outcome.” (p. 239) They begin by outlining the
assumptions that most frequently appear in the literature: 1) “the etiology
and pathogenesis of schizophrenia are, in part, environmentally influenced.
2) the therapist’s model of the mind draws heavily upon theories and
observations concerning preoedipal psychological development. 3) virtually
all postulate a real or fantasied negative first experience between the
patient-as-infant and his or her mother. 4) “utter schizophrenia does not
exist….even the ‘craziest’ of patients retains an element of ego in touch with
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AND
reality.” (pp. 239-240) They find in the literature that generally a good
patient has “1) an ego-dystonic illness leading to a wish for treatment; 2) the
presence of good premorbid features; and 3) the presence of some capacity
for one or more of the following: self-observation, curiosity, delay,
frustration tolerance, problem solving, attachment, concern, and humor.”
(p. 240) They then reviewed the elements of the therapeutic process and the
technical attitudes of investigative psychotherapy. “The patient holds all the
trump cards. Therapists must tolerate negativism and ultimately accept the
patient’s right to psychosis. Especially with chronic patients, it is important
to realize that the person is the illness rather than host for the illness.
Psychosis is often ego-syntonic and deeply cherished like an old familiar
security blanket. Getting better therefore is like a death, like losing an old
friend.” (p. 241) They then discuss technical interventions. “The component
strategies of elucidating,” include 1) listening and observing, 2) treating
psychotic content as signal, 3) acknowledging feelings, 4) elaborating detail,
5) demanding facts,6) tolerating the mobilized transference and
countertransferences.” “By demonstrating tolerance of what the patient
disavows, the therapist helps the patient repossess split-off aspects of his
psychic experience.” (p. 243) They then present an elegant, experience-
near, case history of a man who recovered from chronic and severe
schizophrenia, over the course of a long hospitalization at Chestnut Lodge.
“Perhaps one reason for the successful outcome of the second regression
was that the patient and therapist shared a real experience, namely, despair,
and survived, thus accomplishing something together.” (p. 252)
Helm Stierlin et al presented “Why some patients prefer to become manic-

depressive rather than schizophrenic.” The authors observed fifteen
families where a young adult member suffered from manic-depressive
illness. Systemic family therapy was utilized, using the circular questioning
method of Selvini-Palazzoli. They observed families operating by a “digital
code” similar to the on-or-off of computer coding: “a person is either good
or bad, honest or dishonest, controlled or uncontrolled, responsible or
irresponsible, and so on. There is no in-between…. Related to this “is the
notion shared by all members that one can and must ‘will’ certain emotions.
Interpersonal and intrapsychic negotiation thus becomes impossible, and
intolerable emotional dilemmas result….Manic-depressive families…live in a
world of mutually exclusive yet constantly reconstructed extremes—
extremes in attitudes, roles, behaviors, and values.” (p. 260) The authors
see the goal of family treatment as fostering individuation by questioning the
family members’ assumptions.
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Bjørn Rund “Attention, communication, and schizophrenia” has carefully

investigated the cognitive disorders in schizophrenic patients and the
communication deviances in their parents, finding significant correlations
between them. He set up an experiment guaranteed to produce the
communication conflicts he wanted to study: Each parent was given a map
but the father’s had an extra street. They are supposed to navigate to a
particular spot. Rund studied how they negotiated and possibly solved the
dilemma. He has concluded that his work supports Vigotsky’s theory that
higher mental functions are internalized social relations. This resonates
beautifully with the preceding paper dealing with the manic-depressive
disorder.
Michael Stone “Analytically oriented psychotherapy in schizoptypal and

borderline patients: At the border of treatability” studied the positive and
negative factors distinguishing the likelihood that a treatment relationship
could be established. “On the positive side: likeableness, autoplastic
defenses, high motivation, psychological-mindedness, genuine concern,
good moral sense, self-discipline and low impulsivity. Negative factors
include, beside the opposites to the aforementioned, vengefulness and
parental abusiveness or exploitation. A scale for measuring the balance
between these positive and negative factors is proposed.” (p. 275)
Nancy Morrison, “Shame in the treatment of schizophrenia: Theoretical

considerations with clinical illustrations” is a paper we feel should be
rescued from the relative oblivion of this journal article, to be read by current
trainees in mental health. It clearly and convincingly demonstrates how the
universal experience of shame is central in the development of
schizophrenia. It plays “a vital role in autonomy and personality development,
symptom formation, character pathology, and interpersonal relationships.
”Shame is a reaction involving hiding, and this has led to its hiding from
psychological observation. It damages the boundaries of the self and it
incorporates the opinions of the other into the self-experience. It produces
“humiliated fury,” but when this is towards someone on whom one is
dependent, passivity can result, and escalating shame can result, leading to
chronic self-doubt and interpersonal inhibition. Clinical examples are given
that show that when the therapist highlights shame and self-consciousness,
the level of collaboration can improve dramatically.
James Grotstein “The Schreber case revisited: Schizophrenia as a disorder of

self-regulation and of interactional regulation.” Rather than getting locked
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AND
into debating whether schizophrenia is a disorder of nature or nurture,

Grotstein hypothesizes primary and secondary disorders of attachment,
presenting as disorders of self-regulation and interactional regulation. The
paper, following that of Nancy Morrison, can be seen as an amplification and
development of her thesis as well.
The second Journal issue contained seven articles:
Marvin Skolnick, “A group approach to psychopharmacology with

schizophrenics” showed how the over-worked ward administrator can use
group techniques to move the act of medicating from something in which the
doctor is the active and the patient the passive partner, to an activity in which
other patients can make the psychologically meaningful interpretations
about resistance to receiving these substances, thus helping not only that
particular duo but the other community members as well. “It is not just the
medication that needs to be metabolized by the patient. The dynamic forces
within the system must be metabolized by the pharmacotherapist and in a
coherent way brought back into the treatment if the patient is to be helped
by medication and not harmed.” (p. 326)
John Cegalis and Stanley Possick presented “Carbamazepine and

psychotherapy in the treatment of schizoaffective psychosis” “The authors
describe the interactions between and the differential effects of
carbamazepine and individual psychotherapy in the treatment of a
schizoaffective patient. Carbamazepine’s impact on the patient’s affective
life facilitated the establishment of a working alliance in psychotherapy. As
the patient began to understand and differentiate aspects of his affective,
cognitive, bodily and interpersonal experiences, his life situation stabilized
and his carbamazepine dose requirements diminished.” (p. 327).
Pier Maria Furlan and Gaetano Benedetti, “The individual psychoanalytic

psychotherapy of schizophrenia: Scientific and clinical approach through a
clinical discussion group” describe an ambitious and effective long-term
support system for psychotherapists treating patients struggling with
schizophrenia, which hearkens back to Clara Thompson’s 1938 “Miracle
club,” and to the Chestnut Lodge small group meetings. Fourteen years of
working in a clinical supervision group allowed for the careful study of the
very personal and complex nature of this psychoanalytic approach. “Each
meeting was dedicated to the discussion of one particular therapy carried
out by a member of the group and written up in advance. After the general
116
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discussion, the group leader presented both his previously written

assessment and a synthesis of the discussion. All the discussions were
recorded in their entirety.” They documented the presence of symbiosis, and
saw it as predictive of a good outcome. Case examples are given, but one
wishes the transcriptions could be made available, as a model of excellent
instruction.
Per Vaglum et al, “Why are the results of milieu therapy for schizophrenic
patients contradictory? An analysis based on four empirical studies.” The
authors found that the contradictory findings can be explained when one looks
at the varying ward “atmospheres.” Anger and aggression impede, while
support, practiciality, and oder are positive. Confrontational group therapy is
detrimental. “Community groups may become anti-therera peutic pseudo-
groups.” Having more older patients diminishes the level of aggression. “A
high percentage of psychotic patients, a high number of patients, and a high
staff turnover may lead to a detrimental atmosphere.” (p. 349)
William Wilson et al “A psychotherapeutic approach to task-oriented groups

of severely ill patients” contains much wisdom in guiding the group leader
working with psychotic patients. The group leader must be much more
active and structuring than when working with a less sick group, and “must
actively work to provide for the structure, stability, and safety of the group
when group members are unable to provide these for themselves.” (p. 363.)
The paper includes helpful illustrations.
John Gunderson and Arlene Frank, “Effects of psychotherapy in

schizophrenia” presented data that was part of a two year follow-up study
which hypothesized that insight-oriented individual psychotherapy would be
more efficacious than supportive therapy in the treatment of medicated
schizophrenic patients. The authors found little difference between the two
groups at follow-up (Stanton et al., 1984; Gunderson et al., 1984). This study,
and discussions of its findings, was the focus of an entire issue of
Schizophrenia Bulletin, and it stimulated far-reaching dialogues about the
value of insight-oriented psychotherapy in the treatment of schizophrenia.
Yrjö Alanen et al, “Developing a global psychotherapeutic approach to

schizophrenia: Results of a five-year follow-up” described a five year follow-
up study of 100 schizophrenic patients, who were divided into four
subgroups. Alanen described five modes of psychosocial treatment, which,
in conjunction with medication, were found to be optimal for different patient
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AND
groups. This work culminated in the establishment of Alanen’s model

treatment for schizophrenia: Need Adapted Treatment ( Alanen, 1997 ).
We hope this summary of the VIIIth International Symposium on

Psychotherapy of Schizophrenia has given the reader some sense of the
richness and diversity of the conference. Reading through these diverse
papers, each conveying an intense devotion to scholarship and clinical
acumen, conveys the deep commitment of the membership of ISPS to the
clinical task of understanding and helping individuals who struggle with
psychosis. Even though the case presentations were not included in these
two issues, the reader still “comes away” from this meeting strengthened by
the variety of perspectives presented, which were often strengthened by well
thought-out research projects.
118
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References
Adler, D.A (1985). A framework for the analysis of psychotherapeutic approaches to
schizophrenia. The Yale Journal of Biology and Medicine, 58:219-225.
Alanen,Y. (1997). Schizophrenia: Its Origins and Need Adapted Treatment. London:
Karnac Books.
Alanen, Y, Räkköläinen, V., Rasimus, R., Laakso, J., and Kaljonen, A. (1985)
Developing a global psychotherapeutic approach to schizophrenia: Results of a
five-year follow-up. The Yale Journal of Biology and Medicine. 58: 383-402.
Cegalis, J. and Possick, S. Carbamazepine and psychotherapy in the treatment of

schizoaffective psychosis. The Yale Journal of Biology and Medicine. 58: 327-336.
Fleck, S. (1985). Foreword. The Yale Journal of Biology and Medicine. 58:207.
Furlan, P. and Benedetti, G. (1985) The individual psychoanalytic psychotherapy of

schizophrenia: Scientific and clinical approach through a clinical discussion
group. The Yale Journal of Biology and Medicine. 58: 337-348.
Grotstein, J. (1985) The Schreber case revisited: Schizophrenia as a disorder of self-

regulation and of interactional regulation. The Yale Journal of Biology and
Medicine. 58: 299-314.
Gunderson, J. and Frank, A. (1985). Effects of psychotherapy in schizophrenia. The

Yale Journal of Biology and Medicine. 58: 373-381.
Gunderson, J.G., Frank, A., Katz, H., Vannicell, M., Frosch, J., Knapp, P. (1984).
Effects of psychotherapy in schizophrenia: II. Comparative outcome of two forms
of treatment. Schizophrenia Bulletin. 10: 564-598.
Keats, C. and McGlashan, T. (1985) Intensive psychotherapy of schizophrenia. The

Yale Journal of Biology and Medicine. 58: 239-254.
Lidz, T. (1985). A psychosocial orientation to schizophrenic disorders. The Yale

Journal of Biology and Medicine. 58:209-217.
McGlashan, T. and Keats, C. (1989). Schizophrenia: Treatment Process and Outcome.

American Psychiatric Press, Washington.
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AND
Morrison, N. (1985) Shame in the treatment of schizophrenia: Theoretical considerations

with clinical illustrations. The Yale Journal of Biology and Medicine. 58: 289-297.
Rund, B. (1985) Attention, communication, and schizophrenia. The Yale Journal of

Biology and Medicine. 58: 265-273.
Skolnick, M. (1985) A group approach to psychopharmacology with schizophrenics.

The Yale Journal of Biology and Medicine. 58: 317-326.
Stanton, A.H, Gunderson, J.G., Frank, A. F., Vannielli, M.L., Schnitzer, R., and
Rosenthal, R. (1984). Effects of psychotherapy in schizophrenia: I. Design and
implementation of a controlled study. Schizophrenia Bulletin. 10: 520-562.
Stierlin, H, Weber, G., Schmidt, G. and Simon, F. Why some patients prefer to be-
come manic-depressive rather than schizophrenic. The Yale Journal of Biology
and Medicine. 58: 255-263.
Stone, M. (1985) Analytically oriented psychotherapy in schizotypal and borderline

patients: At the border of treatability. The Yale Journal of Biology and Medicine. 58:
275-288.
Tienari, P. Sorri, A., Lahti, I, Naarala, M., Wahlberg, K.-E., Ronkko, T, Pohjola, J. and
Moring, J. (1985). The Finnish adoption study of schizophrenia. The Yale Journal
of Biology and Medicine. 58: 227-237.
Vaglum, P., Friis, S. and Karterud, S. (1985) Why are the results of milieu therapy for
schizophrenic patients contradictory? An analysis based on four empirical stud-
ies. The Yale Journal of Biology and Medicine. 58: 349-361.
Wilson, W., Diamond, R., and Factor, R. (1985) A psychotherapeutic approach to task
oriented groups of severely ill patients. The Yale Journal of Biology and Medicine.
58: 363-372.

Columbia, Maryland 21044
Stanley Possick, M.D.

102 Marvel Road
New Haven, Connecticut 06515
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Gaetano Benedetti
Book of ISPS Symposium

in Turin 1988
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AND
Audience of Turin
Symposium with P.M.
Furlan and G. Benedetti
Pier Maria Furlan.

Chairman of Turin
Symposium
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9. The IXth ISPS Symposium

in Turin. Italy, in August 1988
Approaches to Psychosis: from the One-to-One Laboratory to the
Psychosocial Models
Pier Maria Furlan
There were a number of reasons for deciding to host the IX edition of the
ISPS Symposium in Turin.1
For many years Gaetano Benedetti, the Italian-born psychoanalyst and

Professor of Psychiatry at the University of Basel, Switzerland, had been
running training programmes on borderline and psychotic pathologies in Italy,
especially at the Centro Studi di Psicoanalisi in Milan 2, at various Universities
and private3 and public medical facilities. Psychoanalytical theory had always
been highly regarded in Italy but was often limited to individual training and
less accepted at an official institutional level. Most of the university psychiatric
units were oriented towards biological and behavioural theories with a few
exceptions, such as Florence, Genoa and Pavia, whose directors were
members of the Psychoanalytical Association or open to social problems like
in Bologna and Milan.
The favourable reception in the VIII ISPS symposium at Yale University in the
U.S., both with regard to our group and to the research presented, and the
encouragement of historical figures such as Ruth and Theodore Lidz, Stephen
Fleck, as well as the fear that the Italian experience in individual psychotherapy
could be missed in favour of family oriented care, outweighed any resistance.

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
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
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AND
Benedetti, as a member of the board, put forward the candidature of the

University of Turin and the Centro Study in Milan, seconded by David
Rubinstein, a Cuban-born U.S. psychotherapist interested in our research.
Given that Benedetti, nearing the twilight of his university career, wished to
host the symposium in Italy, his contagious enthusiasm led us to underestimate
the difficulties we would face. Generally these difficulties were ideological and
economic; locally they came from the university context, as we will see below.
Moreover, the regional health administration was not supportive and provided
no funding. The banks and insurance companies refused sponsorship on the
grounds of image (life insurance does not cover mental illness) and the only
possibility of help came from the pharmaceutical firms. On the other hand,
asking for support for a symposium based on “psychotherapy,” risked being
interpreted as against “psychopharmacology.” Our university clinic in Turin,
biologically oriented, was very suspicious of other treatments for schizophrenia
with all decisions being taken by the director, a full professor of psychiatry (at
the time I was associate professor of psychiatry).
The real work of organisation started one year later and the first issue we
had to deal with was the format of the symposium. The first three symposia
held in Switzerland were meetings of experts focused on defining the inner
methodology and the specificity of this approach to schizophrenia. This
rationale was gradually broadened in the later symposia and the attendance
extended to include people working in public healthcare facilities, interested
in the social aspects as well as in individual or group dynamics. The
Attendance at Yale rose to 250. The possibility and desire to increase
enrolment led to plan the budget for a much larger conference in Turin. This
planned enlargement led to some apprehension and debate on the part of
those who feared a change in the spirit of the symposium.
Alongside the financial necessities, were a number of cultural and

contextual factors. Until the 1970s little psychodynamic literature had
arrived in Italy or been translated into Italian. Apart from occasional
publications of works by Sigmund Freud after World War II (by Fratelli Bocca
Editori) and of books dealing with social problems from a psychoanalytical
point of view, such as those by Weiss, Musatti, Servadio, there was no
systematic body of publications on new trends in psychiatry. Not only was
psychoanalysis hardly accepted in academic circles, but even psychiatry was
dominated by neurologists who considered psychiatrists as second class
doctors. Part of this situation was also due to the cultural conservatism of
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The IXth ISPS Symposium
the Italian Psychoanalytical Association interested in the preservation of

“analytical purity.” It was thanks to a few young pioneers, who had studied in
Switzerland4 and come back, that there was a major transformation in
outlook. Pier Fransesco Galli, Benedetti’s first Italian pupil, founded and
edited the first series of psychodynamic books ever translated in Italy
(publishers Feltrinelli and Boringhieri) and in Milan in 1970 he organised the
International Congress on Psychotherapy. This new approach had an
important impact on young doctors in Italy, many of whom decided to receive
psychoanalytical training, even outside the official Italian associations.
Therefore their studies had been oriented by the theories and research of
many of the luminaries who had participated in the previous symposia and
for us, the organisers, it would have been inconceivable to organize such a
conference in Italy for only a small group of participants. Furthermore, for
many of us, involved in the heated debate over the closure of the mental
hospitals, it seemed essential to demonstrate the centrality and implication
of social and psychodynamic factors in mental illness.
One of the first decisions taken with Benedetti was to open the symposium
to all the professionals with an interest in the field, doctors and
psychologists in training and even students. Many of the leading figures of
the symposium were a little suspicious of this change in the typology of
attendance. In Italy the situation was more complex and a short description
of the situation seems necessary in order to understand better the
background to the decision to host the symposium and to further
development of its format.
Psychiatry in Italy: Historical Background

Medical attention towards poverty and mental illness started nearly
contemporaneously in the capitals of the great Italian kingdoms and
principalities in the middle of the eighteenth century, and moral psychiatry
was developed in some hospitals allocated in hygienic and rationally built
facilities, even far before the well known transformations introduced by
Pinel in the Salpetrière. Vincenzo Chiarugi wrote an important book about
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AND
the rights of his patients in Florence in 1785 where the facilities were very
humanitarian. Psychiatric illness found a place in medicine different from
the courtyards of churches, prisons, asylums for beggars and vagrants or
even the roads. In Turin in 1838 King Carlo Alberto built a mental hospital
designed by an innovative architect aware of the importance of cleanliness
and medical hygiene, even though the result was more similar to a military
barracks. However, the quality of the hospital depended on the
magnanimous attitude of the prince and not on medical advances.
The first professor of psychiatry (the director of the mental hospital) was
appointed by the University of Turin in 1870, but we had to wait until 1904 for
the first national psychiatric law which stated that all the provinces ought to
have at least one hospital, with two doctors and nurses and that patients had
to be hospitalised with respect and compassion. Some of the nineteenth
century mental hospitals were like self-contained cities, with small factories
and workshops run by both lay and religious staff (Opera Pia). The hospital had
to maintain some hygienic and medical standards, even if all the admissions
were compulsory and motivated by “dangerousness toward themselves and
others and being a public scandal;” the consequence of the hospitalisation
was the loss of civil rights and a life long police record. However it seems
important to underline that at this time the law was an important new step in
the government’s policy towards the care of social problems.
An internal immigration, which lasted more than a hundre d years and

started with the unification and the transformation from an agricultural and
“latifondo” economy to an industrialized state, led to inequalities and deep
changes in the social organization. The asylums were full of “Pellagra”
disease due to a mono alimentation with corn, not recognized as such by the
dominant Lombroso school. The creation of more than a hundred mental
hospitals, which in general were able to offer a higher life standard than that
of the population, has still to be considered as remarkable progress.
However, Italian psychiatry was increasingly influenced by German
psychiatry, pessimistic about therapeutic possibilities; psychoanalytic
thought was not accepted by academics5. Between the two world wars the
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

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custodial role triumphed over the medical role and thus the degradation
rapidly increased, in some places beyond any imaginable description. Some
of the mental hospitals in the fifties and sixties were the worst kind of
asylum, very often without any respect for basic sanitation and health
requirements. Psychiatry had an administrative status and budget separate
from that of the rest of the health service; it was considered an inferior
branch of medicine and psychiatrists were paid less than other doctors.
The degradation was becoming evident and the pharmacological progress of

the fifties did little to halt the deterioration. Of course it is not true that all
those who went in never came out, but they were certainly admitted into a
circuit which, besides degrading them, also degraded the facilities and all
who worked there. The illness and its treatment created still more illness
and still more degradation.
In many regions in my country, we started with the dehospitalization process

in the late sixties, understanding that more than sixty percent of the people
hospitalised in the large mental hospitals were not psychiatric patients but
just represented one of the weakest parts of the population. More than a
hundred thousand patients, one patient per every four hundred citizens,
were in more than a hundred and twenty mental hospitals all over Italy.
Under the influence of the students movement of 1968 the new generation
of psychiatrists, nurses and social workers started a strong campaign in
mental hospitals to humanize the care system. We obtained the approval for
a popular referendum against the Manicomi (the Mad Houses) and thus, to
avoid what was considered a political risk, the parliament in 1978 approved
a law which promulgated the transformation of the hospital centred
psychiatric care model into a community oriented system, with the closure
of mental hospitals, the introduction of a psychiatric ward in the general
hospitals, the need to centralise psychiatric care within the local district and
the diffusion of mental health centres all over the country. (It was the so-
called Basaglia Law or Law 180, which was then included in the General
Health Reform).
The psychiatric reform started with a great enthusiasm but at least for a
decade was in progress in a different manner in different parts of Italy.
Franco Basaglia died in 1980 and the difficulties to organise a psychiatric
community oriented system, after the first enthusiastic period, became
more and more evident. Many general hospitals were not in favour of the
introduction of a psychiatric ward and hospital doctors were against the care
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AND
and “triage” of mental health patients in the emergency room; for these
professionals a “psychotic crisis” had nothing to do with a “stroke.”
especially in the emergency room. Furthermore part of the public opinion
still considered mental illness as synonymous with dangerous behaviour
and politicians were afraid of the unknown economic effects of such a
transformation; in fact the old mental hospitals, even if they no longer
accepted patients, lasted for twenty years more, and thus the welfare system
(the public health system in Italy was and still is free of charge for all
citizens) had to maintain a kind of “double system” for mentally ill patients.
Finally, the professionals who used to work in the mental hospitals, moving
to the community, were disoriented because of the lack of clear indications
about the community system, and the enthusiasm of part of the young
doctors was not sufficient to cope with the daily increasing difficulties.
We had to find the space in the crowded general hospitals to put the
psychiatric ward in, and we had to change the mentality of the other non-
psychiatrist doctors and staff members. Certainly the result, on the one
hand, was that a number of the psychiatric wards were located in improvised
and inadequate situations, but, on the other hand, this sudden and
compulsory introduction strongly reduced the stigma towards both
psychiatric staff and patients. This introduction led to the spread of liaison
psychiatry and, of course, to the consideration of the psychiatric operator as
a peer by the rest of the general hospital staff. It should be pointed out that
the reform law was a political act and did not indicate the methodology,
resources and administrative tools, which were left to the local
administrations, more precisely to the parliaments of the twenty Regions
into which Italy is divided. The first local law was written in 1988, and some
regions drafted their local administrative guidelines ten years later. The
growth of mental health services was completely undifferentiated, followed
local and personal initiatives, and the resources necessary to build mental
health organisations were arbitrarily assigned by the local policy makers.
The tepid involvement of university teaching hospitals, as said before,

determined a cultural gap in the training of young doctors and psychiatrists;
they received classic Jasperian and Bleulerian psychiatry, while the “every
day” psychiatry outside the universities was different. Other colleagues,
attracted by progressive psychiatry were, to some extent, influenced by the
seductive paradoxes of anti-psychiatry and by the conviction that the
aetiology of mental illness was just round the corner, the corner of the
mental hospital wall. It was an ideological conviction, which was to be
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revealed as only partially true for a part of the pathology, but which proved
to have the power to overturn the economic interests, the social fears and
the political resistance of the period.
Thus many of the specialists in neurology and psychiatry (we had to wait until
the middle of seventies for the separation between the two specialties), not
satisfied with their training, decided to have a personal psychoanalytical
training and not necessarily with official members of the International
Society. Leaving aside the great differences in the quality of what was
offered, we had to cope (and still have to cope) with many problems: how to
introduce and how to provide psychotherapy in a public service and in a
community care organization. The request for personal psychotherapies
from the new generation of psychiatrists increased enormously. Many
private schools were opened by colleagues who had been trained in France,
Switzerland, Germany, the United Kingdom. In a study conducted by me in
1985 we found that more than half of the doctors working in the community
services had had personal psychoanalytically oriented treatment and over
two years of training in psychotherapy, even if not officially recognized by the
national or international associations. On the contrary just ten percent of the
colleagues still working in mental hospitals had received similar training,
even if they were expected to transfer to the community services. Finally one
of the effects of the introduction of community psychiatry was the growth in
demand for treatment by younger patients, a kind of pathology which was
unknown by many psychiatrists who used to work in the mental hospitals. All
these were the most important factors that contributed to the decision to
enlarge the number of enrolments and to open the Symposium to everybody
interested in the field.
Practical arrangements
The final change in our planning work was the decision to postpone the
Symposium for one year – from 1987 to 1988 - which also stemmed from a
personal interest: the fact that the medical school of Turin University was
duplicating its facilities in a former Tuberculosis hospital near the city, the
San Luigi Gonzaga Hospital, able to host part of the growing number of
students. I was trying to obtain the possibility to include the teaching of
psychiatry and to set up a community oriented mental health service, and
thus to apply the psychiatric reform for the first time at a university level.
Furthermore the responsibility for the organisation of the symposium
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AND
depended mainly on my few young collaborators6 and myself, since it was

difficult to collaborate on an effective daily basis with the Milan group and
its members who, in turn, lived in several other cities in North Italy. A young
lecturer from Oxford University, Dr Martin Solly, Ph. D., resident in Turin,
helped my basic English (and he still is the reviser of this paper) and a new
symposium organization body, the ICM, believed in the initiative and agreed
to share part of the economic risks. Many of the previous organizers and
pioneers of the ISPS answered positively: Yrjö Alanen, David Rubinstein, Jarl
Jørstad, Endre Ugelstad, Lyman Wynne, Stephen Fleck, Ira Levine. Only
Chistian Müller withdraw his participation after a first acceptance.
The decision not to restrict admission introduced the problem: how many and
where? We hoped to attract a high attendance of young doctors through the
choice of themes and speakers, but we had to consider the lack of knowledge of
English in Italy. Thus it was important to provide simultaneous translation from in
order to reach an attendance of more than four hundred people, an attendance
able to cover the expenses of forty-sixty invited speakers, bearing in mind that
young professionals were unlikely to be able to pay a high symposium fee.
The impossibility to foresee the number of participants led us to make some

“blind” decisions; one of these was the symposium facility. At this time the
FIAT Company was studying the destiny of its most important former factory,
more than 500,000 square meters7 and rented out in this “ghost factory” the
“sala delle alte presse” where the vehicle parts were pressed in the shape,
an immense bare expanse in reinforced concrete with a huge number of
columns like a post-industrial Cathedral of Granada - on the ceiling remains
of rails used for moving pieces received from the nearby blast furnaces and
on the floor the marks of fifty years of car production.
Positive answers were far more frequent than negative ones from all over
Europe; from the Nordic universities of Umeå in Sweden and Turku in Finland
to Beersheba in Israel or Double Bay in Australia, as well as from the two
coasts of the United States. Most of the principal schools and therapeutic
approaches to schizophrenia were represented. Already from the acceptances
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

130
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of speakers and from first call answers it was possible to draw a sort of
intellectual map of psychological therapies for severe mental illness, even if the
language barrier and some economic reasons may have discouraged a higher
participation from Francophone and Ibero Hispanic countries. In any case we
received enrolments from twenty countries, even if the majority from abroad
came from the Nordic and Anglo-Saxon world. A gratifying surprise was the
participation from East Germany of the prestigious Humboldt University.
The programme rationale consisted of alternating local and foreign work

groups in the same session, thanks to the simultaneous translation, in order
to enhance the discussion and reciprocal exchange and to leave the plenary
sessions to the most representative speakers of the different schools. In
fact, a first call for attendance gave us the surprise of 450 positive answers
asking for more information and the number of foreign speakers rapidly
overtook the one hundred mark.
From Italy we received more than three hundred abstracts and more than a
hundred and fifty from abroad; I personally decided to accept all of them
even if with a little difference, dividing the Italian proposals into papers
accepted and free communications. The first papers were presented with
simultaneous translations as were all the foreign papers. It was a
considerable effort to provide the translation for all the presentations of
participants from other countries; it seemed worth providing a full
presentation of what came from foreign colleagues, considering what has
been explained above about the Italian situation.
There were some last minute phone calls on the eve of the symposium from
Italian colleagues who apologized for not being able to attend Turin; on the
contrary, there were many others who wanted to confirm enthusiastically
their presence, implying that they were not sensitive to external pressure or
even light threats. Leaving aside personal reservations, the Turin Psychiatric
Institute was against the psychodynamic school. Moreover the recent
inauguration of a university community oriented psychiatric facility at the
San Luigi Hospital, able to host such an important international event, was
badly accepted by part of the Italian psychiatric establishment.8



131
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AND
This was one of the reasons that I insisted on the ICM maintaining the
participation fee as low as possible; a request that proved, in the end, to be
incorrect and the budget of the symposium closed with an economic loss.
Fortunately, right from the opening, the attendance of new participants was
good and, “against all odds”, in the end the foreign attendance reached 400,
including speakers, and the total over 1300, including 200 invited speakers
and 300 free communications. The only decorations in the immense hall
were two five meter high cypress trees, kindly provided by a florist friend of
my family. Nevertheless the symposium venue, as modern industrial
archaeology, impressed the foreign guests and received their compliments.
The Presentations
The title of the symposium “The Psychotherapy of Schizophrenia:
Approaches to Psychosis: from the One-to-One Laboratory to the
Psychosocial Models” aimed to follow the traditions of the previous
symposia as a continuous revision of the research and practices of the
different psychotherapies of schizophrenias: individual, family, systemic and
group, but gathering together the social and anthropological points of view,
as the introduction to the book by Gaetano Benedetti and myself pointed out:
“successful treatment might be more possible in situations where a
combination of approaches is used, bearing in mind that schizophrenia has
many origins and many forms and might even be many different illnesses.”
Thus four fields were privileged: Theoretical Problems of Schizophrenia,
Individual Psychotherapies and Clinical Approaches, Family and Group
Treatments and Hospital, Institutional and Milieu Treatment, considering
pharmacological intervention as transversal, but nevertheless emphasizing
that schizophrenia cannot be treated by only a single approach, and also that
schizophrenia is such a complex situation that it cannot be confined within
the simple boundaries of the term “illness.” The main papers were each
followed with a comment by an Italian expert.
Benedetti also underlined that schizophrenia is not only a medical disorder

but a biographical facet of human beings and it is a challenge to the whole
of society to understand, accept and reintegrate the psychotic patient
amongst us, even if he was only able to dedicate himself to a single aspect:
the “dyadic,” individual, therapy. Nevertheless he identified the “therapeutic
transforming images” deriving from the therapist’s capacity to identify
132
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himself with the catastrophes occurring within the patient. In this way the
psychotherapy becomes progressive and the psychotherapist’s discovery of
this “progressive psychopathology” is the meaningful continuation of the
“regressive psychopathology” studied by Bleuler, Schneider and
Kretschmer.
Barbro Sandin, representing the University of Uppsala, Sweden, described

the schizophrenic’s paradox: “he or she who is no one. Someone is and
expresses his or her being in words of non-being.” Peter Giovacchini, from
Chicago, U.S., described the treatment issues of the fact that
schizophrenics seem to be operating at primitive levels that antedate the
establishment of coherent object relations and they do not perceive
themselves as autonomous human beings; often they do not feel human.
Adolfo Pazzagli, from Florence, a pioneer of the psychoanalytical approach
in Italy, answered the Giovacchini paper establishing a clear-cut difference
between the manner of functioning which characterizes transitional space
described by Winnicott and the functioning of the schizophrenic in his or her
relationship with inner and outer reality, which remind us of “transitional
space”, which, however, is missing in the psychotic crisis, different from a
transitional area.
The key papers were not only on individual psychotherapy. Paul Watzlawick,
from Palo Alto and Stanford, U.S., starting from the Albert Einstein
statement that “It is the theory that decides what we can observe” and citing
an old paper by Falret and Lasègue, established the theoretical bases of the
systemic therapy, based primarily on what goes on between individuals, and
on how the family system and the wider community contribute to the
maintenance and exacerbation of the pathological condition through their
beliefs, attitudes and, above all, their supposed help. He stated that, as
clinicians, we are not also trained in epistemology and may thus be quite
unaware of the fact that in naming something “schizophrenic” we are doing
very much the same: taking a name for the thing named, i.e. creating a
reification. And depending on the nature of this reification, treatment
methods based on it will have different results from those based on another
reification. It was Romolo Rossi, from Genoa, Italy, the discussant, who
pointed out that our theoretical models of interpersonal functioning of
schizophrenia are, in a sense, fictions pertaining more to narrative methods
than historical or scientific proceedings, partly because our knowledge of
schizophrenia is decidedly clinically parasitic, and it derives only from
clinical experience.
133
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AND
Theodore Lidz, from Yale University, U.S., pursued the concept that the
intrapsychic chaos, that we term schizophrenia, derives from and reflects
the chaos-inducing family environments in which these patients have been
brought up and thus the need to refocus attention on the psychosocial
nature of the disorder and the central role of the family. In this way he
established a scientific link with Pekka Tienari, from Oulu, Finland, another
main speaker, and his research on adoptive children with or without genetic
predisposition, referring strongly to an interaction between the effects of
genetic vulnerability and family environment (however, with a need for
further research on manifest disorders in very disturbed families). Bertram
Karon, of Michigan State University, U.S.A., also stressed the importance of
the family and the father figure in the formation of delusions, asking
himself how to transform the transference into a therapeutic instrument
from a non useful defense. Arnaldo Ballerini, from Florence, Italy, in an ideal
continuation of Karon’s paper, stressed the importance of depressive
feelings in the formation of delusion and as countertransference,
contributing to the birth of a psychotherapeutic process. Murray Jackson of
the Maudsley Hospital in London, U.K., described from a Melanie Kleinian
point of view the “Schizoid Mental States,” paying particular attention to the
fear of emotional closeness to objects, deriving from unconscious fantasies
of a pre-Oedipal (or early Oedipal nature, in Kleinian theory), in the attempt
to achieve a deeper understanding, beyond the more familiar
psychoanalytical concepts “which are adequate and appropriate for the
neurotic patient but insufficient for the psychotic.” From the far Australia,
Joan Symington also looked at the early phases, but using the infant
observation, observing over and over again the ubiquity of the post partum
depressed state of the mother which follows a transitory state of euphoria.
Her lecture was positively accepted by Adriana Guareschi Cazzullo from
Milan, one of the Italian founders of infant psychiatry, who still pointed out
the difference of some childhood psychoses from schizophrenia, while Irene
Matthis from Umeå, Sweden, quoting Aristotle’s Nicomacean Ethics,
introduced an important - even if (in my opinion) open to discussion -
principle that doctors cannot decide to heal a patient or make him or her
healthier; the doctor’s decision does not concern the goal or the aim, but
only the road, the method to be chosen. Of course her provocative
statement, philosophically well sustained, arose from a personal
conception of the therapeutic unconscious. The individual perspective was
closed by a theme whose importance was, in those days, underestimated: a
project for the insurance coverage of schizophrenia by Massimo Moscarelli
from Milan.
134
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The clinical approaches were treated by many speakers. John Kafka, from
Washington, U.S.A., put forward his theory that the “abnormality” is in the
object rather than in the thought process proper; “insight” for psychotic
patients involves insight into the characteristics of their object formation. John
Gunderson, from Cambridge, Mass., U.S.A., presented the results of the
important Boston Psychotherapy Study with Schizophrenic Patients,
previously exposed in the 1981 Heidelberg Symposium, designed to provide a
more rigorous test of whether a dynamically based psychotherapy (exploratory
insight oriented-EIO) added appreciably to the benefits of the usual supportive
treatment (reality-adaptive supportive-RAS) of schizophrenic patients. Among
many other important results, RAS may help the patients feel better but
unlikely to affect some of the more persistent negative symptoms. EIO,
especially if directed to the out-of-therapy relationships, can have very
beneficial effects upon the more negative symptoms of schizophrenia. It
suggests an important role for dynamically informed exploratory
psychotherapy, a role which is not apparent (or may even be contraindicated)
at the start of the long-term therapeutic process schizophrenic patients
usually require.
Another study, based on a large sample of individual psychotherapies, a

hundred, treated by the Benedetti group in Milan, Italy, under his supervision
was made and presented by myself. The aim of this research was to better
understand the relationship between psychoanalytical theory and
therapeutic factors. One of the many other methods used in this research
was to compare the results of psychotherapies held in the public sector and
those in other groups followed by therapists in private practice. Many
suggestions to obtain a better recovery came from this comparison, such as
communication of therapists’ feelings, involvement of families, deep
observation of different individual feelings of the therapist and their
“synchronisation” with the patients’ feelings, different dosages of
neuroleptics, significantly lower in private practice with better symptomatic
results. Even if in the public sector we could observe less good results, the
more the clinical situation was severe the better the results reached.
Probably a more sympathetic approach by the therapist is limited by the
parameters and difficulties of the public setting. From the research it
emerged that patients’ feelings change during the course of the therapy
while recalls, as memory contents, never change, a dynamic which may help
in the understanding of early conditioning factors in schizophrenia. In
conclusion this research on severe schizophrenic patients tried to
demonstrate that the psychotherapy of schizophrenia does help patients but
135
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AND
depends on a strong relationship between therapist’s feelings and the

setting9. Many of these statements were confirmed and developed by in-
depth studies of clinical cases such as those by: Bent Rosenbaum from the
Danish Schizophrenia Study, Stavros Mentzos from Frankfurt a.M., Germany,
David Feinsilver from the Chestnut Lodge Sanatorium, Maryland, U.S.A.,
Michael Selzer from Cornell University, New York. U.S.A., Arno Gruen
representing the Therapeia Foundation in Helsinki, Finland, Giangiacomo
Rovera from Turin - especially clarifying problems connected with schizo-
affective disorders -, Joachim Küchenhoff and Peter Warsitz from Heidelberg,
Germany, David Anderegg from the Austen Riggs Center, Mass., U.S. Training
and supervision were dealt with by Per Stenfelt, Sonja Levander, Anders Berge
and Michael Selzer (Karolinska Institute, Stockholm, Sweden) and Ann-
Louise S. Silver (Chestnut Lodge, Maryland, U.S.A.).
Family and group treatment were the object of particular attention and
introduced by Lyman C. Wynne (Rochester, N.Y., U.S.A.) who exposed his
thirty-four years of experience, starting from his first approaches to the
patients’ whole families when he engaged them in a task that had a
psychoanalytic form: to notice their thoughts and to put them into words.
This early approach was too neutral and exploratory and contributed to
confirm the families’ worst fears of being blamed. Furthermore the
healthy, compensatory coping and adaptative potentials of these families
were greatly underestimated, and sometimes iatrogenically undermined.
For that reason Wynne has increasingly adopted the role of family and
patient consultant rather than of therapist, discovering how effective and
competent many of these families become in the face of multifaceted,
difficult problems for which there are no easy answers. Wynne stated that
his approach has much in common with “psychoeducational family
therapy,” however, without a treatment contract. Wynne was also co-
researcher of the Finnish Adoptive Family Study of Schizophrenia,
presented by Pekka Tienari and his group from Oulu, Finland. Unlike the
previous genetically oriented Danish-American adoptive research, in
Tienari’s project also the important environmental family factors in
schizophrenia and schizophrenia-spectrum disorders are studied. Still,



136
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also the Finnish data suggest that psychotic illness occurs in adoptees
primarily when a genetic factor, indexed by schizophrenia of the biological
mother, and disturbances in the adoptive family are both present. Thus the
concept of genetic and biological vulnerability is compatible and can be
integrated with psychosocial approaches. Mara Selvini Palazzoli, from
Milan, Italy, re-proposed the pattern of the disturbed family and the
contribution of her new methodology: from the previous so-called
paradoxical interventions in favour of an invariable series of prescriptions,
which has permitted her to identify many individual reactions and to
underline some transgenerational strategies, the early disturbed
relationship of the parent couple, a “stalemate of the couple,” which is
connected with the children disturbance’s and could be considered the key
point of her work. Stephen Fleck from Yale University in New Haven, Conn.,
U.S.A.), one of the hosts of the previous symposium, traced a psycho- and
socio-dynamic parallel between families and Mental Health Services with
a conclusion particularly welcomed by Italian professionals: mental health
services must practice as teams and their task and system dynamics are
comparable to those of families. The Italians Piero De Giacomo, Giordano
Invernizzi, Alberto Merini, Carmine Munizza, Giorgio Bisacco (Bari, Milan,
Bologna and Turin) developed from an Italian point of view many of the
above mentioned family-patient-service relationships, demonstrating a
good application of psychodynamic theory in the daily practice during the
transitional period of the closure of the mental health hospitals.
Yrjö Alanen and collaborators, from Turku, Finland, one of the universities
most involved in the psychological treatment of schizophrenias, presented
further experiences in the twenty year old Turku project, centred on need-
specific treatments of schizophrenic patients, considering that it is not
recommended to treat all patients with the same psychotherapeutic
method. This means that treatment must be conceived as an interactional
developmental event and it is helpful to continuously assess the course and
outcome of the treatment, which involves the possibility of modifying
therapeutic plans. The starting point is represented by a first joint meeting
with all the family members, successfully arranged in 87 % of the cases.
The family members and (sometimes) other individuals close to the patient
are invited to commit to the exploration of the situation and treatment while
they are themselves given therapeutic support. The therapeutic approach
has to be planned and implemented integratively, combining therapeutic
activities in a manner that meets the needs of each patient as well as those
of the people making up his or her personal interactional network.
137
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AND
Examination and treatment are dominated by a psychotherapeutic approach

and different therapeutic activities should support and not impair each
other, avoiding any degeneration into routine, bearing in mind that the
whole therapy is an ongoing process. Gisela Ehle from the Humboldt
University of Berlin (DDR) gave us a look from the east side of the iron
curtain (we were just before the wall’s destruction). The approach was
primarily behavioural, but it was extremely clear that many psychodynamic
concepts were implied, such as ambivalence, defences, transference and
countertransference. The conclusion was that psychotherapy can help
pharmacological compliance and can stimulate self-help activities. Franz
Schwarz and Johan De Rijke from the Munich University (Germany) pointed
out that, except for the above mentioned work by Alanen, there were hardly
any results from differentiated studies from which psychodynamic
knowledge can be drawn. Therefore they presented a study of 94 patients
selected from 238 schizophrenic or psycho-affective patients treated
psychotherapeutically, of whom the entire course of life history was
carefully examined. A symptom catalogue of 180 items at the start of
therapy and after follow up was developed. The change was impressive,
especially in schizophrenics and in the area of sexuality and partnership.
Thus, the authors concluded that a structural change occurs in the ego and
in the super-ego and that object relations reach a more mature level with a
clear-cut gender difference, only recently treated in the literature; maybe
males have extreme difficulties in the development of gender identity.
Expressed Emotions were taken into consideration by Chris Mundt of
Munich University as a useful tool for working with relatives in groups and
supporting them to found self-help organizations, to acquire information on
the relatives’ expectations, and to establish a hierarchy of curative group
factors.
A further important session was represented by “Hospital, Institutional

and Milieu Treatments.” Ruth Lidz (Yale University, U.S.) presented her
experience in the care and supervision of patients treated with
psychotherapy and neuroleptics and concluded with a statement which
today should be considered obvious: psychotherapy cannot be effective
unless the therapist or the therapeutic team believes that psychotherapy
can cure or greatly ameliorate schizophrenic disorders. In Italy, twenty
six years after the psychiatric reform, this statement remains necessary
for the daily work in community oriented therapy. Luc Ciompi and his
group from the Social Psychiatric University Clinic of Bern, Switzerland,
presented the first results of the four year pilot project “Soteria Berne”
138
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(following the experience of Loren Mosher, also speaker at the

symposium), and proposing an integrative biological-psychosocial
evolutionary model available for the great majority of schizophrenics.
The sensory-motor structures, Piaget’s “schemata,” because they are
generated through actions and interpersonal transactions, represent a
kind of “condensation” of social and family dynamics. There are three
phases in the development of schizophrenia. First, a vulnerable
premorbid terrain characterized by specific defects in information-
processing, with a tendency to cognitive over-inclusion and emotional
oversensitivity. Then, under the influence of additional stressors, the
outbreak of manifest psychosis takes place. The third phase is the long-
term evolution which is much more variable. Ciompi and Müller had
presented eight evolutionary curves, most of which do not have a
significant biological or genetic correlation. On the contrary, psycho-
social factors may have more importance and, at least partially,
chronicity may even represent a psychosocial artefact. Thus one of the
most important principles for therapy and prevention should consist in
trying to avoid overloads of confusing stimuli, especially in the form of
cognitive-emotional contradictions and conflicts. Eight principles were
selected as the main therapeutic guidelines, summarized in here: small,
transparent supportive setting; protection from stimuli and close human
support; personal and conceptual continuity; no medication strategies;
collaboration with family and partners; clear and identical information
for everybody; induction of realistic expectations; systematic follow-up
and relapse-prevention. Consequently “Soteria Berne” is a small and
open therapeutic community located in a very normal-looking nice
former hotel building; the treatment is divided into three phases taking
place within the community and one outside: the calming down, the
phase of activation after two weeks, a gradual reintegration into normal
life; the fourth phase begins with discharge and lasts for a minimum of
two years. The results were favourable or rather favourable in 66 %,
permitting a much better integration of the frightful psychotic experience
into the patient’s life-continuity and personal identity than the usual
treatment. A further contribution from Turku came from Jukka Aaltonen
and Viljo Räkköläinen, presenting and integrating systemic and
psychoanalytic approaches to schizophrenia in a psychiatric ward in a
facility which did not have any psychodynamic tradition, and thus
demonstrating with many theoretical and technical contributions how the
setting can be developed to a community suitable for psychodynamic
interventions.
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AND
Attention on the psychiatric ward represented also the core of the paper
by Thomas Herzog from the University of Freiburg, Germany. The attention
is centred on the great variation between different nurse relationships, as
well as between three different wards, an unfavourable milieu for many
patients. Nursing staff lack the opportunity to openly discuss their
emotional reactions towards patients and their relatives. Letting nurses
actively participate in family or relative groups allows overcritical or
rejecting attitudes to be challenged, a practice widespread in the
community therapy system in Italy, as emerged in a very rich discussion
and after a paper by Teresa Corsi Piacentini (Association for Psychoanalytic
research, Milan) on training work in a public mental health service, where
this participation was underlined. The Italians Vittorio Volterra (Bologna),
and Alberto Giannelli and Massimo Rabboni (Milan) presented comparative
research between different groups of schizophrenics and there were
another 130 authors whose interesting research and experiences our
limited space does not allow us to summarise here. At this point it is
worth noting that, on the one hand, a generally correct methodology used
to approach schizophrenic syndromes and, on the other, an abandonment
of the psychoanalytical rigidity of the technical indications were
characteristic to this symposium, compared with those from the 1950s
and 1960s.
Soon after the symposium we started looking for a publisher of the

proceedings book. This proved more difficult than we had anticipated. The
publishers we approached were unwilling to take on the project through fear
of poor post-symposium sales. Finally Hogrefe & Huber Publishers and their
scientific editor, Dr. Peter Stehlein, agreed to publish on condition that
certain selection procedures were followed and that a subject index was
included. An indispensable help was provided by a proof reader Mrs.
Kathleen Lindquist and, from the first moment of the organisation, Dr.
Martin Solly. The book The Psychotherapy of Schizophrenia. Effective Clinical
Approaches – Comtroversies, Critiques & Recommendations, over four
hundred pages long, was edited by Gaetano Benedetti and Pier Maria Furlan
and printed by Hogrefe & Huber publishers in the USA in 1993 in a handsome
hard bound edition.
The satisfaction with the symposium was general despite unpredictable but
easily solved daily problems. The food served at the symposium was
considered good and many participants also walked round the two kilometres
motor car circuit on the roof, enjoying the panoramic view of our Alps, Monte
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Bianco, Monviso, Monte Rosa and Il Cervino, better known as the Matterhorn,
which were also seen from the country house of the family of my dear wife,
Mariella, in the courtyard of which the final dinner for the speaker was
served.
Afterthoughts
Unfortunately, this period only lasted for a few years. The complex process
of deinstitutionalisation, the introduction of community based system made
practitioners and nurses so busy that they had to delay personal
psychodynamic training or to choose the easier option of behavioural
training. Even if we cannot consider them as primary causes, some facts
linked with the symposium almost certainly had an impact.
The publication due to lack of funding only in English of the proceedings,

rendered them inaccessible to many colleagues. Furthermore, the lack of
interest by most of the Universities in Italy in Community Psychiatry led to
other consequences, such as: the failure to establish a wide-reaching
network of committed people and institutions after the Symposium.
No formal post congress follow-up study was made, however my impressions

are the following.
The high participation of experts from all over the world encourages mental
health staff to treat severe pathology and not just provide assistance.
However, there was a decline in the previous enthusiasm for the changing of
the mental health system linked to the closure of the mental hospitals. The
more chronic pathologies still remained in the latter and therefore
untreated, becoming a new challenge for young psychiatrists. In many
districts the request for psychotherapeutic training increased markedly as
well as did the number of private psychodynamic schools.
Thus, my staff and I could only carry through personal initiatives in addition
to our ongoing work.
Nevertheless, the whole experience of the Symposium and the cultural

climate it created was extremely beneficial for our closure of the largest
Italian Mental Health Hospital in Collegno and the start of the restoration of
the splendid Royal Chartreuse of Turin.
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AND
References
G. Benedetti & P. M. Furlan (eds): The Psychotherapy of Schizophrenia. Effective
Clinical Approaches – Controversies, Critiques & Recommendations. Toronto:
Hogrefe & Huber, 1993.
Pier Maria Furlan, M.D.

Department of Psychiatry, University of Torino, Italy
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Book of ISPS X Symposium

Stockholm 1991
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AND
Loren Mosher and the host

Johan Cullberg,
Stockholm
Program of X Symposium of Stockholm
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10. The Xth ISPS Symposium

In Stockholm, Sweden, in
August 11-15 1991
Facilitating and obstructive factors in the psychotherapy of
schizophrenia
Johan Cullberg
The process of Stockholm being elected to hosting the

symposium
During the 9th symposium in Turin 1988, the Swedish group was informally
approached by Bjørn Østberg and Endre Ugelstad from Norway. Would we be
prepared to take the responsibility for the next symposium? At that time we
were happily ignorant about the internal political tensions in the ISPS. After
a brief discussion we accepted to arrange the symposium in Stockholm in
case the suggestion was accepted by the board. Because of my academic
affiliations I would serve as the chairman. In order to accept such a position
I needed the “guarantee” to have a group of highly competent people around
me, who were prepared to assist with time, advice and work. The suggestion
was greeted with enthusiasm in the Swedish group.
The next step was a discussion with John Gunderson of the ISPS board. Since
I was rather unknown to the board, John was eager to hear about my
ideological position and how I, in case of being elected, would arrange the
conference, which boundaries and topics we would promote etc. I informed
him that to my mind all kinds of functional psychoses should be included in
such a conference. Personality disorders, on the other hand, should not be
given priority. I also was eager to present my interest in a broad approach
including biological, psychological and social aspects as pathogenetic as
well as curative factors. The symposium to the Swedish group thus would
imply a dialogue between the different professional arenas with the person
with schizophrenia in the centre. Gunderson’s report to the ISPS committee
resulted in an official declaration at the end of the Turin meeting that I would
be responsible for the next symposium in Stockholm.
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AND
The preparatory process

We had three years to prepare the symposium. The working group consisted
of Sonja Levander PhD, Andrzej Werbart PhD, Olle Lönnerberg MD, Margareta
Falk MD, Irene Matthis MD, Inga Mellström (secretary) and myself. We had
regular contacts by letter with the international ISPS advisory group.
The practical details were taken care of by the Stockholm Convention

Bureau. I took on the responsibility to find the financial support needed. The
Stockholm City and the Ministry of Social Welfare showed generous interest
and we soon felt that the immediate financial problems would be solved.
Perhaps it should be remembered that the issues of psychological
understanding of schizophrenia and other psychiatric disorders was very
popular during those years in Sweden, also in political circles. There had
been an ongoing tension between a psychodynamic and a biological camp.
During the eighties the dynamic camp was the most cherished in media, so
getting money for this purpose was not very difficult. (Today the “ideological”
situation has been totally reversed.) Economically we had a “break-even”
with around 450 attendants paying the fee and the actual number showed to
be almost 700 including invited participants.
One of our first tasks was to define the central theme of the conference. We
arrived at the following formulation: “Facilitating and obstructive factors in
the psychotherapy of Schizophrenia” and it was accepted by the international
advisory board. We felt privileged to be able to put conflicting themes and
points of view to the fore. Of course one of the hottest issues was the
negative results from the McGlashan study (1984) of the long-time
schizophrenic patients treated at the psychoanalytical stronghold at
Chestnut Lodge. Also the studies of Gunderson (1984) and Wallerstein (1986)
had shown supportive psychotherapy as effective as explorative
psychotherapy. These findings contributed to an acute identity crisis of the
ISPS ideas – denied by some and leading to a total break with the
psychotherapy of psychoses by others.
Another issue which we wanted to pick up was the advancement of cognitive-

behavioural and educational methods during the eighties. There was a
mutual devaluation between the psychodynamic and the CBT camp, the
patients being the losers. The possibility to offer the proponents of the
different schools an opportunity to listen to each other seemed important,
even if it meant a serious challenge to some of the ISPS people.
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The Xth ISPS Symposium
A third issue was to emphasize the self-curing factors in long-term

schizophrenic persons. Here Harding’s (1987) studies were seminal
indicating the amelioration in outcome several decades after the first
diagnosis for patients who were not institutionalised. Were optimal social
conditions a precondition for being able to make use of psychological
treatments?
We felt that our central themes would cast light upon the different ways of
assisting versus disturbing the important self-healing facilities in the person
with schizophrenia. Our main interest was to put the suffering person in
focus more than certain theories or methods.
The making of the programme

I will not go into any detail about the contents of the different contributions –
some of the most important ones are presented in the congress report, a book
published by Andrzej Werbart & Johan Cullberg (1992). The first lecturer to be
invited was John Strauss who was asked to hold the opening lecture on “The
person with schizophrenia as a person”. Then the ISPS members were invited
to present papers and a general message announcing the conference was
sent to different international groups within the area of psychology and
psychiatry. We formed an abstract paper group to set some basic standards for
the quality of the scientific contributions. In a few cases we had to turn down
abstracts that had been submitted, others were accepted after a discussion.
A historical lecture was held by the legendary professor Gaetano Benedetti,

one of the pioneers of the ISPS, where he briefly characterised the previous
symposia and some of the contributors.
The contributions were divided into different blocks. Discussants were

designed to all invited lecturers, which gave increased possibilities for
critical reflection.
One block named The inner world that was comprised by mainly
psychoanalytic lecturers. Most of them had a clinical approach: Murray
Jackson on schizoid thinking, Barbro Sandin on schizophrenic strategies for
survival, and Bryce Boyer on regression in transference. Also the French
semiotic psychoanalytic thinking was represented by the Nordic contributors
Iréne Matthis, Svein Haugsgjerd and Bent Rosenbaum.
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AND
The second block, Psychotherapeutic models, was mainly devoted to the

presentation of new and promising pathways. Luc Ciompi talked about the
Swiss “Soteria project” for first episode schizophrenia patients. Manuel
González de Chavéz Menéndez (chairman of the present Madrid conference)
described group therapy experiences with schizophrenic patients and Carlo
Perris and David Fowler talked about cognitive psychotherapy for this group
of patients.
One block was devoted to Biological and Psychosocial factors. Here Pekka
Tienari described the latest results from his seminal project studying the
interactions between genetical and rearing environmental factors. Stephen
Fleck gave a synthesising lecture on the biological and psycho-social factors.
Family as a social milieu was highlighted by Michael Goldstein’s research,
and Helm Stierlin reconsidered the role of the family from theoretical and
practical points of view. Social context was also accentuated in Yrjö Alanen’s
lecture on psychotherapy of schizophrenia in community psychiatry. Loren
Mosher talked about treating psychotic persons in a therapeutic social
milieu.
Anne Lindhardt from Denmark and Per Vaglum from Norway were invited to
give personal reviews of the Symposium during the last day and also gave
hints about the future of the psychotherapy of schizophrenia. Per stressed
that today’s many negative findings regarding effects of psychotherapy often
may depend on the comparison of group means, meaning that positive and
negative effects are neutralising each other in the research situation. He
also pleaded for the necessity to be open to new techniques and to new facts
which perhaps not always fit into our theoretical models. Anne’s thoughtful
reflections dealt with the complexity of the schizophrenia concept and of the
necessity of broadening our views so that also man as a biological person
can be included. The therapist’s curiosity is a basic factor for increasing our
knowledge and therapeutic courage. She also discussed the gender issue;
male patients often tend to have a worse outcome in therapy than females.
And how shall we interpret the surplus of women amongst the audience and
among the therapists? Finally: our obligations to present our issues in a way
that gives meaning and understanding also to “outsiders” like politicians
and other lay people must not be forgotten!
In addition of these lectures there was an abundance of seminars and

workshops where several researchers and therapists who would appear at
later conferences presented their first paper.
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The Xth ISPS Symposium
The setting
Stockholm kindly enough appeared at it’s best; bright sun, mild winds and
the Stockholm Water Festival going on during late evenings. At the opening
ceremony, after the deep tones of an ancient bassoon, the Swedish Deputy
Prime Minister Odd Engström gave an insightful address to the Symposium
delegates.
The magnificent festival firework on the waters outside the Royal Opera
Restaurant happily coincided with the farewell party when Stephen Fleck
generously at his dinner speech told us that this had been the “best
congress.” Almost 700 delegates would return to the outside world with a
realistic hope for an international development of the psychotherapy of
schizophrenia.
The economic surplus was partly used to sponsor a National conference in

Sweden, which was the beginning of the later “Parachute project” for first
episode psychotic patients. The rest of was sent to David Feinsilver to support
the 11th conference in Washington DC, which also included a visit to the
historical Chestnut Lodge.
Afterthoughts
This conference probably meant that the great dominance of psychoanalytic
theory and ideology was broken and that new ways of looking to the problems
were approaching – not necessarily as competing with the old ways but
refreshing and stimulating new experiences. I also believe in the necessity to
have a diagnostically open mind. The validity of the schizophrenias is not too
well defined and the psychosis concept must continue to be more central than
the schizophrenia concept.
And we must not forget Per Vaglum’s nightmare: That the patients are given
very good individual or family therapy, but since they live in a destructive
institutional or social milieu, the good effects of psychotherapy are
destroyed by the environment. Be that large psychiatric wards, isolation in a
lonely flat, or being subjected to overmedication. That must be another
important challenge for the ISPS: to help us create such milieus which are
really therapeutic and to continue to show our interest in the therapeutic use
even of the biological treatment methods. After all, we are treating a person,
not a bunch of receptors.
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AND
References
Gunderson JG, Frank AF & Katz HM (1984). Effects of psychotherapy in schizophre-
nia II. Comparative outcome of two forms of studies. Schizophr Bull, 10. 564-598.
Harding CM, Brooks GW, Ashikaga T, et al. (1987). The Vermont longitudinal study of
persons with severe mental illness, II: Long term outcome of subjects who ret-
rospectively met DSM-III criteria for schizophrenia. Am J Psychiatry 144, 727-735.
McGlashan TH (1984). The Chestnut Lodge follow-up study II. Long-term outcome of
schizophrenia and the affective disorders. Arch Gen Psychiatry 41: 141-144.
Wallerstein RS (1986) The psychotherapy project of the Menninger Foundation: An

overview. Journal of Consulting and Clinical Psychology, 57:195-205.
Werbart A, Cullberg J (eds) (1992) Psychotherapy of schizophrenia: Facilitating and

obstructive factors. Scandinavian University Press, Oslo.
Johan Cullberg, M.D.

Anders Reimers väg 7
S - 117 59 Stockholm, Sweden
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David Feinsilver
Chairman of Washington Symposium
Yrjö Alanen receiving

ISPS honorary gift
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AND
Endre Ugelstad receiving

ISPS Honorary gift
Stephen Fleck
receiving ISPS
Honorary gift
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Jack Rosberg and

Bent Rosenbaum
Llan Treves and

David Feinsilver
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AND
Malcolm Pines, Dianne Lefevre

and Murray Jackson
Opening Ceremony of
Washington Symposium
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Ruth and Theodore Lidz
Stanley Possick
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AND
D. Feinsilver during gala

dinner of Washington
Symposium ISPS
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11. The XIth ISPS Symposium

June 12.-16.1994 in
Washington, DC, U.S.A.
Schizophrenia: Psychotherapy and Comprehensive Treatment
Stanley Possick and Ann-Louise S. Silver
The symposium, “Schizophrenia: Psychotherapy and Comprehensive

Treatment” was held in Washington, DC at the Washington Renaissance
Hotel, June 12-16, 1994. About 480 people attended this rich, festive and
lively meeting. David Feinsilver, MD, chair of this event said this meeting
would “focus on integrating recent divergent trends in understanding the
biological, psychological and social dimensions of treatment.” The
meeting’s international board consisted of seventeen leaders of our field:
Drs. Alanen, Ciompi, Cullberg, Feinsilver, Furlan, Gunderson, Leff, Levine,
Orwid, Østberg, Possick, Rosenbaum, Schwartz, Stierlin, Tienari, Ugelstad,
and Wynne. The Chestnut Lodge organizing committee included Drs.
Bullard, Jr., Cohen, Goodrich, Fenton, Heinssen, Israel, Rieger, Silver,
Waugaman, along with A. Tolins, ATR. The U.S. Organizing committee
included many of these people along with Drs. Boyer, Carpenter, Gabbard,
Gibson, Goldstein, Gunderson, Hogarty, Keith, Kernberg, Liberman,
Mosher, Munich, Rabinowitz, Scharff, Schulz, Selzer, Sharfstein, Steinman,
and Volkan. Honorary members included Drs. Benedetti, Fleck, Jørstad,
Lidz and Müller. Susan B. Miller served nobly as the administrative
secretary/treasurer.
Setting and Program

Almost all of these people participated in the program in some way,
guaranteeing from the outset that this would be an outstanding learning
experience for all in attendance. The meeting included an opening reception
at Chestnut Lodge, with a tour of the grounds. An international folk and
American square dance party was held on the second evening.
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AND
Historically, a special meeting took place on Tuesday afternoon, to discuss

the feasibility of the ISPS becoming a formal Society. A gala banquet and
awards ceremony was held at the Great Hall of the National Building
Museum. A beautiful glass piece with the text “Lifetime Achievement Award
to … for Outstanding Contribution to the Psychotherapy of Schizophrenia,
June 15, 1994” was given to 10 pioneers: Yrjö Alanen, Gaetano Benedetti,
Bryce Boyer, Stephen Fleck, Murray Jackson, Jarl Jörstad, Theodore Lidz,
Christian Müller, Endre Ugelstad and Lyman Wynne, later regarded as the first
Life Honorary Members of the ISPS.
The arrangement of the symposium received contributions from six

pharmaceutical companies. One hundred and twenty speakers were invited
and 140 independent paper presenters came from 22 countries. The lower-
than-expected attendance was attributed to the atmosphere of
demoralization among U.S. mental health workers, due to the general
devastation of institutions brought about by insurance companies’ managed
care firms. Because of the surprisingly low turn-out, the committee was
forced to ask the invited speakers to forego the promise of total
reimbursement. Seventy-five percent of the speakers responded favorably.
Dr. Feinsilver managed the chronic stress attendant to the organization of
this meeting with great dignity and perseverance.
The program of the symposium was divided into eight main sessions, each
session including a single plenary panel followed by a group of concurrent
panels. These sessions were: I: Introduction to the Bio-Psycho-Social
Model; II – Bio-Psycho-Social Vulnerability; III – The Biological Perspective;
IV – The Psychological Perspective; V – The Social Perspective; VI – The
Integrative Perspective; VII – Evaluation and Research and VIII – Directions
for the Future. These sessions were held sequentially. The first consisted of
a single panel, “The Integrative Perspective: An Introductory Case
Presentation, given by Michael Selzer, co-authored with Jonathan Krieger
who was the patient’s therapist. The formal discussants were Will Carpenter,
Daniel Schwartz, and Ian Falloon.
Session II included a plenary panel composed of Yrjö Alanen, Luc Ciompi and
Thomas McGlashan, with discussion by Michael. Robbins. As Robbins noted,
McGlashan’s model differed greatly from those of Alanen and Ciompi.
McGlashan tried modeling the dynamic moment of hallucination, developing a
hypothesis about the neural network responsible for hallucinations and
drawing on evolving understandings of parallel processing computers. Robbins
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The XIth ISPS Symposium
ultimately concluded that McGlashan’s theories found little place for

psychoanalytic techniques, and little meaning in schizophrenic communication.
On three of the days, the day concluded with Small Discussion Groups,
allowing participants to get input regarding the panels he or she had not
attended, and to help highlight key themes. Participants were assigned to
groups so there would be a mixture regarding nationality and discipline.
Each small group had a chairperson who helped facilitate discussion and
noted material to be presented at the closing plenary discussion. From 7
a.m. to 8:15, independent papers were presented (usually to a small
gathering of earlybirds).
Papers published in the journal Psychiatry

While David Feinsilver expected that twelve to fifteen papers of the seventy
submitted would be published in the journal Psychiatry, ultimately just four
were published, by Alanen, Ciompi, Feinsilver and Kafka. Tape recordings had
been made of the entire meeting by Goodkind-f-Sound, but these are no
longer available. These four presentations were part of a series in the journal
which highlighted the treatment of individuals suffering from schizophrenia.
The editors were particularly interested in papers which explored various
psychotherapeutic endeavors, which served as crucial components of
comprehensive treatment approaches to schizophrenia. This orientation was
consistent with the central theme of the Washington Symposium.
Yrjö Alanen (1997) does a masterful job of exploring both biological and
psychosocial vulnerabilities, and linking them to the development and
course of schizophrenic disorders. He then considers the treatment
implications of his hypotheses. In this context, he discusses “Need-Adapted
Treatment”. In this treatment model, case specific therapeutic needs are
defined – with the aid of initial “therapy meetings”, participated by the
patient, his/her family members and the therapeutic team - , and various
modes of treatment, e.g. family-and environment-centered crisis
intervention, intensive individual therapy, therapy of the primary and/or
secondary family, milieu therapy, medication (preferably in low doses), are
employed as indicated by clinicians. Alanen’s focus on listening to,
understanding, and treating all aspects of the schizophrenic individual’s
difficulties in an integrated way represents the equivalent of therapeutic
neutrality with the schizophrenic person.
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AND
Luc Ciompi (1997) presents a complex and very sophisticated bio-psycho-

social conceptualization of the development and treatment of schizophrenia.
Drawing on decades of work with schizophrenia, Ciompi’s model is based on
affect-logic theory. “It postulates that fundamental affect states (or emotions,
feelings, moods) are continuously and inseparably linked to all cognitive
functioning (or “thinking” and “logic” in a broad sense), and that affects have
essential organizing and integrating effects on cognition. Schizophrenia is
understood as an altered mode of affective-cognitive interaction based,
possibly, on disturbed (loosened) affective-cognitive connections.” (p 158)
Ciompi points out that his hypothesis suggests particular ways of
understanding the evolution, course, and treatment of schizophrenia. Like
Alanen (1997), who cites Ciompi’s work, Ciompi proposes a bio-psycho-social
model of the evolution of schizophrenia, in which he links neurobiologic,
psychodynamic, and psychopathic phenomena. His hypothesis also leads to
“a new understanding of the psychopathological core phenomena [of
schizophrenia] such as ambivalence, incoherence, and emotional flattening.”
(p 158) It also leads to “innovative therapeutic approaches, with special
emphasis on the emotional atmosphere of therapeutic settings and
methods,” (p 168) Finally, Ciompi’s hypothesis raises the possibility that
schizophrenia might be an affective disorder.
In an elegant clinical paper, David Feinsilver (1997) hypothesizes that the

therapist’s counteridentifications with that which is frustrating his or her
schizophrenic patients at moments of great urgency for the patient, lies at
the very heart of what is mutative in the psychotherapy of schizophrenic
patients. The therapist’s awareness of his or her own countertransferences
to the schizophrenic person, and the material being presented, clarifies the
therapist’s counteridentifications with the patient. This allows the therapist
to work in a more integrative way with the patient. Feinsilver says that the
therapist may “make focally targeted interventions that integrate supportive
and interpretive aspects of the comprehensive bio-psycho-social treatment
that such severely ill patients require.” (p 260) The therapist’s capacity to be
aware of and integrate fragmenting tendencies within himself, in
identification with the patient’s doing so, helps schizophrenic patients to
“integrate such fragmenting tendencies within themselves.” (p 248) He
argues against the tendency “to see one aspect of the patient’s problems as
the “be-all-end-all answer” to the exclusion of all others.” (p 248) In this
sense Feinsilver’s ideas and therapeutic approach are quite consistent with
Alanen’s.
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John S. Kafka (1997), a psychoanalyst working at Chestnut Lodge, has written

a complex and rich paper, in which he describes the evolution of his views
about the nature and treatment of schizophrenia. He elucidates the process
of an inner journey, the result of which is Kafka’s integration of a
longstanding and deeply felt humanistic (“romantic”, psychodynamic)
approach to schizophrenic individuals with more recent neurophysiological
data and his own insights about the nature of schizophrenic objects and their
link to thought disorders (“classical” approach). Kafka also considers and
describes the clinical implications of his hypotheses. He builds bridges
between seemingly incompatible ways of conceptualizing and treating
schizophrenia (making contact with another person versus treating a
generally describable disorder). The process he describes is a very personal
one, but Kafka also captures the nature of the internal struggles with which
so many of the participants at the Washington Symposium grappled.
In the first section of his paper, Kafka explains what he means by classic and
romantic visions in the conceptualization and treatment of schizophrenia.
This is followed by a brief historical perspective on the treatment of
schizophrenic people at Chestnut Lodge. He also outlines the dangers
inherent in utilizing a completely “romantic” or “classical” approach to the
schizophrenic. Kafka draws heavily on work by Strenger (1989) and Cohen
(1994) in this section of the paper.
Kafka discusses Strenger’s paper on classic and romantic visions in

psychoanalysis, and he applies this model to psychodynamic psychotherapy
of schizophrenia. These two visions share a common interest in the concept
of autonomy, but have differing views about what autonomy is. The classical
nineteenth century notion of autonomy was articulated by Hegel, who
believed that each person must recognize that he is just one “aspect of the
general structure of reality” (p 262), and that he must submit to the whole.
Kierkegaard, who represents the romantic vision, understood autonomy in
terms of the “individual’s ability to attain his own subjective truth” (p 262)
(Kafka quoting Strenger p 596). Kafka’s clinical approach to schizophrenia
was originally very consistent with a romantic notion of the patient’s
autonomy. This perspective had its origins in a “long-standing humanistic…
tradition in psychiatry” (p 262), and it was associated with heroic efforts by
dedicated clinicians.
Kafka notes that this approach was reflected in earlier clinical work with
schizophrenics at Chestnut Lodge. No schizophrenic person was seen as so
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AND
different from other people that he or she was permanently inaccessible,

isolated, and unresponsive. Harry Stack Sullivan’s belief that the social
sciences could help in making and maintaining contact with schizophrenic
patients contributed to the sense of therapeutic optimism at the hospital.
Kafka, citing Cohen’s (1994) presentation at the Washington Symposium,
notes that Sullivan influenced Frieda Fromm-Reichmann, who viewed the
schizophrenic person as a participant, not simply a victim, in his or her
family drama. The patient’s autonomy in this conceptualization is close to
the romantic view of autonomy. Fromm-Reichmann also paid close
attention to the patient’s responses to anxiety. Kafka notes that she became
increasingly concerned with ego defenses which delayed ego development.
She also believed that it was crucial to use language with the patient that
communicated “to the patient that he or she was being understood.” (p 263)
Kafka views countertransference as “part of the romantic tradition because
it emphasizes the personal” (p 263) reality of the therapist. Feinsilver’s
paper illustrates this beautifully.
In summary the romantic view of the schizophrenic person is highly

individualistic, and it focuses on a longitudinal, i.e. developmental and life-
history approach to understanding and treating the patient. In contrast, the
classical vision takes a more cross-sectional approach to the patient. It
focuses on a specific symptom complex at a given point in time. Kafka feels
that the primary interest in the classical vision is on the general structure of
reality rather than on its development. He believes that exclusive use of a
“classical” perspective with the schizophrenic may lead to a type of “tunnel
vision” (p 263) about the patient. The clinician utilizing only a “romantic”
perspective may minimize the great differences between the workings of his
or her mind and the schizophrenic’s. Kafka goes on to highlight other
potential problems associated with the exclusive use of either a “romantic”
or “classical” view of schizophrenia. He notes Strenger’s description of the
psychoanalyst’s internal tensions between his classical and romantic
attitudes towards a given analysand. There is a constant tension between
identification with one’s own perspective and the need to detach from it to be
able to reflect on one’s self from the outside. These tensions are
considerable for the psychoanalyst, who is working with non-psychotic
patients. Kafka believes the tensions are far greater for the psychotherapist,
who is working with psychotic patients.
Nathaniel London’s work (London, 1973), regarding the differences between

a unitary and a specific theory of schizophrenia helped Kafka to develop his
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own specific theory about the core problem in schizophrenia. That is,
London’s work helped Kafka integrate his “romantic” vision of schizophrenia
with a more “classic” one. Kafka moves from the struggles of the individual
clinician to the hospital. He raises the following question: Can advances
derived from a romantic vision be safeguarded in modern hospitals, when
these hospitals are pushed in the direction of a classic vision of
schizophrenia? Kafka addresses this question by describing changes in the
treatment approach at Chestnut Lodge. The changes took place during the
years before the Washington Symposium (1994). There is less focus on
individual psychotherapy. There is an even greater emphasis on the milieu
than in the past. There is an increased use of medications. Residential care,
social therapies, and rehabilitation are all emphasized.
In the second part of the paper, Kafka describes his own efforts to integrate
a more “classical” perspective, which includes the development of a specific
theory of schizophrenia, with his long-standing “romantic” vision of
schizophrenic individuals. We will not attempt to discuss Kafka’s theory
building or its implications for clinical technique. Suffice it to say, he is
concerned with the schizophrenic’s objects, which he terms “atmospheric
objects”, and their role as the most salient feature of the schizophrenic’s
thought disorder. He illustrates his beliefs with a lovely clinical example (the
Heidi story, p 266). He describes the physiological evidence which supports
his belief that disordered rhythms in the brain “lead to idiosyncratic
schizophrenic object formation and this, in my view, is the basis of
schizophrenic thought disorder” (p 267). He goes on to discuss synesthetic
phenomena and déjà vu experiences. Kafka says, “My thoughts about the
uncanny interpretation of synesthesia-related and temporal lobe-related déjà
vu experiences form a bridge between what has been viewed conventionally
as psychological and biological approaches to the phenomenology of
schizophrenia” (p 268) Kafka discusses this in some detail and then, using a
clinical example, illustrates its implications for clinical technique. “It is
important that knowledge of cognitive defects of schizophrenics inform some
aspects of the treatment, but such techniques can coexist with the romantic
notion of the value of an individualized approach that requires dynamic
understanding.” (p 270) He uses work by Reiss to illustrate further “the
marriage of classical and romantic vision.” (p 270) Kafka summarizes his own
integrative work as follows “For me there was, however, an evaluation, a
reconciliation of perspectives. Although the atmospheric schizophrenic
objects may be the result of a “deficiency,” as seen from the outside, the
therapist struggling to understand these idiosyncratic, not commonsense
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AND
objects, to comprehend them also from within (the patient), has a romantic
vision by virtue of the intense focus on this particular inner reality of the
individual. The classic outside view, the recognition of the schizophrenic
“deficiency” coexists with the respectful search for the individual’s inner
truth.” (p 272) The point is not whether one agrees or disagrees with Kafka’s
theory of schizophrenia. Rather, it is that each of us must struggle with the
types of questions he raises. Kafka’s presentation thus formed a philosophic
tent within which the many presentations of this meeting found a place as
illustration or elaboration.
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References
Alanen, Y.O. (1997) Vulnerability to schizophrenia and psychotherapeutic treatment
of schizophrenic patients: towards an integrated view. Psychiatry 60: 142-157.
Ciompi, L. (1997). The concept of affect logic: an integrative psycho-socio-biological

approach to understanding and treatment of schizophrenia. Psychiatry 60: 158-170.
Cohen, R. History of treatment of schizophrenia. Paper presented at the ISPS

meeting in Washington, 1994.
Feinsilver, D. (1997) Comprehensive countertransference and comprehensive

treatment for the schizophrenic patient: the psychotherapeutic heart of mutative
treatment. Psychiatry 60: 248-261.
Kafka, J. (1997) Romantic and classic visions in the therapy of psychosis: a personal
perspective and evolving theory of schizophrenia. Psychiatry 60: 262-274.
London, N.J. (1973) An essay on psychoanalytic theory: two theories of schizophrenia.

Parts I and II. International Journal of Psycho-Analysis 54:169-193.
Strenger R.C. (1989) “The Classic and the Romantic vision of Psychoanalysis”.
International Journal of Psychoanalysis.70 (4):563-610
Stanley Possick, M.D.

102 Marvel Road
New Haven, Connecticut 06515

Columbia, Maryland 21044
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AND
The ISPS appeared under

this name as such in the
12th Symposium, organized
by Brian Martindale in
London, in 1997, with an
important participation of
professionals from all the
continents and interventions
from all the therapeutic
approaches.
Brian Martindale,
Chairman of London Symposium
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12. The XIIth ISPS Symposium

in London, October 1997
Building bridges
Brian V Martindale
Personal Background
My first ever contact with the ISPS was the 10th ISPS conference in
Stockholm organised in 1991 by Johan Cullberg and his Swedish colleagues.
This was a most inspiring experience. I recall being most moved by the many
sophisticated accounts of a wide range of psychologically based
interventions for those with psychosis given by Scandinavian colleagues. It
was clear that such interventions were relatively widespread, a situation
which contrasted greatly with the UK at that time, where such interventions
were confined to a few services and they were regarded as somewhat unique
whether analytic, cognitive behavioural or using “expressed emotion” family
work. I had the impression that the professional ‘distance’ from psychotic
patients was less in Scandinavia and that there was more of a cultural
attitude that whatever their biology, patients had gone ‘under’ because of the
slings and arrows of outrageous fortune in vulnerable persons.
In 1988 I had organised a UK conference involving leading psychotherapists

from other European countries. This had played an important part in loosening
my somewhat idealised island mentality about UK psychotherapy and it was
here that I first met Johan Cullberg. He, together with some others, has
become a most inspiring figure, colleague and friend over the subsequent
years. An outcome of the 1988 UK psychotherapy conference was my
contributing to the formation of a European wide Federation of Psychoanalytic
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AND
Psychotherapy organisations focussing on the Public Sector (the EFPP)i .

During the course of the Stockholm ISPS conference, I spent time together
with Murray Jackson and Michael Conran, (two British psychoanalysts who had
spent many decades working in the NHS with services focussing on psychosis)
who had got to know of my organisational experience and contacts in Europe.
They were coming towards the end of their NHS careers and had been involved
in the ISPS for many years and wanted the conference to come to the UK for
the first time. I took little persuasion from Murray and Michael that there could
be many positive consequences for the UK and my appetite was whetted to try
and make our dream come true.
Laying the foundations

I soon found that this idea - of organising a major international psychosis
conference in the UK and bringing a considerable number of international
experts in a wide range of psychological approaches - captured the imagination
of a considerable number of people as well as the UK mental health
organisations to which they belonged. There was excitement at the possibility
that such a conference could make an impact on professionals and policy
makers. In the late 1980s and early 1990s there was increasing disillusionment
with many aspects of UK mental health services and the rather dominant
biological framework in which treatment took place.
At that time, British cognitive behaviour therapists were gathering

increasing clinical research evidence for the effectiveness of their
interventions in psychosis; there was also frustration that the relatively few
UK nurses who had trained in psychosocial interventions were not being
adequately supported in carrying out this work. Also the skills of many
practitioners from all core professions (including the arts therapies and
social workers trained in case work) whose understandings of psychosis
encompassed a psychodynamic framework often felt unappreciated and
struggled to find the space to use their skills in individual, group and
community settings.
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The XIIth ISPS Symposium
I think that the ISPS board were impressed that a considerable number of a
provisional planning committee came over to the 11th ISPS meeting in
Washington in 1994 and presented our case together, aiming for the 12th
ISPS conference to be held in the UK in 1997. It felt somewhat like a small
scale bid for the psychosis Olympics! We were successful and the torch of
enthusiasm was now firmly lit.
I was elected as the chairman of organising and scientific committees. We

divided ourselves into two groups, one was responsible for developing the
scientific programme. The other was a large group of people formally
representing a whole host of UK mental health organisations whose members
were involved in psychosis. This combination of two groups -one dedicated to
a high class ‘scientific’ (or perhaps better expressed ‘professionally relevant’)
international conference programme and the second group concerned with
ensuring full publicity and support for the programme from a wide range and
large number of relevant UK professionals - was certainly the key to the
success of the conference in terms of UK participation. The full list of the core
members of the UK scientific committee as well as supporting organisations
is given in Appendix 1.
Although it will be clear how many organisations were involved it is

important to highlight how important for the conference and its influence
was the support of the President and several component faculties of the
Royal College of Psychiatrists together with the British Psychological
Society, the Royal College of Nursing and key persons within the Department
of Health.
The reader will not be surprised that our conference title was BUILDING
BRIDGES with all its significances in terms of organisations, modalities,
disciplines, as well as the bridge building with patients and their families
where there is psychosis
A major headache, and a non-pharmaceutical cure – for us at least

We quickly ran into a major problem which may have been a blessing in
disguise. In the early 1990’s there was only one conference centre in London
that would both take a 1000 or so participants and had an adequate number
of rooms for the many parallel sessions we needed. We were confident that
national and international attendance would be high, if we could provide
plenty of opportunities for people to present on a wide range of themes
relevant to psychosis. Our problem was that there was absolutely no
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AND
financial surplus from the previous ISPS conference and we could not make
any of the very considerable advanced payments for the conference venue
and for the production and mailing of international publicity. The ISPS was
completely broke before we had started!
This was a source of enormous strain and I found myself wondering if my

coronary arteries would last until 1997. As a result of an a urgent foray to try
and interest professional conference organisers, we were most relieved
when a European wide organisation based in Brussels not only agreed to
take the full financial risk of the whole conference but also were more than
ready to sign a contract unconditionally offering £20,000 to our parent ISPS
organisation at the end of the conference. In retrospect, I think the company
may not have realised that the pharmaceutical companies would not
necessarily contribute that much sponsorship to an organisation focussing
on psychological interventions – but I was certainly greatly relieved that we
could now concentrate on putting on the professional side of the meeting –
the full financial risk and presumably a headache being ‘transferred’ to the
conference company!
The Conference
For those visiting the UK, the conference setting could not have been
improved on. The Houses of Parliament, Big Ben and Westminster Cathedral
were fully visible just across Parliament Square through the extensive glass
frontage of the Queen Elizabeth II centre.
We had close to a 1000 participants and during the course of the four and a
half days there were more than 307 presentations, let alone the added
contributions of invited discussants and the active participation of many of
the chairpersons.
Our aims were to make available to both the leaders of mental health
organisations in the UK and ‘ordinary’ mental health practitioners the
knowledge and experience of a wide range of psychologically based
interventions that could be of use to persons with psychosis and their
families. We wanted to highlight not only what was happening in a range of
other countries but also to underline how much expertise, experience and
knowledge from research was available in the UK but how little this was
applied.
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We spent considerable time carefully selecting our invited speakers and it

seems appropriate to give a very brief account of their contributions. We
hope that this will not detract from memories of some 250 other speakers
from many countries who, in smaller scale settings, contributed enormously
to the success of the conference. In this account there is not space to
describe the several social occasions and the London settings of both the
Speakers and Conference Gala that contributed to the conference’s success.
However an important historical event for ISPS took place during the London
conference. This was the official transformation of the ISPS from an
organisation that put on conferences to an international organisation that
had a wider range of functions aimed at promoting and supporting those
interested in the development at national and local level of psychological
interventions in psychosis. This will be described in a separate chapter.
Two important pioneers of psychosis psychotherapy, professor Helm Stierlin,

M.D., Ph.D., from Heidelberg. Germany, and Barbro Sandin, Ph.D., from
Ludvíka, Sweden, were invited as Life Honorary Members of the ISPS.
Invited Speakers
It was especially important for the conference and its aims of making a long
term impact in the UK that amongst other important dignitaries the
conference was opened by the UK Minister of Health, Rt Hon Paul Boateng
and the President of the Royal College of Psychiatrists who had been
involved during the planning stages (Dame Fiona Caldicott).
There were a number of major themes that orientated each day. One day had a
number of plenary presentations on British perspectives on the psychological
therapies, whilst another day concentrated on the breadth of contexts within
Europe for developing psychological therapies. A further pair of sessions
focussed firstly on first episode psychosis and then ‘chronic’ psychosis. Another
day focussed on the EVOLUTION of contemporary ideas about psychosis and
the last day looked ahead to improvements in prevention of psychosis, optimum
protection and optimum therapies for persons with psychosis
Michael Robbins (USA) gave a most challenging opening address. First he

emphasised the fallacy of many past and current endeavours which
attempted to reduce the understanding of schizophrenia to a single
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AND
theoretical framework, whether psychological or biological and he

emphasised the importance of general systems theory. In surveying the
range of interventions, he considered that most approaches reinforced and
stabilised basic elements of the dis-ease in the individual, family and social
systems (iterative processes). It was the exception that a therapy was aimed
at actualising the potential of the individual through mutative processes
which might therefore often inevitably involve periods of disruption and
reorganisation of individual, familial and social systems. To my mind,
Michael Robbins’ view remains a most important consideration that needs
far more attention than it receives.
A full afternoon was devoted to hearing the experiences of a range of UK and

USA users, carers and family members as well as those of professionals.
This ‘experience near’ event was a great success and made a big impact on
many professionals. In 1997 it was relatively uncommon to have such active
user and family participation in a large professional conference. For many,
this was the first time they had heard in an organised way directly from
users, carers and children of the mentally ill. Perhaps some of what was
conveyed had more connection with what Dr. Robbins was referring to than
we realised at the time.
An outstanding presentation was given by Wayne Fenton of the USA who

managed to synthesise much of the relevant contemporary research in a way
that gave considerable inspiration and support for developing the objectives
of the ISPS in pursuing psychological interventions.
Family approaches
Julian Leff (UK) is one of the best known of UK schizophrenia clinicians,
researchers and innovators and he focussing especially on the reduction in
relapse and readmission rates when ‘expressed emotion’ (EE) can be
lowered in families. Professor Leff was at pains to emphasise his view that
expressed emotion is neither peculiar to schizophrenia, nor the reason for
its onset. In considerable contrast, Lucy Johnstone revisited the ‘taboo’
subject of the role of the family in schizophrenia. She was of the view that
collective avoidance of looking more closely at certain evidence leads to
considerable limitations in both theories of psychosis and in the practical
work and help offered to families and individuals.
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Pekka Tienari (Finland) has devoted much of his professional research life
to a project studying adopted away children of mothers who had
schizophrenia and in so doing uniquely examining BOTH sides of the nature
–nurture controversy. His research shows an interaction between the
genetic factors and factors in the rearing environment. The idea of
protective factors in families is inherent in this most important work. Peter
Steinglass (USA) gave an overview of the trends in family therapy in recent
decades and highlighted the promising developments of multi-family
groups (MFGs) where there is psychosis and his evaluation of the effective
components of MFGs.
Cognitive and Psychodynamic approaches

Max Birchwood (UK) gave a thorough overview of current theoretical
underpinning of the cognitive therapy framework and its relation to the ‘self’
and ‘identity’ in psychosis and their interrelatedness with interpersonal
problems and withdrawal. Birchwood’s thinking has clear connections with
dynamic ideas especially in the concealed personal meaningfulness
contained in psychotic ‘symptoms’. Liz Kuipers and Philippa Garety (UK)
described one of the first UK studies showing the effectiveness of cognitive
behaviour therapy for psychotic symptoms refractory to medication and that
this improvement was maintained at follow up and they delineated the six
stages of the approach.
Murray Jackson (UK) has extensive experience of supervising as a

psychiatrist and psychoanalyst since retiring from the NHS. He spoke
cogently about the deterioration of psychiatry in the face of market forces
leading to minimalist short lasting interventions in psychosis (he
emphasised that there were notable exceptions). Jackson gave a vivid
account of the potential contributions of psychoanalytic thinking to psychosis
services and made a plea for an ISPS charter of rights of patients with
psychosis that including assessments that involved a psychodynamic
interview and formulation.
In contrast to the UK situation, Richard Munich (USA) gave the reasons for
his, perhaps (with hindsight) rather hopeful, view of the resumption of
general interest in psychodynamic psychotherapy in the USA. There has
been an increase in awareness that symptomatic improvement and
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AND
environmental manipulations do not correlate well with functional

improvement. Also psychodynamic therapists were now adopting a much
more flexible technique according to the phases of the disturbance and
there was much greater preparedness of therapists to work alongside
practitioners of other modalities.
Concern is increasingly expressed across nations at the increasing and

very large number of psychotic patients in prison and forensic services.
Pat Gallwey (UK) gave an enthralling account of disturbances in
unconscious thought processes in those who come the way of these
services.
The early phases of psychosis and the first episode

ISPS owes a great deal to the Finnish need adapted approach pioneered over
more than two decades by Yrjö Alanen and his colleagues. The conference
had a special session on the first episode of psychosis, an area that in 1997
was beginning to attract the interest of policy makers around the world.
Jukka Aaltonen gave another exciting and radical Finnish presentation,
describing a whole community approach in Lapland where all the mental
health professionals involved are becoming fully trained in family therapy.
Any call for a prodrome or psychosis situation is responded to the same day
and an open dialogue process is initiated with the whole family and
professionals. This radical intervention in the system has led to a marked
reduction in the incidence of psychosis and in in-patient care, but a rise in
the incidence of prodromal cases seen, neuroleptic usage is needed in only
30% of cases and at the time there were no new long term cases since the
project started.
Johan Cullberg (Sweden) and his colleagues gave some most encouraging
results from the first years of the ‘Parachute’ project in which many Swedish
centres are participating adapting the Finnish need-adapted approach for first
episode psychosis patients and Pat McGorry (Australia) gave an inspiring talk
giving an overview on aspects of prevention in psychosis. He looked at the
possibilities a) emerging from the recognition of prodromal disorders in
psychosis, b) for improved outcome if phase and need specific therapies are
applied according to age and stages of development especially youth orientated
approaches c) from reorganisation of services to allow for such optimal and
phase specific therapies, aiming also to minimise harm and trauma.
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One of the most important challenges is how to translate the positive

evidence from research of the effectiveness of psychological and
psychosocial interventions and equip staff in regular services with the skills
to implement the findings. Tony Butterworth (UK) gave an overview of the UK
multicentre Thorne training initially for nurses, highlighting its achievements
and limitations so far. The latter particularly relate to the organisational
changes needed to accommodate the skills of trained persons.
Cultural Contexts
Suman Fernando (UK) gave his views that racist ideologies permeate UK
psychiatry and psychology, leading to inequalities in diagnostic and
therapeutic practice. He was also of the opinion that the psychological
therapies, (when offered) were inappropriate to the needs of black people
especially. In contrast to some other areas of society he thought that
psychiatry remained mono-cultural with innovations by black and other
minority groups not permeating the established systems. Michael Stone
(USA) gave an erudite historically orientated perspective on contemporary
ideas about the psychoses and how cultural factors varying with time might
either disguise the existence of psychoses (e.g. religious practices and
beliefs) or expose the afflicted person in a particular era.
Group, Residential, Community Therapies and Nationwide

expectations
Sonja Levander (Sweden) described alternative settings to hospital for first
episode psychotic patients consisting of 9 bedded community home-like
environments. The journey of two persons through this kind of setting was
described in depth to bring the approach alive for the audience. (We now
have good evidence of the difference that this approach can make in terms
of patient satisfaction and long term outcome as well as cost savings. An
example of research demonstrating this won the research prize in this
conference (1)–see Research Prize below). Shalom Litman (Israel) described
changing the treatment practice in a local service in Israel from one using a
large number of lengthy hospital admissions, followed by individual follow
up that centred mainly on medication compliance. The reformed service was
organised principally on dynamic group frameworks that ranged from hostel
settings to community social and therapeutic groups. The local success,
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AND
once staff resistance was overcome, led to its extension to a large number of
the Israeli geographical areas with marked reduction in bed usage and
marked increase in successful community rehabilitation.
By way of contrast, Reinmar du Bois and Michael Günther (Germany) illustrated

the therapeutic potential of a long-term residential therapy of resistant
schizophrenia in adolescence with the intention that this time be used to
promote adolescent maturation by utilising the interpersonal relationships
established in the context of every day life opportunities offered in the residential
setting. Nick Kanas (USA) gave a résumé of outcome studies of group
psychotherapy highlighting variations in outcome according to approach and
focus. As a result he has developed an integrated method utilising a structured
focus in the more acutely disturbed, later moving to examining interpersonal
relating in outpatient settings. Kanas underlines the cost-effectiveness and wide
applicability of these approaches and high attendance rates.
Marvin Skolnick (USA) gave a rich account of a therapeutic community for

‘chronic’ schizophrenia. He was at pains to emphasise that ‘chronic’ is a
result of complex interactions involving local society, institutions and family.
The therapeutic community approach allows fresh opportunities for the
“poetry” of psychotic symptoms to be understood and for its translation and
development, albeit against resistances that have multiple sources.
Andrew Sims, a former president of the Royal College of Psychiatrists, gave

an account of the development of Nationwide Clinical Standards for services
and their potential value in improving the overall care of the whole
population of persons such as those who suffer from schizophrenia, (a
rather uncanny predictor maybe of eight years later when UK services are
dominated by targets and ‘expert’ guidelines). Pier Maria Furlan (Italy) was
the principle organiser of the 9th International ISPS symposium in Turin and
his talk described many of the issues that are left in Italy in the wake of the
1978 Italian Law that transformed Italian psychiatry. He focussed especially
on the lack of coordinated planning and evaluation of the intermediary
facilities compounded by the lack of interest in many universities in
community psychiatry.
Dame Fiona Caldicott, now that she had relinquished her Presidency of the
College, was able to give a riveting account of her experience as head of a
profession in relationship with politicians in moving forward a mental health
agenda.
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Research Prize
There were many research presentations at the conference. In the
announcements for the conference, we announced an innovation for the
ISPS – that there would be substantial financial prizes for the best research
papers submitted. There were twenty two submissions. Nearly all were of a
high quality. The unanimous choice to win the competition was a paper by
Wayne Fenton and Loren Mosher (1), in which they randomly admitted
patients to the psychiatric unit of a general hospital or an eight bedded
community crisis home using an adaptation of Soteria House principles
including a visiting psychiatrist. Clinical outcomes were no different but
there were substantive reductions in bed days needed and savings in costs.
One of the important implications of the research is that it points to a
potential release of money for improved community therapies. Highly
commended were papers by
a) William Sledge, Larry Davidson and colleagues from Yale, USA on

community social interventions reducing recurrent admissions,
b) Gráinne Fadden researching the problems of implementing psychosocial
interventions routinely,
c) Dr. Moggi of Switzerland on a particular approach to dual diagnosis
patients and
d) Roberta Sciani and Orazio Siciliani of Italy on a self psychology therapy
model.
The Arts, Art therapies and Psychosis

Following the opening ceremony, we were especially fortunate to have been
able to engage actors from Shakespeare’s Globe Company who dramatised
extracts from Shakespeare and show us “that way madness lies.” Our
convenors were to have been Alice Theilgaard, Mark Rylance and Murray Cox.
However Murray sadly died suddenly shortly before the conference.
There was also an impressive and unique exhibition entitled ‘Images of

Psychosis’ bringing together historical and contemporary UK examples of
‘psychotic’ art, outsider art and art work. This was organised by Sheila
Grandison, the Talbot Rice Gallery, the Aberdeen Art Gallery and the University
of Edinburgh. This was the first time the Scott ish Collection of Art
Extraordinary had been seen outside of Scotland and included the collection of
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AND
Joyce Laing, a pioneer of art therapy and mid nineteenth century psychiatric
art from Crichton Royal Hospital that predated the Prinzhorn collection.
Joy Shaverien, (UK), a Jungian analyst and art therapist gave a rich talk,
discussing the use of the art object in therapy as a complex transactional
vehicle allowing a sense of control over the primitive or disturbing yet being a
route for the recovery of symbolic and communicative function. She expressed
concern about the future of arts therapies in the changing settings where the
severely mentally ill are seen. Louis Sass (USA) gave a very profound
philosophical and phenomenological paper on Modernism, Primitivism and
the madness of Antonin Artaud whereas Abbe Steinglass (USA) gave a visually
exciting presentation making connections between the arti stic process and the
development of psychosis and a therapeutic intervention through looking at
the disturbing idea of both artist and patient and the stages of transformation
of that idea into its final visual outcome and how this and the ‘idea’ is affected
when there is an observer of the process (e.g. therapist).
Yaron Shavit an Israeli born pianist living in London, played extracts from
Schumann’s last piano compositions before he made a suicide attempt by
throwing himself into the Rhine. He compared these with extracts from
earlier works of Schumann showing how the change of style reflected his
state of mind.
The longer term outcome of the conference

It is difficult to evaluate the effect of a major conference. It needs to be
considered at many levels and in many contexts. If one was evaluating the
ISPS Swedish conference of 1991, would the evaluators have taken into
account that one first time participant from the UK was sufficiently inspired
by that conference to bring all the UK mental health organisations and the
Department of Health together to put on a major international conference in
the UK and its effects on the UK?
Certainly it would be impossible to evaluate the international impact of the

London ISPS conference on its participants from 120 countries, though
there were many favourable comments that have continued to be received
over the subsequent years including indications that it motivated many
persons to become actively involved in the psychological approaches to
psychosis.
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The approaches to psychosis in the UK

In terms of benefits to the UK, the timing of the conference was most
fortuitous. The UK had recently elected a new government who had pledged
to modernise the health services and that mental health was one of the
priorities. Planning was underway and early intervention in psychosis
became one of three pillars of the mental health modernisation announced
in 1999 (alongside alternatives to hospitalisation through crisis and home
treatment teams and new ‘assertive outreach’ services for the hard to
engage and isolated patients with psychosis). Government mental health
staff involved in planning modernisation of UK mental health services
participated in the conference and went on to visit overseas first episode
centres whose leaders had participated in Building Bridges.
It is important to remember the breadth of presentations made by UK

delegates at the conference that demonstrated the extent of knowledge and
expertise: users and carers, psychoanalytic approaches, arts therapies,
group and therapeutic community, let alone the internationally renowned
work in family and cognitive therapies with a sound efficacy base.
Perhaps the conference played a significant part in reducing the stigma that
exists against the range of psychological / talking therapies and gave many
participants and the presenters a sense of pride as they demonstrated their
knowledge and skills to appreciative international audiences. Certainly the
overall mood in the UK has been a much more optimistic one concerning
psychological therapies in the decade since the conference. However the
degree of resistance, the lack of systems that can lead to changes in
practice, the shortage of training opportunities and career opportunities for
trained staff remain formidable.
More tangible spin offs from the conference are

• the formation and considerable achievements of the ISPS UK and
• the publication that followed from the conference.
The ISPS UK
Following on from the model of the conference and its planning, the ISPS UK
committee that formed after 1997 the ISPS UK network was multi-modality
and multi-professional. It may be helpful for others to know the breadth of
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AND
expertise represented on our committees. Psychodynamic, cognitive, family,

arts therapies, nursing, social work, group and therapeutic community,
several faculties within psychiatry including child and adolescent as well as
psychology and in recent years we have had user and carer participation. Its
chair was determined that ISPS UK would minimalise the unhealthy
factionalism that impedes progress in the more widespread implementation
of psychological therapies.
Clearly a number of us wear more than one hat! In 2001, ISPS UK became a
recognised charity and adopted a constitution not dissimilar to that of the
parent ISPS organisation with a formally elected committee who are also
trustees of the organisation. In 2004, David Kennard, a psychologist who has
a background in the therapeutic community field took over as chair of ISPS
UK from Brian Martindale and further developments of the organisation are
well under way.
It should not be under-emphasised that the crucial ingredient to transform

the enthusiasm of experienced but busy clinical professional committee into
a nationally relevant one was the appointment of a paid ‘organiser/
administrator’ for one day a week. This was possible once we had organised
a conference that deliberately generated sufficient funds for the organiser.
We advertised nationally and were able to choose from a very good field of
applicants. Antonia Svensson was our unanimous choice and very capably
provided the means by which the growing membership was organised and
established a two way relationship with the committee. Many international
members will recognise Antonia’s name as, following her move to Greece in
2002, she became the ‘Organiser’ for the International ISPS organisation and
was succeeded in the UK by Annabelle Thomas, who came with considerable
valuable experience of running conferences.
At the time of writing (2005) the organisation had some 500 members and
has held three residential conferences each involving about 300
professionals and a good number of day conferences. Some of themes we
have focussed on may be of interest: the residential conferences on a) the
therapeutic relationship, b) ways of listening, seeing and being with those with
psychosis c) changing practice. Two one day conferences have been held on
groups and psychosis and two on the inpatient experience and in late 2005
there will be a day conference on culture and psychosis. A most useful
innovation developed by Chris Burford has been a membership email
discussion group which has played an important part in adding to a sense of
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an ISPS UK identity by allowing members to bring ‘hot’ topics for others to

respond to and debate as well as a ready forum for information sharing.
I think it is true to say that there has been relatively little interdisciplinary
and intermodality strife in the ISPS UK because there is a place for every
group at the top table and the conferences have been organised in a way in
which our members can be well informed about the different approaches
and a fair amount of debate and discussion about differences can be built
into the meetings. The rapid growth of the implementation of early
intervention in psychosis in the UK has lead to the ISPS UK being a naturally
attractive home for many interested persons.
ISPS UK has continued to involve the leaders of the UK mental health

professional groups and to maintain links with the department of health
and its regional developments in the mental health field. Subgroups have
started to form on both geographical basis and on a modality basis. There
is for example a regular ISPS UK psychoanalysis and psychosis meeting in
London, a multi-modality meeting in the North of the UK as well as nursing
and family groups that are forming. We have our own lively Newsletter that
is available both on the web and in printed version to all our members.
Publications
A new ISPS book with UK authors (Kennard, Fagin, Grandison and Hardcastle)
is to be published in 2006. It has the provisional title: Feeling Your Way
Through: Accounts, Reflections and Commentaries on the Experiences of
Acute Psychiatric In-Patient Care. There have been wide-spread concerns in
the UK about the lack of therapeutic emphasis and other adverse features of
wards in recent years and we have high hopes that this book’s usefulness
will be of constructive value to many mental health practitioners.
Following the 1997 conference, we deliberated hard as to what kind of publication

would best follow on. Clearly we had available a most outstanding range of
papers. With time and resources being finite, we decided in conjunction with the
International ISPS Board that in view of the zeitgeist, an evidence based book
would best complement the conference. Brian Martindale, Anthony Bateman,
Michael Crowe and Frank Margison, who all had various active roles in the
conference were the editors and collected together a whole range of international
experts in a spectrum of psychological therapies who all produced high quality
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AND
chapters. The chapters aimed to have two functions a) to give grounding in the
basis of the approach b) to outline the research evidence for effectiveness.
It was important for the UK that the book was published by Gaskell press
–the publishing arm of the Royal College of Psychiatrists. The title of the
resulting book is Psychosis: Psychological Approaches and their
Effectiveness. Putting Psychotherapies at the Centre of Treatment (2). It has
been reprinted and may well be updated in 2006.
The book certainly played an important part in ensuring that some of the
momentum and enthusiasm that the Building Bridges conference generated
was translated not into a museum of hopefully good memories of a
conference but into a Bridge to the Future of Psychological Therapies in the
UK and we hope for participants from other countries, just as the 10th and 11th
conferences and their inspiration had formed an important bridge to the UK.
I am sure that all involved in the UK conference are grateful to the organisers
of the earlier ISPS conferences that had inspired us.
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Appendix 1
The following were the core members of the UK scientific committee, who
worked closely in liaison with the ISPS Board of the time.
Admistrator / Secretary
Joyce Piper
Treasurer
Jeff Roberts
Members
Anthony Bateman
Michael Crowe
Domenico di Ceglie
Suman Fernando
Kevin Gournay
Sheila Grandison
Lucy Johnstone
Malcolm Pines
Paul Robinson
Brian Martindale (Chair)
Appendix 2
The following UK organisation were actively involved in supporting the
conference
The Department of Health

The Royal College of Psychiatrists (several faculties)
The British Psychological Society
The Royal College of Nursing
The United Kingdom Council for Psychotherapy (UKCP)
The British Confederation of Psychotherapists (BCP)
The Association of Child Psychotherapists (ACP)
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Institute of Psychoanalysis
The Association of Psychoanalytic Psychotherapy in the NHS
Institute of Family Therapy (IFT)
The British Association of Art Therapists (BAAT)
The Association of Professional Music Therapists (APMT)
The British Association of Dramatherapists (BADth)
The Association for Dance Movement Therapy (ADMT)
Group for the Advancement of Psychodynamics in Social Work (GAPS)
Association of Therapeutic Communities (ATC)
The Institute of Group Analysis (IGA)
Arbours Association
References
Fenton, W.S. and Mosher, L.R. Crisis residential care for persons with serious men-
tal illness. In: Psychosis - Psychological Approaches and their Effectiveness. Eds
Martindale et al. 2000. Gaskell.
Psychosis: Psychological Approaches and their Effectiveness. Putting

Psychotherapies at the Centre of Treatment. Edited by Martindale, B., Bateman,
A., Crowe, M. and Margison, F. Gaskell Press. 2000 ISBN 1 901242 49 8
Cullberg, J., Levander, S, Holmqvist R et al: One-year outcome in first episode

psychosis patients in the Swedish parachute project. Acta Psychiat. Scand.
106:276-285, 2002
Brian Martindale, MD
Consultant Psychiatrist, RW9 South of Tyne and Wearside
Newcasle, U.K.
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AND
2000 Stavanger 13th

International Symposium for
The Psychological Treatment
of Schizophrenia and other
Psychosis.
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Stavanger Symposium
attendants resting outside
Venue
The Queen of Norway with

Stavanger Symposium
Chairman
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AND
Gerd Ragna Bloch Thorsen
Jan Olav in Stavanger 2000
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13. The XIIIth ISPS Symposium

in Stavanger, Norway, on
June 2000
Schizophrenia and other psychoses: Different
stages – different treatments?
Jan Olav Johannessen and Gerd Ragna Bloch Thorsen
Background
As is evident from the fact that the 5th ISPS conference was organised in Oslo,
Norway, in 1975, the psychotherapeutic approaches towards psychotic
disorders, such as schizophrenia, have held a strong position in Norwegian
and Scandinavia for many decades. This tradition has also been strong in the
part of Norway where we were trained and have spent most of our
professional career. Psychodynamic understanding and psychotherapy have
been, and still are, corner stones of the comprehensive treatment programs
that we try to offer all patients, including those suffering from psychotic
illnesses. This includes “phase-specific” and the more comprehensive
“need-adapted” treatment strategies that are so important in all
Scandinavian psychiatry for people with psychosis, developed via the work of
Tähkä, Alanen, Cullberg and also significantly by Endre Ugelstad. In 1981
Stavanger hosted the “Scandinavian Psychotherapy Congress” where Veikko
Tähkä presented a version of his paper on “Psychotherapy as phase-specific
interaction: towards a general psychoanalytic theory of psychotherapy” (1).
His work had been presented previously at the Scandinavian Psychoanalytic
Congress in Helsinki in 1978, and by the early 80’s was already obtaining
great influence in the Scandinavian psychiatric milieus.
This work, together with local interest for epidemiology, pointed us in the
direction of working with first episode psychosis. So, locally in the
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Stavanger region, we gradually developed some interest for and

competence on the combination of psychotherapy with early psychosis.
Further on this was combined with a recognition of the importance of
empowerment, and transferring knowledge to patients and relatives, as
well as the public, to reduce anti-stigma, reduce delays in treatment onset
and to include patients as active participants in their own treatment. We
started with public information campaigns combined with conferences for
professionals from Norway. Based on previous smaller conferences, the so-
called “Schizophrenia days” surfaced in 1989. This is an annual conference
for professionals, the public, patients, relatives, school pupils, students and
so on. It is a professional conference with a very high quality of invited
speakers, with public lectures, art exhibitions, theatre, films, music and a
lot of other cultural events. The purpose of these is to demonstrate that
people suffering from psychotic disorders are much more than their
disorder. Actually two of Stavanger’s most famous artists, the poet Sigbjørn
Obstfelder and the painter Lars Hertervig, both suffered from serious
psychiatric disorders; a hundred years after their deaths, none of their
contemporaries, so-called well functioning co-citizens, seem to be
remembered. “Schizophrenia Days” is a yearly conference, not only
focusing on schizophrenia, but also on different psychiatric disorders. It has
grown over the years and by 2005 we had about 3000 participants of
different backgrounds. This experience with organising rather large
conferences was part of the reason why the Stavanger milieu was asked to
take responsibility for this 13th ISPS symposium. This mixture of
psychotherapy for psychosis, early intervention in psychosis and
information and education work formed the local matrix in which this
symposium was embedded.
The organizing and scientific committees were led by the writers, Jan-Olav
Johannessen as the chairman and Gerda Ragna Bloch Thorsen as co-
chairperson. Very early in the process of organising this symposium, we
understood that the Stavanger milieu was too small, and our professional
network too limited, to take on such an enormous task as organising the
kind of symposium this really is. Therefore, we had to build on the whole
Norwegian psychological/psychiatric/psychotherapeutic milieu, as well as
the insight and competence of the ISPS executive board and other
international professional capacities. We also formed an international
advisory board, a national scientific committee, and a local organising
committee (Appendix 1).
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The XIIIth ISPS Symposium
The theme
When we were asked to organize this meeting, it was clear to us from the
very beginning that the theme should reflect the common Nordic experience
of phase specificity regarding understanding and treatment of psychosis. For
those of us stressing the importance of early detection and treatment of
psychotic disorders, the rationale behind our engagement differs. For us, it
was the personal experience of treating schizophrenic patients in different
stages, meeting them for the first time when their illness had lasted, say one
week versus three years, versus meeting them in the very chronic psychotic
stages that one can see at times. We also knew that the psychological
treatments were under great pressure to prove both their effectiveness and
also their cost-effectiveness. So it was, and still is, our conviction that
concentrating on the very early stages of psychoses could mean a revival
also for psychological treatments, the possibility of developing better and
more targeted treatment strategies, and that it would be easier for the
patients to engage in a therapeutic relationship when they are offered help
at an early stage in the illness development. In addition, this relationship
would then be, as we very well know, the most important “tool” in resolving
the intra- and interpersonal conflicts that are the basis or contribute to the
psychological breakdown that a psychosis really is.
The town authorities in Stavanger as well as the county authorities in

Rogaland supported the idea of applying for this important congress to come
to our area. And the royal family, represented by Her Majesty Queen Sonja,
agreed to be the royal patron of the ISPS 2000. We were also very lucky to get
Professor B. Saraceno from the WHO to participate in the opening of our
conference and give a lecture titled “WHO strategies in the field of mental
health.” We had 70 workshops and symposia, 50 posters, 50 free papers, and
about 15 plenary keynote presentations.
The symposium was divided into four major themes with what we saw as a
built-in natural logic between them. The first day focused on “the nature of
psychosis,” the second on “what kind of psychotherapy for which patient?,”
the third one on “early intervention in psychosis” and the forth on “integrated
treatment: research – education – future aspects.”
In the foreword for the ISPS 2000 abstract book, Acta Psychiatrica
Scandinavica, Supplementum, No 404, Volume 102, 2000 (2), the organisers
wrote:
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“Schizophrenia and other psychosis: Different stages – different treatment.

Harry Stack Sullivan pointed out already in 1927 (3) that “the psychiatrist
sees too many end states and deals professionally with too few of the
prepsychotic.” At the same time he also stated that “the great number of our
patients have shown for years clear signs of coming trouble before the
breakdown,” and “it is never easy to say just when the schizophrenic patients
has crossed the line into actual psychosis.” In 1955 Lewis B. Hill (4) stated in
his book “Psychotherapeutic Intervention in Schizophrenia” that “if the crisis
is badly treated or is neglected, then the liability to chronic disabling illness
is vastly increased. It is quite possible that the thousands of patients in the
state hospitals diagnosed as chronic undifferentiated schizophrenics are, in
fact, the result of inadequately treated acute schizophrenia.” These
observations made by clinicians and researchers throughout the last century
have led us to understand that the functional psychosis in general, and
maybe schizophrenia in particular, are conditions that develop through
different stages.
These disorders have different stages of illness development and the end
stages may very well be the result of too late intervention in the previous
stages.
The concept of early intervention has vast implications for the therapeutic
approaches and especially for the way we organise our psychiatric health
services. Important work has been done during the last decade in this field,
with pioneers like Ian Falloon, Patrick McGorry, Max Birchwood; Heinz
Häfner; Johan Cullberg to mention a few. Their work, presented at the 13th
International Symposium for the Psychological Treatments of Schizophrenia
and other Psychoses, gives an indication that by intervening in earlier
stages, it can be possible to prevent, delay or modify the manifestation of a
psychotic disorder such as schizophrenia.
Much of the research on different psychotic disorders and schizophrenia

does not differentiate between these different stages of illness development;
i.e. in most of the research done, all patients with a schizophrenia diagnosis
are considered the same, regardless of duration of untreated illness, age,
episode number, gender and so on. Future research, both psychological,
psychosocial and biological, should focus more on different sub-samples
within these diagnostic categories. We think, for example, that duration of
untreated psychosis is highly underestimated as a prognostic factor. There
are now indications from research done in Australia, Germany, Scandinavia
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and other parts of the world, that prognosis could be better if one intervenes
early. The patients are more compliant with the treatment, and more
motivated for psychological treatments. Future research should therefore
concentrate on “refining” the different sub-categories of these serious
disorders according to number of episode, age, and so on.
The different contributions at the ISPS in Stavanger in June 2000 look upon
functional psychoses and schizophrenias as processes and the result of
internal and external factors, where the psychosis, or the mental
breakdown, will be treated as such. We challenge the opinion that
schizophrenia is a biological genetic disorder with an inevitable descending
course. On behalf of both the patient and the people working in the field of
psychiatry, we want to reinstall hope in the treatment of these serious
conditions and provide future treatment in a humanistic tradition.
The nature of psychosis

Patrick McGorry of Melbourne, Australia, gave the first plenary speech with
the title “The nature of psychosis: Different stages – different treatment”. He
specifically addressed the concept of psychosis, and demonstrated that
these are disorders that develop in stages. He stated that the optimal
treatment of psychotic disorders has been viewed as independent of phase
of illness until recently. He described a phase-oriented approach to
treatment, with emphasis upon the earlier phases of illness and role of
psychological therapies. The other plenary speech was given by Jeremy
Holmes from Devon, UK: “Can narrative approaches help in our
understanding and management of psychosis?.” He stated that narrative
based medicine and evidence based medicine form a symmetrical thesis and
antithesis. The task of the practitioner is to synthesise them. He stressed the
need to understand the role of unconscious motivation as well as genes and
neurotransmitters if you are to understand how a psychotic illness arises in
the context of a particular life story. He offered an attachment based
perspective suggesting that there are direct links between the physiology of
attachment in infancy, the development of language, and adult narrative
styles.
Other important contributions related to this theme, the nature of psychosis,

were given by Lars Thorgaard from Denmark, who presented ideas for a
therapy-directed classification of schizophrenia based on an empathic
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understanding, Phillipa A. Garety from UK who talked about “Delusions:

investigations into the psychology of delusional reasoning,” Paul C.
Bermanzohn from US who talked about “Neglected syndromes in
schizophrenia” and Colin Ross, US, who gave an excellent speech on
“Psychoses, delusions and dissociation. The need for integration.
Theoretical and therapeutical implications.”
Other symposia focused on cognitive disturbances, philosophical aspects of

schizophrenia, the prodromes of psychosis and schizophrenia, and
assessment of psychoses.
What kind of psychotherapy for which patient

In this part of the symposium, which was held on the second day, the plenary
meeting was chaired by Pier Maria Furlan of Turin, the organiser of the ISPS
1988 in Turin.
Thomas McGlashan from New Haven, US, gave an overview of what he called
“The potential of relationships in the work with schizophrenic patients.” He
stated that these relational treatments are the oldest we have, but they are
in danger of becoming remnants of the world antiquity. Therefore, he tried to
demonstrate their relevance by showing, for example, the impact of
psychosocial forces on the natural history of schizophrenia and to connect
that to present day outcome dimensions of particular relevance to
psychosocial treatments.
Max Birchwood from Birmingham, UK, gave a talk called “Threats to

engagement in psychological treatment for schizophrenia.” Professor
Birchwood based on the cognitive tradition, and made a point of the fact that
their research group has noticed several major threats to engagement and
treatment. And, in a way, these observations reach over to the more
psychodynamic understanding and treatment of psychosis, where the
interpersonal relationship is judged to be of utmost importance.
This day, Gaetano Benedetti from Basel, Switzerland, was invited to give an
honorary lecture titled “The two phases of dreams in the psychotherapy of
psychotic patients.” Professor Benedetti, being one of the founders of the
ISPS, also received a special price from the organisers, honouring the work
he has done for patients suffering from schizophrenia during at least five or
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six decades. Professor Benedetti has visited Stavanger and other places in
Norway on several occasions, and his work has had a major influence here.
“The David Feinsilver award” was given to a young researcher, Dr. Zgantzouri
Kontantia from Greece, who presented the award lecture “Psychotherapy
process research is schizophrenia, paranoid type: the investigation of
delusional formation through the evaluation in session events.”
The variety on symposia, workshops and posters addressed the topic of

psychotherapy, individualised, according to single patient’s needs. Susan
Hingley from the UK gave a brilliant overview of “The psychodynamic
psychotherapy of psychosis. Theory and practice”, in the same symposium
as present board member of ISPS International, Ann Louise S. Silver, US,
delivered a speech on “The stages of treatment of psychosis.” Doctor Silver
delineated the stages in the evolution of treatment of psychosis in the United
States. She stated that evaluation of such stages depends on the always
evolving treatment philosophy of the therapist and the organisations with
which the therapist is affiliated. She contrasted the staging of treatments in
the pre and post medication eras, and drew on her almost quarter of a
century experience at Chestnut Lodge.
Other symposia on this day addressed multi-family groups in first episode

psychosis (William McFarlane, Maine, US), while the well-known author Jay
Neugeboren from New York gave a lecture on the topic “Transforming madness,”
from his new book based on his experiences with his brother Robert who has
suffered from mental illness for decades. We also had a separate symposium
addressing the ethical issues in early intervention research on psychosis, a
symposium conducted by Franz Resch from Heidelberg, Germany, a former
board member of the ISPS, on “Psychosis in children and adolescents,” and a
variety of other very important and in-depth contributions from all over the
world.
Early intervention in psychosis

There were three plenary lectures on this day. The first one was given by Tor
K. Larsen, Stavanger, Norway, who gave a lecture titled “Early intervention in
Psychosis. Theory, practical models and cost/benefit.” He gave an outline of
the Scandinavian multi-centre program TIPS (Early Treatment and
Intervention in Psychosis) project.
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Johan Cullberg of Stockholm, Sweden talked about “Experiences of

psychotherapeutic intervention at different stages of psychosis.” He
stressed that the acute psychosis is mostly a disorder with good prognosis
in the sense that the psychotic symptoms disappear. In his experience the
psychotherapeutic practice of experienced dynamic or cognitive therapists
is not so different as could be believed considering the ongoing debate. He
underlined that we need both aspects. Bjørn Rishovd Rund of Oslo, Norway,
talked about “Cognitive remediation of patients with schizophrenia: Does it
work?”. Neurocognitive dysfunction is the core deficit of schizophrenia. He
stated that cognitive dysfunction have proven to be the best predictors of
prognosis and outcome, and that the obvious area to attack is the one that
is most impaired and most damaging, the person’s psychosocial
functioning. This makes cognitive disorders an appropriate target for
treatment and rehabilitation. Central symposia and workshops in
connection to this theme were “Personality and psychosis,” “Development
of psychosis in children” to name a few. Franz Resch gave an outstanding
overview on “Psychosis in Children and adolescents: Developmental
aspects,” and John Read of Auckland, New Zealand addressed a topic that
maybe was “the talk of the conference,” “Child abuse and schizophrenia:
The need for training in abuse enquiry and therapeutic response.” Milieu
treatment, training and implementation, and psychologically interventions
for ultra high risk populations, were other topics that were central in our
presentations.
Integrated treatment: Research, education, future aspects

Wayne Fenton, formerly at the Chestnut Lodge hospital, now at the NIMH in the
US, gave a plenary talk on “Depression, suicide and suicide prevention in
schizophrenia.” Epidemiological data indicate that nearly 80 % with a diagnosis
of schizophrenia will experience a major depressive episode at some time
during their life. Suicide is the single largest cause of premature death among
individuals with schizophrenia. Patients in a defined high risk group may benefit
from more intensive psychosocial support to evaluate an elicit suicidal ideation
during high risk periods. Anthony Lehman, US, summarised “integrated
treatment: What does research show?.” Professor Lehman is the main author
of the so-called PORT report that has suggested a minor role of psychodynamic
psychotherapies in the treatment of schizophrenia. His lecture raised an
intense debate and challenged the ISPS to come up with an alternative report.
The ISPS board actually did this, as the Journal of the American Academy of
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Psychoanalysis and Dynamic Psychiatry came out with a special issue in 2003
“The Schizophrenic Person and the Benefits of the Psychotherapies” (editors
Ann Louise S. Silver and Tor K. Larsen).
Robert E. Drake, also from the US, gave a talk on “Assertive outreach
treatment.” Important symposia and workshops in relation to this day’s main
theme were on milieu treatment in psychosis, service and staff prerequisites
for helping psychotic patients, integrated treatment in first episode
psychosis, day treatment of psychotic patients.
Publication
Based on the most central themes of the conference, the book “Evolving
Psychosis – Different Phases, Different Treatments” is issued. The process
of bringing a book together with more than 20 authors from all around the
world is not an easy task, so the book will surface, hopefully in the spring
of 2006. Editors are Jan Olav Johannessen, Brian Martindale and Johan
Cullberg (5).
Summary
The ISPS 2000 in Stavanger gathered about 800 participants from all over the
world. The themes of plenary lectures, symposia, workshops, oral
presentations and posters were wide spread and covered many, many
different topics. In that aspect the ISPS 2000 was true to the goals of the
ISPS organisation. It also made a good financial contribution to the
organisation for the years to come, so that it has been possible to support
local organisations, issue a newsletter, establish a web-site, support our
book-series and allow the board to meet on some occasions to try to build
the organisation even further.
The ISPS received substantial financial support from the local community
and we want to express our gratitude to the town of Stavanger and Rogaland
county that hosted us in a very warm and satisfactorily manner.
For the Norwegian psychiatric milieu to host the ISPS 2000 was the
experience of a lifetime, an experience that we would not have wanted to
miss for anything.
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References
Tähkä V. Psychotherapy as phase-specific interaction. Towards a general psychoanalytic
theory of psychotherapy. Scand. Psychoanal. Rev (1979) 2, 113-132.
Johannessen JO (ed). Abstract book 13th international symposium for the

psychologicaltreatment of schizophrenia and other psychosis. Acta Psych Scand
, 404, vol 102, 2000.
Sullivan HS. The onset of schizophrenia. Am J Psychiatry 1927/1994, 151

Supplement 6:135-139.
Hill LB. Psychotherapeutic intervention in schizophrenia. Chicago 1955. University of

Chicago press.
Johannessen JO, Martindale B, Cullberg J. Evolving psychosis. Different stages,

different treatment. Brunner- Routledge. London. 2006.
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International Advisory Board
R.K.R. Salokangas, Finland Phillipa Garraty, UK Franz Resch, Germany

Klaus Lehtinen, Finland Julian Leff, UK Henry Jackson, Australia
Thomas McGlashan, USA Bob Hinchelwood, UK David Fowler, UK
Wayne Fenton, USA Jeremy Holmes, UK David Kindon, UK
William McFarlane, USA Murray Jackson, UK Douglas Turkington, UK
Patrick McGorry, Australia Anthony Claire Luc Ciompi, Switzerland
Jane Edwards, Australia Eabhard O’Callahand, Ireland Loren Mosher, USA
Max Birchwood, UK Norman Sartorious, WPA Johan Cullberg, Sweden
Erik Simonsen, Denmark Rachel Jenkins, UK Pier Maria Furlan, Italia
Bent Rosenbaum, Denmark Bent Åke Armelius, Sweden Brian Martindale, UK
Anne Lindhardt, Denmark Sonja Levander, Sweden Patrick McGorry, Australia
Lars Thorgaard, Denmark John Strauss, USA Courtenay M. Harding, USA
Stanley Possick, USA Otto Kernberg, USA Heinz Häfnert, Germany
David Feinsilver, USA David Rosenfeld, Argentina Ian Falloon, New Zealand
Executive National Scientific Committee
Jan Olav Johannessen, Torleif Ruud, Tor Kjetil Larsen,

Chief Psychiatrist, Medical Director, Research Fellow,
Rogaland Psyciatric Nordfjord Psychiatric Center University of Oslo/Rogaland
Hospital, Chair Psychiatric Hospital
Gerd-Ragna Bloch Thorsen, Kari Thuseth, Per Vaglum,
Rogaland Psychiatric Medical Director, University of Oslo
Hospital Møre og Romsdal
Svein Friis, Torleiv Odland, Sissel Gilbert,

Professor, Psychologist, Psychiatrist,
University of Oslo SEPREP Gaustad, Oslo
Eivind Haga, Kjetil Hustoft, Dan Tungland,

Psychiatrist,Rogaland MD, Psychiatrist, Rogaland Psychologist Hospital
Rogaland Psychiatric Psychiatric Hospital
Hospital
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AND
National Scientific Committee
Rolf Grawe, Anne Grete Skogstad, Thor Severinsen,

Psychologist, Psychologist, Meddical Director ,
Tronheim Sandviken Hospital, Skien
Bergen
Emly Pape Ellefsen, Kåre Teiten, Representative from
Medical Director, Lien, Oslo Norwegian Medical Norwegian Psychological
Association Association, Anne Seim
Grønningseter
Representative from Philippe Caille, Sverre Vavin,

Norwegian Association of MD, Oslo MD, Oslo
Nurses. Tore Sørlien,
Research Leader, Troms,
SEPREP
Svein Haugsgjerd, Lars Christian Opdal, Bjørn Rishovd Rund,
MD, Oslo MD, Oslo MD, Oslo
Inge Joa, Per A. Thorbjørnsen, Tone Sem Langfeldt,

Psychiatric Nurse. Rogaland Psychiatric Information Chief Psychologist,
Psychiatric Hospital Foundation, Stavanger Rogaland Psychiatric
Hospital
Rune Eliassen, Anne Torsvik Henriksen, Kjetil Hustoft,

Chief Psykologist, Rogaland Head Nurse, MD
Psychiatric Hospital Rogaland Psychiatric Rogaland Psychiatric
Hospital Hospital
Sigurd Mardal, Bjarte Stubhaug, Knut Ivar Iversen,

Chief Psychologist, Country MD, Contry Hospital of MD, Åsgård, Troms
Hospital of Haugesund Haugesund
Ingrid Spurkland, SSBU
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Local Arrangement Committee
Jan Olav Johannessen, Gerd-Ragna Bloch Thorsen, Per A. Thorbjørnsen,

Chief Psychiatrist, Rogaland Psychiatric Psychiatric Information
Rogaland Psyciatric Hospital, Hospital Foundation, Stavanger
Chair
Torleif Ruud, Eivind Haga, Tor Kjetil Larsen,

Medical Director, Psychiatrist, Rogaland Research Fellow,
Nordfjord Psychiatric Center Psychiatric Hospital University of
Oslo/Rogaland Psychiatric
Hospital
Inge Joa, Tone Sem Langfeldt, Chief Aslaug Frafjord,
Psychiatric Nurse. Psychologist, Rogaland Rogaland Psychiatic
Rogaland Psyciatric Hospital Psyciatric Hospital Hospital
Anne Torsvik Henriksen Kjetil Hustoft, Bjarte Stubhaug,

Head Nurse, MD, Psychiatrist, MD, Country Hospital of
Rogaland Psychiatric Rogaland Psychiatric Haugesund
Hospital Hospital
Steinar Aarstad, Inge Vinje, Dan Tungland,
Rogaland Country MD, Rogaland Psychiatric Psychologist Hospital
Hospital Rogaland Psychiatric
Hospital
Andreas Helliesen, Tor Brandsborg, Gunhild Tjensvold,

Art Consulant, LPP Rogaland Psychiatric
Rogaland Psychiatric Hospital
Hospital
Jan Erik Nilsen, Rogaland Marit Liland Øverland,

Psychiatric Hospital Mental Health
Johannessen, Jan Olav, M.D.

Chief Psychiatrist, Rogaland Psychiatric Hospital
Stavanger, Norway
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AND
ISPS Board Members in

Melbourne Symposium
2003
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Melbourne Symposium Venue

2003
P. Mc.Gorry Chairman of
Melbourne Symposium
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AND
J. Read, R. Bentall and

A. L. Silver in Melbourne
Symposium
Madrid Congress
Booth in Melbourne
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14. The XIVth ISPS Symposium

in Melbourne, Australia, in
September 22.-24, 2003
Reconciliation, reform and recovery: creating a future for psychological
interventions in psychosis
Patrick Mc Gorry
Personal Background
From the earliest stage of my psychiatric career, I had been interested in
psychotherapeutic approaches to recovery from psychotic illness. As a
medical student in the 1970s, I was influenced by the iconoclastic writings of
Laing and other antipsychiatrists, which not only challenged the coercive
manner in which people with psychosis were responded to, but also held out
the hope that innovative psychological and social interventions might have a
central place in recovery. When I entered training in psychiatry and witnessed
the widespread lack of a human response to patients in traditional services, I
resolved in a similar way to many in the ISPS, to try to humanise the care of
the seriously mentally ill. A practical and human psychological approach was
going to be central to this endeavour. Many pioneers had chosen the
secessionist route with some limited success (eg Soteria); however to really
impact on the bulk of patients, I believed that reform would need to transform
and embed itself with routine systems of care. This remains a challenge for
all of us in ISPS if we wish to see psychological approaches offered to all
patients.
During my training I began to learn about the interpersonal school of

psychiatry, founded by Sullivan, and was deeply inspired by the writings and
humane approach developed by John Strauss. I was convinced that the hope
and respect for the patient engendered within this approach was a crucial
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AND
ingredient in psychosocial care and recovery for people with schizophrenia

and other psychoses. Silvano Arieti’s magnum opus “Interpretation of
Schizophrenia” (1955) was a wonderful bridge from the psychoanalytic
period to the modern era and contained the seeds of the cognitive-
behavioural approach, as well as modelling synergy with the biological
perspective. I also became familiar with the pragmatic Scandinavian
approach to psychosis, in which biological approaches seemed to be able to
coexist with psychotherapy and family and social interventions. Unlike in
Anglophone cultures, where dogmatism and reductionism reigned, in
Scandinavia neither biology nor psychology was neglected or devalued, and
a balanced and integrated approach to the patient and family was sought.
This model owed much to the pioneering work of Yrjö Alanen and his
colleagues in Finland, however a flexible and tolerant approach could be
found across many Scandinavian centres. Scandinavia also pioneered the
idea of early intervention in psychotic disorders, through the NIPS project,
conducted in the 1980s. Alanen et al. 1994. This project also integrated drug
and psychotherapies in the early treatment of psychosis and provided a
foundation for the early psychosis reforms of the 1990s, led by several
Scandinavian centres, particularly Stavanger (Dr. Jan-Olav Johannessen),
Copenhagen (Dr. Merete Nordentoft), Stockholm (Prof. John Cullberg) and
Turku (Prof Raimo Salokangas).
Indeed, it was this nexus with the international early intervention network
which led to my formal involvement with ISPS. Most of the leaders of the early
psychosis field whom I had got to know well, for example Max Birchwood,
Tom McGlashan, Jan-Olav Johannessen, and Johan Cullberg, had had a
strong interest and track record in psychotherapy or psychological research.
I first attended an ISPS congress in 1997 in London and was impressed by the
diversity of psychosocial approaches included in the program, as well as a
tacit acceptance by most participants that drug therapies played a central
role in recovery for most people. Brian Martindale and his colleagues insisted
and demonstrated that tolerance and celebration of diversity was a strength,
and that unity among those with a commitment to psychological approaches
was essential. This remains the case today and was also the message
imparted to me when I was invited by Johan Cullberg to join and help form the
inaugural ISPS Board. Other members of this board, Jan-Olav Johannessen,
Brian Martindale, Torleif Ruud, Courtney Harding, and Franz Resch all had a
similar view. This gave me great confidence that ISPS could become a
credible force and platform for the reform and humanisation of psychiatric
care around the world. During the 1990s, with the advent of new and better
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The XIVth ISPS Symposium
tolerated drug therapies, the rediscovery that antipsychotic medications were

equally if not more effective at low doses, and the rise of evidence-based
forms of psychotherapy, notably cognitive-behaviour therapy and family
interventions, the prospects seemed brighter than ever for integrated,
evidence-based and humane care for people with psychotic disorders. After
the great success of both the London and Stavanger conferences, my
colleagues and I accepted with enthusiasm the honour and the challenge of
hosting the 14th ISPS congress in Melbourne in 2003.
The Conference
The Context and Theme
The 14th ISPS Congress was the first time this meeting had been held in the
Southern Hemisphere and only the third time it had been held outside
Europe. Furthermore, this was the first time an international
schizophrenia conference had ever been held in Australia. For these
reasons, the Scientific and Programme Committees were determined to
make it a memorable event, with both the science and the art of the field
represented. The Scientific Committee comprised Professors Vaughan
Carr, Henry Jackson, Michael Startup, David Kavanagh, and David Castle,
Doctors Carol Harvey, John Gleeson, Andrew Chanen, John Farhall and
myself as convenor, and we were able to assemble a program of the
highest quality thanks to the calibre of the invited speakers and the
wonderful submissions received from all corners of the world.
Sponsorship and support was readily forthcoming from a wide variety of
sources, notably Eli Lilly (Major Sponsor), the Colonial Foundation, the
World Psychiatric Association, the Royal Australian and New Zealand
College of Psychiatrists, the Australian Psychological Society, the Early
Psychosis Prevention and Intervention Centre (EPPIC), SANE Australia,
VICSERV, the Victorian Department of Human Services, Bristol-Myers-
Squibb, Novartis, Mayne Pharma, Sanofi-Synthelabo, Janssen-Cilag,
Organon and Lundbeck. These sponsors represented the peak
organizations and pharmaceutical companies with a stake in the care of
and a commitment to people with psychotic illnesses in Australia. Their
support was essential to the success of the meeting and was greatly
appreciated by the organising committee of ISPS, particularly that from the
pharmaceutical industry, which strongly supported the congress
financially, even though the main focus was clearly on non-
pharmacological treatments.
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AND
The theme chosen was “Reconciliation, Reform and Recovery: Creating a

Future for Psychological Interventions in Psychosis”. This was intended to
promote integration of treatments, to challenge psychological as well as
biological reductionism and indicate the need for a forward-looking and
more evidence-based approach. The term reconciliation was especially
meaningful to Australians due to its usage as a term for the process of
healing and recovery for the indigenous people, some of whom were involved
in the opening ceremony. In my welcoming address I sought to challenge the
participants and the members of ISPS that we faced choice between
renaissance and irrelevance, between moving forward in a united and
professional manner, rejecting biological reductionism, yet embracing the
evidence-based paradigm and the synergy between biological and
psychological interventions, or gazing nostalgically into the past through the
lens of psychological reductionism.
I went on to say:
“The problem with both extreme swings of the pendulum is that they
involve reductionism, which is not only inappropriate given the
complex biopsychosocial nature and impact of psychotic disorders, but
also inadequate to bring about a good recovery and quality of life for
patients and families.”….
…..”We expect our conference to be a watershed in evolving and

guaranteeing a future for psychological interventions in psychosis. The
complexion of psychological interventions will need to be different,
more sophisticated and more effective than what has been on offer in
previous eras if it is to prosper.”
This challenge of integration versus reductionism became the focus of the

plenary debate of the Congress, entitled: “Can biological and psychological
interventions be integrated in the treatment of psychosis.”
The setting for the congress was the Melbourne Convention Centre in the
heart of Melbourne, next to the famous Yarra river, the only river in the world
which flows upside down (it is a notorious muddy brown colour!), something
by which colleagues from the northern hemisphere seemed unsurprised!
The atmosphere in Melbourne was electric that week not only because the
ISPS congress was being held, but also because it was Grand Final week, the
week leading up to the final of the Australian Football League competition
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(not soccer but Australian football!), which was played 2 days after the
conference was completed, with a win for the Brisbane Lions over the
Collingwood Magpies for the second year in a row.
The Conference Itself

The conference commenced on Monday 22nd September 2003 with 5 parallel
workshops on Substance Use Disorders and Psychosis (David Kavanagh,
Amanda Baker and Kathryn Elkins); Cognitive-behaviour Therapy and
Psychosis (Richard Bentall); Psychoanalytic Approaches to Psychosis (Brian
Martindale and Ann-Louise Silver); Family Intervention in Psychosis
(Margaret Legatt, Colin Reiss and colleagues); and Relapse Prevention in
Psychosis (Jo Smith and John Gleeson). These workshops covered the main
psychosocial approaches and proved to be a well-attended preliminary skill-
based component to the main event, creating a buzz in the lead up to the
welcome reception which was held at the Melbourne Aquarium that evening.
Sydney has a harbour, Melbourne an aquarium, however Melbourne is much
more psychologically-minded than Sydney!
The conference proper was opened the next day with a welcome ceremony
conducted by the Wurundjeri people, the original owners of the land on
which the congress was being held. The conference was then opened by the
Victorian Minister for Health, the Hon. Bronwyn Pike, who has a keen interest
in mental health and a genuine commitment to the mentally ill in our own
part of Australia, the State of Victoria. Welcome addresses were also
delivered by myself and Dr. Jan-Olav Johannessen, the inspiring President of
ISPS, both of which highlighted the need for integration of therapies and
early intervention. They emphasised that psychosocial approaches were
especially needed and likely to be most effective for young people early in the
course of psychotic illness.
Superb keynote addresses from Wayne Fenton, Fred Frese, Jim van Os and
Richard Bentall then followed. We were most fortunate that these high
profile speakers with punishing schedules made the considerable effort to
travel to Australia. Dr. Wayne Fenton, the former and last medical director
of Chestnut Lodge, and now one of the leaders at the National Institute of
Mental Health in Washington, gave a seminal address on the key theme of
integration. Dr. Fenton’s background made him the ideal person to argue
the case for integration of perspectives and therapies, which he did most
convincingly. Dr. Fred Frese from the National Alliance for the Mentally Ill
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AND
in the USA spoke next. For me this was the most memorable session I have
ever experienced at a psychiatric conference. Dr. Frese has suffered from
schizophrenia for many years and has made a substantial recovery. After
overcoming the illness, he qualified in clinical psychology and went to
become the Director of Psychology in a clinical service where he was once
a patient. In recent years, he has become a highly effective advocate for
people with schizophrenia and their families. His address was full of
wisdom, humour and clear-headed guidance to the field. It was followed by
an extended standing ovation, the first and only time I have seen this occur
with such spontaneity and emotion at a conference. Dr. Frese’s
contribution was on a par with a similar performance some years back at
the American Psychiatric Association congress by Dr. Kay Jamison, also a
clinical and academic psychologist, and author of “An Unquiet Mind,” who
has suffered from bipolar disorder. Sincere thanks go to SANE Australia for
facilitating Fred’s participation in the meeting. ISPS should also take pride
that in the fact that its most compelling plenary session was delivered by a
consumer, a person with a psychotic illness. This would not have been
imagined at the time that Professors Benedetti and Müller held the first
ISPS meeting in 1956.
The keynote addresses continued at this standard with Prof. Jim van Os from
Maastricht speaking on the interaction of vulnerability to psychosis with the
social environment. This topic, which he and his team have contributed to
greatly, illustrates the vital role that psychological and social factors play in
the expression of biological vulnerability to psychosis and the onset and
course of illness, and creates the space for psychosocial treatments.
Professor Richard Bentall, who has made an enormous contribution to the
development of cognitive therapies in psychosis, then gave his scholarly
critique of the Neo-Kraepelinian diagnostic approach to psychotic disorder,
a critique which has paved the way for a more symptom and syndrome based
therapeutic approach. Highlights of the afternoon concurrent sessions were
really too numerous to mention, but included Dr. Andor Simon’s studies of
recognition of early psychosis by general practitioners, Dr. Peter Trower’s
presentations on CBT in psychosis, a session focused upon substance use
and psychosis, and a cutting-edge session on psychological interventions in
prodromal or ultra-high risk patients, featuring work from Melbourne,
Manchester and Cologne.
Day 2 of the congress faced head on one of the central issues in the field,
namely the question of psychogenesis of psychosis. Trauma as a causal risk
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factor for psychosis and comorbidity within psychosis was considered by

three excellent keynote speakers. Dr. John Read commenced with an
impassioned plea for childhood trauma to be recognised as a causal risk
factor for psychosis, if not the causal risk factor. Prof. Paul Mullen presented
an erudite, amusing and more objective review of the issue with some new
data from Dunedin, which nevertheless provided cautious support for this
notion. Finally, Dr. Tony Morrison provided a comprehensive review of the
whole interface between trauma and psychosis, including the related issues
of comorbidity, sequential morbidity and diagnostic confusion. The
conclusion of this session seemed to be that trauma was likely to be one of
the causal risk factor for psychosis as well as for comorbid complications in
people with psychotic illness. Dr. Morrison subsequently edited a superb
monograph on this fascinating subject.
The plenary debate then flowed seamlessly from this session and addressed
the central theme of the congress, that of integration. Influenced by the
views of the President, Dr. Jan-Olav Johannessen, the Scientific Committee
decided to test the resolve of ISPS for integration by framing a head-to-head
debate on the subject. It was therefore entitled “Can biological and
psychological interventions be integrated in the treatment of psychosis.” Our
hope was that progress towards integration would follow a full airing of the
issues and the related emotions. However this debate was not one between
biological reductionism and psychological reductionism, which might have
pointed the way to integration. Rather it was rather “lop-sided” as a debate
between those sympathetic to psychological approaches who believe in
integration with biological therapies, and those who do not, and who
consequently argue for a form of psychological reductionism. This was to
become something of a microcosm of the whole conference. Moderated by
Mr. David Galbally, a well-known Melbourne barrister, the debate featured
Prof. Henry Jackson, Dr. Wayne Fenton and Dr. Brian Martindale speaking in
favour of integration, and Prof. Richard Bentall, Dr. Ann-Louise Silver and Dr.
John Read against. There was also an expert panel who listened to the
arguments and offered responses. This panel comprised Prof. Alan Fels, a
business academic and father of a young woman with schizophrenia, Prof.
David Castle, a professor of psychiatry, Mr. David Clarke, the CEO of VICSERV,
the peak body for NGO-based psychosocial rehabilitation in Victoria, Ms.
Barbara Hocking, the CEO of SANE, the national mental health charity for
serious mental illness, Dr. Grace Groom, the CEO of the Mental Health
Council of Australia, Ms. Janet Meagher, a mental health consumer, and Dr.
Amghad Tanaghow, the Chief Psychiatrist for Victoria. The audience also had
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AND
a substantial opportunity to contribute to the discussion. I saw the debate as

a contest between passion and polemic on one side and evidence and an
appeal to collaboration on the other. Years of understandable frustration
with the failings of traditional psychiatry led to polarised opinions from the
”no” team and a total rejection of the role of drug therapies in the treatment
of schizophrenia, a position felt to be untenable by all members of the “yes”
team. The panel strongly supported the perspective of integration, however
the audience appeared to be quite polarised with surprisingly many people
expressing at least some sympathy for the reductionist arguments of the
“no” team. Speaking personally, I am not convinced that this was a helpful
exercise, as the “soapbox” atmosphere seemed to reinforce to prejudices
rather than promote mutual understanding and respect for opposite points
of view. The positions were put with such emotion and passion that there was
little room for compromise in the end. Perhaps the trajectory of ISPS since
that time is the best indication of whether facing this issue head on was a
wise move. It may be better to focus on what unites us rather than that which
divides us within ISPS.
The remainder of the second day was taken up with a range of quality
presentations across seven concurrent sessions. Key themes were family
interventions, adherence-promoting strategies, psychotherapy and cognitive
therapy programs and a comprehensive overview of the Danish National
Schizophrenia Project, which featured supportive dynamic psychotherapy as
a key strategy. Posters were displayed throughout the symposium and
attracted a great deal of interest. A series of ISPS board meetings, general
assemblies of both the ISPS and the IEPA (International Early Psychosis
Association), and numerous meetings of national and regional ISPS groups
were also held during the conference. The conference dinner was held on
the Wednesday evening in the Plaza ballroom of Melbourne’s famous Regent
theatre, at which the highlight was the poetic humour of Dr. Gerd-Ragna
Bloch-Thorsen, which was extremely entertaining. The atmosphere at the
dinner was relaxed, friendly and collegial and the entertainment (the singing
waiters) arrestingly good!
The final day featured 3 more excellent keynote addresses and the
presentation of ISPS awards. Dr. Tor Ketil Larsen presented in his typically
amusing style a systematic review of psychosocial interventions in
psychosis, concluding that, despite progress in recent years focusing around
CBT and family interventions in particular, much more needed to be done to
strengthen the evidence base for psychosocial treatments in psychosis. Dr.
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Frank Margison spoke on integrating approaches to psychotherapy in

psychosis, a paper which was subsequently published in the Australian and
New Zealand Journal of Psychiatry (Margison 2005). This contribution was
as scholarly as it was practical, and highlighted the strengths and
weaknesses of integrating different psychotherapeutic approaches. The final
keynote address was by Dr. Brian Martindale, who showed the audience,
through theoretical argument and the medium of real live case material how
a psychodynamic perspective could influence and enhance the clinical care
of people with psychotic illness.
Following this final keynote address, a series of ISPS awards and life
memberships were presented. The recipient of The David Feinsilver Award
was Ishita Sanyal from Kolkata, India. Four distinguished pioneers of
psychosis psychotherapy were invited to receive The Life Honorary
Membership of the ISPS: Johan Cullberg, Julian Leff, Harold F. Searles and
John S. Strauss.
The conference moved into the final concurrent session in which most of the
themes explored in earlier sessions were further built upon, including
dissociation and psychosis, engagement and pathways to care, multi-family
group interventions, comorbidity, early intervention, group methods, CBT
and psychodynamic approaches. The diversity yet solidity of these domains
was impressive.
The conference concluded with a mature and inspiring closing address from
the President of ISPS, Dr. Jan-Olav Johannessen, and a warm invitation to the
Madrid Congress of ISPS in 2006 from the convenor, Dr. Manuel González de
Chávez and his enthusiastic and friendly colleagues.
Epilogue
The 14th ISPS congress was a successful endeavour, which brought together
ideas, passion and scientific data in support of psychological interventions in
psychosis. It was also widely reported in the Australian print and electronic
media, partly due to the controversial views expressed at the meeting. A
book capturing the best work of the conference is in preparation edited by Dr.
John Gleeson, Dr. Eoin Killackey and Prof. Henry Jackson from the University
of Melbourne and EPPIC. Some of the material presented has already been
published (eg. Margison 2005) and some has been submitted (eg. Jackson et
al.). Following on from the conference both Australian and New Zealand
213
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AND
national groups of ISPS have been established. The polemic and polarisation
of the membership and the speakers at the meeting certainly slowed this
process in Australia, where psychiatrists, psychologists and other mental
health professional have been quite comfortable with an integrated
biopsychosocial approach to psychosis for some time. The credibility of the
ISPS brand in Australia at least was affected by some of the more extreme
views expressed at the conference. In my personal opinion, ISPS itself has
continued to struggle since the conference with this issue, and I believe the
latter has the capacity to keep psychological issues on the sidelines of
clinical care unless a more pragmatic approach, modernised, yet consistent
with the integrated treatment approach of Alanen and a previous generation
of Scandinavian colleagues, is unambiguously embraced by the organization.
This will be the challenge for Madrid and beyond.
References
Alanen, Y., Ugelstad E., Armelius B., Lehtinen K., Rosenbaum B. and Sjöstrom K.
“Early Treatment for Schizophrenic Patients. Scandinavian Psychotherapeutic
Approaches” Scandinavian University Press. 1994.
Arieti, S. Interpretation of Schizophrenia. New York: Brunner.
Margison F. Integrating approaches to psychotherapy in psychosis. Australian and

New Zealand Journal of Psychiatry 2005;39: 972-981. (2005)
Jackson HJ, McGorry PD, Killackey E, Bendall S, Allott K, Dudgeon P, Gleeson J,

Johnson T, Harrigan S. The ACE project: A randomised controlled trial of CBT
versus Befriending for first episode psychosis: Acute phase and one-year follow-
up results. Psychological Medicine (submitted).
Patrick McGorry MD, PhD, FRCP, FRANZCP.

Professor of Psychiatry, University of Melbourne,
Locked Bag 10,
Parkville. VICTORIA. 3052.
AUSTRALIA.
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AND
First Program of XV ISPS Congress of Madrid
Dr. Chavez, Chairman of

ISPS Madrid 2006
216
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Mirtcho Savov,
Congress Manager,
and Manuel González de Chávez
promoting Madrid Congress
at Melbourne
XV ISPS Congress
Madrid Venue
217
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AND
Flyer ISPS MADRID 2006
General University
Hospital “Gregorio
Marañón”, Madrid
218
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15. Planning of the ISPS

Congress (Symposium XV) in
Madrid 2006
Global Views and Integrated Therapies
Chairman
“These are my people” I thought in August 1991 in Stockholm while I was

attending the Xth International Symposium for Psychotherapy of Schizophrenia
sessions for several days that was being held there.
It was the first time I had gone to an International Symposium of

Psychotherapy of Schizophrenia. I had read almost all the books with the
lectures that had taken place in them with great interest. I knew that they were
forums that gathered prominent professionals with experience and dedication
to psychotherapy of psychotic patients. I was able to buy the previous
Symposium books, but did not know where or when the next International
Symposia would be and if it was possible to participate in them.
It was Yrjö Alanen who told us that the X th Symposium in Stockholm was going
to be held. Months earlier, I had recommended to one of my collaborators
from the Hospital “Gregorio Marañón“ from Madrid, Dr. García-Ordás, to
travel to Turku to have direct experience with the psychotherapeutic program
with psychotic patients that was developed there. This was, in my opinion, one
of the best examples of advanced organization of public psychiatric care
dedicated to these patients.
In those years, prior to the generalization of internet, all information and

organization of Symposia were done by regular mail. Alanen gave us the
address of Johan Cullberg, who was the Chairman of the Organizing
Committee of the Xth International Symposium and thanks to this information,
we could attend some Symposia that we had only known through the reading
of their books for the first time.
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AND
After having read the publications of the Symposia, attending one of them, the
Stockholm Symposium, was such an unforgettable experience as having seen
the photographs of scenery and then seeing it in person. Never before, in any
international congress or scientific meeting had I felt so identified with the
other people attending, with their work and with their professional experience,
even with this s imple, respectful and attentive style, so characteristic of the
ISPS members, probably derived from the daily psychotherapeutic work with
the sufferings and problems of difficult and complex psychotic patients. Thus,
during those days, in almost each session, conference or debate, I repeated to
myself “These are my people.”
We received the information about the Washington Symposium very late and
could not go there, as we would have liked to. But we did go to the XII
Symposium of London, and the ISPS then organized as an International
Society, to the XIII Symposium of Stavanger and to the XIV of Melbourne. In
all of them, I have always had the satisfaction of sharing the same interests,
concerns, attitudes and values with professionals from other places in the
world. I can assure you that many of the people I have most admired during
my professional life are members of ISPS and I also believe that our Society
has been becoming, over these years, the main reference group for all the
therapists dedicated to psychotic disorders.
Thus, when I was invited by the members of the Board in the spring of 2002
to organize the XV Symposium of the ISPS in Madrid in 2006, I was faced
with a great challenge and great responsibility. I had to decide if I would
assume all the risks, efforts and tasks of this collective project for several
years.
After taking the necessary time to consider this decision and discuss it with
my team and other Spanish friends and professionals, whose opinion and
collaboration I greatly value, I formally presented our proposal to organize
the XV Symposium or International Congress in Madrid in 2006 to the ISPS
Board.
If no unforeseen event prevents it and we are able to hold it skillfully, the

ISPS MADRID 2006 will give us the opportunity to personally meet again. It
will be important for our international organization in the performance of its
objectives and it will also allow us to establish the ISPS in Spain and perhaps
in other Spanish speaking countries, achieving new members from those
attending the Madrid Congress.
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Planning of the XV ISPS Congress (XV Symposium)
Madrid belongs to these great cities having the attraction and infrastructure
for carrying out many international congresses every year. It is, in fact, a
large, geographically well located, city with many transportation facilities. It
is turistically and culturally very active with all kinds of hotels and
magnificent equipment, that allow for many international congresses,
conventions and fairs that are continuously held here.
In our General University Hospital “Gregorio Marañón” of Madrid we have

the motivation and dedication to psychotherapy of psychoses. Furthermore,
we have had experience for the last eleven years in the organization of Yearly
Courses of Schizophrenia, that has an audience of more than 600 to 800
persons from all over Spain and close countries such as Portugal.
These Schizophrenia Courses , that have been attended by professors from

Spain and other relevant countries in this field, have been acquiring
increasing prestige and constitute a wonderful base to conduct the
International Congress of the ISPS in 2006. Our objective is to organize it on
the same level as the previous ones of Stockholm, London, Stravanger or
Melbourne. We make an express acknowledgement of our admiration for all
those who have organized the International Symposia of Psychotherapy of
Schizophrenia with great merit and success.
When the ISPS Board preliminarily accepted our proposal, it decided that
two of its members, Brian Martindale and Jan Olav Johannesen, would visit
Madrid in January 2003 to see the possible Congress sites and agree on the
characteristics and general conditions for a mutual agreement between the
International ISPS and local organizing society, the Foundation for the
Investigation and Treatment of Schizophrenia and other psychotic disorders,
thanks to whose financing, we have been conducting the Schizophrenia
courses in Madrid every year.
With our guests, we inspected the different possible sites in Madrid, that
chosen for the Congress and other places of interest for the future
congressmen and congresswomen. During this trip, we obtained better
knowledge of the ISPS as an organization and the advice of Brian and Jan
Olav on their respective experiences as organizers of the Symposia of
London and Stavanger were very useful to us.
By February 2003, we were already working on the ISPS 2006 Congress. Our
first task was to ask for projects and budget estimates from the best
221
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AND
congress organizing companies that work in Spain. We made a previous

selection of the best ones and held many interviews for a careful discussion
of the budgets and projects with their responsible directors. The economic
budgets presented by all the companies were very similar. The cost of the
organization of the ISPS Madrid 2006 would always be more than six hundred
or seven hundred thousand euros, according to the number of those
attending. Thus, we had to choose the organizer that offered us the most
experience, credibility and quality and we personally visited their offices to
know the team with which would be working during the next years better.
Finally, we chose Viajes Iberia Congresos as the organizing company. We chose

it both for the ISPS Madrid 2006 and for the Annual Courses of Schizophrenia.
In this way, before 2006, we would have three more scientific events, the
Schizophrenia Course of each year, to synchronize the scientific committees
with the professional organizers and to improve, year by year, the many tasks
and innumerable aspects involved in the good organization of this type of event.
At present, we can affirm that this choice was correct and we have worked very
satisfactorily during all these years with the teams of competent and
professional persons who make up Viajes Iberia Congresos, with their
directors, André Vietor and Mirtcho Savov, and with Carmen Benavent , ISPS
Project Manager and true organizational soul of our ISPS Madrid 2006.
In June 2003, we presented the budget and project to the ISPS Board and a
formal contract was signed by the three of us: ISPS, as international
scientific society, the Spanish Foundation for Investigation and Treatment of
Schizophrenia, as local organizing society and Viajes Iberia Congresos, as
Professional Congress Organizer (PCO) for the ISPS 2006 Madrid, after
submitting it to legal advice, with all the responsibilities and obligations of
each one of the parties.
Together with the ISPS Board, we soon decided on the congress dates,
according to the possibilities of using the site chosen for it, the schedule of
other events that would take place in Madrid in 2006 and that of other
international congresses having possible interest for our associates. We also
chose the general subjects “Global Views & Integrated Therapies,” ”Improving
Services & Helping Persons and Families with Psychotic Problems,” to stress
the perspective of our Society on these disorders and the best organization
of the services that we advocate, with psychotherapeutic interventions and
more complete integrating programs that more effectively help both the
patients as well as the families.
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Knowing the importance of organizations of families and users in achieving

a better quality of care received, we wanted the associations of our country
(Spanish Confederation of Associations of Families and People with Mental
Disease ,FEAFES) and our continent (European Federation of Associations of
Families of People with Mental Illness, EUFAMI) to be integrated into the
same Organizing Committee. The purpose of this was for them to indicate to
us their priorities and to facilitate a fruitful exchange with the ISPS members
and with those attending the Madrid Congress in 2006.
The third subject of the Madrid Congress is a fortunate coincidence: the XV

Symposium or Congress of the ISPS of Madrid in 2006 coincides with the
50th Anniversary of the First International Symposia for the Psychotherapy
of Schizophrenia that Christian Müller and Gaetano Benedetti organized in
Lausanne, Switzerland, in the year 1956. And it is also a pleasant
circumstance that after so many years, most of the organizers of all the
previous international Symposia and many of the main leading figures
presently continue with us and can come to Madrid to celebrate together and
to receive our merited tribute in these days.
Half century of Symposia dedicated to Psychotherapy of Schizophrenia and

a journey of professional meetings through cities of several continents,
with increasingly greater number of persons attending and an increasingly
larger range of approaches and modalities of intervention as shown by the
pages of this book, whose preparation and edition to distribute it among
the ISPS members and those attending this Congress, has also been a
happy event.
However, one of the most rewarding aspects of the organization of the

Madrid Congress has been to work with Yrjö Alanen and Ann Louise Silver,
as editors, and with each one of the authors who have contributed to the
preparation of this book, over the last years. I have relived with pleasure our
common history and I have valued even more the effort, lucidity and
dedication of those who, step by step, Symposium after Symposium, for 50
years, had made the way to opening up the road that we are now in.
The Board, the Honorary members of ISPS and the organizers of previous
Symposia of Psychotherapy of Schizophrenia have done the utmost to help
us. They have agreed to form the nucleus of the International Scientific
Committee together with other relevant professionals of this field. Other
outstanding Spanish professionals have also agreed to constitute the
223
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AND
Organizing Committee and to participate actively in the development of the

scientific activities.
We did not want to construct the scientific program of the Congress and its main
sessions, its Debates, Symposia, Workshops and Special Workshops, Lectures
and other activities from Madrid, or from a supposed power. We have summoned
all the members of ISPS and all those interested in this field to participate in the
Congress and we have received many proposals in our web site.
All the Abstracts received were evaluated through an encoded access to our
computer system that facilitates independent, multiple and simultaneous
assessment and scoring of each proposal. The evaluations of different
members of the Scientific Committee, according to their availability, and their
areas of dedication and knowledge, have come from all the continents. They
have given us their opinion and score on each Abstract, without knowledge of
those of the other raters. The computer system used automatically gave us
the result and mean score. We should state, with associative pride, that the
Abstracts of all the main sessions have been evaluated above 7 and 8 points
in a range of 0 to 10. We have thus achieved a truly democratic participation
in the creation of the scientific program of this Congress.
This is the Congress of all those who wanted to participate and it has been
designed and decided among all of us. At present, these are our interests and
concerns, our skills, techniques, interventions and therapeutic practices, our
investigations and our approach and organization developments. We are this
Congress, as we were in each one of the previous Symposia. The special
Supplement of Acta Psychiatrica Scandinávica, that will include all the
Abstracts presented, will be the first written testimony of this moment, which
will then be later on all publications of our contribution to it.
Why have we called this ISPS MADRID 2006 the XV Congress and not the XV
Symposium? After having received almost 80 Abstracts for all the Main
Sessions in the spring of 2005, the Organizing Committee thought that it
was not adequate to continue to use the word Symposium to describe a
scientific event that included 40 Symposia and several fundamental Debates,
that gives us the opportunity to attend many four hour long Special
Workshops and two hour long Workshops, with important participations
from all over the world. This is a Congress that lasts four days and also has
special Sessions and main lectures, with many posters and hundreds of oral
communications.
224
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In these 50 years of history, we have been growing in volume and active

participation of those attending, in greater number of proposals with greater
scope. This has made it necessary for us to organize many simultaneous
sessions of Workshops and Symposia. We believed that here in Madrid it
was now necessary to call that which both now, and in recent previous
editions, were already truly Congresses as ISPS Congress.
How and why have we grown in the last fifty years from the First Symposium
of Lausanne until this XV Congress of Madrid? In the previous chapters of
this book, we have been reading and almost seeing how each one of the
Symposia was carried out. All of these have been marvelously described by
their own organizers or by some of their most outstanding participants. We
are presently fortunate to be able to read our history, written by those who
have been outstanding in it. Our historians are themselves, our history.
This has not been a period of fifty years of crossing the desert. They have
been years of growth, development, maturing of all the psychotherapeutic
interventions we know. They have been being discovered and unfolded. They
have been communicated, taught, practiced and extended. They have shown
their efficacy, helping our patients and the persons they live with and love.
Going against the current of organicistic or biologicistic, simplistic and

comfortable psychiatry, the number of mental health professionals who are
not satisfied with this poverty of models and approaches, with this lack of
knowledge and carelessness in attention to psychoses is increasingly
greater. Those attending the Symposia have grown while the
psychotherapeutic practices with psychotic patients have extended. We have
been meeting and knowing each other. We have listened to each other and
learned one from another. We have wanted to meet again, to know our
works, our advances and our therapeutic experiences.
The need to organize ourselves in the periods between Symposium and

Symposium occurred very early, although it took time to materialize. The
creation of ISPS was a significant step to remain in contact. It facilitated the
organization, circulation, publicity and promotion of the last Symposia.
If the publication of the ISPS Newsletters has kept us periodically informed,

the creation of the local networks of ISPS, with their own conferences and
meetings, has allowed for knowledge, meeting and stimulus by regions,
countries or territories of all the professionals of this field. Finally, we have
225
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AND
achieved direct communication within the ISPS and with all related
professionals and persons with the development of computer science, our
web pages and e-mail lists.
Based on this solid network, constructed over the years due to the
motivation and dedication of many professionals, we have promoted the XV
Congress of ISPS of Madrid from the presentation made in the XIV Congress
of Melbourne in 2003 to the present date. The video that links Melbourne
with Madrid has been distributed in all the local meetings with our flyers and
preliminary programs. We have opened the web of ISPS MADRID 2006 to all
types of proposals and abstracts. We have requested and received many
initiatives and suggestions in the e-mail lists of ISPS.
We are very grateful to many members of the ISPS and other professionals
and organizations. This congress is being conducted and constructed with
the help and generosity of everyone. We have been able to transform the
merited fees of well known professionals, who have not mentioned or
requested them, into grants for those others of less economic income or
those from developing countries.
We are going to celebrate the 50th Anniversary of the International Symposia

dedicated to Psychotherapy of Schizophrenia and one century since the
onset of these psychotherapies in the dawn of psychoanalysis with one and
a half thousand congressmen and congresswomen in our XV Congress of the
ISPS. We will pay homage to our pioneers and to our Life Honorary
Members, whose number would be much greater if it was not limited by our
statutes. These and many other already deceased outstanding professionals
dedicated their lives and work to psychotherapy of the psychotic patients.
They gave new life and hope to these patients. They are our inspirers,
motivators and teachers. They are the true authors of the existence,
development and organization of this XV Congress of Madrid; the creators of
the reality of this dream.

Chief of Psychiatric Services
General University Hospital “Gregorio Maranón”
c/ Ibiza 43, 28009 Madrid, Spain
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AND

PART II:
THE ISPS TODAY
The ISPS gets organized
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AND
CHAPT. 16 to 18 PHOTOGRAPHS
Logo ISPS
Torleif Ruud
228
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ISPS News Letter
John Read. Mosher, Bentall, Models of Madness,

ISPS Collection Book
229
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AND
Psychoses of Johan Cullberg.

ISPS Collection Book
Evolving Psychosis, ISPS Collection Book
230
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16. The Establishment of the

International Society for the
Psychological Treatments of
Schizophrenia and Other
Psychoses
17. Development of the ISPS

newsletter, website and
secretariat
18. ISPS in the Age of the Internet
231
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16. The Establishment of the

International Society for the
Psychological Treatments of
Schizophrenia and Other
Psychoses
Brian Martindale and Jan Olav Johannessen
The reader will already be more than familiar with the fact that for the first
forty years of its existence, the ISPS had the single but important function of
organising Symposia (and now international Congress) every three years for
clinicians to discuss their clinical work and its theoretical underpinnings.
For many years these clinicians were predominantly psychoanalytically
orientated. The shift to encompassing a plurality of approaches was gradual
and was already visible in the 1980s, especially in connection with the Turin
conference of 1988, which was held at a time when family approaches to
psychosis and other disorders had become very topical and an evidence base
for their effectiveness was beginning to emerge. The introduction of the so-
called ‘need-adapted comprehensive treatment strategies’, especially in the
Nordic countries, also made a significant contribution to this broader and
more integrated orientation.
During these years the ISPS acronym stood for the International Symposium
for the Psychotherapy of Schizophrenia.
The gestational period of the Society

The broadening of the functions of the ISPS had a gestational period of about
6 years. The most important figure in promoting the idea that the ISPS
233
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AND
should develop a broader range of functions and activities was Endre

Ugelstad from Norway. Endre Ugelstad was well known in his country and in
the ISPS for his encouragement of long term supportive psychotherapeutic
approaches for those with psychosis and for his skilled supervision of staff
in carrying out this dedicated work. He had a psychoanalytic training, but the
kind of work he encouraged could be carried out by all clinicians who had the
capacities to form relationships with the psychotically vulnerable and he
believed fervently that maintaining good long term relationships should be a
primary objective for clinicians and this in itself would lead to considerable
improvements in their quality of life of the patients.
Ugelstad was active in promoting the changing function of ISPS during the
Board meetings in Washington in 1994 and we are sure he was delighted that
Dr David Feinsilver, the President of the 1994 ISPS symposium, was keen to
make this a reality. Up until 1994, the President of the next conference was
the President or Chairperson of the ISPS Board which was composed of the
organisers of past conferences and of the next one. When London was
chosen in 1994 for the 1997 conference, Brian Martindale declined the
chairmanship because of the need to separate the development of the
organisation from that of organising the conference and Johan Cullberg was
elected to continue as the President of ISPS during this critical phase of its
development and transformation.
There is a lot in a name!

We recall much earnest discussion at a Board meeting in Johan Cullberg’s
Stockholm flat as to whether to and how to adapt the name. In the end a
number of points of view were retained:
a) the need to retain the title letters of ISPS if possible in order to offer
continuity of association and identity with its earlier life
b) the need to find a form of words that would contain the word
schizophrenia as well as encompassing other psychoses. This was
because of a concern that if we dropped the word schizophrenia, our
message that verbal therapies are relevant to those given that
diagnostic categorisation might get lost. On the other hand we
wanted to legitimise our involvement with a wide range of other
psychoses.
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c) we wanted to indicate that the new society was open to a broad

range of psychological approaches and therefore we chose the
words psychological treatments. This is because the term
psychotherapy in some countries is synonymous with psychoanalytic
psychotherapy. We also wanted to keep our boundary to the
psychological as there are many organisations focussing on the
social aspects of psychosis.
So after much juggling, we retained our name as ISPS but its former full title
of International Symposium for the Psychotherapy of Schizophrenia became
transformed to the International Society for the Psychological Treatments of
Schizophrenia and other Psychoses!
A constitution is born
In the two years before the London conference, much work was done in
preparing a constitution. Much of this was drafted by Brian Martindale who
had previous experience of developing a European wide organisation for
psychotherapists (the EFPP).
Our main objectives were to provide a relatively simple framework within

which individuals and groups of individuals at different levels, local, national
and international could begin to plan activities relevant to the general field
of psychological therapies of psychosis that made sense to them and to
ensure that there was an international network that would support and
promote groups of persons. Constitutions are rather boring documents but
they should be a base from which exciting things can be done and so has
been the case with the ISPS.
The ISPS objectives

Here are the objectives as laid out in the new constitution:
to promote the appropriate use of psychotherapy and psychological

treatments for persons with schizophrenias and other psychoses.
to promote the integration of psychological treatments in treatment plans

and comprehensive treatment of all persons with schizophrenias and other
psychoses.
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AND
• to promote the appropriate use of psychological understanding and

psychotherapeutic approaches in all phases of the disorders including
both early in the onset and in longer lasting disorders.
• to promote research into individual, group and family psychological

therapies, preventative measures and other psychosocial programmes
for those with psychotic disorders.
• to support treatments that include individual, family, group, and

network approaches and treatment methods that are derived from
psychoanalysis, cognitive-behavioral, systemic and psycho-educational
approaches.
• to advance education, training and knowledge of mental health

professionals in the psychological therapies and psychosocial
interventions in the treatment and prevention of psychotic mental
health disorders for the public benefit regardless of race, religion,
gender or socio-economic status
The constitution was agreed and therefore the new society inaugurated
during the ISPS conference held in London in 1997. Since the momentum
had gathered full pace in 1994, we had experienced the most untimely death
of Endre Ugelstad in 1996 and sadly David Feinsilver’s illness also proved to
be fatal.
Johan Cullberg was our first chairperson following inauguration and

creatively steered a lively active international committee and the
organisation through to 2000 during which time the very developments that
the formation of the society was intended to foster began to appear. Jan Olav
Johannessen took over as chair from the time of the 2000 meeting in
Stavanger and the organisation has undergone considerable further
development during these last years.
An organisational base
The ISPS was especially fortunate to have in its midst a protégé of Endre
Ugelstad – Torleif Ruud – who did a great deal to lay the organisational
foundations of the new organisation. He arranged for ISPS to be registered
in Norway and hence free of tax expectations. He arranged for an
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administrator to take care of the daily matters and finally he became the
editor of the impressive ISPS Newsletter and webmaster of the ISPS website
(www.isps.org). These communication means have plaid a crucial part in
helping ISPS members gain a sense of being part of an international
community and to have available information about developments that
serves as a source of encouragement and ideas to those in other countries.
ISPS networks – 57 varieties

The new international society formed with the intention that it would
encourage professionals and others to be much more active in between
major conferences in ways that would promote psychological therapies.
Perhaps this has been the most important consequence of the formation of
the new society. We now have a considerable number of networks around
the world, and are represented on all five continents. The USA and the UK
have several hundred members each. Lively groups have formed in the
individual Scandinavian countries. New Zealand and Singapore now have
active networks. We are not strict about geographical boundaries and some
groups have formed across national lines, for example the Flemish speaking
ISPS group and the Central European group under Ivan Urlic’s initiative. A
group has formed in Israel and before long we will have networks in
Germany and Spain. In some countries the networks have organised
themselves into more local groups. For example the USA has groups that
meet in a number of the major cities and a Northern group has formed in the
UK. Some whole networks are composed of persons interested in a
particular modality; others are expressly multimodality from the beginning
out of which subsections form.
Overall there is an exciting sense of an organic process of development of

networks on a global basis that should do much in the long term to ensure
the viability and vitality of psychological approaches and that they occupy
more of the centre stage in treatment services.
These networks are evolving a whole range of different functions. Some

networks have already held a considerable number of local and national
ISPS conferences and have their own internal newsletters. Some have set up
local groups to discuss and assist clinical work (there are now two
psychodynamic groups in different regions of the UK). The UK and the USA
have their own email discussion groups and more recently an international
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AND
discussion group is taking off. Carer and user participation is becoming a

more prominent feature.
To further promote the organisation, the board seeks to be present with

information material, books, brochures etc at the most important
international congresses. This, together with publishing the Newsletter,
puts some economic strain on our organisation, and the financial situation is
a topic that attracts a lot of energy. We have no obvious sponsors except for
our individual members, but we now offer the possibility of institutions and
organisations to become members themselves. In time we hope to earn
some money from book sales.
Publications
In the last decade, there has been an increasing emphasis on evidence
based approaches to treatments. This is problematic for psychological
therapies especially in such a complex set of disorders as the psychoses, but
the Board support the publication of an evidence based book on the
psychoses following on from the 1997 inaugural meeting.
Psychosis: Psychological Approaches and their Effectiveness: (Putting

Psychological Treatments at the Centre of Treatment) was the result and
from a UK point of view it was important that the book was published by the
Royal College of Psychiatrists in conjunction with the ISPS. The editorial
team of this book was formed by Brian V. Martindale, Anthony Bateman,
Michael Crowe and Frank Margison.
A most successful venture was an international group that set itself up to

challenge the PORT report (an influential USA set of recommendations
about treatments in schizophrenia). This led to alterations in some of the
revised recommendations and to a most useful volume of The Journal of the
American Academy of Psychoanalysis and Dynamic Psychiatry Vol 31, No. 1,
Spring 2003. Special Issue: The Schizophrenic Person and the Benefits of the
Psychotherapies—Seeking a PORT in the Storm. Guest Editors: Ann-Louise
S. Silver and Tor K. Larsen.
The Board then agreed the need for a series of books and to have an
international publisher. By the time of this publication, the ISPS series
published by Routledge should have six volumes available. The series editor
is Brian Martindale.
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Models of Madness (John Read, Loren S. Mosher and Richard .Bentall)

Evolving Psychosis: different stages different treatments
(Johannessen, Martindale and Cullberg)
Psychosis (Cullberg)
Psychosis: Working With Families and Groups of Families
(Trond Grønnestad, Anne Lise Øxnevad and Gerd-
Ragna Bloch Thorsen)
Dead Landscapes: Psychopathology, Psychodynamics and Psychotherapy
of Schizophrenia (Gaetano Benedetti)
In-patient Therapies in Psychosis
(Kennard, Fagin, Hardcastle and Grandison)
At this point in time, the ISPS Board is exploring the feasibility of an

international journal for the Psychological Therapies of Psychosis. This is a
major undertaking and will need careful preparation if it is to be viable.
The future
Others will make their own comments later in this volume about the future
of the ISPS. We see the development of local networks as being the engine
of change of practice. Research has shown the difficulties of moving
professionals on from a training in psychological therapies to actual use of
skills in clinical practice. A considerable component of this problem in our
complex and difficult work is the lack of skilled support and place for regular
discussion and supervision of clinical work. Hence an important component
of networks will be to encourage the development of more local support
groups. An important additional aspect of local groups will be the
development of organisational and political skills to effect change at macro
service level planning. Publications –both professional books, possibly a
journal and Newsletters will all be important methods of sharing
information and innovations as will increasingly sophisticated use of
electronic communication including video communication. Our conferences
both local and international will continue to have many functions in
supporting and encouraging the networks.
Together with other organisations such as the WAPR (World Association of

Psychosocial Rehabilitation), the IEPA (International Early Psychosis
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AND
Association, and the World Health Organisation we would like to engage in

building and transferring competence in the psychological treatments by
offering practical support for specific sites, and by connecting sites that
would want to learn from each other.
We have also become an affiliated organisation of the World Psychiatric

Association for several reasons not the least of which is to demonstrate the
place and the room for psychological treatments of psychosis within such
large organisations both now and into the future.
Taking a global perspective, the future of the psychological therapies in

psychosis is looking relatively brighter in many countries compared with a
decade or two ago. This is not to say that in most countries mental health
systems are still dominated by the search for unrealistic short term solutions
acting synergistically with rather restricted explanatory models in these
complex disorders. Users and carers voices are playing an important part in
changing the approaches of many professionals and in addition much will
depend on how well organisations such as the ISPS support professionals in
their own learning and then becoming effective at researching and ‘selling’
their products.
Brian Martindale
Consultant Psychiatrist, Psychoanalyst,
South Tyne and Wearside
Mental Health NHS Trust, U.K.
[email protected]
Jan Olav Johannessen

Professor, Chief Psychiatrist,
Rogaland Psychiatric Hospital,
Stavanger, Norway
[email protected]
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17. Development of the ISPS

newsletter, website and
secretariat
Torleif Ruud
This chapter describes briefly the development of the ISPS newsletter and
website, as well as the secretarial and financial services.
The ISPS newsletter

The ISPS newsletter was started in 1994 by Endre Ugelstad as the first editor
when ISPS after the symposium in Washington was developing a more
formal network and preparing to become a society. Before Endre died in
1996, Torleif Ruud was asked to take over as editor, and he has continued as
editor up to the ISPS congress in 2006.
The newsletter has usually been published two times a year, but only once
some years.
The first issues of the newsletter were printed in Norway and in black and
white. For a couple of years in the late 90s the newsletter was printed and
distributed by a congress bureau that was engaged by ISPS to give
secretarial services between the congresses. The logo of ISPS was selected
by the ISPS board in collaboration with the congress bureau during this
phase.
Since ISPS in 1998 made a contract with SEPREP in Norway to be a

secretariat, the newsletter has again been published and distributed from
Norway. After a period where the editor also did the layout, Ellen Jepson in
Stavanger has been engaged as graphical designer to make the layout. Her
work and the change to full color printing of the 16 pages newsletter greatly
improved the visual quality. Since Antonia Svensson has been engaged part
time as organizer for the ISPS, she has done most of the work of gathering
and proofreading material.
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AND
The aim of the newsletter has been to communicate ideas and experiences
between members and a growing number of local groups in the expanding
international network. As the local groups have developed, there have been
more reports from their meetings and other activities. The newsletter has
also contained book reviews, brief biographical sketches of honorary
members, brief reports on research or clinical work, and information on
upcoming meetings and other events. The newsletter has been sent to all
members, and it has also increasingly been spread through local groups and
in congresses as information on ISPS to recruit new members. During the
last years 3-5000 copies were printed and distributed of each issue. The
newsletter has also been available in an electronic version on the ISPS
website.
The ISPS website

Preparation of the ISPS website www.isps.org was started in collaboration
with the congress bureau that arranged the ISPS congress in London in
1997, but was then transferred Norway when the ISPS board decided to have
its secretariat in Oslo, as described below.
The website company Netpower was chosen for several reasons. ISPS had
good experiences with the work they had done for the ISPS congress in
Stavanger 2000, they were less expensive than other companies we
checked, and they had developed website modules we could manage
ourselves to publish material on the website without having to pay extra for
such daily work.
The collaboration with Netpower on the choice of modules and the design
of the website was done by Torleif Ruud, and Ellen Jepson was involved in
the graphic design to keep some visual similarities between the newsletter
and the website. Torleif Ruud became editor of the website in order to
coordinate the publishing in the newsletter and on the website. Most of the
work with posting material on the website has been done by Antonia
Svensson within her part time job as ISPS organizer. The website has been
in operation since 2003.
The website contains information on the ISPS, information on local groups,

information on upcoming events and reports from recent events, book
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reviews, lists of recommended articles and books, and links to other

websites. Visitors to the website may sign up to receive email messages on
news as they are published. Electronic versions of all the newsletters since
2000 are also available on the website. There is also a membership form that
can be used to sign up as members of ISPS, as well as information on how
to form local groups.
The website has several possibilities that we are not using fully, and we
realize that we are just in the beginning of exploring and developing its
potentials for ISPS.
One of the great potentials is that all local groups may have their own
website for free within the ISPS website. The access to these is through the
expandable menu system, but we have also the possibility to let each local
group have their own web address leading directly to their own website, like
www.isps.org/uk, www.isps.org.us and www.isps.org/nl. The US chapter of
the ISPS has also developed their own website www.isps-us.org with links to
the ISPS website.
With the developments of local groups, there has been a gradual increase in
material published on the website. But this has not been enough to have
news as often as we would wish. Increasing use of the website by
communications and publications from members and local groups is a goal,
as this also is an important factor to increase the number of visits to the
website. Another important factor for a website to be found by people
searching the internet is to have mutual links to other websites, and this also
needs to be developed further.
A possibility to run discussion groups on the ISPS website has not been used
much by the members. But an Email discussion group organized by Chris
Burford in the UK has been used much by many of those who have access to
it. This has been an important forum for discussion between active members
of ISPS across the world.
SEPREP as a secretariat for ISPS

In the phase of preparing the ISPS as a society, the needs for a secretariat
was planned to be taken care of by a congress bureau. When the first board
of ISPS decided to leave this model, the board chose to make an agreement
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AND
with SEPREP in Oslo to have secretarial functions for a low fee. SEPREP
(Centre for Psychotherapy and Psychosocial Rehabilitation for Psychoses)
is a Norwegian competence centre and network of clinicians, researchers,
users and carers sharing the same objectives as ISPS. SEPREP is
organising nationwide multidisciplinary training programs in treatment of
persons with psychoses, and spreading information on psychoses through
a bulletin and other media. Endre Ugelstad, who was active in developing
ISPS as a network into a society, was one of the founders of SEPREP in
1990.
The choice of using SEPREP as a secretariat was on several reasons.

SEPREP could offer a secretary that was available all work days, and still to
be paid only for the hours working with specific tasks for ISPS. This
secretary would also keep the books for the ISPS accounts. Collaboration
with this secretariat was also easy, as the ISPS editor and treasurer Torleif
Ruud at that time was chairman for SEPREP. It would also be useful to have
the secretariat in Norway as the next ISPS congress was going to be in
Norway in 2000.
Wenche Løyning in SEPREP has since 1999 worked part time for ISPS as
secretary and book keeper. Letters and newsletters to members and local
groups have been distributed by Wenche. The secretary has been available
daily for ISPS, but ISPS has only paid for the amount of hours she has used
on specific task for ISPS, not for the availability. ISPS is grateful to SEPREP
for these services and support.
From 2003 ISPS has engaged Antonia Svensson as a part time organizer.
With her professional training in psychology, she has been able to do work
that a secretary could not do, and that ISPS board members did not have
time to do in their unpaid spare time work for ISPS. Antonia had experience
from similar work for the ISPS local group in the UK, and she was engaged
on the basis that ISPS UK had been very pleased with her work. As an
extended member of the secretariat, she has taken care of several important
tasks related to board meetings, contact with local groups, collecting of
material for the newsletter and publishing material on the website. She has
worked in close cooperation with the chairman, the board, contact persons
in local groups, the secretary in Oslo, and the editor of the newsletter and
website. Antonia was first based in London and then moved to Athens. She
has done most of her work using Email, but she has also attended ISPS
meetings.
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ISPS accounts and treasurer

Brian Martindale was treasurer the first years after the inauguration of the
ISPS as a society at the congress in London in 1997. When the secretariat of
ISPS was established in Oslo in 1999 Torleif Ruud became treasurer. The
accounts were started with the transfer of a surplus from the London
congress in 1999 and the transfer of a small amount that Endre Ugelstad had
collected from members of the ISPS network between 1994 and 1996. The
account books have been kept by Wenche Løyning, secretary of the SEPREP
secretariat in Oslo.
The work and development of ISPS as an international society was made

possible by the large surplus generated from the ISPS congress in Stavanger
2000. The board realized that it would take several years to establish an
organization that could get adequate funding from membership fees, and
chose a strategy that the international congresses every third year would
give a surplus to run the society in the years between the congresses. The
plan was to use the money of the society on activities that were considered
to create and stimulate local groups and increase the number of members.
International congresses, local or national meetings, having a part time ISPS
organizer, contributing to start of local groups, the newsletter, the website,
publishing of books and board meetings (mostly at international congresses
to save travel costs) were considered to be such key activities and
investments to build the ISPS as an international society. In this way the
board to the decision and priority was to use the available money over the
next years.
The expenses increased as the international and local activities increased.

The congress in Melbourne in 2003 only generated a limited surplus, but the
activities could be continued using the part of the surplus that were still left
from the congress in 2000. Increased expenses to edit and print a quality
newsletter and increased distribution costs due to large number of copies
being sent to local groups were discussed by the board several times, but the
board decided to keep on with the newsletter as it was one of the few
reasons to become a member.
The state of the accounts and overviews of income and expenses were
presented at the ISPS business meetings in Stavanger in 2000 and in
Melbourne in 2003. The finances has been reported and briefly discussed in
most board telephone meetings. As we approach the time of the ISPS
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AND
congress in Madrid in June 2006, there will be little or no money left in the
ISPS accounts, and society and the new board need face the challenge on
how to proceed.
Torleif Ruud
Sintef Unimed, P.O. Box 124 Blindem,
H-0314 Oslo, Norway
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18. ISPS in the Age of the Internet

Chris Burford
Internet is one of the remarkable emergent phenomena of the late 20th

century, transforming human relations for good and bad on a global basis.
The interlinked global financial system is mirrored by a new emergent global

civil society. How healthcare is managed is one of the key areas of debate, of
investment of money and human energy, and of a struggle to make that
investment responsive to social control. Yet with drug companies
manufacturing new anti-psychotics competing globally for a market now
worth several billions dollars a year, if anything it feels more difficult for
members of ISPS to get psychotherapeutic approaches on the agenda than
50 years ago. And the competitive ratio for these large drug companies is
about one sales representative for every 5 doctors. We instead need to
network to get the alternative priorities across.
Fortunately mental illness, including one of the greatest scourges,

psychosis, is a key area of concern to people across the world. Through
families or friends most people are aware that the horror of insanity, is part
of the risk of being human. We have to build our links internationally
understanding the human and social dynamics that underlie successful use
of the technological possibilities of the internet.
The technicalities of the internet are a shifting terrain, which shapes new
possibilities of communication and stifles old ones. Viruses spread across it
faster than migratory birds, or mass air travel can spread more familiar
diseases. These in turn are answered by anti-viral defence systems, which
at least some of the better off population of the world, such as perhaps
ourselves, can afford.
So the triennial ISPS Symposia, started 50 years ago by our heroic founders
based in counties somewhat adjacent to the main stream of European and
western academic culture, and which have survived the onslaught of
biological reductionism over the decades, now have new possibilities of
communication.
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AND
One suspects that participants at the first symposium did not all travel by air.
What has survived as an important coalition of islands of resistance, perhaps
each in their own circumstances for somewhat accidental adventitious
reasons, can now communicate 24/7. But this is like the old curse of the devil
granting your most heartfelt wish, a story that probably occurs in many
different cultures and languages. The joy of almost instant, infinite global
communication can bring experiences themselves analogous to psychotic
crisis in an individual, if not an actual epileptic fit. One of the paradoxes is
that the most prominent international figures are probably even more
vulnerable than most, because of having achieved such a high level of
connectivity already, within their workplace, their profession, their country,
their academic circles and their participation in international conferences of
a more conventional nature. Just one more connection might destabilise the
whole house of cards, or leave their “mail box full” and inaccessible to
everyone.
What are the technical constraints of the internet for us?
The creation of the internet gives one possibility for an international

organisation: to create its own webpage. Search engines can locate this for
you. As I write this article Google has in 0.12 seconds just given me over 23
million links to web-pages linked with the letters ISPS. Fortunately only the
first 10 are listed and they all seem to have something to do with things
called ISP - internet service providers.
But by adding “mental” after “ISPS” to the search term, the choice is
reduced to slightly under a quarter of a million.
Even better the first three, miraculously are
”[PDF] UNITED STATES CHAPTER”
and
”ISPS-US: About Us”
followed by
”ISPS”
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“Conference Report: “Society and Mental Health” 4th Stavropol Conference.

ISPS wants to promote better knowledge of the psychological approaches …
www.isps.org/ 16 Dec 2005 - Cached ”
It would of course have been slightly more diplomatic for international

relations if the international website had been listed before the US one, but
since Google’s search rules are secret, to avoid attacks by viruses and
hackers, we should not grumble.
We only have to click on one of the links, speedily to get to the internet hub
of ISPS, its website www.isps.org.
The internet is about no one point of view being dominant but allowing a
choice of routes to your goal. It is thoroughly post-modernist. As the
international ISPS site and the US ISPS site support each other with cross
links, this is a good start. The seeker to have learnt which search terms to
enter into a search engine like Google.
A website such as www.isps.org or www.isps-us.org can be updated with

information as regularly as time and money permit, but is competing in an
environment in which there are now 8 million websites.
One measure to increase visits, is that visitors to the ISPS international

website can now request a prompt whenever it is updated and a further visit
is indicated.
One activity that can promote more interaction is a bulletin board. This was
an early form of communication in the internet, where discussants go to a
single place and add comments under particular themes or “threads”.
There is this facility on the international website of ISPS www.isps.org, but
it has not been much used because it has not generated much traffic, and
it has not generated much traffic because, so far, it has not been much
used. The secret of these internet networks is traffic: its movement,
control and guidance. Hopefully contacts with or “hits” on the ISPS website
have been promoted by a further initiative, ISPS-INT, an Email
information/discussion list, which is the main subject of this article. (In the
US this is called a listserve, after the programme that first successfully
organised this activity).
An Email list echoes the corresponding societies of the 18th century and the
radicalism of the later Enlightenment, and the French Revolution. In the
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AND
ferment of ideas the radical intellectuals of the new middle classes had the
interest and resources to arrange to circulate any letter from one of their
members to all their members, through the new postal services. These were
expensive enough to exclude the majority of the population but cheap
enough to make them a source of ideas subversive to the old absolutist
monarchies.
With the power of computers it is now a simple measure to arrange that a

letter sent to a list of 100 can be distributed to all 100, provided the computer
owner is paying the cost of the machine, the software, the connection to the
internet, and now, indispensable, regularly updated protection against
viruses. A potentially ever growing society of like-minded discussants can
form across the world. The warmth of the human connections made during
the intensity of a symposium can be carried on afterwards, during the three
years of relatively isolated endurance, before the next symposium. But this
blessing is a curse if it is not placed in a humanly manageable context.
Fortunately ISPS has now experience of two Email information discussion

lists that have been going on for more than six years: in the US and in the UK.
The US has been moderated by Joel Kanter, whose support and cross
fertilisation I warmly acknowledge, now with the added administrative skills
of Karen Stern, execute director of ISPS-USA. The character of the two lists
is somewhat different. Although the UK list is only a few weeks older, during
this time it has seen under 3,000 letters, the US list over 12,500. All are still
accessible in the archives.
A list is a living relationship and is shaped as much by the members, their

experiences and their attitudes, as those of the list moderator. It is not
possible to predict exactly how a list will develop. It is like a plant or an
infant, which has to survive and grow with tender loving care, and occasional
shaping, guidance, or even more rarely, pruning.
A list is also a creative dynamic between those who want to discuss and those
who want to read. All discussants can be assumed to be readers at least from
time to time. Most readers are not discussants. The ratio needs to be about 10:1
or 20:1. A more equal ratio leads to a list that is a chat room of intense interest to
the participants but of doubtful interest to many others. In the feverish superfluity
of the knowledge economy, there is an abundance of choice of commodified bits
of information, and links. In an overabundant economy competition, so the
economists say, is through quality. What links give the best signal to noise ratio -
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as judged by the punter, the internationally known researcher, the psychoanalyst

who has worked for 30 years with psychotic patients?
In a relatively stable orderly list with a large membership, most people stay
on it to scan what is going on, including what might be new or controversial.
It is therefore like scanning the letters page of hopefully a favourite journal:
you look out for authors or themes of particular interest to you.
For a group it allows the individual members to scan the movement of the
herd. But if there are very few contributions at all it is hard for the members
to get the necessary information. The amount of transactional energy falls
too low: there is little reason to unsubscribe, but little reason to join.
An early list may be like a small bright hot star, with lots of energy. There
may be passionate exchanges, sometimes called flame wars, in which the
rules of email circulation can rapidly produce a multiplying chain reaction.
Even if only half a dozen people are involved, the letter boxes of everybody
could easily be filled up with 20 communications or more a day, about an
argument that most people would prefer to avoid. An old list might be like an
old blue giant star, large but with little activity going on, losing energy, and
fading away, until by chance drawn into a larger conglomeration of
communications traffic and energy, that best meet the consumers’ sense of
quality: a good signal to noise ratio.
These delicate dynamics suggested that the launch of an international E-

mail list for ISPS was therefore something that would not necessarily
occur spontaneously. It might have occurred by the US becoming more
open to international participation, particularly because of its rich range
of psychodynamic viewpoints. A disadvantage might have been that it has
played an active role in helping members of the US chapter bond together
as a society, with already a high number of daily E-mails, many
of them to do with local conditions of work, mostly outside mainstream
mental health services. By contrast the UK chapter of ISPS had the
advantage of a membership based largely in the state sector, with a
cohort of psychologists who have developed therapeutic initiatives along
CBT lines, and responding to government directives for more
“psychosocial” and user friendly service interventions. But the UK list is
relatively weak on psychodynamic contributions, and individual
therapeutic interventions.
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AND
Besides at a time of controversial hegemonic wars against terrorism

involving both the US and UK, it was perhaps more diplomatic not to offer
a takeover, especially because the lingua franca probably had to be
English.
With enough vision and enough determination, it therefore seemed desirable

to try to front-load a new E-mail list, launching it on the back of the last
international symposium in Melbourne 2003 by giving complimentary
membership of the list to those who attended the symposium.
The first need was to get the general blessing of the international board of
ISPS at a time when the board members were very busy dealing with enough
E-mails already, and were investing energies and resources in developing
the international website, www.isps.org. Complimentary membership of the
UK list gave some opportunity for board members to decide what might be
involved and whether this might be useful even though they could not read
every E-mail themselves.
Careful thought needed to go into making sure the initiative was seen to be
complementary and not in competition with the website initiative. One of the
methods was to ensure that links to the international website were
automatically added onto every E-mail message. Another was to flag up on
the E-mail lists news of additions to the E-mail site. The discussion board on
the website had to be tested to see how much this facility met the
developmental needs of ISPS under present conditions. Hopefully these
initiatives are felt on balance to be genuinely complementary.
The goal was therefore personally to invite as many participants at

Melbourne ISPS 2003 to subscribe to an international E-mail information/
discussion list, from as many countries as possible. Personal contact was
important not only to establish some degree of trust, but because the
Australian data protection act, had rather strict conventions. There was also
the question of equity in an unequal situation. To avoid the new list being
dominated by the British or the Americans, who were well used to E-mail, it
was necessary to concentrate first on identifying participants from other
countries. There were also large contingents from Scandinavia, Australia
and New Zealand. It was at that time unclear whether they wanted to use
Melbourne as an opportunity to launch their own Email information/
discussion lists, and perhaps in languages other than English. With the
support and understanding of representatives from these countries, the
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compromise was to invite membership from presenters at Melbourne in

their cases, and in all other cases from all ordinary members. By October
2003 and with crucial help also of Antonia Svensson, ISPS International
Organiser, members were enrolled under appropriate email addresses from
over 20 countries.
The feedback was interesting. One internationally valuable researcher

apologised in a friendly fashion explaining that he already received 150 E-mails
a day. Another member of the ISPS board felt unable to join, no doubt for the
same reason. But all other board members did.
The launch in December 2003 was therefore very tentative. In order not to
startle the horses, as we say in idiomatic English, I tried to set the scene very
gently as if this were the closing session of Melbourne 2003, that as the
lights gradually became stronger, we could see we were all sitting there still.
I promptly received an unsubscription from a member with a good research
record, who wished to be saved from the poetry. An important ISPS
researcher also unsubscribed understandably perhaps because the list
cannot really function as a highly focussed research list. But on the whole
there have been remarkably few unsubscriptions. All posts remain
“moderated” which is a bit unusual but allows members not to be irritated
by the occasional aberrant E-mail going to 150 people. I still often however
receive messages saying
Jag kommer att vara borta från kontoret fr.o.m. 2005-12-16 och kommer inte
tillbaka förrän 2005-12-21.
Jag kommer att svara på meddelandet när jag kommer tillbaka.
I am away from the office until 21/12.
but continue to have difficulty contacting the individual to ask him or her to
amend his Microsoft “out of office” settings. Mastering the technology is a
challenge for all of us. Naturally I do not approve of these messages for
circulation to the rest of the subscribers.
Moderation also allows me to tweak contributions from across the planet,

from brave people for whom English is not their mother tongue, particularly
for things like prepositions, which are very idiomatic. I think there is perhaps
a problem that whereas in an international conference face to face, armed
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AND
with a carefully translated paper, the presenter can communicate quite

effectively with a bit of good will, and warm body language, a written
submission to a fast moving E-mail list can feel particularly exposing. I am
sure this inhibits many valuable contributions.
Despite few drop outs, negative feedback has been useful in another way,
particularly as confidence in the list grew, and people risked making
contributions themselves. The number of messages rose, and per day became
unpredictable. I risked remonstrating with a member with many international
links when he complained that he had been away only a few days, and there
were 150 E-mails in his letter box, that it was his responsibility to manage his
E-mails in an orderly way. But I thought more about it too.
There were advantages for myself, an d also for the list, to try to peg
messages to a maximum of 3 per day Monday to Friday. This would allow the
busiest of international experts to know what they are scanning and to be
selective. It would allow me time to think over the weekend. It would allow a
mixture of contributions and abstracts of interesting articles from the major
psychiatric journals so that we could keep an eye on developments outside
as it were as well as among ourselves.
By agreement with the ISPS board, and the local chapters, the invitation to
membership has now been extended to any member of a local chapter, or
international individual member. A number have joined particularly from
eastern Europe and Israel, where chapters of ISPS are in formation. More have
come in from Scandinavia and the USA, enriching, rather than disrupting the
dynamic, and a further announcement is due on the UK list. Indirectly ISPS-
INT may have helped the dynamic towards the formation of a New Zealand
chapter with perhaps its own E-mail list, and Australia is to follow.
Numbers have climbed to over 190, with an additional 19 addresses noted by

“Yahoo groups” as “bouncing”, a strange painless invisible process whereby
someone has slipped out of contact because the E-mail address no longer
connects.
Particularly gratifying at the time of writing this contribution, was to

forward a request for help in Greece, and to receive within 24 hours 4
recommendations from extremely busy internationally-known “experts”.
This suggests we have been able to win an increase in numbers with a most
competitive high signal to noise ratio.
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To keep the dynamic between readers and contributors at an appropriate

level as moderator, I see myself sometimes as a sort of hopefully educated
chat show host, mostly encouraging, sometimes seducing or prodding, to
stimulate enough controversy to hold interest, but not so much as to shut
down communications, through overt conflict.
Another dynamic is that empirical researchers save their best insights till
conferences where they trade and swap their research and consider joint
projects. They prefer to scan the literature between conferences. It has
therefore probably become useful to forward to the ISPS-INT list, the most
interesting abstracts from the electronic table of contents of leading
psychiatric journals. Hopefully this brings a new link for even the best
connected empirical researcher, while raising the questions for all ISPS
members of how these new findings are best integrated with therapy for
individual patients.
It helps also to remember the story Rumi told of the elephant many centuries
ago.
We are all blind on the internet, groping or palpating a very large elephant.
Each on our own cannot describe the beast in front of us, but with
perseverance and patience a more comprehensive picture can emerge, of
schizophrenia, if that elephant exists, or the various human tendencies to
have psychotic experiences, if it does not.
It will also be important to be able to discuss with mutual respect the evidence
of efficacy in a whole series of individual cases, with the bigger problem of how
to move onto effective services in the field that can meet the needs of tens of
millions of people with schizophrenic type illnesses world wide.
While each moderator brings their own intuition and experience, the future
of an E-mail list is above all in the hands of the members. As the list grows
larger, a process of differentiation needs to occur to promote a more
sophisticated level of global networking. It may be that each individual can
effectively scan only 3 or 4 lists, and those selectively. We need to have
enough flexibility and enough stability. It may be that ISPS can help the
formation of chapters in many more countries each with their internet
connections. Meanwhile other parallel lists are possible on a world wide
basis for those who wish to specialise: on the interface between increasingly
dynamic biological and neurological models, on the tendencies within CBT to
engage more explicitly with emotions, on the problems of engagement and
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AND
delivery of interventions for families, on the specialised understanding of

what psychoanalytic interventions may be best for which patients.
Networks, like those of the human brain, and of the human mind, are
inherently dynamic. In between symposia, hopefully ISPS will make use of
the electronic opportunities to achieve our global aims in a dynamic and
creative fashion.
Chris Burford
Consultant Psychiatrist. St Ann’s Hospital, London H15.
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AND
Ann L. Silver
Jan Olav Johannessen and

Brian Martindale
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Establishment of
Local ISPS activities
19. Europe
20 A. United States of America
The ISPS-US
20 B. Australia
20 C. New Zealand
20 D. Eastern Asia
259
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Establishment of Local ISPS activities
19. Europe
Brian Martindale and Jan-Olav Johannessen
Introduction
As can be seen from the list of fourteen International ISPS Symposia, most
of the conference activity of the ISPS since its foundation has taken place in
Europe with only three symposia taking place outside of its boundaries (two
in the USA and a recent symposium in Australia).
We think this accurately reflects the favourable degree to which

psychological approaches have been developing within mainstream mental
health services in certain parts of some European countries especially the
Scandinavian countries that have hosted more than a third of the European
ISPS symposia.
As has been already presented in a the preceding chapter, it was hoped that
by creating appropriate central organisational structures, it would then be
possible to create local frameworks or scaffolding within which
professionals (and users and carers and administrators) could find ways of
creating support to develop and share clinical experience and knowledge of
psychological approaches and that effective ways would be found of
influencing service development. It may be important to underline that the
formal formation of the ISPS society in 1997 occurred at both the nadir of
despair of many at the strength of influence of “Decade of the Brain” (The
U.S.A. Presidential Proclamation 6158, 1990) with its magical expectations
of finding ‘the biological cause’ and a cure for ‘schizophrenia’ and at the
very same time a growing ascendancy in other geographical areas of
reasonably sound experiences of being able to implement psychological
therapies as a central component of therapy, whilst still respecting the
increasing knowledge from genetic, biological, neuropsychological and
pharmacological contributions.
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AND
In this chapter, we outline the developments that are taking place in various
parts of Europe within ISPS frameworks and links. These are given in
alphabetical order. There was a Scandinavian wide ISPS network that held
meetings but it has recently been considered that more regular support will
come from each country having a network for local meetings, even though it is
hoped that there will still be Scandinavian wide ISPS meetings from time to
time.
CROATIA
During the early part of the twentieth century, when Freud was develping his
momentous insights into the human mind and its development, Croatia was
part of the Austrian-Hungarian empire, and its capital was Vienna. The well
known psychiatrist and psychoanalyst from Zagreb, Stjepan Bettelheim
brought the ‘new psychoanalytic science’ to Croatia. By the 1930’s Zagreb
had become the centre for the spread of psychodynamic thinking and
therapeutic approaches in South-Eastern Europe. Unfortunately, at that time
the psychodynamic approach to psychotic patients was not widely accepted
by psychiatric and psychological circles.
In the late 1960’s the Zagreb psychiatrist Dr. A. Maletictrained and worked in
Chestnut Lodge Hospital in USA and on returning started seminars on the
psychotherapy of the psychoses. This marked the beginning of the
systematic training of psychodynamically oriented psychiatrists,
psychologists and psychiatric nurses in the psychodynamic approach to
psychotic patients.
Initially this approach was only with individuals and through therapeutic
community approaches in day hospitals. Other psychiatrists and group
analysts such as D. BlaÏevic, E.Cividini-Stranic, E.Klain, started training
courses in psychodynamic understanding and therapy in the chronic
psychiatric hospitals. The ‘movement’ was spread further by S. Strkalj-
Ivezic , B. Restek-Petroviç, N. Oreskovic-Krezler, S. Bioaina and many
others in the North of Croatia. In the Mediterranean part of the Country
there were Lj.Moro and her colleagues in Rijeka region, J. Jeliaic and H.
Marainko in Pula region, and I.Urlic and his co-workers V. Matijevic,
M.Vlastelica, S.Pavloviç and some others in Split and the region of
Dalmatia. Therefore a psychodynamically oriented individual and group
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Establishment of Local ISPS activities Europe
approach to psychotherapy of psychoses had been practiced for more then

30 years in Croatia. In spite of this tradition, the psychodynamic approach
remained in the shadow of wide spread pharmacological therapeutic
approach.
This has been furthered by S. Strkalj-Ivezic and I. Urlic who have, since 1997,
been organising the yearly ‘School of Psychotherapy of Psychoses’ in the
setting of the Inter-University Centre in Dubrovnik. The subtitle of the School
is Towards the comprehensive therapy of psychoses. During the activity of
the School many prominent workers from other countries came to lecture
and exchanging their experiences with the participants: from Chestnut
Lodge and Austin Riggs in the USA; also from the UK, Italy, Denmark,
Greece, Poland, Germany, Austria, Slovenia and Croatia.
ISPS Croatia in collaboration with the IGA Zagreb and Croatian Medical
Association and psychiatric professional associations are developing not
only the psychodynamic culture in approaching psychotic patients, but
associations of family members of psychotic patients, anti-stigma
programmes and also research.
DENMARK
Up to now, ISPS activities have been through the networking of the
Danish National Schizophrenia project (DNS) in which 16 centres meet
twice a year. This network organised some years ago a very successful
Nordic ISPS seminar on “Subjectivity and the treatment of psychoses”.
The presentations (made by: J Parnas, J Cullberg, P Möller, S Levander,
K Lehtinen, S Gilbert) were centered around themes such as:
‘Phenomenology, the Self and schizophrenia,’ ‘Subjective experience of the
prodromal phase,’ ‘On the generalisation of psychotic experience,’ ‘The
therapist’s subjective experience of the patient’s psychotic phenomena,’
and ‘Subjective perspectives on life, death, and illness in persons with
schizophrenia.’
Now we plan to initiate an independent ISPS organisation in Denmark in

March 2006, and in relation to that we shall invite persons from the
International ISPS to present different topics. Furthermore, we are planning
to host the 2009 ISPS congress in Copenhagen.
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DUTCH SPEAKING GROUP

An innovatory ISPS network of the Dutch speaking group has drawn together
practitioners in Holland and Belgium under the leadership of psychiatrist
Jan Leijten together with the group’s board members Ludi van Bouwel, Jos
de Kroon, Margreet de Pater and Dirk de Wachter
This group has been operating as a society since 2002, calling itself the
Netherlands-Flanders ISPS Network. It has held three successful
conferences with up to 150 participants, including Johan Cullberg (Sweden)
and John Read (New Zealand) as speakers at two conferences. A further
meeting has focussed on family approaches to psychosis. The group
participated with the Dutch Society for Psychiatry in a symposium on
Psychotherapy and Psychosis. These activities have led to the consolidation
of the group and have widened the membership.
Recently the right wing government has brought in measures that have
greatly restricted the amount of psychotherapy that patients can receive to a
maximum of 25 sessions and this has led to a reaction by the group and
cooperation with the Dutch Society for Psychiatry in this issue.
FINLAND
The interest in psychological treatment of schizophrenia and other
psychoses and in the ISPS activities in Finland has old traditions. It had
already begun during the 1950s when three Finnish psychiatrists, Martti
Siirala, Kauko Kaila and Allan Johansson, had their psychoanalytic training
in Switzerland, led by teachers like Gustav Bally, Medard Boss and Gaetano
Benedetti. They also participated in the first ISPS symposia in Lausanne and
Zurich. After their return to Finland Siirala and his colleagues founded the
Therapeia Foundation in 1958. The training programs established by the
Therapeia have had a special emphasis on psychoanalytically oriented
individual therapy of schizophrenic patients.
Another group was formed in the Department of Psychiatry at the University

of Turku at the end of the 1960s, led by professor Yrjö Alanen and his co-
workers Viljo Räkköläinen, Klaus Lehtinen and Jukka Aaltonen. Alanen and
his team also organized the IVth ISPS symposium – the first one outside of
Switzerland - in Turku 1971.
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The Turku approach had a broad psychodynamic basis including both family
and individual therapies and establishment of ‘psychotherapeutic
communities’ at the hospital ward. The project led to the establishment of
the Finnish ‘need adapted approach’, and spread to several centres around
Finland during the National Schizophrenia Project (years 1981-1987),
especially in the establishment of family-centred acute psychosis teams.
Later the API project (Acute Psychosis Integrated Treatment 1992-1998, led
by Ville Lehtinen) became influential. Jukka Aaltonen and Jaakko Seikkula
have been important leaders in the development of flourishing systemic-
psychodynamically oriented family therapeutic activities.
The Finnish psychotherapists have participated actively in many ISPS symposia

with presentations of their projects and therapy reports. Maybe the domestic
activities including various training programs have been a contributory factor in
the diminished need to develop a local ISPS organization in Finland. There have
been preliminary talks of the establishment of a Finnish ISPS organization but
so far no decisive actions have been taken. Still, there has been more active
participation in the Inter-Scandinavian activities, esp. the NIPS (Nordic
Investigation on Psychotherapy of Schizophrenia) -Project as well as in the
symposium the Scandinavian ISPS group arranged in Copenhagen.
FRANCE
France has a rich tradition of clinical and theoretical contributions to the
psychology of psychosis and especially well known are the adaptation of ideas
from Jacques Lacan into clinical work . There is also a strong tradition of
involving psychoanalytical ideas in work with families. There is no organisational
structure that link with ISPS but certain individuals have made important
contributions to ISPS conferences such as Francoise Devoine, Jean-Max
Gaudilliere, Pierre Delion and Didier Houzel. We think it is a matter of time
before there are stronger links, though language will be one complicating factor.
GERMANY
Over several decades, there have been a number of German groups with
connections with the ISPS and in 1981, the seventh ISPS symposium was
held in Heidelberg organised by Helm Stierlin. The latter had a considerable
international influence as a result of his creativity in his clinical and
theoretical work with families that have a psychotic member.
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AND
In more recent years Franz Resch, Professor of Adolescent Psychiatry in

Heidelberg became a member of the ISPS Board. He initiated a German wide
network during the World Association for Dynamic Psychiatry meeting in
Munich in March 2001. The new network organised a symposium on “Pre-
morbid personality development and its impact on the initiation of
psychosis” and a further meeting took place during the congress in
connection with the opening of the “Prinzhorn Exhibition” in Heidelberg,
September, 16th 2001
In 2002, Resch and his colleagues organised a well attended ISPS

conference again in Heidelberg that was linked with a ISPS Board meeting
and a number of members of the ISPS Board gave presentations (McGorry,
Australia, Johannessen, Norway and Martindale UK.)
ISRAEL
In 2004 and 2005, there was a rapidly growing interest in forming an ISPS
network in Israel due to the efforts of Orna Ophir, Shlomo Mendelovitc,
Shmuel Kron head of Shalvata mental center and Dr. Ilan Treves who worked
in Chestnut Lodge in the late 1980’s. They launched the network with a
conference in June 2005 that had some 250 participants from all over Israel.
It had the enchanting title of ’Wonders in the underground. Psychotherapies
with people living with schizophrenia.” Ann-Louise Silver was the overseas
speaker. Shalom Litman who has been connected with the ISPS for many
years also spoke about the nationwide spread of group therapeutic work that
facilitated the closure of the long stay hospitals and created a new paradigm.
The group intend to have an annual conference and bimonthly meetings.
ITALY
Italians have been very active participants in ISPS conferences especially
since the large Italian ISPS symposium held in Turin in 1988, organised by
Pier Maria Furlan. The authors of this chapter are very aware of the rich and
extensive contributions of clinicians to psychosis throughout Italy using
interventions based on psychoanalytic and family systemic approaches as
well as their psychosocial revolutions in the organisation of care. Of course
the influence of Gaetano Benedetti in many parts of Italy has been extensive.
We are hopeful that we will soon hear of networks forming that will link with
ISPS that will continue to support these traditions and maintain the
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international links. In the last two years Professor Tullio Scrimali from
Catania of Sicily, with an emphasis on CBT, has made good links with the
ISPS especially through his annual conference, Volcanic Minds, to which a
number of members of the ISPS Board have been invited and actively
participated introducing the breadth of modalities that ISPS represents.
NORWAY
Norway has hosted two international ISPS symposia: Oslo in 1975 and
Stavanger in 2000. The Scandinavian countries have been one of the
strongholds for psychological treatment of psychosis, especially as part of
the so-called ‘need adapted’ treatment programs. These are individually
designed comprehensive treatment programs, usually based on a
psychodynamic understanding and a practical, eclectic therapeutic approach.
ISPS Norway was founded in 2004, as the Scandinavian ISPS was dissolved
as a result of the basis of a wish to develop national chapters in the Nordic
countries. It’s secretariat is situated in Hamar in eastern Norway, where we
also have our regular national ISP conferences in January each year.
As well as giving inspiration to our clinical work, these conferences form the
basis for the financing of the secretariat. At present we have about 150
members.
POLAND
Professor Yrjö Alanen (Turku, Finland), through his lectures there and
translation into Polish of his book on the need-adapted approach to
Schizophrenia has been influential in Poland and it is hoped that an ISPS
network will soon formed.
RUSSIA
The main seat of ISPS-Russia is in the town of Stavropol, situated close to
the Caucasus region in the south of Russia.
Dr. Igor Bylim, chief psychiatrist in the Stavropol region, together with
clinical psychologist Alexey Koryoukin, are the driving forces in the ISPS-
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AND
Russia. The ISPS-Russia is co-organiser of three yearly national conferences

in Russia, together with the Stavropol psychoanalytic society. At present they
have about 20 active members.
Representatives from ISPS-Russia have participated at the two last ISPS-

international conferences.
SLOVENIA
In 2005 ISPS Slovenia was founded as an organization for the development of
clinical work and research on psychotherapeutic approaches for psychotic
patients. This followed a two day meeting in Portoroz of about 50 Slovenians.
Professor Urlia, Dr Ivezic and Dr. Bioaina, our Croatian colleagues were most
helpful in the formation of the organisation.
In Slovenia there is a long tradition (going back more than 40 years), of

group analytic work with patients with schizophrenia. This was developed
by Dr Franc Peternel, a member of the Institute of Group Analysis (London)
who practised as a psychiatrist at the Ljubljana University Psychiatric
Hospital.
Many Slovenian psychiatrists who are doing individual and group work with
patients with psychosis have attended the Dubrovnik School of Psychotherapy
for psychoses (see ISPS Croatia in this chapter) and a most important clinical
and scientific collaboration has developed. Further ISPS Slovenia meetings
are planned for late 2005 and 2006.
SPAIN
Madrid, the host city for the 15th ISPS International Congress, coinciding
with the 50th anniversary of the founding of ISPS, has for eleven years been
hosting an annual two day conference focusing especially on the global
approaches to the psychoses and schizophrenia and psychotherapeutic and
psychosocial treatments which could help those persons.
Dr. Manuel González de Chávez and his colleagues have been the driving force
behind these events that have drawn participants from the whole of Spain
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leading to an attendance of up to eight hundred. A host of international experts

including ISPS members have contributed amongst the main speakers
ensuring that our Spanish colleagues are well informed about developments
around the world and this has facilitated the development of Spanish
approaches and psychotherapeutic programmes.
Plans are in advanced stage to ensure that following the 2006 international
ISPS conference, the existing Spanish ISPS network will develop considerably
and that the conference will also encourage other Spanish speaking
countries and Portugal to form their own networks.
SWEDEN
ISPS-Sweden started in Stockholm in 2002. At the beginning the enthusiasm
was considerable and we started by having two meetings a year, a model we
have held on to.
Our initial aim was to discuss the different factors that we considered
important for the improvement of the care and treatment of psychotic
patients. Our aim was to write our own guidelines, as we were disappointed
with those that were to be presented by the Ministry of Health. We wanted
more emphasis on psychological methods, a change of the psychiatric
organisation and an increased awareness of the patient’s subjective
understanding of his or her problems.
However, the number of active participants decreased, and the general

opinion was that we needed more time for social interaction and more
contact with interested people outside the association. So in the autumn
of 2004 we had a big open meeting with Jaakko Seikkula of Finland as an
invited speaker. In the spring of 2005 the members met with John Read
from New Zealand for a whole day to share his experience, and some
reporters were invited to interview him in order to reach a wider
audience.
For the future we would like some programs to include actors, authors or
painters - former patients and others - who try to convey aspects of their
experience of psychosis.
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AND
SWITZERLAND
Switzerland is the home country of our ISPS founders, Gaetano Benedetti
and Christian Müller. Benedetti’s important writings have been translated
into German and Italian and a second book will appear in English in time for
the Madrid conference and the 50th anniversary of the founding of ISPS
which this book commemorates. Since 1956, Benedetti has been professor
at the University of Basel, where he has trained and supervised many
generations of psychoanalysts and psychoanalytical psychotherapists. In
1969 the then newly founded “Centro di Studi die Psichologia Clinica e
Psicoterapia” chose him and Professor Cremerius as their first and foremost
teachers. (In the following decades he taught in Basel and Milan in parallel).
In the course of the years the Milan institute became a centre of teaching and
research on the psychopathology and psychoanalytic psychotherapy of
psychoses. Publications of this Institute are testimony of this work. In 1972
Benedetti received the “Frieda Fromm-Reichmann-Prize” in Dallas, USA
and the “Jakob Burckhardt-Prize” in Basel 1981 for his scientific work. In
1990/91 he was proposed by the University of Basel for the Nobel-Prize.
Since the development of the ISPS into a formal organisation in 1997, the
main link with the ISPS has been through the lively Swiss network of the
EFPP (European Federation of Psychoanalytic Psychotherapy in the Public
Sector http://www.efpp.org/) which has sections devoted to child,
adolescent, group and individual adult work and which should soon have a
family section. Many of our Swiss colleagues in the EFPP work with people
with psychosis. As well as Benedetti’s work and influence, particularly
noteworthy is the work of ISPS member Julia Pestalozzi who has contributed
to the theory of disturbances in symbol formation.(ref. International Journal
of Psychoanalysis) and to the role of the body image, e.g. dysmorphophobia
in psychotic states.
As yet professionals from other theoretical modalities have not formed

networks.
UNITED KINGDOM
The UK has an extensive ISPS network of some 400 members. Hosting the
12th International ISPS Symposium in 1997 in London was a tremendous
impetus to implementing the psychological approaches to psychosis and to
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forming an ISPS UK framework to further develop interest, skills and their

implementation. Full details of the developments of the ISPS UK network
and its activities are contained in chapter devoted to the 12th ISPS
symposium, ‘Building Bridges’.
COMMENTARY
The decision to actively encourage the formation of ISPS networks in
countries, cities or regions followed on from the major change in focus of the
ISPS that was embedded in the creation of a constitution in 1997. The
summaries contained in this chapter indicate how much progress has been
made in a short time underlining the growing realisation that in order to
change practice it was going to be necessary for interested clinicians to be
in regular local contact for support and education and to determine a local
developmental plan. The foundations laid augurs well for the future of the
psychological therapies in psychosis in he countries mentioned. Although it
is of course hoped that the growth of such therapies will proceed apace
without the need for an organisation such as the ISPS, it would be naïve to
assume this. In fact not only will it be necessary for such groups to gather
professionals, it will also be necessary to ensure that at different hierarchies
in the mental health services there is adequate representation arguing the
need for such services and addressing obstacles to their provision. We
anticipate that in the next decade there will be a continuing growth of ISPS
groups, hopefully with many of them involving users, families and carers and
that some groups will be active in creating the conditions for policy change
and implementation at local and national levels.
E-mail contact details:

Croatia: Ivan Urlic and Sladia Ivecic
[email protected] [email protected]
Denmark: Bent Rosenbaum and Susanne Harder

Finland: Klaus Lehtinen

[email protected]
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Flemish network Jan Leitjen

[email protected]
Greece: Koukis Anastassios

[email protected]
Israel: Orna Ophir

[email protected]
Italy: Ivan Urlic and T ullio Scrimali

Norway Anne-Cathrin Emilsen

[email protected]
Russia Alexey Koryoukin

[email protected]
Slovenia Marjeta Blinc

[email protected]
Spain: Manuel González de Chávez

[email protected]
Sweden Sonja Levanger

[email protected]
Switzerland Julia Pestalozzi

[email protected]
UK Annabelle Thomas
[email protected]
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Establishment of local ISPS activities
20 A United States of America

The ISPS-US: A Personal
Account
Introduction
ISPS-US held its seventh annual meeting in November, 2005. Our
membership is approaching 300. We are a young group, gradually growing in
numbers and cohesiveness. In the past, people came to me at our meetings,
expressing how positively they felt towards the various presentation. Now,
many say, “I love ISPS!” We have a recipe for success: spicy talks on efforts
to start new Soteria Houses and to renew programs, talks on research
especially supporting humanistic approaches, heady theoretical discussions,
but the centerpieces, surrounded by case presentations, are the talks given
by recovered patients who tell us about their current projects. This year we
heard from Joanne Greenberg, Catherine Penney, and Will Hall.
We are very proud of the part we played leading to the removal of the
onerous recommendations against individual and family psychodynamic
therapy for patients with schizophrenia, that were dropped from the Patient
Outcome Research Team’s revised report. (Lehman et al., 1998 & 2004) The
PORT no longer says “psychotherapy aimed at understanding unconscious
drives or getting at the psychological roots of schizophrenia is never
appropriate.” The authors admit that this was a “level C” recommendation,
based on expert opinion, not hard data. They now say that they omitted
comment on this modality since it is no longer practiced, just as insulin coma
treatment is a thing of the past! We are now striving to see a positive
statement regarding psychodynamic therapy of schizophrenia included in a
future edition of the PORT. I will discuss our latest project in the conclusion
of this chapter.
As president of ISPS-US throughout this early phase, I love our group’s

dedication and scholarship. Our lively and informative listserve continues to
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inspire its readers and contributors. It is open to interested non-members

for a three-month introductory period: write to our executive director, Karen
Stern, at [email protected]. Our two-year-old website, www.isps-us.org
contains postings by our newsletter editor, Brian Koehler, that are required
reading in a growing number of training programs. We are an official non-
profit organization, battling against bio-reductionism and against the
pharmaceutical industry’s repeated but unsupported statement,
“Schizophrenia is a brain disease.” We see psychoses as disorders of
profound anxiety and chronic stress. When someone is beleaguered and
bewildered, he or she needs someone who is calmer and who is willing to
stand by and try to help understand. (Alanen 1986, 1997; Ciompi, 1988;
Fromm-Reichmann, 1950; Havens, 1976)
We fully support ISPS whose scope of treatments studied and supported has
widened well beyond psychoanalysis. We aim to foster psychosocial treatments
–to keep the individual sufferer known as a unique human being, with strengths
as well as weaknesses. Mind is not merely an epiphenomenon of brain activity;
illness does not result from bad genes. I believe we should not rely on monetary
support from the pharmaceutical industry which has turned our journals into
info-mercials and some say has turned the psychiatric residency training
programs in the U.S. into training in selling pharmaceuticals. (Angell, 2000 a &
b; Bodenheimer, 2000; Healy, 2003, a & b) I recommend Robert Whitaker’s
book, Mad in America: Bad Science, Bad Medicine, and the Enduring
Mistreatment of the Mentally Ill. It was runner-up for a Pulitzer Prize. Whitaker
was the keynoter at the ISPS-US fourth annual meeting in New York City, in
2002. He is a vibrant speaker and a careful scholar.
ISPS-US was founded on October 10, 1998 by David Feinsilver, M.D. a long-
time Chestnut Lodge medical staff member and chair of its symposium
committee. (Feinsilver, 1986) Quoting from my “Letter from the President” in
our first ISPS-US Newsletter, Summer, 1999, David “saw the Saturday after
Chestnut Lodge’s yearly symposium as a logical time, the Lodge the logical
place for the birth of our organization.” He chaired the ISPS symposium in
Washington in 1994, discussed in a separate chapter of this book. By October
of 1998, he knew that he struggled with advancing colonic cancer. He
gathered a group of thirteen interested Lodge staff members to discuss the
importance of launching a United States Chapter of ISPS. We all saw the
merit of this idea. He later urged me to take on the initial leadership; at first
I demurred. A group in Washington soon formed and joined with a study
group in New York City, headed by Brian Koehler with Julie Kipp. Their group
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Establishment of local ISPS activities United States of America
had been meeting monthly for about five years; Brian and Julie were regular
attendees of the yearly Lodge symposia.
The annual meetings of ISPS-US

By October of 1999, we were able to hold our first annual meeting, at the
Washington School of Psychiatry, co-chaired by Christine Lynn, M.S.W. and
Allen Kirk, M.D., “Creating Space for the Unaccommodated Self in Psychotic
States.” Julie Kipp, CSW, Christine Lynn, MSW, Marvin Skolnik, MD and
Virginia Hendrickson, MSW presented papers. We met the day after the
Chestnut Lodge Symposium which was dedicated to David Feinsilver’s
memory. Paul Carroll, Ph.D. wrote an eloquent summary of the meeting for
our fall, 1999 ISPS-US Newsletter, Vol. #1, Issue #2, which is posted at
www.isps.org and www.isps-us.org. Even in those early days, we began
talking about launching a journal, and about establishing a training and
study center for the treatment of psychoses. We still hope to actualize these
large goals. Julie Kipp, LCSW served as both secretary and treasurer. Joel
Kanter, M.S.W. established our ISPS-US listserve in 1999. At this point we
had branches in Washington and New York. As the organization grew, we
divided the tasks of secretary and treasurer. Julie Kipp continues as our
secretary. Barbara Cristy, LCSW, took over as treasurer, to be succeeded in
2005 by Julie Wolter, Psy.D.
David Feinsilver endowed a fund for a travel scholarship for the person
submitting the best paper on research on the psychotherapeutic treatment
of the severely disturbed; this would fund someone presenting who
otherwise would not be able to afford to attend. There have been two
recipients, Konstantia Zgantzouri, of Crete, Greece, who presented at June,
2000 ISPS meeting in Stavanger, and Ishita Sanyal of Kolkata, India who
presented at the Melbourne 2003 ISPS meeting. Various members of the
ISPS-US board have served as reviewers.
The following meeting “Creating Space to Talk to Patients”, October 7, 2000, also
took place at the Washington School of Psychiatry. The morning’s presentations
were by Wayne Fenton, MD on the history of U.S. asylums, by me on the history
of psychoanalysis and psychosis in the U.S., followed by a beautiful case
presentation by Betty Oakes, PhD, of Austen Riggs. The afternoon’s program
was a quasi debate with Anthony Lehman, MD, on the issue of the PORT Project.
Lacanian philosopher Wilfried Ver Eecke, PhD presented a well-crafted
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AND
challenge to the PORT recommendations against individual and family

psychodynamic therapy for schizophrenia, even in combination with medication.
(Ver Eecke, 2003) William Gottdiener, PhD presented his meta-analysis
demonstrating the benefits of individual psychotherapy for schizophrenic
patients. (Gottdiener & Haslam, 2002; Gottdiener, 2003) At the close of the
meeting, we learned from Wayne Fenton that a revision of the PORT Report was
being planned; he added that he was pessimistic that we could influence it. The
group, however, eagerly pursued the challenge.
I proposed to the ISPS board that an international task force be formed

challenging the PORT. The board responded promptly. Colin Ross, MD and
William Gottdiener, PhD represented the U.S. on the distinguished ISPS Task
Force on the PORT, chaired by Tor K. Larsen, MD, PhD. (Larsen, 2003).
Meanwhile, Douglas Ingrahm, M.D. was soon to assume his new
responsibilities as editor of the Journal of the American Academy of
Psychoanalysis and Dynamic Psychiatry. He invited me to serve as guest
editor of an issue devoted to this important debate, knowing that ISPS did not
yet have its own journal. I invited Tor K. Larsen to serve as co-editor. The
Journal issue, “The schizophrenic person and the benefits of the
psychotherapies—Seeking a PORT in the storm (Silver & Larsen, 2003)”
appeared in the spring of 2003, as Volume 31, Number 1. It now serves as
required reading in at least five college and graduate school classes.
Meanwhile, I was invited to join the 100 experts contributing to the first
revision of the PORT. On receiving the document I was thrilled to see that the
onerous Recommendations 22 and 26 had been deleted.
Our group contributed to other meetings as well. ISPS-US under David

Garfield, MD’s leadership presented a well-received panel at the American
Psychiatric Association’s 2000 Institute on Psychiatric Services, in
Philadelphia, “Out of psychosis and into life: Psychotherapy in the field.”
Presenters included Joel Kanter, MSW, Julie Kipp, MSW, Mary Moller, MSN,
and Michael Robbins, MD, with Wayne Fenton, MD discussant. During 2000,
ISPS-US members presented papers at the meeting of the International
Federation for Psychoanalytic Education (IFPE) held in Chicago, on the theme
of “Psychoanalysis and Psychosis.” ISPS-US became an affiliate member of
IFPE, (www.ifpe.org); an ISPS-US-Chicago branch formed at the IFPE
meeting. In 2003, we presented a panel at the winter meeting of the American
Academy of Psychoanalysis and Dynamic Psychiatry in Chapel Hill, North
Carolina, which I chaired, “Beyond medication: Remembering the spirit and
mind of the psychotic patient.” Presenters included Shelley Alhanati, Ph.D.,
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Clare Mundell, Ph.D., Garry Prouty, D. Sc. and in absentia, Brian Koehler,
Ph.D.. There were many young people in the audience who listened with rapt
attention, and who commented that all the material was both new and
inspiring. It is clear that we need to organize a system whereby our
membership can speak at various mental health training programs.
Our third meeting in 2001, also at the Washington School of Psychiatry, in

2001, “Celebrating our Dialogue” honored Maurice Green, M.D. Eight people
presented or served as discussants. About 60 people attended. Speakers
included Harold Stern, PhD, Andrew Martin, PsyD, Clare Mundell, PhD, Brian
Koehler, PhD, Maurice Green, MD, Michael Robbins, MD, Philip Alex, PhD and
Sue von Baeyer, PhD. We enjoyed our growing comfort with each other.
Our fourth meeting in 2002 was held at the William Alanson White Institute in
New York City and was chaired by Brian Koehler. About 75 attended. We held
the meeting on both Saturday and Sunday, and thirteen people presented
papers. We honored Bertram Karon, (Karon and VandenBos, 1981; Karon
2003) who presented an evocative paper. Harold Stern, PhD presented a
paper, and announced his plan to launch ISPS-US-Philadelphia. At our
business meeting, we adopted Articles of Incorporation and a constitution.
Our fifth meeting in 2003, “The mind behind the brain” was held at the
Thomas Jefferson Medical University in Philadelphia and was chaired by
Harold Stern, PhD. John Strauss, MD served as keynoter, “Subjectivity in
psychiatry: How can we do better?” In many ways, this has become the
theme for our two subsequent meetings. We honored Anni Bergman, PhD in
absentia, and watched a compelling documentary on her successful
treatment of an autistic girl. We mourned the passing of Victoria Conn, R.N.,
who had been the co-chair of this meeting. Again, we met for two days, and
heard from 27 speakers, and for the first time we held two simultaneous
tracks. The meeting closed with a lively and provocative panel, the outcome
of which was the launching of the ISPS-US e-seminar on psychoanalysis and
psychosis, moderated by Michael Robbins, M.D. Karen Stern, M.A had been
such a huge help in organizing this meeting that we then hired her as our
Executive Director.
Our sixth meeting in 2004 was held at Chicago’s Institute for Psychoanalysis.
Our keynoter was Leston Havens. (1976, 1986) We heard from twenty-six
presenters, including overseas speakers Chris Burford from London,
Danielle Bergeron from Quebec, and Francoise Davoine and Jean-Max
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AND
Gaudilliere from Paris. We explored the various ways psychosis is

understood by individuals from a variety of disciplines and theoretical
lenses. This meeting had four tracks and was the first to be held at a hotel.
Each day began with a plenary case presentation which really galvanized the
group. Jessica Wall presented her work with an autistic adolescent girl, and
Greg Rosen presented his work with an adult schizophrenic woman.
Our seventh meeting was held in Boston and chaired by Ron Abramson, MD.
Our keynoter was George Atwood, Ph.D. We explored various approaches to
understanding how people with psychoses experience their subjective
personal universes. The experience of every patient and therapist is valid
according to its own terms. Next year, we will meet in Los Angeles, celebrating
the formation of the ISPS-US-Southern California and the expansion of ISPS-
US-Northern California. Our theme will be “Trauma and Psychosis.”
We now have branches (ordered chronologically) in Washington, New York

City, Northern California, Chicago, Philadelphia, Michigan, New England,
and Southern California. Each branch is financially independent of the
United States Chapter.
A personal history
When we talk about the history of a group, we take for granted the histories
of its members. We assume a basic commonality and we respect each
others’ privacy. However, a unifying principle of ISPS-US is its commitment
to phenomenology, the close study of the events in the life of a person, and
the meaning that person gives to these events. One could say we are
following in the footsteps of Adolf Meyer. (Lief, 1948) Tim Calton, a Lecturer
in Psychiatry at the University of Nottingham presented his findings on the
strong representation of case reports (over 1/3 of all presentations) at our
ISPS symposia; but he warned that in recent years the percent has dropped
steadily. Meanwhile, at schizophrenia research conventions, a mere 2% of
papers highlight the particulars from an individual’s life. (Calton, in this
book).
As Gertrude Stein wrote,
“Sometime then there will be a history of every one of every man and
every woman from their beginning to their ending. Sometime there will
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be a history of every one and every kind of them and more and more
then every one will understand it, how every one is connected with
every one in the kind of being they have in them which makes of each
one one of their kind of them. More and more then this will be a history
of every kind and the way one kind is connected with the other kind of
them and the many ways one can think of every kind of men and
women as one more and more knows them as their nature is in them
and comes out of them in the repeating that is more and more all of
them.” Gertrude Stein, The Making of Americans, p. 126.
But while we have many papers illustrating their message with a case
presentation or some vignettes, I know very little about the lives of most of
the members of ISPS-US beyond aspects of their careers. We play our
personal cards close to our professional vests, learning much about our
close colleagues when we read their obituaries. Personal accounts belong
with our analysts, therapists, and perhaps family members and close
friends. But it is nobody else’s business. And yet the members of ISPS-US
have chosen career paths that differ from the mainstream of their
professional cohorts. We are a strange lot; we stay with our patients over the
long haul, through frustrating and often terrifying phases, struggling to form
relationships with people who have pulled away into their own tortured
worlds. We fight a strange battle repeatedly. When we succeed, we are told
that we have not cured “a schizophrenic,” but that the original diagnosis was
wrong. Our colleagues look to the heavens when we challenge the general
belief that “schizophrenia is a brain disease.” Again, quoting Gertrude Stein,
“Disillusionment in living is the finding out nobody agrees with you not
those that are and were fighting with you. Disillusionment in living is
the finding out nobody agrees with you not those that are fighting for
you. Complete disillusionment is when you realize that no one can for
they can’t change. The amount they agree is important to you until the
amount they do not agree with you is completely realized by you. Then
you say you will write for yourself and strangers, you will be for
yourself and strangers and this then makes an old man or an old
woman of you.” Gertrude Stein, The Making of Americans, p. 282.
Having an organization like ISPS-US thus keeps us young. We tend to

support each other, saying “yes” when the larger mental health community
shouts a resounding “no.” (This assertion minimizes the divisions within
ISPS-US, just as those outside Chestnut Lodge assumed a strong
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AND
philosophic unity, when actually big divisions existed there as well.) How
have we gotten ourselves into such a place of stubbornness? My guess is
that we each made this decision at a very early age. Frieda Fromm-
Reichmann, who died in 1957, one year before the ISPS was born, said, “I
was born to be a psychiatrist because beginning at three, I knew all the
secrets in the family and I took care not to disappoint my parents.” (Silver,
Psychoanalysis and Psychosis, p. 470).
My story (which I hadn’t yet shared with the ISPS-US group) begins with my
mother, as all personal accounts usually do. She was born in Warsaw. Her
father came to the U.S. when she was two years old; he worked in New York
City’s Lower East Side garment district. When my mother was four, she
came to the U.S. in steerage, along with her mother, Frieda, and her older
brother, Ben, on the last ship bringing immigrants at the start of World War
I. The voyage was stormy; her mother was severely seasick; my mother
thought she would die; her brother ran around the ship, making friends with
children on deck. My mother never forgave him for abandoning them. My
grandmother later developed a thriving dressmaking business. She could
sew a dress from sketches she made of dresses displayed in the windows of
Saks Fifth Avenue. My mother went on to be first in her class at a huge and
very competitive public high school, and then began at City College. But
something happened, and she did not complete the first semester nor did
she return, but worked for twelve years as a registrar at the Joint Diseases
Hospital.
She met my father at an adult camp in the Catskills, where my father was
the camp doctor. He was a public health physician. They married and moved
away from their families to Syracuse, New York where I was born. Among my
father’s duties as a health officer was performing lumbar punctures on
children suspected of having contracted polio. He dreaded infecting his own
children. He gowned up in surgical attire and a mask before coming into the
house, then showered before greeting us. Such a profound joy and relief
swept through our family when Jonas Salk announced discovery of the polio
vaccine, when I was about nine years old.
When I was four, we had moved to Albany, the state capital, when my father
was promoted. This was shortly after the world learned about the Holocaust.
My grandmother had been one of nine children. One brother had immigrated
to Argentina; the rest went to Russia and were killed. It was only recently,
visiting the Holocaust Memorial in Israel that I suddenly realized that it
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wasn’t just the seven siblings who died, but their spouses, children, the
children’s spouses and their children. They probably numbered between fifty
and one hundred people. My lack of acknowledgement of their very
existences left me flooded with guilt and grief, and I realized that I, too, have
a form of holocaust survivor syndrome, a workaholic trying to live for those
who were lost or were never born. My mother suffered more intensely but
privately; her mother had raised $1 million in war bonds, hoping this would
help her family. Helping the beleaguered who live in a psychotic world seems
my logical career sub-specialty.
Against my mother’s strong opposition, my father contracted to share

ownership of a two-family house with a colleague from the health
department, someone who would fill in for his older brother. We lived on the
second floor, the other family on the first floor. My mother had wanted a
single family home – even a tiny cottage. She became irritable, exploding at
me, and I became provocative. Once, she yelled at me and as she left my
room, I stuck out my tongue – I was sure her back was turned. She spun
around and spanked me. “I have eyes in the back of my head. I saw what you
did.” As a four-year-old, I believed her, even though I never got a glimpse of
those extra eyes. But I knew she was terribly perceptive. She often said, “I
know you better than you know yourself,” and her observations seemed to
prove it. I wanted to be able to see the world as she did. I tried very hard to
imagine seeing through her eyes, and in an instant when I felt like I was
succeeding, I experienced getting sucked inside her skull. I drew back from
this exercise in terror that I might get stuck in there forever.
The family tension increased over the next years. The downstairs parents chain-
smoked. The father asked my father to write him prescriptions for barbiturates;
my father refused. My mother could hear the two daughters crying for long
periods at night – the parents were too drugged to hear them. She became
terrified that they would set the house on fire, smoking in bed. She developed
severe insomnia which only made her more irritable. She claimed she could
listen at the wall and hear the downstairs couple plotting to take over the entire
house and throw us out. I listened at the wall and heard nothing. I was about
twelve. I read Freud’s Introductory Lectures, trying to figure out what kind of
paranoid my mother was. My father was in analysis with Clinton P. McCord, who
had been analyzed by Freud. McCord had made the famous slip of the pen when
paying for the first month of analytic sessions, “Pay to the order of Sigmund
Fraud.” McCord and his wife Alma organized the Albany Psychoanalytic Study
Group, whose members were physicians from various specialties. They rotated
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AND
homes for the monthly meetings. I was officially allowed to eavesdrop, sitting
behind the chair that would one day be my analytic chair.
When my mother’s insomnia worsened, my father arranged a consultation

for her with Dr. McCord. I fervently hoped she would be treated. (I wasn’t
making any progress with her at all.) She came home from that consultation
exultant. McCord said she had made more progress in one session than
most people made in years. She had figured out that she was not
fundamentally fearful that the downstairs neighbors would set the house on
fire, but was consumed with guilt over a fire she had inadvertently started in
her family’s apartment when she was seven. She had gone into her mother’s
sewing room looking for something and had turned on the light, not realizing
that there was an iron plugged into the same socket. The fire was easily
extinguished. Nobody was hurt, but the experience scarred her.
Dr. McCord let her feel his biceps. She felt honored. This interaction still
puzzles me. I was in despair that he had congratulated her and sent her away.
She didn’t even feel deprived, but even felt rewarded by this strange gesture. I
knew that this one session couldn’t resolve the depth of difficulties. Perhaps
my destiny was sealed that day, and I’ve had no real choice but to treat patients
others would call “unanalyzible” and stubbornly stay with them for as long as
it takes. In my psychiatric residency, we were assigned Fromm-Reichmann’s
posthumous paper, “Loneliness.” I knew I needed to learn everything she had
to teach. I went to a Chestnut Lodge symposium, where Harold Se arles
delivered his paper, “Unconscious processes in relation to the environmental
crisis.” He received a standing ovation, and I knew I’d found my future analyst.
When I began work at Chestnut Lodge four years later, I felt immediately at
home, and this was not a cozy feeling. The first day on one of the units I saw
a young woman who looked a lot like me, with the same frizzy black hair –
she was staring ahead vacantly. I felt like I was looking at myself in a mirror,
or looking at my crazy self. My mother died during my first year at the Lodge,
her repeated advice to me having been, “Don’t get too involved with your
patients.” I don’t think she meant sexually, but emotionally: don’t absorb
their craziness. Don’t fall into their skulls and end up seeing the world
through their eyes. Maintain your boundaries. I don’t think she ever would
have earned a diagnosis of schizophrenia.
It’s only now, on writing this, that I see a fundamental connection between
my mother’s abhorrence and dread of the downstairs neighbors’ dependency
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on sleeping pills and my own sense of despair over the profession’s over-
reliance on the various so-called “anti-psychotic” medications, medicines
that work primarily by putting the limbic system to sleep as it were, dulling
salience, or the ability to respond emotionally to ongoing experiences,
whether internal or external. (Kapur, 2002, 2003)
At Chestnut Lodge, in the 1980s, some of the women on the medical staff
formed a study group on working with potentially violent patients. We began
with a literature review, and then moved to an autobiographic phase which
we called the “what is a nice girl like you doing in a place like this?” phase.
We took turns telling aspects of our life stories. We all started by talking
about our mothers. Our backgrounds were very diverse. The only
commonality we found was that we all considered our mothers very
depressed. One had been suicidal. We all felt that our mothers’ difficulties
formed a large motivating factor in our career paths. We presented our
findings at a Lodge symposium, but never published. (LaVia, D. et al. 1986)
A philosophy of ISPS-US
The charismatic Gaetano Benedetti, (Benedetti, 1987, 1988, 1993) co-
founder of ISPS, was born in 1920. He comes from a family with a proud and
long scientific tradition. He worked for ten years with Manfred Bleuler, and
has been a professor of psychiatry in Zurich, Rome and Basel. He has been
awarded many honors, has published about 400 papers and over 20 books.
He has spoken in over 100 international conferences in Europe, North
America and Asia. While stressing the value of the triennial meetings, he
says [unpublished] that more vital are the ongoing small groups within
institutions, where colleagues can discuss their preverbal communication
experiences, bringing the colleagues closer to a group therapeutic
symbiosis. “…if the therapist manages to overcome the fear of symbiosis,
then the work is half done. Of course the resistance of the patient is still to
be overcome, which is impossible sometimes…”
This fear of symbiosis was what I had dreaded when I tried at age four
literally to see the world through my mother’s eyes. Now, I realize that we
develop theory in part to maintain our personal boundaries, armoring
ourselves in theories that allow us to pull back from the immediacy of
therapeutic symbiosis, to generalize as if disembodied, hovering above the
therapeutic dyad, observing it like a scientist viewing an organism through a
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AND
microscope. John Strauss, who was the keynote speaker at the 5th annual
ISPS-US meeting, asks, “In this difficult and fascinating field which ought to
be a human science, how do we deal with being scientific about humans, how
do we deal with subjectivity and objectivity at the same time?” We
professionals use theory to guard ourselves from over-identification with our
patients. We can draw back and think about their dynamics when we
resonate with their fragmentation and feel that we ourselves might shatter.
A patient once said to me, from his cold wet sheet pack, that he was a comet
– a cluster of hunks of ice held in fragile connection by each other’s
gravitational pull. He warned me not to get too close to him, or I might
become a comet too, and what good would one comet be to another?
It was not until the 1994 meeting in Washington that a formal organization
was finally formed, thanks to the efforts of Chestnut Lodge’s David Feinsilver
and others on the ISPS board. David founded ISPS-US in October 1998, as he
struggled with the final stages of colonic cancer. The mission of ISPS is to
promote the appropriate use of psychotherapy and psychological treatments
for persons with schizophrenias and other psychoses, to promote the
integration of psychological treatments in treatment plans and
comprehensive treatment for them, to promote the appropriate use of
psychological understanding and psychotherapeutic approaches in all
phases of the disorders including both early in the onset and in longer
lasting disorders and to promote research into individual, family, group
psychological therapies, preventive measures and other psychosocial
programs for those with psychotic disorders. We support treatments that
include individual, family, group and network approaches and treatment
methods that are derived from psychoanalysis, cognitive-behavioral,
systemic and psycho-educational approaches. We advance education,
training and knowledge of mental health professionals in the psychological
therapies and psychosocial interventions in the treatment and prevention of
psychotic mental disorders for the public benefit regardless of race, religion,
gender or socio-economic status. Reflecting the large umbrella, the name of
the group enlarged also, moving from the International Symposia for the
Psychotherapy of Schizophrenia to the International Society for the
Psychological treatments of the Schizophrenias and other psychoses – still
keeping the initials ISPS. But there is a consensus that this organizational
name is just too long and awkward. But what this new name might be is not
yet clear. As concern grows that the very name “schizophrenia” is outmoded
and pejorative, connoting an incurable brain disease, we may decide to
relinquish the ISPS initials. And there is tension between the psychoanalytic
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contingent and the others; are the psychoanalysts trying to pull the group
into the past, are we obstructionists, elitists? The group is open to everyone,
mental health professionals and others in the mental health field, patients
or consumers and their families and friends, and all interested others. We
are not interested only in the treatment of psychosis, but in all aspects of
understanding it.
The Melbourne 2003 meeting seemed centered around the debate “Can
psychological and pharmacological approaches be integrated in the
treatment of schizophrenia?” I participated on the “con” side of the debate,
along with John Read (2001, 2003, 2004) and Richard Bentall (1990, 2003). I
thought we won a clear victory over enormous odds, but the moderator
declared the event a draw. Wayne Fenton (my friend and co-worker at
Chestnut Lodge – our fathers had worked together at the New York State
Department of Health decades earlier) represented the “pro” side of the
debate. On arriving at the microphone, he joked with the audience saying, “I
wish I were as sure about something as Dr. Silver seems to be about
everything.” The audience responded with a low “ooh” that seemed to me a
polite booing. My remarks do not represent an official viewpoint of ISPS-US
although many in that group agree with me; they are posted at the ISPS
website, www.isps.org. I believe that this debate will be with us for decades
to come. We stand for the humane and optimistic treatment of psychosis,
one person at a time.
ISPS-US, now in its seventh year. Our growth parallels that of ISPS itself. It
has been invigorated by our very active listserve. We fought and partially won
a big battle regarding the American Psychiatric Associations guidelines for
the treatment of schizophrenia which drew from the Patient Outcome
Research Team’s or PORT’s recommendations. Recommendations 22 and 26
in the first version recommended against psychodynamic treatment even in
combination with medication, and recommended against psychodynamic
family therapy. The National Alliance for the Mentally Ill quoted these
recommendations prominently in their literature to families. Through our
annual meetings, we believe we were instrumental in the dropping of those
two onerous recommendations from the second issue of the PORT Report.
However, we will not be satisfied until the PORT writes in favor of the kind of
work we do. We are organizing a clinical survey of our 300 members, which
will be the foundation for a research project which should yet again
demonstrate the value of getting to know the patients we treat. And we are
working on a text book written by members of ISPS-US, edited by David
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AND
Garfield who organized and headed our ISPS-US-Chicago branch and who
chaired our very successful 6th annual meeting there. We want to conduct a
research study in which we compare the work in clinics that are infused with
this phenomenological energy with those that are struggling to be maximally
efficient. We want to look at how the patients are doing, how they feel about
their treatment, and we want to see how the staff feels, and if the longevity
of employment at those clinics becomes significantly different. But
fundamentally, we want to see a resurgence of dedication to the multitude of
individuals struggling with psychotic disorders, bringing them need-specific
treatment (Alanen, et al., 1986; Alanen, 1997).
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Schizophrenia: Approaches to Psychosis: From the One to One Laboratory to the
Psychosocial Models. Turin, September 14-17, 1988. Published by ISPS.
Bentall, R. (ed.) (1990) Reconstructing Schizophrenia. London. Routledge.

———-. (2003) Madness Explained: Psychosis and Human Nature. London. Penguin.
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Bodenheimer, T. (May18, 2000) “Uneasy alliance: Clinical investigators and the

pharmaceutical industry.” New Eng. J. of Medicine. 342, 20: 1539-1544.
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Dorman, D. (2003) Dante’s Cure: A Journey Out of Madness. Other Press, New York.
Feinsilver, D. (ed.) (1986) Towards a Comprehensive Model for Schizophrenic

Disorders: Psychoanalytic Essays in Memory of Ping-Nie Pao, M.D. Analytic
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Schizophrenia: New Approaches to Psychosocial Intervention, Part 1. Yale
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August, 1985.
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Mentalization, and the Development of the Self. New York. Other Press.
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Psychoanalysis and Psychosis, International Universities Press, Madison, CT,
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Havens, L. (1976) Approaches to the Mind; Movement of the Psychiatric Schools

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404; Vol. 102, pp. 1-85.
Kapur, S. (Fall, 2002) NARSAD Research Newsletter Vol. 14, Issue 3, p. 12.
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Lehman, A. & Steinwachs, D. (1998) “Translating research into practice: The

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Papers. McGraw-Hill Book Co., New York.
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The Psychotherapy of Schizophrenia. Plenum, New York.
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11-15,1991. Published by ISPS.
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Obstructive Factors. Scandinavian University Press, Oslo.
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AND
Whitaker, R. (2002) Mad in America: Bad Science, Bad Medicine, and the Enduring
Mistreatment of the Mentally Ill. Cambridge, MA. Perseus.
4966 Reedy Brook Lane,
Columbia MD 21044-1514
[email protected]
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20 B Australia
John Gleeson
In early 1990s in Australia, The National Mental Health Strategy was

launched in Australia as a joint initiative of the Federal, five State and two
Territory Governments (Australian Health Ministers, 1992). The Strategy set
policy directions and priorities for mental health until mid-1998. The main
thrust of the Strategy included an expansion of community-based, case-
management sector of mental health services and reduced reliance on
inpatient services. These policy developments were refined by further
iterations of the plan in the late 1990s and beyond (Australian Health
Ministers, 1998; 2003). Despite these policy commitments a national
prevalence surveys of people diagnosed with psychotic disorders revealed
that less than 40% of individuals with psychotic disorders reported receiving
counselling or any form of psychotherapy over the previous year (Jablensky
et al., 2000). Not surprisingly, this evidence provided a basis for cogent
arguments for a redistribution in Australia of mental resources for the
treatment of psychosis towards psychosocial treatments and community
supports (Neil, Lewin, & Carr, 2003).
Unfortunately, there is no evidence that the redistribution will be underway

any time soon. In late 2005 the peak body representing carers and
consumers of mental health care, The National Mental Health Council of
Australia, placed the human experience behind this statistic on the centre
stage of the national health debate with the launch of their report into the
state of mental health care. The title of the report is an apt summary of
submissions from across all states and territories: Not for service:
Experiences of injustice and despair in mental health care in Australia (Mental
Health Council of Australia, 2005).
At the last international ISPS conference in Melbourne, in September 2003,

a meeting was held with the aim of developing an Australasian ISPS
network. No doubt many at this meeting were motivated by a working
knowledge of the poor access to the full range of treatment options. After the
meeting, it became clearer that two networks, in New Zealand and Australia,
would evolve with perhaps varying but overlapping priorities.
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AND
With support from ORYGEN Youth Health for a secretariat, Helen Krstev,
Eoin Killackey and John Gleeson communicated with colleagues around the
country to form an initial core working group with links to public sector
mental health services. The initial core working group consists of
representatives from Victoria (Helen Krstev, Eoin Killackey and John
Gleeson), New South Wales (Simon Jakes), Queensland (Sally Plever), South
Australia (Harry Hustig) and Western Australia (Tracey Harrison). This
geographical representation is particularly critical in Australia where there
are significant variations in mental health services across the states and
territories. The group have met regularly via teleconference, and have
agreed that ISPS Australia would have an important role is promoting
psychological interventions throughout the Australian public mental health
sector. ISPS Australia would be particularly motivated to support efforts in
relation to improved access to a broader array of interventions by providing
an additional focal point for clinicians to join with carers and consumer
groups to promote this urgent agenda, with the backing of ISPS
international. The group has also discussed the value the network would
provide in supporting the workforce committed to psychosocial treatments.
Already, approximately 30 professionals have expressed interest in joining
the network even before a call for membership has been launched.
The group has agreed that the main tasks for the establishment of the
network include:
• Formally registering as an association

• Launching the new network and promoting membership
• Establishing and maintaining a simple ISPS Australia web page and
newsletters which would be linked to the International site
• Planning an initial Australian ISPS conference in 2006, as a sate little
meeting attached to a larger conference in the first instance.
It is anticipated that as the network in launched in 2006 it will provide an

active voice in promoting access to psychosocial treatments in Australia and
an important additional resource for clinicians.
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Establishment of local ISPS activities Australia
References
Mental Health Council of Australia, (2005). Not for service: Experiences of injustice
and despair in mental health care in Australia. Canberra.
Jablensky, A., McGrath, J., Herrman, H., Castle, D., Gureje, O., Evans, M., et al.
(2000). Psychotic disorders in urban areas: An overview of the Study on Low
Prevalence Disorders. Australian and New Zealand Journal of Psychiatry,
34(2), 221-236.
Ministers, A. H. (1998). Second National Mental Health Plan. Canberra:
Commonwealth Department of Health and Family Services.
Ministers., A. H. (1992). National Mental Health Plan. Canberra: Australian
Government Publishing Service.
Ministers., A. H. (2003). National Mental Health Plan, 2003-2008. Canberra:
Commonwealth Department of Health and Family Services.
Neil, A. L., Lewin, T. J., & Carr, V. J. (2003). Allocation of resources and psychosis.
Australian and New Zealand Journal of Psychiatry, 37(1), 15-23.
John Gleeson,
14-20 Blackwood Street
Melbourne 3010
[email protected]
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20 C New Zealand
John Read, Jim Burdett, Jim Geekie, Helen P. Hamer, Patte Randal, Dale
Rook, Melissa Taitimu
Although New Zealanders had been individual members of ISPS for some
years, the first move towards forming a national ISPS group followed the
2003 Symposium in Melbourne. We invited three of the international
speakers at Melbourne, Richard Bentall and Tony Morrison (UK) and
Courtenay Harding (USA), to New Zealand to be keynote speakers in our
‘Psychology of Psychosis’ conference, organised jointly with the Psychology
Department of the University of Auckland, immediately after the Melbourne
event. We were delighted to find nearly 200 people, from a range of
disciplines, including users of mental health services, showed up. We
decided, therefore, to make this an annual event – renamed, in order to
broaden the appeal and focus, to ‘Making Sense of Psychosis’. At the second
conference, in 2004, we were again excited that the same number attended
the two day event, at which our keynote speaker was Ron Coleman from the
hearing voices movement in the UK. It was formally agreed, at this
conference, to establish a New Zealand branch of ISPS. A steering group of
five was elected, with the professions of psychiatry, psychology and
occupational therapy represented. We subsequently extended the group to
include a nurse and a service user.
During 2005 we have worked on the time-consuming tasks of registering as

a formal organisation with our government, establishing a bank account and
so forth. Everyone registering for the third annual conference (October 2005)
automatically became a member. Our keynote speaker for 2005 was Dr Colin
Ross (USA), author of ‘Schizophrenia: Innovations in Diagnosis and
Treatment’ (2004).
Six New Zealanders contributed to ‘Models of Madness’ the first in the

current ISPS book series, and members have also written a chapter about
New Zealand for the forthcoming ISPS book “Past, present and future of
psychotherapeutic approaches to schizophrenic psychoses.”
Our objectives in New Zealand are the same as the ISPS as a whole. The
flavour of our conferences was eloquently captured by Dr Nicholas Marlowe
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AND
(Sydney, Australia) when he described our 2004 conference (ISPS Newsletter

- Spring 2005):
“The cultural and professional diversity of the speakers ensured a multi-layered

perspective on the complex and multi-dimensional problem of psychosis. … The
emphasis was upon understanding symptoms and difficulties within the context
of the client’s lived experience. … The courage and openness with which some
of the participants discussed their own personal experience of psychosis and
recovery, focused the conference on the necessity of a person-centred
paradigm.”
We look forward to getting as many Kiwis as possible to Madrid 2006, and to

future ISPS symposia. We are determined to play our part in ensuring that
the ISPS goes from strength to strength in the coming years.
Do plan a trip to the land of Gandalf and Frodo soon.
John Read
Psychology Department
The University of Auckland
Private Bag 92019
Auckland, New Zealand
[email protected]
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20 D Eastern Asia:
The Singapore Chapter
Lyn Chua
Psychological treatment for mental illnesses has not really been established
and its effectiveness not readily acknowledged in Asia. Hence, societies
advocating such treatment for mental illnesses have not attracted much
support. This is mainly due to the fact that the treatment of psychiatric
disorders in Asia has been, and still largely is, very biological in approach. It
is only in recent years that psychological interventions and activities like
those of the ISPS have caught the attention of mental health professionals in
Asia. This has given those in Singapore who believe in the necessity and
effectiveness of psychological treatment to initiate the formation of a local
Singapore Chapter of the ISPS at the end of the year 2003.
Resistance in seeking psychiatric treatment for psychiatric illness has been

a long-standing problem in Eastern Asia. Many East and South-East Asians
have retained their faith in “native treatment.” It is very common for people
afflicted with mental illnesses or psychological distress to prefer being
treated by traditional healers, temple mediums, priests and witch doctors.
This is mainly due to their religious beliefs, cultural influences, folk
traditions and their superstitions that illness, especially mental illness, is
the result of physiological factors (for example, imbalance of the yin and
yang) or of supernatural forces (like spirit possession). The process of
psychoeducation is an uphill task because of such deeply-rooted beliefs.
Moreover, the stigma attached to mental illness is still very strong, and the
suggestion of psychiatric treatment in East and South-East Asia is not
readily accepted. Psychiatric patients and their relatives are, however,
gradually beginning to accept that they have an illness and that, like all other
illnesses, they believe they might benefit from taking medication. Hence, the
approach in the treatment is still largely medical in nature in these Asian
regions, and patients with schizophrenia and other psychotic illnesses are
being treated, until recently, almost solely with antipsychotic medication.
Singapore is an island state in South-East Asia with a multi-ethnic

population which currently stands at 3.5 million. There are three main ethnic
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AND
groups, the largest being the Chinese (77%), followed by the Malays (14%)
and the Indians (9%). The various cultural values and beliefs of this multi-
racial and multi-religious Asian society play an important role in influencing
their attitudes toward the treatment of mental illnesses, especially the
psychoses.
The first psychiatric hospital in Singapore was built by the British colonists
in 1841; it was then regarded as an asylum for the insane, the approach
mainly custodial and medication was given primarily to sedate
“troublesome” patients. With the advent of medical education in Singapore,
care of the mentally ill gradually improved over the years. Psychiatry in
Singapore came of age in the 1980s. It is primarily biological in orientation,
with psychopharmacology as the mainstay of psychiatric treatment;
psychotherapy has not been emphasized. Although there was a semblance
of a multidisciplinary team approach as occupational therapy was present in
1955 and some form of psychological services were introduced in 1956,
these were mainly in the areas of rehabilitation and psychometric testing;
counseling and psychotherapy were provided only on a “limited scale,” for
about only 6% of the patient population as reported by Dr BY Ng in his recent
book on the history of mental health services in Singapore. This has
remained very much the same, with some small changes until more
recently. In April 1993, after several re-buildings and relocations, the new
psychiatric hospital and Institute of Mental Health finally settled in its
present location as an impressive, modern cluster of low-rise blocks with a
bed capacity of 2,943 and state-of-the-art technology.
The usefulness of psychological treatment in schizophrenia and psychotic

illnesses came into significance only in recent years in Singapore. Mental
health care professionals began to realize the need for a holistic approach,
and that medication alone is insufficient in enabling the individual to return
to optimal functioning. Supportive and behaviour therapy was previously
provided on an ad hoc basis by the staff caring for these patients. However,
with the development of the Early Psychosis Intervention Programme (EPIP)
in 2001, patients with schizophrenia and other psychoses referred to the
Programme were routinely provided with psychological treatment by
members its multidisciplinary team. The strategies of EPIP, besides
educating the general public about schizophrenia and networking with
primary healthcare providers, included the provision of a holistic treatment
for all patients. Family and group therapy, individual psychotherapy, psycho-
education, social, educational and vocational guidance, and case
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Establishment of local ISPS activities Eastern Asia
management augmented the pharmacotherapy. A culturally-oriented

psychotherapy “package” named PASTE (Personal And Strategic Coping
Therapy for Early Psychosis) has been developed specifically as a
psychotherapeutic intervention for the multi-ethnic patients in Singapore. It
takes into account individual patients’ personal, religious and cultural
beliefs about the causes of their psychotic symptoms; this contributes to the
development of a stronger therapeutic alliance. The psycho-education
provided has also been given a culturally-relevant slant.
The upsurge of interest in the psychological treatment of schizophrenia

provided the opportunity and platform from which activities of ISPS could be
publicized and promoted in Singapore. Interest in the objectives of ISPS grew
as a result of the involvement of these mental health professionals in
psychological treatment for the mentally ill, and their belief that it is
essential and effective.
This interest resulted in the birth of the Singapore Chapter of the ISPS in
December 2003. A gathering of 32, comprising psychiatrists, psychologists,
social workers, occupational therapists, nurses and case managers voted in
a protem committee of nine, which later met to discuss administrative
matters like registration with the Singapore Register of Societies, opening a
bank account, membership fees, and setting the programme of activities for
the following year. Since we started with no funding and minimal
membership fees, our activities were rather limited; we were unable to
organize any conferences nor invite speakers from overseas. Nevertheless,
we managed to take whatever opportunities that came our way. We were very
fortunate to have had Professor Max Birchwood from Brimingham, UK,
conduct a short workshop on “CBT for patients with First Episode Psychosis”
during one of his visits to Singapore in January 2004. Professor Anthony
Bateman from St Ann’s Hospital in North London who was in Singapore to
conduct a course for the hospital in March 2004, also obliged our Singapore
Chapter with a lecture on “Psychodynamic Psychotherapy in the Treatment
of Schizophrenia.” These sessions generated a great deal of enthusiasm,
discussion and ideas amongst ISPS Singapore members.
Unfortunately shortly after these events, the local Chapter encountered

several obstacles and unforeseen circumstances which have hindered
further development and progress of its activities. However, there are
encouraging signs that the Chapter may regain momentum despite these
difficulties as more interest is generated and more new members from
299
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AND
various others sectors of the mental health services are recruited. We are
optimistic that we will survive these adversities.
Similar to Singapore, the prevalence of a biological approach to the treatment

of schizophrenia is still very predominant in other East Asian countries.
Although there has been some indication of interest from other countries in
this region, including China, Japan and Malaysia, to form local ISPS groups,
they seem to have encountered difficulties in gathering together a group of
people to initiate the formation of such groups in their respective countries. It
appears that the nature of their work, their main treatment approach and the
geography of the country are the main causes of the difficulties. Colleagues
in Hong Kong, however, have started holding gatherings which hopefully will
evolve into the formation of a local ISPS group.
Lyn Chua
Department of Psychological Medicine
Young Loo Lin School of Medicine
National University Hospital
3 Lower Kent Brigde Road
Singapore 119074
[email protected]
300
7535 2a parte 01_7535 001-08 01 09/06/16 12:30 Página 301
Breaking the Covenant
21 A. International schizophrenia
research and the concept of
patient-centredness 1988 – 2004
21 B. Commentary on “Breaking the

Covenant: International
Schizophrenia Research and the
Concept of Patient-Centredness
1988-2004” by Timothy Calton,
Anna Cheetham, Karen D’Silva and
Christine Glazebrook.
301
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
21 A. International schizophrenia
research and the concept of
patient-centredness 1988 – 2004
Timothy Calton, Anna Cheetham, Karen D’Silva & Christine Glazebrook
Funding acknowledgment: This study was supported by a £500 grant from

Nottinghamshire Healthcare NHS Trust
“There is something seriously missing in a field of mental illness that does not attend
closely and broadly to subjective experience and the self” Strauss 1989 p.1771.
The unconscious covenant

What do or should we value in our attempts to understand human
experiences? This universal philosophical dilemma has occupied human
beings since antiquity, and has provoked acrimonious debate within
medicine in general, and psychiatry in particular. Empirical studies using
published research as data have shown that psychiatry, in cleaving to the
‘medical model’ approach to mental disorder, has traditionally valued
objective, fact-based and predominantly biological explanations and
interventions for mental disorders throughout the twentieth century(2-4),
despite challenges from psychoanalytic theory and the anti-psychiatry
movement(5). It could be argued that this preoccupation with the biological
achieved its apogee with the ‘Decade of the Brain’ initiative of 1990(6), which
mandated a reductionist approach to understanding the brain, and
stridently pronounced the validity of a biological perspective for
schizophrenia(7), the paradigmatic mental disorder. Yet, despite the
immense amounts of time, energy and resources poured into this positivist
endeavour, no truly reliable, specific and objective criteria for
differentiating people experiencing mental disorders such as schizophrenia
from, so-called, normal people have been identified(8). Indeed by dint of this
it could be argued that psychiatry maintains an often unconscious covenant
with subjectivity(1).
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AND
The patient-centred ethos

In contrast to the biological approach adopted by mainstream psychiatry, the
‘patient-centred ethos’, which coalesced as a substantive model for the
practice of medicine at the University of Western Ontario in Canada in the
late 1980s(9), explicitly seeks to understand patients’ values as lived
emotional experiences, taking into account their understanding of their
illness and their expectations regarding treatment(10). The core feature of the
concept of patient-centredness is the need to effect a balance between facts
and values, between objective theories of disease and the subjective
experience of illness(11). Within medicine the patient-centred ethos has been
shown to increase patient satisfaction(12, 13) and adherence(14), as well as
improve self-reported health(15) and physiologic status(16). Within psychiatry,
the patient-centred ethos has influenced assessment(17), the diagnosis and
treatment of schizophrenia(18-20), patients’ and carers’ attitudes towards
services(21), and the design and provision of services(22, 23). Perhaps most
significantly, the patient-centred ethos has been enshrined in governmental
policies on mental healthcare provision across the world(24-28). Hence it could
be argued that since the late 1980s theory and research in
medicine/psychiatry should have been informed by both the biological
approach and the patient-centred ethos. This was certainly the position
adopted by our group in attempting to determine whether psychiatry’s
covenant with subjectivity was honoured within the realm of international
schizophrenia research between 1988 and 2004.
The populations studied

Our group evaluated every conference abstract published by the
International Society for the Psychological Treatment of Schizophrenia and
Other Psychoses (ISPS) between 1988 and 2003. In addition we scrutinised
all the conference abstracts published by both the International Congress on
Schizophrenia Research (ICSR) and the Biennial Winter Workshop on
Schizophrenia (BWWS) between 1988 and 2004. The rationale for selecting
conference abstracts was simple; by circumventing the publication bias
intrinsic to journal articles(29), they facilitated a much clearer idea of what the
researchers and clinicians who attended these conferences actually did and,
therefore, valued(30). In addition, the vast majority of abstracts submitted to
these conferences were accepted for publication(31, 32), hence there was
virtually no attenuation of the research once it had been submitted. The
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conferences selected for analysis were, broadly speaking, representative of

the global schizophrenia research community: their output was certainly
much more representative of the international schizophrenia research
output than published work over the same period. The time period was not
chosen arbitrarily, rather it represented the point when a distinct dialectic
emerged between the biological approach (as exemplified by the ‘Decade of
the Brain’ initiative) and a robust empirical model of patient-centredness.
We excluded all abstracts not written in English and removed all duplicates
using pre-defined criteria.
Defining the subjective

Our group formulated, by a process of argument and debate, the following
operational definition of ‘subjective experience’ research:
‘Subjective experience’ research is that in which the main aim of the

research is to address the patient’s subjective experiences, and their
relevance and meaning to the patient, with the latter being evidenced by the
research:
• Addressing the patients’ individual feelings as ‘lived emotional

experiences’
OR
• Considering patients’ ideas and expectations regarding their illness and

treatment.
OR
• Considering patients’ opinions in determining the aims and outcomes of

the research.
Clearly the emphasis on subjective experience was a logically necessary

component, but it was felt that having this as the sole criterion would be too
overinclusive and, hence, not discriminate between research that simply
mentioned, en passant, patients’ subjective experiences, and those pieces of
research that went beyond this, into the ‘lifeworld’ of the patient. To go
beyond the surface and assess the degree to which the ‘lifeworld’ was
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AND
addressed the phrase “…and their relevance and meaning to the patient” was
included. This directly incorporates Mishler’s notion of the subjective
meaning of illness events(33) and was felt, by orienting the definition onto the
lived experience of the patient, not the interests of the researcher, to
facilitate the discrimination posited above. The term “main aim” was
incorporated to ensure that only those pieces of research, which maintained,
as their primary focus, the subjective experiences of the patient, would be
captured by the definition. The subordinate criteria were derived from the
Measure of Patient-Centered Communication (MPCC)(9), a psychometrically
robust semi-structured measure of patient-centredness developed to
facilitate the assessment of patient-centredness in clinical practice. A broad
definition of ‘patient’ was used, based on an understanding of patients as
individuals existing within a variety of systems, including the family.
This definition was then applied to all of the selected abstracts, with each
abstract being rated as ‘subjective experience research’ or ‘non-subjective
experience research’ by the main rater (TC). Additional data were collected
for all three conferences on country of author origin and category of
research (biological, psychosocial, epidemiology, diagnosis and
phenomenology and miscellaneous). For the ISPS conferences data were
also gathered on subtype of research (case report, service description,
theory paper, outcome or trial paper and miscellaneous) and therapeutic
orientation (psychodynamic, cognitive-behavioural, systemic/family or
other). Independently assigned data categories were used wherever possible
in order to minimise rating biases. For all operationally defined criteria good
to excellent inter- and intra-rater reliability was obtained prior to data
collection.
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Results
Population descriptions
The six international ISPS conferences held between 1988 and 2003
produced 1,154 published abstracts. 153 (13%) of the abstracts from the
1988 conference were in Italian and were excluded, as were 9 (0.8%)
duplications. This left 992 abstracts for analysis. The mean number of
abstracts presented per year was 165 (s.d. 90, range 61-280). There were a
total of 9577 abstracts presented at both the BWWS and ICSR between 1988
and 2004. Of these 293 (3.1%) were duplicates and were excluded. This left
9284 abstracts for analysis with the mean number of abstracts presented
per year being 546 (s.d. 307, range 143-1069). Due to the fact that ICSR and
BWWS have identical stated subject matter, aims and abstract acceptance
criteria, it was felt that combining them into one entity, for the purpose of
analysis, was justified, though, for the converse reason, their data were not
combined with those from the ISPS conferences.
Figures 1 and 2 show that the total number of abstracts presented at both
the ISPS and ICSR/BWWS increased over time. This interaction attained
statistical significance in both cases:
Fig 1. Number of abstracts presented Fig 2. Number of abstracts presented

at ISPS by year at BWWS and ICSR by year
300 1200
Number of abstracts presented
Number of abstracts presented
1000
200 800
600
100 400
200
0 0
1988 1991 1994 1997 2000 2003 1988 1990 1992 1994 1996 1998 2000 2002 2004
1989 1991 1993 1995 1997 1999 2001 2003
Year of conference Year of conference
In relative terms the ISPS conferences produced many more psychosocial

abstracts than ICSR/BWWS, with the opposite being true for biologically
oriented abstracts, as is shown in Table 1. The proportions of abstracts in
the remaining categories were similar.
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AND
Table 1. Numbers of abstracts presented in each category for both the ISPS
and ICSR/BWWS conferences.
Number of abstracts Number of abstracts
presented at ISPS (%) presented at ICSR/BWWS (%)
Psychosocial 775 (78.1) 449 (4.8)
Biological 36 (3.6) 6960 (75.0)
Diagnosis and phenomenology 63 (6.4) 840 (9.0)
Epidemiology 53 (5.3) 768 (8.3)
Miscellaneous 65 (6.6) 267 (2.9)
Total 992 (100.0) 9284 (100.0)
Abstracts were presented by authors from 45 countries in the case of the

ISPS, and from 50 in the case of ICSR/BWWS. In both instances, although
abstracts emanated from all six inhabited continents of the world, there was
a pronounced Western bias, with, in the case of ISPS, 857 (86.4%), and for
ICSR/BWWS, 8574 (92.3%) abstracts emanating from European and North
American countries, as is shown in table 2:
Table 2. Numbers of abstracts produced by authors from each inhabited

continent.
Number of abstracts Number of abstracts
presented at ISPS (%) presented at ICSR/BWWS (%)
Europe 670 (67.5) 4191 (45.1)
North America 187 (18.9) 4383 (47.2)
South America 9 (0.9) 69 (0.7)
Asia 42 (4.2) 192 (2.1)
Oceania 82 (8.3) 431 (4.6)
Africa 2 (0.2 18 (0.2)
Total 992 (100.0) 9284 (100.0)
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Subjective experience research

333 (33.6%) of the ISPS abstracts primarily addressed subjective
experiences, whilst only 183 (2.0%) of those from ICSR/BWWS did likewise.
The mean number of subjective experience abstracts presented per year at
ISPS was 55 (s.d.32), whilst for ICSR/BWWS this was 11 (s.d. 9). However, the
proportion of subjective experience abstracts presented at ISPS conferences
actually halved over the study period, whilst at ICSR/BWWS it doubled, as is
shown in tables 3 and 4.
Table 3. Numbers of subjective experience abstracts presented at ISPS

conferences displayed as frequencies and proportions of total overall
number of abstracts by year.
Number of subjective Subjective experience

experience abstracts abstracts expressed as
Year of conference presented per year (total percentage of total number
no. of abstracts presented of abstracts presented per
in that year) year
1988 45 (97) 46.4
1991 58 (124) 46.8
1994 16 (61) 26.2
1997 107 (280) 38.2
2000 74 (268) 27.6
2003 33 (162) 20.4
Total 333 (992)
309
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AND
Table 4. Numbers of subjective experience abstracts presented at the BWWS

and ICSR displayed as frequencies and proportions of total overall number
of abstracts by year.
Number of subjective Subjective experience
experience abstracts abstracts expressed as
Year of conference presented per year (total percentage of total number
no. of abstracts presented of abstracts presented per
in that year) year
1988 2 (148) 1.4
1989 2 (238) 0.8
1990 4 (143) 2.8
1991 4 (270) 1.5
1992 0 (192) 0.0
1993 8 (563) 1.4
1994 4 (289) 1.4
1995 5 (652) 0.8
1996 4 (392) 1.0
1997 14 (768) 1.8
1998 13 (512) 2.5
1999 23 (1021) 2.3
2000 18 (721) 2.5
2001 27 (966) 2.8
2002 20 (697) 2.9
2003 21 (1069) 2.0
2004 14 (643) 2.2
Total 183 (9284)
310
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Across all three conferences psychosocial research was much more likely
than any other category to be associated with subjective experience
research, whilst the opposite was true for biologically oriented research.
Table 5 depicts the relationship between research category and subjective
experience research, expressed in terms of odds ratios with 95% confidence
intervals, for both ISPS and ICSR/BWWS.
Table 5. Study categories associated with subjective experience research;

presented as odds ratios with 95% confidence intervals
ISPS ICSR/BWWS (%)
Psychosocial 4.18 (2.76-6.35) 14.63 (10.68-20.04)
Biological 0.11 (0.03-0.47) 0.13 (0.10-0.19)
Diagnosis and phenomenology 0.72 (0.40-1.27)* 2.09 (1.41-3.10)
Epidemiology 0.92 (0.90-0.94) 0.24 (0.09-0.66)
Miscellaneous 0.34 (0.17-0.68) 4.94 (3.11-7.85)
*Not significant at 0.05 level as 95%CI crosses 1
In the case of the ISPS abstracts only three countries displayed an increased
likelihood of producing subjective experience research (Belgium (OR 4.05,
95%CI 1.21-13.55), Sweden (OR 1.62, 95%CI 1.03-2.57), USA (OR 1.57, 95%CI
1.12-2.21)) and with one, Australia (OR 0.48, 95%CI 0.26-0.87) being
statistically significantly less likely to do same. For ICSR/BWWS, six
countries (Belgium, the Netherlands, Norway, Austria, Canada and Israel)
were associated with an increased rate of subjective experience research
compared to the remaining countries, whilst both the USA and UK revealed
a decreased rate. The results for the association of research category and
country of origin were confirmed by multivariate statistical analysis, using
logistic regression to control for potential confounding variables.
The ISPS in detail

The ISPS abstracts were stratified according to subtype of study and type of
psychotherapeutic approach. In the case of the former categories imposed
included ‘case report’ (the research sought to describe the unique lived
311
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AND
experiences of an individual person or group of persons), ‘service

description’ (the research simply outlined the activities of an individual
therapist, organisation or institution without reference to empirical data),
‘theory paper’ (the research adumbrated an aspect of psychotherapeutic
theory or speculation without reference to empirical data), ‘empirical’ (the
abstract presented findings from empirical research including outcome
studies, efficacy trials etc) and ‘miscellaneous’ (the research could not be
subsumed into any other subtype category). For psychotherapeutic
approach, the categories were self-explanatory and included
‘psychodynamic’, ‘cognitive-behavioural’, ‘systemic’ and ‘other’ (akin to the
miscellaneous category outlined above).
The results showed that the proportion of case report abstracts decreased
by an order of magnitude, from 24.7% in 1988 to 2.5% in 2003, whilst the
proportion of service description abstracts increased rapidly over the study
period, in contrast to the proportion of theory paper abstracts, which evinced
a steady decline. Despite a fall in the mid 1990s the proportion of empirical
research abstracts had, by the end of the study period, come to dominate
ISPS research activity. These results are depicted below in table 6.
Table 6. Numbers of research subtype abstracts presented at ISPS

number of abstracts by year
Case Service Theory Empirical Miscellaneous Total

report description paper
1988 24 (24.7) 5 (5.2) 37 (38.1) 29 (29.9) 2 (2.1) 97
1991 33 (26.6) 20 (16.1) 37 (29.8) 28 (22.6) 6 (4.8) 124
1994 14 (23.0) 9 (14.8) 21 (34.4) 7 (11.5) 10 (16.4) 61
1997 36 (12.9) 86 (30.7) 87 (31.1) 55 (19.6) 16 (5.7) 280
2000 26 (9.7) 58 (21.6) 65 (24.3) 114 (42.5) 5 (1.9) 268
2003 4 (2.5) 48 (29.6) 31 (19.1) 76 (46.9) 3 (1.9) 162
312

In terms of psychotherapeutic approach, the percentage of psychodynamically

oriented research abstracts presented declined steadily from 71.1% in 1988 to
only 16.7% in 2003. In contrast, the percentage of cognitive-behaviourally
oriented abstracts increased from 0 in 1988 to 19.8% in 2003. These results
are shown in table 7.
Table 7. Psychotherapeutic orientation of abstracts presented at ISPS

number of abstracts by year
Cognitive-
Psychodynamic Systemic Other Total
behavioural
1988 69 (71.1) 0 (0.0) 10 (10.3) 18 (18.6) 97
1991 83 (66.9) 4 (3.2) 11 (8.9) 26 (21.0) 124
1994 35 (57.4) 1 (1.6) 5 (8.2) 20 (32.8) 61
1997 166 (59.3) 14 (5.0) 22 (7.9) 78 (27.9) 280
2000 89 (33.2) 10 (3.7) 9 (3.4) 160 (59.7) 268
2003 27 (16.7) 32 (19.8) 6 (3.7) 97 (59.9) 162
When the relationship between both research subtype and psychotherapeutic

approach, and subjective experience research was examined, only case
reports (OR 35.86, 95%CI 18.99-67.72) and psychodynamically oriented
research (OR 2.44, 95%CI 1.86-3.20) displayed a statistically significant
increased rate, with these being confirmed by logistic regression.
Discussion
International schizophrenia research and the concept of patient-centredness
The goal of this study was to investigate the extent to which recent research
presented at the most prominent international forums dedicated to
schizophrenia research could be considered to be patient-centred. The
model of patient-centredness employed suggests that to be patient-centred
is to give equal weight to both the subjective experience of illness and
313
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AND
objective theories of disease. We interpreted this to mean that the subjective

experiences of patients/research participants be equally represented as
valid study outcomes and, hence, that half of all research projects
undertaken in schizophrenia research be explicitly oriented to the subjective
experiences of patients/participants. The fact that only 183 (2%) of the
abstracts presented at ICSR/BWWS (the two most prominent forums in
terms of numbers of abstracts presented) addressed subjective experiences
strongly suggests that this body of schizophrenia research has not been
patient-centred. Although fully one-third of the abstracts presented at
international ISPS conferences between 1988 and 2003 explicitly addressed
subjective experiences, the requisite balance was not achieved meaning
that, though this body of researchers and clinicians have been much more
interested in their patients’ subjective experiences, their corpus of work
cannot, within the constraints of this model, be described as patient-
centred.
The model of patient-centredness deployed within the present study is,

perhaps, it’s most contentious aspect. That is, the balanced model of
patient-centredness outlined above may seem rather arbitrary in its placing
of equal emphasis on the ‘subjective’ and ‘objective’ (or ‘value-laden’ and
‘fact-laden’) aspects of mental disorder. A detailed exposition of the
argument for this balance is beyond the scope of this paper, though it is well
documented in the literature (10, 11, 34, 35). Despite this, it is worth considering the
possibility that the inequities experienced by psychiatric patients
(schizophrenia sufferers amongst them) in adverse socio-political contexts
such as the former Soviet Union(36) and Nazi Germany(37), may not have been
helped by the lack of weight afforded their subjective experiences/values.
These lessons from history suggest that it should be a necessary task of
modern psychiatry, and schizophrenia research within this, to balance the
desire for objective facts with a humane reflection on subjective
experience/values.
Occidental and biological hegemony

Before considering the results from the analysis of the ISPS abstracts in
more detail, it is worth reflecting on some of the ramifications of the results
from all three conferences: The international schizophrenia research effort,
as represented here by conference abstracts from a quorum of forums
dedicated to research into this disorder, was (in numerical terms),
dominated by both the countries of the West and the biological paradigm
between 1988 and 2004. Said dominance may have acted both directly,
through the overt promulgation of Western approaches to the understanding
314
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of schizophrenia and initiatives like the ‘Decade of the Brain’ proclamation,

but also indirectly, via the high costs of attending said conferences, costs
which may have precluded researchers from less wealthy countries
travelling to present their ideas on an international stage. Although
schizophrenia can be reliably diagnosed across different countries and
cultures, its course and outcome varies considerably between developed and
developing countries(38). Given that the Western, biologically-oriented
approach to the understanding of mental disorder is only one
epistemological perspective, it is troubling that researchers from developing
countries are not better represented at these forums. Indeed the possibility
does exist that the Occidental-biological hegemony afflicting schizophrenia
research may be inhibiting a deeper appreciation of the role of cultural
differences in at least the course and outcome of schizophrenia(39).
Breaking the covenant

At this juncture the point should, perhaps, be once again made that ISPS
researchers have quite clearly been much more interested in the subjective
experiences of those they seek to understand and help, than their
counterparts at ICSR/BWWS. That said the proportion of ISPS abstracts
addressing subjective experiences decreased substantially between 1988
and 2003. It is ironic, and not a little worrying that, during a period when a
substantial number of schizophrenia researchers were not overtly
concerned with making subjective experiences the focus of their work, an
organisation with a rich tradition of engaging with subjectivity also appeared
to back away from this approach. The covenant with subjectivity, struck by all
those clinicians and researchers within the mental health arena, on either a
conscious or unconscious basis, has been broken in the field of
schizophrenia research.
The reasons for this disavowal of subjectivity are undoubtedly complex, and
a detailed discussion of the factors contributing to this state of affairs is
outside the scope of this paper. That said sufficient data does exist for a
speculative, though necessarily superficial, consideration of the factors
which may have influenced the creative and intellectual zeitgeist of the ISPS
over the last two decades.
The two variables which showed the greatest association with subjective
experience research within the present study’s analysis of the ISPS
abstracts were psychodynamically orientated research and case reports,
yet, in both absolute and relative terms, these declined dramatically over
315
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AND
the period of study. Said evanescence occurred in concert with the waxing
of service description abstracts, empirical research and cognitive-
behaviourally oriented abstracts. Ostensibly these latter groupings share
little common ground, yet they could all be said to emphasise description
and objectivity over the empathic communion and celebration of subjectivity
which certainly adumbrate case reports and which, to a lesser extent,
inform psychodynamic practice and theory. The results from ICSR/BWWS
show that, at these forums, biologically oriented research, the mode of
research that cleaves most readily to the medical model, with its emphasis
on objectivity, has been valued above all other approaches. The common
factor here would appear to be an overarching epistemology privileging
distance, objectification and the existence of an external world beyond
human consciousness; in short the positivist value system. It appears,
therefore, that in the battle of the ideologies outlined at the beginning of
this paper, the reductionist and materialist philosophy of the ‘Decade of the
Brain’ initiative has succeeded in storming what might have been
considered to be the last bastion of subjectivity in the realm of
schizophrenia research; the ISPS.
Coda
Although the schizophrenia construct remains in many ways an enigma, the
positivist/reductionist project, as exemplified by the ‘Decade of the Brain’
initiative, has produced empirical phenomena sufficiently robust to generate
and inform the development of several coherent theories concerning the so-
called ‘core’ neurobiological problem in schizophrenia. The ‘brain function
laterality’ phenomenon and the ‘disconnection’ hypothesis are two of the
most popular and widely known examples: The former, using data derived
from functional neuroimaging experiments, suggests that schizophrenia is
associated with abnormalities in left hemispheric function, with the general
picture being one of functional overactivity(40). Indeed the ‘reality distortion’
symptom cluster, identified via factor analysis of the symptoms reported by
people diagnosed with chronic schizophrenia(41), is specifically associated
with overactivity in the left parahippocampal and hippocampal areas(42). The
disconnection hypothesis is based on the idea that the brain adheres to the
two fundamental principles of functional specialisation and functional
integration, where the integration within and between specialised areas is
dependent on effective connectivity(43). Broadly speaking the hypothesis
suggests that the ‘core’ problem of schizophrenia is abnormal connectivity
leading to a disintegration of neuronal dynamics in areas such as perception
and response selection(44).
316
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…So what?
Well, the world can be divided up into right and left hemispheres along the
convention of the Greenwich meridian. Assuming that each abstract (from
all three conferences, n=10276) is a marker of functional activity within the
schizophrenia research community, it is possible to compare activity
between each hemisphere. Between 1988 and 2004 the left hemisphere
produced 6889 (67%) and the right 3387 (33%) of the total: In functional
terms there has been left hemisphere overactivation. Equally, if one
assumes that each of the presenting authors at the ICSR/BWWS and ISPS
conferences held between 1988 and 2004 had the opportunity to attend all
of the other conferences then, by cross-referencing author lists from the
collections of abstracts, it is possible to obtain an estimate of the effective
connectivity between these two specialised components of the international
schizophrenia research community. In this instance fewer than 20% of the
different authors attending ICSR/BWWS had presented their work at the
ISPS conferences, and vice versa. In other words the schizophrenia
research community has been subject to markedly impaired functional
connectivity (or ‘splitting’ in psychodynamic terms) at the level of the
communication of ideas.
Taken in toto these findings suggest that, using the same epistemology
adopted by the majority of schizophrenia researchers to define those people
with the condition as disordered, the self-same schizophrenia research
community can also be defined as disordered. The question then becomes
what reality has been distorted and what dynamics have disintegrated, by
dint of this disorder, at the meta-psychiatric level? It may perhaps be the
case that the supposedly objective and material findings of disorder in
schizophrenia are, in part, actually reflections or projections of the observing
body, in this case the international schizophrenia research community. In
short this community may, to a certain extent, be seeing itself reflected in
those it seeks to study. If this is the case then the third person, objective
perspective of schizophrenia must lose the privilege it has been afforded by
the scientific epistemology and greater credence must, in turn, be granted to
first and second (intersubjective) perspectives in the study of the
schizophrenia construct. Despite the problems currently afflicting the ISPS
(see above) it is our opinion that this organisation, with its avowed (though as
yet not fully realised) orientation towards both subjectivity and
intersubjectivity, offers the best hope of regaining the covenant, and showing
the world of schizophrenia research what should be valued in our attempts
to understand this defiantly abstruse part of human experience.
317
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AND
Acknowledgments
The authors would like to offer their thanks to Dr. Brian Martindale, Dr. Ann-
Louise Silver and Dr. Miriam Feinsilver for their unstinting assistance in
locating the ISPS abstracts.
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Timoty Calton
34 Chaworth Road
Nottingham NG27AB
England
[email protected]
320
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21 B. Commentary on “Breaking
the Covenant: International
Schizophrenia Research and the
Concept of Patient-Centredness
1988-2004” by Timothy Calton,
Anna Cheetham, Karen D’Silva
and Christine Glazebrook.
Brian Koehler
One of the principles of therapeutic community is for the hospital, institution

and/or community to examine and treat itself. I believe that Dr. Timothy
Calton and his colleagues paper “Breaking the covenant: International
schizophrenia research and the concept of patient-centredness 1988-2004”
does just that for our ISPS organization. I thought of this principle as I read
with great interest the excellent synopsis of Dr. Calton and his group in the
UK on the degree to which presentations at ISPS and the International
Congress on Schizophrenia Research (ICSR) and the Biennial Winter
Workshop on Schizophrenia (BWWS) conform to what is termed a “patient-
centred model,” i.e., a model which focuses also on the subjective
experiences of patients. Calton and colleagues note that a core feature of the
patient-centred model is to give equal weight to the objective theories of
disease and the subjective experiences of the patient. Their stated goal
was:...”to investigate the extent to which recent research presented at the
most prominent international forums dedicated to schizophrenia research
could be considered to be patient-centred.” Their application of this model
involved a principle that half of all research projects in the study of the
schizophrenias should be devoted to the subjective experiences of patients.
Calton and colleagues highlight the growing positivist reductionism in our

field.They are holding up a mirror to our organization, showing us what we
have become. The papers given at ISPS congresses are increasingly moving
321
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AND
away from an emphasis on subjectivity and phenomenology, as reflected in

fewer case studies and theoretical papers. Papers devoted to service
delivery and empirical, quantitative research are taking their place.
However, ISPS still produces more psychosocially oriented papers than
either ICSR or BWWS. My own view is that radical reductionism is crucial,
but invalid if left at this level of scientific inquiry. The move away from
reductionism in the physical sciences, such as physics, to emergence, is
reflected in the work of Robert Laughlin, a professor of physics and Nobel
Laureate for his work on the fractional Hall effect. Laughlin noted that the
natural world is not only regulated by molecular essentials, but also the
powerful principles of organization which flow out of them: This organization
can acquire meaning and a life of its own, and begin to transcend the parts
from which it is made. At higher levels of complexity, such as is found in
human beings and their relational and cultural contexts, cause-and-effect
relationships are more difficult to document. The reductionistic positivist
ideal that nature will be revealed and understood through division into
smaller and smaller component parts or through sophisticated
neuroimaging techniques such as fMRI, PET and DTI scans-needs to be
supplemented by the study and understanding of how nature organizes
itself, i.e., reductionism giving way to emergence.
The principle of giving equal weighting to subjective experience and objective

neuroscience research has a long history in psychiatry: I think of George
Engel’s biopsychosocial model, Leon Eisenberg’s caution to steer between a
mindless and brainless psychiatry and his quip that the human brain is all
biological and all social, John Strauss and Larry Davidson’s emphasis on the
interaction between person/identity processes and disorder, Yrjö Alanen’s
pointing out that an important starting point for all integrated
psychobiological psychiatry is the insight that interactionality with other
people is part of human biology, etc. Kenneth Kendler, psychiatric geneticist,
in delineating a philosophical structure for psychiatry, underscored the
importance of attending to subjective, first-person experiences. He noted
that the goal of psychiatry is the alleviation of the human suffering that
arises from dysfunctional alterations in particular domains of subjective
experience. Kendler cautioned us not to take advantage of the advances in
molecular biology and neuroscience at the expense of abandoning our
grounding in the realm of human experience and suffering.
Recently, Chris Harrop and Peter Trower noted that the direction of the
causal relationship implicating biology driving symptomatology (upward
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causation) has not been satisfactorily demonstrated, and that downward

causation may be an equally plausible possibility, i.e., the biological
symptoms may actually arise from the symptoms of the disorder. From my
review of the neuroscience research, I would say that it is not so much the
symptoms which drive the biology, e.g., Edward Hundert pointed out that
delusions are often a reflection of the brain’s [person’s] evolutionary strategy
for survival, rather, the biology is the result of experience, in particular
profound and chronic stress/fear/anxiety, including exposure to various
traumas and prenatal stress. Psychotic symptoms are often very meaningful
phenomena when viewed within the context of the individual’s life and from
within the wider sociocultural surround, as well as from the framework of
transgenerational transmission of trauma, which recent research has
demonstrated not only has a psychological/symbolic etiology, but a
biological one as well (epigenetic modification of gene expression). There are
examples of epigenetic, or nongenomic, inheritance, where traits of the
parents, particularly defensive responses to threat, are transmitted to
offspring in a manner not dependent on information encoded in the nuclear
genes. Epigenetics refers to regulation, e.g., by social factors, of gene
expressions that are controlled by heritable but potentially reversible
changes in DNA methylation and/or chromatin structure. For many years I
have been comparing the neuroscience research of schizophrenia with the
neuroscience of stress/fear and have found a very significant convergence of
findings. It is becoming increasingly clear that the neuroscience findings in
schizophrenia research are generally non-specific, possibly due to the
important role of epigenetics and neuroplasticity.
At our ISPS conference in London in 1997, Peter Fonagy cautioned our field
to not give up our emphasis on intensive psychotherapeutic work with
persons with a severe mental illness. Should we abandon this immersion
experience with patients within an intersubjective context, what would we
have by way of knowledge and skill to teach and pass on to future
generations of clinicians? His was a quiet, but powerful voice calling us back
to, and not to sever our roots. Perhaps a sequel to the informative and
relevant research by Calton and colleagues would be a qualitative study
examining the factors influencing this movement away from phenomenology
and subjectivity (from the objective standpoint, clinicians may treat their
patient’s subjective accounts of their experience as indistinguishable from
the illness itself,e.g., a reflection of impaired insight, and/or believe that
speaking with patients about their delusions and hallucinatory experiences
only leads to an exacerbation of the illness itself).
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AND
In their summary discussion of their qualitative research study, Calton and

colleagues, in an imaginative leap, draw “metapsychiatric” parallels between
the psychopathology in schizophrenia, in particular, laterality and
disconnectivity, and the splits and disconnectivity in the field of schizophrenia
research, especially the split between subjectivity/intersubjectivity research
and third person objective research. In response to this metapsychiatric
speculation, I would like to conclude with some thoughts of the two co-
founders of ISPS, Christian Müller and Gaetano Benedetti. Christian Müller
wrote a paper on the resistances we engage in while doing, or to avoid doing
long-term psychotherapy with persons with schizophrenia. One could surmise
that part of the movement away from subjective to objective accounts at ISPS
conferences is a countertransferential retreat from the painful affects stirred
up in our dialogical work with patients; work which can potentially reveal to us
our own patienthood. Gaetano Benedetti saw the ISPS as a place in which we
could autonomously develop our psychotherapeutic understanding and
treatment approaches without interfering with other fields of knowledge, such
as the progress being made in psychiatric molecular biological or
psychopharmacological approaches. Benedetti believed that intensive
psychotherapy reveals more deeply the nature of psychosis, in particular, and
the human condition, in general. He wished for the ISPS group to return with
new and fresh ideas to the significant contributions made by our forerunners,
such as Federn, Sullivan and Fromm-Reichmann. My hope is that, as the
human cell and person must retain its essential structure as it interacts with
its surround, ISPS will remain open to potentially beneficial influences from
other domains of scientific inquiry, such as ICSR/BWWS, without abdicating its
role as an organization devoted to the psychotherapeutic understanding and
treatment of persons struggling with a severe mental illness.
References cited in this commentary are available by request to the author.
Brian Koehler
New York University
80 East 11th Street #339
New York NY 10003
[email protected]
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AND

PART III:
VIEWS ON THE FUTURE
DEVELOPMENT OF THE ISPS
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22. My Views for the Future

Development of the ISPS
Gaetano Benedetti
I have attended many conferences, seminars and “Weiterbildungen” at

psychiatric clinics, psychotherapy and psychoanalysis training centers,
mental health centres, therapeutic communities, and I have produced
reports on psychotherapy of the psychoses both from a theoretical and a
clinical point of view. Many colleagues seemed to be truly enthusiastic
especially about the drawings exchanged with the psychotic patients by
means of progressive mirror drawing.
Unfortunately this enthusiasm about our method was not followed by an

organisational effort to implement it and make it available to patients
hospitalized in clinics or treated by mental health centres and services.
This has caused a feeling of uselessness in me: why should I embark in such
long trips which take away precious time from my family and my work?
However I have not given up and I have not let disappointment and
frustration overcome me.
I have attempted to understand the reasons of this failure and I have reached
the following conclusions.
1) Psychotherapy with the psychotic patient requires a major effort

and it demands the therapist motivation to identify themselves with
the patient. The identification, even though a partial one, with the
“lunatic” creates considerable resistance particularly in those
institutions based on rules and norms. Because of this identification
with those who are outside the norm, the therapist is in a position of
potential conflict with the institution (as I experienced both in
Perugia and in Basel).
2) The therapist-patient and patient-therapist identification, even

partial, paves the way for the therapeutic symbiosis which is the
alpha and the omega of psychotherapy of the psychoses. The
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AND
therapist usually has a number of internal resistances to re-

experience symbiotic events. I will never forget a sentence by Searles
which has always inspired me: “The reason why psychotherapy of the
psychoses lasts for so long is connected to both patient and therapist
resistances to enter therapeutic symbiosis.”
3) The needs and conflicts of the psychotic patient are of a preverbal

nature and they reactivate preverbal conflicts and needs in the
therapist counter-transference. In my opinion these conflicts and
needs must be dealt with preverbal psychotherapeutic instruments
before they can be verbalized. Just as many patients cannot be
reached by mere words, similarly the therapist needs preverbal
instruments and techniques to elaborate the counter-transference
activated by the symbiotic needs of the patient.
The consequence of the above-mentioned points is that:
4) The therapists of a psychotic patient require a reference group

within the institution in which they work and with which they can
share psychotherapeutic experiences that can be seriously
regressive and intense.
5) The reference group within the institution supports the therapist in

the process of partial identification with the psychotic patient,
reducing their loneliness and their possible “estrangement” feeling,
helping them to face the “norm” of the institution.
6) Within the reference group, group experiences and seminars

including preverbal communication ways are fundamental in order to
bring therapists closer to therapeutic symbiosis and to train them.
This can cause, and indeed it always causes, some resistances in a
number of therapists, however the most of the group benefits
dramatically from a “group symbiosis.” In the relationship with the
patient, those who have already experienced preverbal symbiosis
with their colleagues, are much more confident and open to question
themselves in order to come closer to the fragmented experience of
the patient.
On the basis of these considerations, I have begun to transmit my

psychotherapeutic knowledge and experiences to small groups within
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My Views for the Future Development of the ISPS
psychiatric institutions. I have been careful to include the theoretical-

clinic notions into a training programme based on a non-verbal
communication among the participants.
Therefore I have discovered that the more the time and care spent on
bringing this group closer to group therapeutic symbiosis experiences,
the higher the motivation to implement psychotherapy of the psychoses
by means of progressive mirror drawing within the institution.
In this way, in Muensterlingen in Switzerland, and Perugia, Terni and

Turin in Italy, it was possible to create groups of colleagues who carry out
psychotherapies of the psychoses within the institutions by using
progressive mirror drawing in connection with psychotherapy of the
psychoses. On 20-21 May 2005 the first international conference on
therapeutic progressive mirror drawing took place in Muensterlingen.
On the basis of my modest experience, in order to support the starting

enthusiasm and motivation to treat psychotic patients with psychotherapy,
it is crucial to provide groups of colleagues with preverbal communication
experiences and to organise seminars on the subject bringing thus
colleagues closer to group therapeutic symbiosis.
My suggestion to the ISPS is to assist the three-yearly conference, that

is an indispensable informative event, with a focus on the needs of
psychotherapists of the psychoses, which I have listed in points 1, 2
and 3.
A particular effort should be made for creating, within psychotherapeutic

psychiatric institutions, therapist groups trained for facing symbiotic
relationships daily and trained for dealing with the resistances caused by
symbiosis.
A practical way could be the establishment, during the one-week ISPS

conference, of a group of participants interested in exploring preverbal
communication ways in order to bring the group closer to symbiosis.
Another way could be an ISPS proposal to the psychiatric and

psychotherapeutic institutions about the creation of constant training of
groups of colleagues willing to explore preverbal communication ways
which make symbiosis familiar.
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AND
I insist on this point very much because I think that if the therapist
manages to overcome the fear of symbiosis, then the work is half done.
Of course the resistance of the patient is still to be overcome, which is
impossible sometimes, but anyway the therapist will have made an effort
to look for new ways to overcome those resistances.
Gaetano Benedetti
Inzlingerstrasse 21
4125 Riehen
Switzerland
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23. The Understanding and

Treatment of People with
Schizophrenia
John S. Strauss
Over the years approaches to schizophrenia and other mental disorders have
veered wildly from one extreme to the other. This has been especially, but
not exclusively, true of American psychiatry. When I was a psychiatric
resident in the 1960s a large number of chairmen of major departments of
psychiatry in the US were psychoanalysts. Now, a large number are
biological psychiatrists. Common assumptions in the 60’s that schizophrenia
was a result of childhood traumas and environments and thus that the
primary treatment was psychological have been replaced by the view that
schizophrenia is a brain disease, “like any other illness” and that the
treatment is primarily biological. (It is difficult not to believe in the theory
that history runs in cycles, here we are again repeating in a new form the
beliefs dominant at the end of the 19th century). In between the eras of
psychological and biological domination, there have been brief bursts of
belief in the importance of social factors (e.g. schizophrenia is found most
often in the lower classes “because it is there that people are the most
helpless and overwhelmingly dominated by their milieu”). In my experience,
each phase of these viewpoint shifts is enveloped in a belief cloud of almost
total certainty with a bit of disdain for (and neglect of) other possibilities.
Although these wide swerves of viewpoint are generally less pronounced in
other parts of the world than in the US, those other regions are not immune
either. In this wild ride, the ISPS has been a bit of a gyroscope, less
influenced by the swings than most groups, trying often to hold a steadier
course.
In this role of the ISPS where a variety of views individually and in various
combinations are often considered seriously, it is almost too bad that our
group has the title it does, since psychotherapy and even broader
psychological treatments, while often a major focus, have rarely been the
only ones receiving our attention. The interest in a broad range of
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AND
possibilities for the causes and treatments of schizophrenia, gives our group
the almost unique possibility of being a major leader in the field and a hope
for the future if, as many of us believe, schizophrenia really has a complex
biopsychosocial origin and equally complex routes to improvement.
Although there are other people or groups who espouse such a belief, there
are really very few for whom it is more than a kind of slogan and who take it
seriously in their work.
But this broad view is a difficult one to take seriously. It requires attention to
complex thinking (e.g., Morin, 1990) and to systems theory which as the
sociologist Norman Bell taught is not really a theory at all, but a way of
looking at phenomena. It is a way that is difficult indeed. Thinking in terms
of multiple processes seems so realistic, so sensible, and makes such good
clinical sense. And it is so difficult to deal with scientifically. Nevertheless,
many of the members of the ISPS have been world leaders in this difficult
and still unfinished task.
But I am a naive American from Erie Pennsylvania, a small city in what is

almost the midwest of the United States, and I was raised with the romantic
notion that it is possible for things to be perfect, definitive. For an illness,
someone discovers the cause, the cure, and that’s all it takes, with great
relief for all concerned, patients, families, clinicians, researchers. I actually
believe that you don’t have to be from Erie Pennsylvania to be that naïve.
Some of the power behind the many notions of a single cause for
schizophrenia and for its definitive treatment (which to me seem so
simplistic) arises from such beliefs. Now I know after all these years that life
is not always (maybe never) that simple, but still, identifying definitive
causes and treatments is a great model to aim for. And with schizophrenia,
our theories, treatments, and findings are very far indeed from that ideal. We
have made progress I believe. But we have so far to go.
So what can the ISPS do? What should be our role? For one thing, I think we
should be in the center of the field of the world of mental health research,
theory and treatment, not on the edge where we often find ourselves. There
should be hundreds, maybe thousands of people coming to our meetings,
meetings which should be seen as the forefront of progress. We should be
recognized as the leading edge of theory, treatment and research. There I go
again, being from Erie Pennsylvania. But what holds us back? Why aren’t we
that way? What’s wrong with people that they don’t see us that way. Maybe
something is wrong with us too?
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The Understanding and Treatment of People with Schizophrenia
Unfortunately, I do not have the definitive answer. But I do have two

suggestions. The first regards the simultaneous need for theory and data,
not so easy as it might seem. The second suggestion, not unrelated, regards
point of view, from whose perspective do we define the data that are the core
to our future directions and knowledge. Specifically, in this difficult and
fascinating field which ought to be a human science, how do we deal with
being scientific about humans, how do we deal with subjectivity and
objectivity at the same time?
Theory and Data. In the domain of mental health, as in many human

endeavors, people tend to be specialists, good or even excellent in one area,
and not so good, or even incompetent or uninterested in others. In the
mental health field, it is extremely difficult to be skilled at collecting and
analyzing data, and also at developing theories that are both valuable and
profound. It would be hard not to get into arguments immediately about this
point and I have qualms about giving examples. Nevertheless, I will start
with one that makes it particularly difficult for many of my friends to discuss
these things with me. For many years after getting into psychiatry I couldn’t
understand why Freud had never been given a Nobel Prize. His theories were
so beautifully and profoundly developed, based I thought on solid clinical
data. I tended to accept the paranoid interpretation that the Nobel Prize
Committee was prejudiced against anything psychological, especially if it
had something to do with sex. Then, when I became involved with
“descriptive psychiatry” with its rating scales and structured interviews
(which would have gotten me ejected from my psychodynamically oriented
residency), I began to realize how important measurement was. How crucial
were supposedly simple ideas like reliability, the capacity for different
people to agree on what to call or rate something. What I had at first believed
to be pedantic exercises in assigning a diagnosis, I began to see as the
difficult and crucial task of assigning accepted meaning to a noun. I then
recalled that during my medical student and residency years, when I
sometimes asked a supervisor why a patient had been diagnosed as
schizophrenic, I got serious, but now incredible, answers such as “ because
she’s been sick so long”, or “because he relates so poorly to people”, or even
in one instance, “because he’s in this hospital” or of a patient in a famous
twin study, “because his twin has schizophrenia”. A problem in the United
States certainly, but as I learned later in participating in international studies
with the World Health Organization, certainly not a problem limited to the
US. Difficult to build a science or a knowledge base of any kind without better
reliability of nouns (or verbs) than is provided by such diverse and
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AND
idiosyncratic criteria. If definition and measurement are crucial and

complex, so are sampling, statistics, and analysis of results. Good science is
really complicated.
But people who are good scientists, comfortable in the complexities of

scientific method, seem to have trouble developing profound theory. I long
for the days when I could read Freud with total enthusiasm. His theories still
seem to me to be a model of human depth and insight. But when I read a
book like The Wolfman (Gardiner (ed.), 1971) that contains Freud’s case
analysis with his descriptions of the Wolfman’s conflicts and Freud’s
interpretations, and also contains the autobiography written by the
“Wolfman” himself, I am even more impressed by the degree to which in
formulating his theories, Freud seems to have left out huge amounts of data,
even data involving his own interventions (such as Freud’s lending the
Wolfman money, helping him find a job, or making suggestions about a
woman whom the Wolfman thought about marrying). On the other hand,
when I read writings by people who know intimately the complexities of data
collection and analysis, I so miss the kind of profound theory of which Freud
was capable.
One direction I would like to see the ISPS members take, and to encourage
younger members in the field to take as well, is this problem of knitting
together really good deep theory with the respect for the complexities of
science. What does such a combination involve? For the theory part, I think
we need a theory that deals in detail with a person’s psychological
processes, a person’s experience, his or her way of handling information and
feelings, as well as processes of biology and social context.
For the science part, an appreciation is necessary for the issues of definition,
measurement, sampling, statistics and analysis of results noted above. Case
studies are useful as well, although we need a context within which to place
them to assess their validity and generalizability. But because we are a
human science, a science that attempts to deal with the complexities, bio,
psycho, and social, that are essential to being human, I believe we also need
to expand the view of science. We need a science that does not throw out
data because we don’t know how to measure or define them yet or because
we have not developed means for dealing adequately with a particular kind
of information. This holds most especially for the area of subjectivity. Yes,
qualitative research is important, but to make it “scientific” we tend to bend
it towards the quantitative thus losing the kind of power so central to human
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subjective experience, the kind of power for example also generated by

narrative and by the arts. That aspect of experience is a major part of
subjectivity. Thus, one of the difficulties in putting together deep theory and
data based science is that we need to develop a notion of what an adequate
science for humans would really look like. An ideal task for members of this
group!
Objectivity and Subjectivity. Which brings us to my second and related

suggestion. Much of mental health research these days emphasizes what is
understood to be careful science: hypothesis testing, sampling, collection of
reliable data, valid statistical analysis, and the drawing of conclusions closely
related to those findings. The contemporary theories of mental disorder and
approaches to treatment that are most common evolve from this base. All this
is crucial. But what is almost always ignored is the huge amount of data that
is the most difficult to collect and analyze, subjective data. It is poor science
to pay attention only to the data that are relatively easy to collect while
ignoring huge amounts of data that are more elusive. The old joke comes to
mind about the drunk man who lost his keys in the middle of the block but
looked for them at the corner “because the light is better here”. How can we
in academic mental health fields neglect so consistently that huge area of
human experience that is related to subjectivity? By subjectivity, I do not
mean only the “do you hear voices” kind of question on which much of my own
earlier research was based. I do not even mean the “are you working” or “are
you happy” kind of questions which, trying to be broadminded, we have asked
searching for measures of “competence” and “quality of life”. I mean rather
the kind of subjectivity that has to do with the depths and complexities of
feelings, of intentionality, of meaning, and more inclusively, with the question,
“how does this person see himself and the world?”
Now, an adequate pursuit of that problem is going to take some creativity.

Many of us think we already know such things about our patients. And here
arises an ongoing problem in my career, how to undertake the task of trying
to say that our ideas of a phenomenon are incomplete, sometimes even
wrong. In contacts with theater people, actors and directors, I am
continuously amazed, how many very smart, capable and hard working
people spend their entire lives trying to grasp how, really, one person or
another sees himself and the world. These theater people help each other
and hire coaches throughout their lives to deal more adequately with this
ongoing question. Are we so much smarter or more talented than they that
we have already more or less solved this problem? One experience I had in
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AND
this regard occurred about five years ago when I took an acting class. I did it
not to become an actor but because it interested me and because I was
always so bad the few times I tried. As I watched the excellent teacher, Doug
Taylor, at work with successive pairs of students who had been assigned a
role from a famous play, I was incredulous how much it was like watching a
kind of controlled experiment. The words from the script were always the
same, but at the start of the students’ efforts there was nothing real about
the performances. They felt lifeless. Little by little, suggesting how they
might get in touch with their own experience, gestures they might try, things
they might think about, Doug helped the students find the “truth” of their
characters. The words were such a limited part of the reality! Do we know
much about this huge other than verbal area of the psychological and
interpersonal world? Do we get training for it? How recently have you seen it
included in a theory or treatment for schizophrenia? In an art exhibition
entitled “Moi” at the Musée du Luxembourg in 2004, there were assembled
a large number of self portraits by 20th century artists. It was overwhelming,
the diversity of ways in which people represented themselves. Some had
painted traditional self portraits, pictures of their head and shoulders,
others had painted themselves with their families, still others had painted
only their painting materials, others had painted several different images of
themselves in the same picture, others abstractions, some only words
painted on a canvas. Incredible diversity of how people see themselves! To
say nothing of how they see their world.
“We do it (or we know it) already”. Always a difficult part of a discussion when
someone tells you that. I will recount one final experience that might help. A
few years ago I was presenting a talk and a workshop for a group in Tromsö
in the north of Norway. The group included about 150 people, mostly mental
health professionals with a scattering of “consumers” and family members
of consumers. My experience with mental health professionals in Norway is
that they are unusually eclectic and open minded (and nice). As part of the
program and to do something a little different, I had asked an excellent
psychiatrist I know there if he would interview me in front of the group. I
would be someone with paranoid schizophrenia and he would be doing a
follow-up interview with me. A follow-up interview because we had done an
initial interview (“intake” ) a couple years previously with a smaller group
elsewhere in Norway. That experience had gone very well. He was a
wonderful interviewer and we would stop every few minutes for people in the
audience to ask questions or make comments, or we might make some
comments ourselves. For this follow-up interview, “my psychiatrist” started
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by asking me how things were going. I told him “a little better” saying that
the voices were not so loud and that I was working at McDonalds. The job
wasn’t great but it was better than nothing. He then asked me about friends
and family, and very rapidly, I found myself only answering with one word
replies and really not wanting to talk to him any more. It was terrible. I
couldn’t get myself out of that frame of mind. There I was, a major guest of
the conference, all those people out there, and I didn’t want to talk any more.
We struggled on for a few more minutes, and then I said I thought we should
stop and see if we could make any sense of what was going on. I really didn’t
understand except that this strong feeling of not wanting to talk further had
seized me. The other psychiatrist and I both said a few more things and then
we opened the discussion to the audience. Several comments and questions
were volunteered. Many of the questions asked (in a nice way) why I was
being so difficult. I didn’t know myself but then someone at the back of the
audience raised his hand and said, “I’m a consumer too, and I’ve had the
same experiences with my psychiatrist, and he never understands”. Then
another hand went up at the front of the room in the corner. “I’m a
consumer, and I’ve had the same experience with my therapist and she
doesn’t understand either”. Well, at least there were three of us, I wasn’t all
alone. The entire group spent the rest of the time discussing this situation.
And it was always the three of us “against” all of them. We could never get
them to understand our point of view (nor could we understand theirs). There
was never a coming together. Later, I thought perhaps my problem was that
when I talked about my work at McDonalds, the psychiatrist just went on to
his next topic, my friends and family. But I wanted to talk more about my job.
I think I just felt that if he didn’t want to hear about what was important to
me, I wasn’t interested in answering what was important to him. Whatever
the cause, it was a very unsettling but very powerful experience. Not so easy
to understand the point of view, the subjectivity of another person, or even to
accept fully its existence.
Brain science passed through a phase of phrenology, the study of bumps on

the head, partly because there were only limited ways to do better. But that
did not mean that phrenology was sufficient. In the sphere of subjectivity. In
our scientific endeavors, we currently collect information on symptoms,
observed behavior, perhaps even social data which we professionals label
(that question of definition again) as competence. These measures are
probably much more valuable to psychiatry than was the study of phrenology
to brain processes, but just because they are measurable does not mean
that they cover the subjective aspects of our field in an adequate way.
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AND
The ISPS is such a wonderful group to explore these two areas, the bringing
together of science and deep theory to understand illness and improvement
processes from a psychological biological and social base, and the
developing of a view of science that involves meaningful inclusion of
subjectivity. Pursuing these tasks in a more focused way, we could be an
even more meaningful force towards developing our field to become truly a
human science.
References
Morin, Edgar.(1990). Introduction à la pensée complexe Patis : ESF éditeur.
Gardiner, Muriel (ed.) (1971). The Wolf-man New York : Basic Books.
John S. Strauss
50 Burton Street
New Haven CT 06515
U.S.A.
[email protected]
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24. Towards a deeper

integration of psychological and
humanistic values in the
psychiatry of psychoses
Johan Cullberg
There is presently a heavy dominance of biological ideologies and practices

regarding psychosis treatment. This implies an important increase in the
interest in nosology, definitions, and effectivity of treatments. However, we
can observe negative consequences of a one-sided interest in
pharmacological solutions of the psychotic disorders, neglecting the
patient’s needs as a person. There is also academic lack of interest in the
long-term relational aspects of care and a lack of effort to act as the
patient’s consultant and not as his or her boss. This lowers efficacy in care
of psychosis; it even becomes counterproductive with distressing and over-
stimulating patient wards, little continuity in out-patient care, distrust of
medication, and deficient knowledge of the patient as a person and of the
family’s capacities and problems.
We faced the opposite situation in many parts of the Western world one
generation ago. There was a monopolization of psychoanalytic concepts, and
psychodynamic reductionism reduced interest in biological research even
leading to a suspicious attitude about it. There was a simplistic view of
psychosis considering that it mainly expressed a regression to a relational
disturbance during the first year of life. Treatment implied a guided
regression to that stage with corrective emotional experiences and a new
journey back to mental health. The “psychosis therapist” had mythological
and heroic capacities like Orpheus bringing Eurydice back from Hades. This
view, which is not difficult to understand as such, made critical discussions
seem impertinent. Supportive dynamic psychotherapy was downgraded as
second best. (Psychotherapy of psychosis-like chronic dissociative
conditions after early sexual abuse lead to more associations of this kind.
Such conditions are often misdiagnosed as schizophrenia).
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AND
The psychoanalytic golden era suddenly came to an end. It was repeatedly

shown in the early eighties that the therapeutic gains were very limited in
most cases of psychoanalytic treatments of long term schizophrenia and it
could scarcely be regarded as an acceptable method, also considering the
expenses in time and money. This does not mean that psychoanalytical
theories of pre-oedipal development need to be abandoned. They may
provide a deep meaning for the understanding of psychotic thinking. But the
causal view on disturbances during these stages being the genesis of a
psychosis is not well founded and also counterproductive to good care.
Neuroleptic treatment was regarded as the only effective therapeutic agent

in many clinics. In fact it was believed that the risk of postponing the
treatment of a schizophrenic patient implied immediate neuroleptic
treatment and nothing more. The myth of a “toxic psychosis” included the
need for “immediate neuroleptization”, and was widely spread all over the
world during the early nineties. Doses were high and the patients’ and
relatives’ protests were regarded as expressing their lack of education.
However, PET studies from the late nineteen-eighties slowly brought
psychiatrists to understand that the doses they were taught to use were five
times or more too high, leaving the patients chronically intoxicated with a
ruined life quality. Suddenly, the patients’ complaints were listened to. New
types of antipsychotic medication were also produced with somewhat less
devitalizing side effects. All these agents, however, have other specific side
effects, which after a period make them less popular. I believe that the last
century’s misuse of neuroleptic medication will be regarded, by a later
generation, as one of the deplorable encroachments on the rights of mental
patients. As a life-long functional lobotomy, it is comparable with the large
scale surgical lobotomies a little earlier.
At present, family treatment and cognitive psychotherapy are both regarded

as evidence based treatments in schizophrenia, beside medication. It will be
a question of time and research to show that specific dynamic therapies are
essential in working with acute psychosis. In spite of this knowledge
implementation of professional psychological treatments is meager. One
reason for this is the impact of the pharmaceutical industry with its huge
economical resources. But there is a visible change at present towards more
integrative views on psychosis and schizophrenia. Gradually both
researchers and clinicians have begun to realize that a biological or
psychosocial view is insufficient. We have to adapt to a dialectical view, trying
to expand several theoretical models and to apply them simultaneously.
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Towards a deeper integration of psychological and humanistic values in the psychiatry of psychoses
There will always be an epistemological gap – clinical experience will testify

how wisely we adhere to that gap or if we choose to deny it.
The impact of ISPS becomes visible here.
We presently know through extensive research that there are three elements
in the treatment of psychotic patients that are not exchangeable and which
all must be considered. They are
• a good milieu in a comprehensible and low-stress environment
• reliable and constant therapeutic persons who may be forming a

containing relationship with the patient, and the relatives
• pharmacological treatments of sedative and/or antipsychotic types at

lowest effective doses
The primary idea for me with the ISPS is to form good arguments for
professionalizing and increasing the psychological care in all psychiatric
clinics, thus humanizing the treatment of psychotic patients. That means
that we should show that we cannot treat these patients as if the main
problem is to provide his or her malfunctioning D2 receptors with
antipsychotic medication immediately, and with sufficient doses. Instead we
must demonstrate the meaningfulness of approaching the patients as
individuals who primarily need understanding, human encounter and
realistic hope. Through intensified bio-psycho-social research and much
more listening to and talking with psychotic patients we may better
understand their psychological situation and that they are not different from
others, even if their needs are sometimes expressed in more complicated
and distorted ways.
To conclude: In the decades to come I hope that the ISPS thinking will
penetrate even deeper into the psychiatric services. I hope that the struggle
between biological and humanistic and between cognitive and dynamic will
increasingly belong to history. We shall have to regard our task in a
dialectical view. The risk for mistreatment will be diminished when we try to
keep the three requirements of psychosis treatment in mind, not
monopolizing one of them.
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AND
Johan Cullberg
Anders Reimers Vag 17
11750 Stockholm
Sweden
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25. The Future of

Psycho-Social Approaches to
Schizophrenia: Facing up to the
Challenges Ahead
John Read
My Maori colleagues here in New Zealand argue, convincingly, that the

trouble with us Europeans is that we move into the future facing forwards.
This has some obvious advantages, such as not walking off the end of a pier.
They suggest, however, that it is wiser to walk forwards looking backwards,
so as to remember where you are coming from, and especially to pay tribute
to those who went before. I have recently begun many of my lectures with
this anecdote, since it is rather pertinent to my main area of research, the
childhood and intergenerational origins of madness. In the context of this
book, however, it reminds me to pay homage to those who have battled, long
before I joined in, for the rights of people who experience what ‘western’
societies call psychosis to be listened to, to be understood in the context of
their life histories and to have their experiences treated as valid and
meaningful by mental health professionals. So let me do that by saying how
honoured I felt when Yrjo Alanen invited me to be part of this very special
book. To be in the company of so many legends of our field, some no longer
with us, is a lovely feeling for me. Thank you Yrjo, and thank you to all who
have laid the bedrock, over the past fifty years, for the future that I will try to
discuss here.
My own history with the ISPS is short in comparison with most other
contributors to this book. Prior to 1999 I had not heard of ISPS throughout 20
years of working (as a clinical psychologist) with, or managing mental health
services for, people diagnosed psychotic, and, since 1994 when I entered
academia in New Zealand, researching the psychosocial causes of
hallucinations and delusions. This may say something about the relatively
narrow focus of ISPS historically compared to now, and may be my first clue
to what might determine the future. Why did I only hear about the ISPS as a
result of being approached because of my research publications? Have we
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AND
been guilty, in the past, of not reaching out broadly enough to the thousands
of people around the world, including professions beyond psychoanalysis
and medicine, as well as service users and their families? How many, like
me, would be delighted to find they are not alone in trying to make sense of
psychosis and to provide humane alternatives to the dominant ‘diagnose and
drug’ paradigm? How many would have found comfort, support and
inspiration from discovering that there is, and has been for decades, an
international organisation dedicated to furthering that cause? Or perhaps
my ignorance of ISPS had more to do with my having somewhat despaired of
professional organisations ever addressing these important issues and my
having, therefore, put my energies more into supporting user/survivior led
groups?
Certainly when the call came I was very excited. Jan Olav Johannsen wrote
to inquire if I might possibly be interested in presenting my research on the
relationship between child abuse and subsequent psychosis at the ISPS 2000
Symposium in Stavanger. He didn’t exactly have to twist my arm. I arrived on
my first ever trip to Scandinavia expecting to find perhaps fifty people, half of
whom would see psychological treatments from the traditional ‘adjunct to
the essential medication’ perspective. I found 800. Moreover, I came to
realise, from countless conversations with some truly inspiring folk, that
most present seemed to believe that psychological understandings and
treatments were at least as important, or more important, than trying to
artificially alter people’s biochemistry. They understood that mental health
problems, including psychosis, were largely caused by other human beings
- including the social circumstances we collectively inflict on some people,
and that therefore the best solutions were probably human rather than
chemical or electrical.
Surrounded by all these bright, enthusiastic, dedicated people from all

corners of the world, the future of the ISPS as an organisation, and the
future of what it has been promoting for 50 years, seemed very secure But
I was suddenly awakened from my dream. A plenary speaker, from the
U.S.A., was displaying a huge slide of ‘the schizophrenic brain’ and
promulgating the usual poorly substantiated dogma about genetic
predisposition and brain disease. Surely this would be challenged from the
floor of the conference. I waited. It seemed, to me, to be a defining moment
for the future. Surely someone at this conference, of all conferences, would
find the courage to speak about the lack of good science underpinning
these stale, old, simplistic and reductionistic myths and how they have
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The future of Psycho-social approaches to Schizophrenia
induced unwarranted pessimism, in clients, families and professionals for

decades. Surely someone would point out that finding some malfunction in
the brain tells us nothing about whether the person concerned has a
genetically-based illness because, of course, the brain is effected by the
environment. Surely, at this conference, someone would remind the
speaker of the irrefutable evidence that social factors, poverty for example,
are powerfully predictive of ‘schizophrenia’. I waited, determined that for
once it would not be me who raised these issues. I needed to know if,
despite all those wonderful conversations I had enjoyed, nobody was willing
to publicly challenge what, to me, are some of the primary obstacles to
achieving the goals of the ISPS.
Sadly, it has become frightening for us to go against the grain on these

issues. I have, so many times, seen junior staff or family members try to
argue that someone’s ‘symptoms’ (or complaints as Richard Bentall prefers
in ‘Madness Explained’) are understandable reactions to something that has
happened to the person. At this point a psychiatrist (or, to the shame of my
own profession, sometimes a psychologist) will explain, politely to the family
member but often rudely to the staff member, that what we are dealing with
here is an illness, a brain disease, a bio-genetically based disorder that has
little or nothing to do with life events or circumstances. When ‘patients’ try
to make the same point they are accused of not having ‘insight’. What better
indicator is there of the dominance of the ‘medical model’ than the sad fact
that the term ‘insight’, which used to refer to our ability to understand our
current difficulties in relation to our life histories, now means our
willingness to agree with our doctor about the causes of our problems. Well,
actually, I can think of a few competitors for this dubious honour. How about
the fact that programmes to ‘educate’ families that schizophrenia is an
illness and that early family environment is therefore entirely irrelevant have
been called ‘psycho-education’ rather then ‘bio-training’? Another
contender might be ‘compliance therapy’ - the use of cognitive and other
therapy techniques to persuade people to take their drugs.
It can be an even scarier business to go against the grain outside the domain
of clinical practice. Most mental health professionals and academics in the
field tend to stay well clear of the media. I can see why. The many terms
publicly thrown at me by biological psychiatrists when I have disseminated
my own research beyond the safer territory of scientific journals include
‘dangerous’, ‘naive’, ‘family-blaming’, the all encompassing diagnosis ‘anti-
psychiatry’ and, my personal favourite, ‘unreconstituted Laingian’. I am, of
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AND
course, by no means alone in being publicly vilified for publicly citing the
research that shows how very limited, and sometimes just plain wrong,
simplistic biological explanations of, and treatments for, madness can be.
Many before me have paid a much greater price. The question, for the future
of the ISPS, how many will have to speak up, together, before we can do so
without fear of attempts to bully us back into silence?
So I do understand just how scary it was, in Stavanger, in 2000. I assumed,

and hoped, that many others were sitting there wondering whether it was
worth challenging the ideologically-driven inaccuracies and assumptions of
the speaker and his ‘schizophrenic brain’; wondering whether they could get
the words out right; fearing that the response would be the usual
condescending platitudes implying that the challenger was ignorant or
naive. So when I did eventually stand and raise my hand, which I noticed was
trembling even more than my knees, it wasn’t to find out how the speaker
would respond. I knew that. I wanted to know what the other 800 people in
the hall thought. If my challenge was met with the usual silence (and the
usual, comforting but politically useless, ‘well done John’s afterwards in
private) perhaps the ISPS was not for me after all. Very accustomed as I am
to public speaking I was horrified to find that my voice, on this occasion, was
shaky, that my sentences were getting muddled up, and that the microphone
in my hand was dancing merrily around and getting rather damp. I sat down
wishing I hadn’t bothered. But then the applause reached my battered ego.
It was strong and sustained. I knew, then, that my involvement with ISPS
would be equally strong and sustained.
The purpose of this rather egocentric, perhaps narcissistic, approach to

assessing the future of the ISPS is to identify what I believe are some of the
barriers to furthering the goals of the ISPS over the next 50 years. What has
been achieved in the first 50 years has been documented earlier in this book.
It is impressive. It is especially impressive because of the professional and
political climate in which the various successes have been accomplished. The
ISPS was formed almost simultaneously with the introduction of the anti-
psychotics in the early 1950s. The ensuing decades saw, in the mental health
field in general, a significant and sustained lurch towards the nature end of the
timeless ‘nature-nurture’ debate. Psychological treatments gradually became
firmly relegated to accessories to drugs, rather than treatments of first choice.
Psychologists for instance, who should have been taking life histories and
helping people make sense of their disturbing experiences, busied themselves
designing ward management programmes (revealingly entitled ‘token
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economies’) to assist the nursing staff maintain some semblance of control in

the inevitable chaos of hospital wards. (Will we ever learn that it is not a good
idea to round up the 100 or so most distressed and distressing people in the
neighbourhood, put them in the same building and then claim they don’t
improve there because of the debilitating nature of their illness?).
This overemphasis on the bio-genetic, at the expense of the psycho-social,

was exemplified by the 1990s being called ‘the decade of the brain’. This was
all fuelled by many factors. How the ISPS relates to these factors will, I
believe, be the major determinant of how the ISPS, and the aims it aspires
to, will fare over the next fifty years. The first step is to name these barriers
to a more humane, effective and evidence-based approach to psychosis.
Doing so is itself a barrier for many. For some, especially academics,
identifying economic and political variables goes beyond our ‘area of
expertise’. It takes us beyond the realms of ‘science’. Too many of us still
believe that mental health policy and practice is largely determined by
value-free research. From this perspective what we should focus on in the
coming years is a better research-base for our various psychological
treatments. This is, of course, hugely important. One of the most exciting
developments in the few years of my involvement with ISPS has been the
growing involvement in ISPS of the British cognitive psychologists who have
demonstrated that their own approach to treatment works, and that it works
with or without medication. While this seems to be a worry to a minority of
psychoanalysts who may fear a take over by a less ‘in depth’ approach than
their own, the ISPS is more likely to accomplish its goals the more it can
demonstrate, to other people, that a range of psychological approaches to
treatment do in fact work. It is not enough to ‘know’ this yourself from your
own clinical experience.
Nevertheless I doubt that any amount of well-designed research will, by

itself, be sufficient to bring about the changes that so many within ISPS have
worked for since 1956. So here is my best attempt to list the factors, beyond
good research, that will determine the success of the ISPS beyond Madrid
2006.
Highlighting the social causes of psychosis.

Our historical focus on treatments rather than causes has sometimes
limited our involvement in the crucial nature-nurture debate with regard to
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AND
psychosis. Some of us may have decided that because it is now accepted that
everything is partly caused by genetics and partly by the environment (or
more accurately by interactions between the two sets of factors) this is a
futile debate. However, the relative emphasis we place on the two is hugely
important in terms of policy and practice and cannot be ignored. We should
therefore support and encourage research-based challenges to the often
methodologically weak bio-genetic theories that have dominated for so long.
While further etiological research will obviously be welcome we have to read,

and overcome our polite silence about, the existing research about poverty,
violence, urban living, isolation, child abuse, discrimination etc
We must not be fooled by the current illusion of a ‘bio-psycho-social’

paradigm that does include psychological and social factors in the ‘stress-
vulnerability’ equation but only in the relegated role of exacebators or
triggers of a predominantly bio-genetic vulnerability. We will need to argue,
repeatedly it seems, that abnormal neurotransmitter function or brain
structure is not evidence of a brain disease of the kind that is largely
unrelated to the social environment. Brain researchers in other fields
understand that the brain is inevitably influenced by the environment
(especially, but not only, in the earliest years of life). We must help
biologically oriented psychiatrists and policy makers grasp this fundamental
fact
Working with the consumer/survivor movement

There are good arguments to have a professional only organisation. Apart
from anything else, the understandable anger of many ‘user’ groups is
sometimes turned on those organisations most willing to work with them.
This can be painful. Nevertheless we risk emulating the systems we are
trying to change if we fail to find meaningful mechanism for working
together on shared goals. And what about families? Currently the primary
organisations for family members adopt, with eager financial support from
the pharmaceutical industry, a biological/illness framework. Many family
members have told me over the years they are uncomfortable with this
approach, or with being told what to think by any organisation. Finding ways
to include family members who share our goals will not be difficult. Some
ISPS branches are already including service users and family members and
this could be formalised at an international level.
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Challenging the biasing effects of the pharmaceutical

industry
There is no getting around the fact that it is in the interests of drug companies
to promulgate bio-genetic causal theories and medical treatments. It is their
job to produce profit for their shareholders. They do it very well, with massive
resources of the kind we can never match. The ISPS faces a major strategic
and ethical challenge here because we have a history, like almost every major
organisation in our field, of accepting drug company money. Without them, we
have come to believe, we could not hold our conferences or fund our
newsletters. I am not convinced this is true. Our annual conference in New
Zealand (in its third year in 2005) is attended by 200 people and is self-
funding. Admittedly it is a far bigger enterprise to organise an international
symposium. On the other side of this argument our ‘sponsors’ have not yet
influenced the content of our conferences (other than by their advertising).
Perhaps, one might argue, as long as they are willing to stomach some of us
identifying the many adverse effects they have on our field, and some of the
tactics they use to maximise their profits, we should continue to accept their
money. Personally I look forward to a time – hopefully before fifty years have
gone by – when this will no longer be necessary.
All of this leads me towards the central strategic challenge facing ISPS. It is
the same challenge faced by any organisation trying to promote an agenda
against powerful vested interests. Those interests, for us, go beyond the
drug companies of course. They extend to national governments who are
only too delighted to be told that psychosis is a bio-genetically based brain
disease and that therefore nothing can be done to prevent it by improving the
social conditions in which our children grow up, that all we can do is to spend
more money on drugs to ‘alleviate the symptoms.’ The challenge is how to
grow the organisation so as to achieve its goals without alienating those who
currently disagree with us. For example, how do we persuade more
psychiatrists, without antagonising them, that their drugs should not always
be the first line of treatment and that their diagnostic labels may be doing
more harm than good? I don’t know the answer to this. I do know that being
silent is not an effective method of persuasion. When I sometimes feel that I
have annoyed a potential ally by putting the case too strongly I reassure
myself by remembering that you can’t win everybody over to what you believe
and that you can be so fearful of alienating people that you end up not saying
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AND
what you really think. I am also bolstered by the fact that general population
survey all over the world find that the public (our clients !) (1) understand
that psychosis is caused predominantly by bad things happening to people
and (2) prefer psychosocial treatments to medical ones.
In the years ahead of us ISPS members will disagree about how to handle
the challenges I have identified. We will disagree, too, about which is the
‘best’ psychological approach to psychosis (a fun but futile debate since
different people require different approaches). We will disagree about other
things, including, I am sure, the name of the organisation (which I would like
to see be something like the International Society for Psych-social
Approaches to Psychosis). I am so grateful, however, to have found an
organisation that is having such discussions and disagreements. I know the
future of the ISPS is secure because I have met so many people who are
willing to put their time and energy into making sure that this is so. I only
wish I could have met all those who went before them.
notes:
1. This chapter expresses my personal views and not those of the ISPS
Executive Committee of which I am currently a member
2. Rather than provide specific references I have listed some of the many
books that adopt a similar perspective to my own and/or provide research
evidence for arguments or statements I have made in this chapter
Bentall R (ed.) (1990) Reconstructing Schizophrenia. London:Routledge.

Bentall R (2003) Madness Explained: Psychosis and Human Nature. London:Penguin.
Boyle M (1990) Schizophrenia; A Scientific Delusion. London:Routledge.
Breggin P (1991) Toxic Psychiatry. NY:St. Martin’s Press.
———— (1997) Brain Disabling Treatments in Psychiatry. NY:Springer.
Chamberlin J (1988) On Our Own. London:MIND..
Cohen D (1988) Forgotten Millions. London:Paladin
Gosden R (2001) Punishing the Patient: How Psychiatrists Misunderstand and Mistreat
Schizophrenia. Melbourne:Scribe.
Johnstone L (2000) Users and Abusers of Psychiatry, 2nd edn, London:Routledge.
Joseph J (2003) The Gene Illusion. Ross,UK:PCCS.
Karon B, vanden Bos G (1999) Psychotherapy of Schizophrenia: The Treatment of
Choice. NY:Aronson.
Larkin, W. Morrison, A.P. (in press) Understanding Psychosis and Trauma. Hove, UK:
Brunner-Routledge.
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Laing R, Esterson A (1964) Sanity, Madness and the Family. London:Penguin.

Lidz T, et al. (1965) Schizophrenia and the Family. NY:International Universities.
Millett K (1990) The Loony-bin Trip. NY:Simon & Schuster.
Mosher L. Hendrix V, Fort D. (2005) Soteria: through madness to deliverance,
Philadelphia, Xlibris, 2005.
Newnes C, et al. (eds) (1999) This is Madness. Ross,UK:PCCS.
———— (2001) This is Madness Too. Ross,UK:PCCS.
Read, J., Mosher, L, Bentall, R. (Eds.) (2004), Models of Madness: Psychological, Social
and Biological Approaches to schizophrenia. Hove, UK: Brunner-Routledge.
Rogers A, et al. (1993) Experiencing Psychiatry: Users’ Views of Services. Basingstoke,
UK:MacMillan.
Ross, C (2004) Schizophrenia: Innovations in Diagnosis and Treatment. NY: Haworth
Press
Ross C, Pam A (1995) Pseudoscience in Biological Psychiatry: Blaming the Body.
NY:Wiley.
Sarbin T, Mancuso J (1980) Schizophrenia: Medical Diagnosis or Moral Verdict?
NY:Pergamon.
Sullivan H (1962) Schizophrenia as a Human Process. NY:Norton.
Thomas P (1997) The Dialectics of Schizophrenia. NY:Free Association.
Valenstein E (1998) Blaming the Brain: The Truth about Drugs and Mental Health.
NY:Free Press.
Whitaker R (2002) Mad in America: Bad Science, Bad Medicine and the Enduring
Mistreatment of the Mentally Ill. Cambridge, MA:Perseus
John Read
Psychology Department
The Minority of Auckland
Private Bag 92019
Auckland, New Zealand
[email protected]
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AND

PART IV:
ANNEXES

I. The ISPS Constitution

(With minor changes approved by the ISPS general assembly June 7, 2000)
ARTICLE 1
TITLE
The name of the organisation shall be HE INTERNATIONAL SOCIETY FOR THE
PSYCHOLOGICAL TREATMENTS OF THE SCHIZOPHRENIAS AND OTHER
PSYCHOSES hereafter referred to as "The Society".
ARTICLE 2
LEGAL STATUS
The Society will be an international society governed by the law of Norway.
ARTICLE 3
OFFICIAL LANGUAGE
The English text of the Constitution of the Society shall be the official text.
ARTICLE 4
The formal address for all communications shall be that of the appointed
Secretariat of ISPS of that time.
ARTICLE 5
OBJECTIVES OF THE NETWORK
5.1a to promote the appropriate use of psychotherapy and psychological

treatments for persons with schizophrenias and other psychoses.
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AND
5.1b to promote the integration of psychological treatments in treatment

plans and comprehensive treatment of all persons with schizophrenias
and other psychoses.
5.1c to promote the appropriate use of psychological understanding and

psychotherapeutic approaches in all phases of the disorders including
both early in the onset and in longer lasting disorders.
5.1d to promote research into individual, group and family psychological

therapies, preventative measures and other psychosocial programmes
for those with psychotic disorders.
5.1e to support treatments that include individual, family, group, and network
approaches and treatment methods that are derived from psychoanalysis,
cognitive-behavioral, systemic and psycho-educational approaches.
5.1f to advance education, training and knowledge of mental health

professionals in the psychological therapies and psychosocial
interventions in the treatment and prevention of psychotic mental
health disorders for the public benefit regardless of race, religion,
gender or socio-economic status.
In pursuance of the above objectives the Society shall have the following
powers:
5.2a to promote an International Executive Committee structure for the
Society to support continental, regional and national networks of
professionals that will aim to fulfill the objectives in 5.1
5.2b to enhance awareness amongst professionals, administrators and

legislators in the public sector about the psychological therapies and
psychosocial interventions and to make available to the general public
knowledge of such therapies and interventions and where so, to bring
to the public's attention the scarce availability of such therapies and
interventions
5.2c to facilitate communication amongst mental health professionals

administrators and legislators worldwide, by means of publications,
newsletters, journals, scientific conferences and other meetings.
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The ISPS Constitution
5.2d to create a central institution for the collection, provision, maintenance

and spread of information and knowledge of the psychological therapies
and psychosocial interventions relevant to psychotic disorders.
5.2e to establish, carry on, promote, organise, finance and encourage the
study, writing, production, publication and distribution of books,
periodicals, monographs, pamphlets, articles and other literature and
to arrange meetings and lectures and to arrange for the reading of
papers and holding of seminars or discussions and to circulate any
periodicals and literature that may be deemed advisable by the
Executive Committee and to provide library facilities.
5.2f: to purchase, take on, lease or hire or otherwise acquire, real or

personal property and rights or privileges and to construct, maintain
and alter buildings;
5.2g: subject to such consents as may be required by law, to sell, let,

mortgage, dispose of or turn to account all or any of the property or
assets of the Society.
5.2h: to undertake and execute any charitable trusts which may lawfully be
undertaken by the Society.
5.2i: to borrow or raise money on such terms and on such security as may be
thought fit provided that the Executive Committee shall not undertake
permanent trading activities in raising funds for the said objects;
5.2j: to establish and support or aid in the establishment and support of any
associations or institutions in accordance with the aims in ARTICLE 5.1
and to subscribe or guarantee money for charitable purposes.
5.2k: to join or affiliate or cooperate with and subscribe to any association,

society or corporation and to purchase or otherwise acquire and
undertake all or any part of the property, assets, liabilities and
engagements of any such association, society or corporation.
5.2l: to do all such other things as shall further the said objects or any of
them, but not to do anything which will breach the national law of a
member state.
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AND
ARTICLE 6
MEMBERSHIP
Membership shall be open to all individuals, groups and organisations of

mental health professionals, administrators and legislators upon payment
of the subscription fee. The executive committee has the absolute power to
exclude from membership persons that it considers would not benefit the
organisation and its objectives. Membership is not indicative of, and must
not be used to indicate any form of professional competence or expertise.
ARTICLE 7
THE EXECUTIVE COMMITTEE OF THE SOCIETY
7.1 The affairs of the Society shall be managed by an International

Executive Committee.
7.2 The Executive Committee will be composed of up to eight members

who will be elected by ballot in conjunction with a Formal General
Meeting of the Society for a maximum period of 4 years before further
elections must take place.
7.3 There shall be no restriction on the number of terms of office for which
an Executive Committee member may be elected.
7.4 THE CHAIRPERSON shall be elected from amongst the Executive

Committee members and by the Executive Committee members at its
first meeting following their election at a Formal General Meeting.
Other Executive members will be appointed by the Executive
Committee itself to the positions needed for it's functioning. These
shall include a treasurer and a secretary and minutes shall be taken of
all meetings and decisions made.
7.5 Members of the Executive Committee may resign by giving notice in

writing to the secretary.
7.6 The proceedings of the Executive Committee shall not be invalidated by

any failure to appoint or by any defect in the appointment of any member.
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7.7 The Executive Committee shall be convened at least annually by the

chairperson. An official convening may take the form of telephone or
video conference meetings involving a quorum of members. A quorum
shall be at least four elected members. Additional meetings must be
called by the chairperson if at least four Executive Committee
Members sign a letter expressing a request to meet.
7.8 The Executive Committee shall appoint an organisation or committee

to be responsible for THE ORGANISATION of the recommended
triennial symposium of the network. This committee shall be
accountable to the Executive Committee
7.9 The Executive Committee may from time to time appoint such sub-
committees as may be deemed necessary, and may determine their
terms of reference, powers, duration and composition, provided that
all acts and proceedings of any such sub-committee shall be fully and
promptly reported to the Executive Committee.
7.10 The Executive Committee shall have the power to appoint and dismiss
a paid secretary and such other employees of the Society, not being
members of the Executive Committee as it may from time to time
determine, or to arrange with any other organisation for the provision
of secretarial and administrative services.
7.11 The Executive Committee shall have the final authority to determine
membership of the Society.
7.12 The Executive Committee shall take its decisions by a simple majority
of those present and voting at official meetings. In the event of a tie,
the chairperson will have an extra casting vote.
7.13 The Executive Committee has the power to make 'Honourary Life
Member Awards' for up to a total of twelve living persons who have
made outstanding professional contributions to activities that
correspond to the Objectives of the Society.
ARTICLE 8
FORMAL GENERAL MEETINGS
8.1 The Executive Committee must call Formal General Meetings of the
network which must take place at least every four calendar years.
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AND
8.2 At the Formal General Meeting the business shall include the
election of the Executive Committee and consideration of a general
report of the Executive Committee and the accounts.
8.3 At least one year prior to elections, the Executive Committee shall
appoint from amongst itself a nominating committee of at least four
persons. In forming this committee the Executive Committee shall be
mindful of the need for both geographical representation and
experience of the International Society.
8.4 Mindful of 8.3 above, the Executive Committee will resolve upon the
method of voting in respect of elections to the Executive Committee
and any other major agenda items at any Formal General Meeting.
8.5 Notification of elections and their date and place shall be given by post
to all members, to be posted at least five calendar months before the
election. The closing date for receipt of nominations and items for the
agenda (which may only be sent by mail or facsimile) shall be three
calendar months before the date of election. Agenda items will only be
considered from ISPS Members subscribing members.
8.6 All nominations must be proposed and seconded by subscribing

Society members and may be accompanied by a supporting
statement.
8.7 The list of nominees and a provisional agenda and information as to the
form in which voting will take place must be sent to subscribing members
at least one clear calendar month before the Formal General Meeting.
8.8 Though it is permissible for there to be more than two nominations

from members resident in the same country, no more than two
members whose usual residence is in the same country in the year of
election may be elected to the Executive Committee. With this
exception the (up to) eight nominees with the greatest number of votes
shall be elected to the Executive Committee. In the event of a tie for the
final places, the other members of the New Executive Committee will
vote between those tied persons for the final place(s).
8.9 All other decisions at a Formal General Meeting shall be decided on

the basis of a simple majority of votes cast.
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ARTICLE 9
FINANCES
9.1 The Executive Committee shall have power to obtain, collect and
receive money and funds by way of contributions, donations,
subscriptions, deeds of covenant, legacies, grants or any other
lawful method, and to accept and receive gifts of property of any
description.
9.2 The Executive Committee shall determine the level of subscriptions

and the METHODS OF PAYMENTS and require payment of fees within
such time as the Executive Committee shall determine but not less
than one month from the demand. No person shall be entitled to vote
if that person has not paid his dues within a period of SIX months
following demand. The Executive Committee shall also have the power
to expel a person or organisation for non payment of fees.
9.3 The income and property of the Society, whencesoever derived, shall
be applied solely towards the object of the Society as set forth in
ARTICLE 5 and no portion thereof shall be paid or transferred directly
or indirectly by way of dividend, bonus or otherwise howsoever by way
of profit to any member of the Executive Committee: provided that
nothing herein shall prevent the payment in good faith of reasonable
and proper remuneration to any servant of the Executive Committee
not being a member of the committee, or the repayment to members
of the Executive Committee or any sub-committee appointed under
ARTICLE 9.10 hereof of reasonable and proper out of pocket
expenses.
9.4 The financial year shall run from 1st January to the 31st December.
9.5 The funds of the Network including all donations contributions and
bequests, shall be paid into an account operated by the Executive
Committee in the name of the Society at such bank as the Executive
Committee shall from time to time decide. All cheques drawn from the
account must be signed by at least two persons authorised by the
Committee, at least one of which must be an Executive Committee
member.
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AND
ARTICLE 10
DISSOLUTION
The Society may be dissolved by a Resolution passed by a two-thirds majority

of those present and voting at a Special General Meeting convened for the
purpose of which at least 21 days notice shall have been given to the
members.
Such resolution may give instructions for the disposal of any assets held by
or in the name of the Society, provided that if any property remains after the
satisfaction of all debts and liabilities, such property shall not be paid or
distributed among the members of the Society. Such assets or property but
shall be given or transferred to such other charitable institution or
institutions having objects similar to some or all of the objects of the Society
as the Society may determine. If and in so far as effect cannot be given to this
provision then to some other charitable purpose
ARTICLE 11
AMENDMENTS TO THE CONSTITUTION
Alteration to this Constitution shall receive the assent of two-thirds of the

members present and voting at a Formal General Meeting or a Special
General Meeting. A resolution for the alteration of the constitution must be
received in writing by the Secretary of the Society at least four months
before the meeting at which the resolution is to be brought forward. At least
two calendar months clear notice of such a meeting must be given in writing
by the Secretary to the membership and must include notice of the alteration
proposed.
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II. History of ISPS Board

members 1990-2006
ISPS Board members 1990-1997 (Unofficial)
Yrjö Alanen,Finland
Endre Ugelstad,Norway
David Feinsilver,USA
Torleif Ruud,Norway,
Johan Cullberg, Sweden
Brian Martindale,UK
Per Maria Furlan,Italy
ISPS Board members 1997-2000
Johan Cullberg, Sweden (Chair)

Pier Maria Furlan, Italy
Courtenay Harding, USA
Jan Olav Johannessen, Norway
Brian Martindale, UK
Patrick McGorry, Australia
Franz Resch, Germany
Torleif Ruud, Norway
Jan Olav Johannessen, Norway (Chair)

Johan Cullberg, Sweden
Courtenay Harding, USA
Franz Resch, Germany
Ann-Louise Silver, USA
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AND
Jan Olav Johannessen, Norway (Chair)

Manuel González de Chávez, Spain
Ann-Louise Silver, USA
Ivan Urlic, Croatia
Lyn Chua, Sigapore
John Read, New Zealand
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III. ISPS Life Honorary Members
Yrjö O. Alanen, by Manuel González de Chávez

Gaetano Benedetti, by Brian Koehler
L. Bryce Boyer, by Sue von Baeyerer
Johan Cullberg, by Sonja Levander
Stephen Fleck, by Ann-Louise S. Silver
Murray Jackson, by Brian Martindale
Jarl Jørstad, by Svein Haugsjerd
Julian Leff, by Brian Martindale
Theodore Lidz, by Ann-Louise S. Silver
Christian Müller, by Luc Ciompi
Barbro Sandin, by Kia Sjöström
Harold F. Searles, by Ann-Louise S. Silver
Helm Stierlin, by Michael Wirsching
John S. Strauss, by Ann-Louise S. Silver
Endre Ugelstad, by Torleif Ruud
Lyman C. Wynne, by Susan McDaniel
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ISPS Life Honorary Members
Yrjö O. Alanen
Yrjö Alanen is one of the professionals who have

helped shape the history of schizophrenia, its
understanding and its global, flexible approach
adapted to the needs of patients.
Professor of Psychiatry (Emeritus) Yrjö Olavi Alanen was born Jan. 31, 1927 in
Kurikka, Finland. He got his M.D. degree in the University of Helsinki in 1952
and did his specialist training in psychiatry and neurology in the Psychiatric
University Hospital in Helsinki from 1954 to 1957. He was appointed to senior
level clinical positions in this hospital from 1958 to 1968, after which he was
appointed Professor of Psychiatry and Chairman of the Department of
Psychiatry at the University of Turku, Finland. This position also included the
chairmanship of the Department of Psychiatry and clinical work as Medical
Director of the university hospital The Clinic of Psychiatry of Turku. He retired
in 1990, however, since then he has continued his professional work as a
psychotherapist and teacher, dedicating more time than previously to writing
and editing books in his field.
Alanen had already begun his personal psychoanalysis in 1955 and was one
of the first candidates for psychoanalytic training after IPA training became
possible in Finland in 1965. He became a member of the Finnish
Psychoanalytic Association in 1969. His main interests have been the
psychodynamic study of schizophrenic psychoses and individual and family
psychotherapy of schizophrenic psychoses. He instigated the first regular
family therapy training in Finland in 1979 and acted as a member of the first
trainer group in family therapy. This training soon became very popular and
more extensive in different parts of Finland because, among other things, of
its multi-professional quality. Family therapy training was also later
established at an advanced special level. In the 1990s Alanen joined his
closest working pupils and co-workers Viljo Räkköläinen and Jukka
Aaltonen in the establishment of the advanced special level training program
in psychodynamic individual therapy of seriously disordered patients.
Among other things, Alanen’s early studies dealt with family environments
and dynamics of schizophrenic patients, leading to the monographs The
Mothers of Schizophrenic Patients, 1958; and (together with co-workers)
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AND
Family in the Pathogenesis of Schizophrenic and Neurotic Disorders, 1966.

These studies already included features of integrated views, typical to
Alanen’s later theoretical and clinical ways of thought. In 1959-60 he was
Research Associate in Yale University Dept. of Psychiatry in New Haven,
Conn., U.S.A., working in Theodor Lidz’s team. In 1979 he received the
seventeenth annual Stanley R. Dean Research Award, given by The American
College of Psychiatrists and The Fund for the Behavioral Sciences in
recognition of basic research accomplishment in the behavioural sciences
contributing to our understanding of schizophrenia.
In 1971, Yrjö Alanen organized the IVth ISPS symposium, held in Turku,
Finland. After that, he was a member of the international executive committee
of the ISPS until 1997. He is a lifetime honorary member of the ISPS.
In Turku, Alanen, along with his co-workers, established the Turku

Schizophrenia Project, which led to the development of the now well-known
need-adapted approach, an integrated and individualized psychotherapeutically
oriented treatment of schizophrenic patients, leading to several later projects
and practice in Finland and in the other Scandinavian countries. This approach
and its results are presented in Alanen’s major work, the book Schizophrenia –
Its Origins and Need-Adapted Treatment (London: Karnac, 1997), which has also
been published in Finnish (1993), German (2001), Polish (2001), Spanish (2003)
and Italian (2005). During the 1980s, he was the leader of The Finnish National
Schizophrenia Project, which aimed for a more psychotherapeutic and
humanistic treatment of psychotic patients. According to the follow-up in 1992,
both the amount of “new” and “old” long-term schizophrenic patients in
Finnish mental hospitals had diminished about 60 per cent over 10 years. In the
1980s and ‘90s Alanen also led, together with Endre Ugelstad and other
Scandinavian colleagues, the NIPS (Nordic Investigation on Psychotherapy of
Schizophrenia) project, aiming to promote psychodynamically oriented study
and treatment of new schizophrenic patients within the community psychiatric
context (cf. the book Alanen et al.: Early Treatment for Schizophrenic Patients;
Scandinavian psychotherapeutic approaches; Oslo: Scandinavian University
Press, 1994). He is also one of the editors of the book Psychotherapie der
Psychosen; Integrative Behandlungsansätze aus Skandinavien (V. Aderhold et
al., eds, Giessen: Psychososozial-Verlag, 2003).
In 1982-84 Alanen acted as the chairman of the Committee of Mental Health

in Finland, aiming at the innovation of the activities to a more open
care–oriented direction and to end the separation of psychiatric
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ISPS Life Honorary Members Yrjö O. Alanen
organizations from the organizations including other medical specialties.

The proposals of the Committee led to a new Mental Health Act, enacted in
1991, after the establishment of an Act joining the organizations for special
health care together. From 1982 to 1985 Alanen also held the position of
Research Professor, Academy in Finland, coinciding with his work as the
leader of the National Schizophrenia Project.
Yrjö Alanen is an honorary member of 9 scientific and/or professional

societies, including – besides the ISPS – the Finnish, Swedish and Polish
Psychiatric Associations and the European Family Therapy Association. His
special interests have included cross-country skiing and still include,
especially, literature (he has published two essay books in Finnish, one of
them dealing with Dostoyevsky’s The Idiot and The Devils). He is married to
Johanna, née Aalto, has four children and six grandchildren.
Yrjö Alanen has had a complete life of lucidity, dedication and devotion. He
investigated the familial dynamics of psychotic patients while establishing
the most effective familial and individual psychotherapeutic strategies and
interventions and the global health care devices that these patients require
for their recovery. He took charge of the psychotherapeutic training of all the
professionals, of the creation of early psychotherapeutic and familial
intervention teams, of the development of integrated therapeutic programs
and of the investigation of the results of these programs on improvement or
overcoming of psychotic disorders.
From the city of Turku to the rest of Finland, from Finland to the other
Scandinavian countries and to many other parts of the world, the figure and
the work of Yrjö Alanen has had a decisive influence and has been a great
example for many professionals in our field.
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Gaetano Benedetti
Professor Gaetano Benedetti noted:
“Over half century of psychodynamic research has

proved that schizophrenia is not only a medical
disorder, but a biographical facet of the human being-it is a challenge to the
whole of society to understand, accept and reintegrate the psychotic patient
amongst us.”
(Ninth International Symposium on the Psychotherapy of Schizophrenia)
“It is in the psychotic’s suffering that the most serious problems of the
human mind are encountered. Tackling them means illuminating the human
being with signification and sense, gaining a better understanding of the
human being in general, not only of the psychotic person.”
(Tenth International Symposium for the Psychotherapy of Schizophrenia)
Gaetano Benedetti was born in 1920 in Catania, Sicily. He joined the

psychiatric staff at the Zurich University Clinic Burghölzli in Switzerland in
1947, where he increasingly focused his work on the psychoanalytic
psychotherapy of psychotic patients. He worked closely with Gustav Bally,
Medard Boss, Marguerite Sechehaye, and Christian Müller. Benedetti and
Müller co-founded the International Symposium for the Psychotherapy of
Schizophrenia (ISPS) in 1956 at the psychiatric clinic at the University of
Lausanne in Switzerland.
The ISPS has evolved into the currently thriving International Society for the
Psychological Treatments of the Schizophrenias and Other Psychoses
(www.isps.org and www.isps-us.org). The impetus for founding ISPS was
Benedetti and Müller’s dissatisfaction with the predominantly reductionistic
orientation of European psychiatry and they had sought the aid of
psychoanalysis to find a different approach to the schizophrenias.
In 1956, Benedetti was also appointed professor of psychotherapy at the

University of Basel. He continued his work with persons diagnosed with
schizophrenia until he retired in 1985. However, Professor Benedetti
remains active into the present in his teaching and supervision of clinicians
engaged in psychosis psychotherapy. His favorite book has been translated
into many languages, in German it is called “Todeslandschaften der Seele”
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AND
(1998), and in Italian, “Alienazione E Personazione Nella Psicoterapia Della

Malattia Mentale”(1980). His collected papers were published in English
under the title “Psychotherapy of Schizophrenia” in 1987 by New York
University Press. Professor Benedetti has published a multitude of articles
covering such topics as gender differences in psychosis psychotherapy, the
use of a therapeutic assistant, emergency interventions in psychotic crises,
facilitating factors in psychosis psychotherapy, the ego structure and self-
identity of the person with schizophrenia and the task of psychoanalysis, and
mirror-image experiences in psychosis psychotherapy.
Benedetti moved psychoanalysis with psychotic persons away from the

primary emphasis on transmission of cognitive insight, to the transmission
of therapeutic transforming images, of transitional subjects, of mirror
phenomena, of patient-therapist symmetries, of therapeutic dreams, of
progressive psychopathology. He believes that our concept of psychosis
psychotherapy must be broad enough to include our psychological concern
for the schizophrenic human being as differentiated from, but not divorced
from the study of the neurobiological processes observed in schizophrenia.
Benedetti sees therapeutic transforming images as arising from the
therapist’s ability to identify with the catastrophes occurring within the
patient, to live them as if they were our own, to the point in which the
therapist’s latent psychotic nuclei may be mobilized. However, these become
part of the dialogic interweave, which is ‘antipsychotic.’ The therapist’s
containment and consubstantiability with the negative, anxiety-ridden,
aspects of the patient helps the latter to gain awareness of the positive
aspects of her or his self. It is then that the “transitional subject” emerges
within the unconscious or conscious mental processes of both patient and
therapist. This also signifies that a “progressive psychopathology” is
proceeding, in which previous psychopathological phenomena, such as
transitivism and appersonation, become therapeutically transformed, e.g., a
patient may still hallucinate, but the hallucination may be an empathic,
correct interpretation of the patient’s situation.
Recently, in describing the role of the therapeutic symbiosis, Benedetti

commented:
“The dynamic of symbiosis is based upon transference and countertransference;

special however is the kind of object, caused by the therapeutic setting, to
which the self of the patient relates. The object here is a therapeutic one. This
means, basically, that it does not ‘invade’ the patient’s self with its own wishes,
demands and expectations, but mirrors back his own positivized image. The
fragile psychotic ego is not confronted with demands and fragmented by a
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ISPS Life Honorary Members Gaetano Benedetti
stranger. It encounters itself, its own healing origin, in the positivizing mirror of
the therapist” (personal communication).
For Benedetti, delusions are a sort of existential truth for the patient.
Therapists allow themselves to be pulled into the delusion in order to stand
in the same place as the patient before confronting the patient with her or
his delusions. By this, one gains a kind of citizenship within the closed world
of the patient. The less dangerous, non-fragmenting therapeutic object is
gradually experienced by the patient as a kind of second self, which helps
the patient withstand panic and feelings of helplessness. Therapeutic
devotion is experienced by the patient as a “niche” for her or his own identity.
Paradoxically, Benedetti believes, that only the deep experiencing of
symbiosis between patient and therapist can lead to the overthrow of
symbiotic confusion in the patient. Most recently, Professor Benedetti is
concerned with negative and positive self-images, therapeutic mirror-
images, self-objects and transitional subjects in the dreams and in the
imaginations of psychotic patients.
Benedetti’s influence on European psychosis psychotherapy has been very

great, especially in Italy and Switzerland and in the Nothern European
countries as well. For the past almost 20 years, Benedetti has collaborated
with his colleague Maurizio Peciccia. In 1986 they developed a
psychotherapeutic method referred to as “progressive mirror drawing.”
Benedetti and Peciccia hypothesized that the core psychological deficits in
schizophrenia are two incompatible nuclei of the self. One is characterized by
excessive symbiotic needs and the other by excessive needs for separation
which can take on autistic-like coloring. There is a de-integration of the
separate and symbiotic selves in schizophrenia. Psychosis psychotherapy,
according to this model, is oriented towards an integration of the symbiotic
(interdependent) and separate (autonomous) selves.
Between 2000 and 2005 Benedetti and Peciccia have, according to the latter,
“extended the principle of symbiotic/separate self integration and sensorial
integration not only to psychotherapies but also to the rehabilitation of
psychotic patients using new techniques in new therapeutic contexts”
(personal communication, Maurizio Peciccia).
Brian Koehler
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L. Bryce Boyer
1916-2000
“The analyst must have the courage to speak
the truth and to hear the truth”
L. Bryce Boyer.
Bryce Boyer was a brilliant and intuitive clinician, a dedicated psychoanalyst,

and a cantankerous and much beloved teacher. He spent most of his
professional life working analytically with seriously disturbed patients,
imposing very few changes in the analytic frame while so doing. Although
thoroughly trained in ego psychology, Dr Boyer developed a different
theoretical orientation as he worked with patients struggling at the level of
narcissistic neurosis. He was among the pioneers who relied on
countertransference information to understand the early, perhaps even
somatic, communications of his patients. Working at the pre-oedipal level in
those early days also involved some difficulty with the psychoanalytic
establishment who, at that time, thought that the analyst should respond only
to verbal communications and that those verbal communications and
interpretations should be at the oedipal level. In his later years, he appreciated
the validation that came with the influx of psychoanalysts who were eager to
learn about using countertransference information. Dr. Boyer wrote and taught
extensively in the area of working psychoanalytically with the regressed patient.
He also wrote about, and was deeply interested in, the Rorschach test
especially in relation to other cultures. For many years he studied the
Mescalero Apache Indians, along with his wife Ruth, who was an
anthropologist. Dr. Boyer authored and co-authored, edited and co-edited
numerous books, including Psychoanalytic Treatment of Schizophrenic,
Borderline, and Characterological Disorders, 2 editions; The Regressed
Patient; Technical Factors in the Treatment of the Severely Disturbed
Patient; Childhood and Folklore: A Psychoanalytic Study of Apache
Personality; Master Clinicians on Treating the Regressed Patient, Vols. 1 and
2; Vols. 7-19 of The Psychoanalytic Study of Society; A Rorschach andbook
for the Affective Scoring System, 3 editions; and numerous articles. Many of
his books and articles have been translated into such languages as German,
Italian, Spanish, Portuguese, Norwegian, and Finnish.
In terms of his personal biography, Dr. Boyer was always quite frank and
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AND
revealing about his early life. Dr. Boyer’s mother was severely disturbed and
paranoid. Dr. Boyer has often attributed his capacity to understand and
interpret regressed patients at a visceral level to the necessity of understanding
and interpreting his mother. He has also attributed to his mother the
development of the belief that the acting out behavior of seriously disturbed
patients is not merely resistive, but is also an effort to communicate and recall
experiences for which these patients do not as yet have words. Because his
mother could respond to his interpretations, and they would calm her, his
conviction grew that narcissistic disorders could be treated by psychoanalysis.
Dr. Boyer encountered several significant colleagues as he trod what must have
been a lonely path in those early days of treating severely disturbed patients
psychoanalytically. He struck up a friendship and a productive collaboration
with Peter Giovacchini, M.D., starting in 1967. Dr. Giovacchini once wrote to Dr.
Boyer that “We grew up together” (personal communication to LBB) as they
wrote and edited their way collaboratively through many volumes of
psychoanalytic articles. Another colleague who was very important to Dr. Boyer
was Tom Ogden, M.D. They first met in the context of a psychiatric teaching
hospital, and went on to form the Center for the Advanced Study of the
Psychoses. The Center, along with other endeavors, included a study group
where psychoanalysts and psychotherapists presented difficult cases involving
difficult patients. Dr. Boyer sat at one end of the table and Dr. Ogden at the
other. The understanding of the patients presented unfolded in the discussion
around the table and in the back and forth between Drs. Boyer and Ogden. The
participants also read and discussed the writings of Bion, Winnicott, Klein
among others. This was a rich environment for learning what was previously
thought to be unteachable. Another major topic of conversation at that table
was the absolute interdependence of transference and countertransference.
Many a case presentation found resolution when the understanding developed
of the mutual introjections by the analyst and the analysand of each other’s
unconscious or preconscious projective identifications, a major teaching of Dr.
Boyer. In 1982, a grateful former patient of Dr. Boyer donated a sum of money
in Dr. Boyer’s name to establish a treatment center. The Boyer House
Foundation took shape. This treatment center continues to this day, with well-
trained staff working psychoanalytically in a residential, long-term, open,
therapeutic community. The staff works diligently to understand the patients
through the countertransference, sometimes coming together in the weekly
case conference like slices of a pie becoming whole again, as each therapist
brings forward his/her countertransference based understanding of the patient
in question. As the staff each represents an individually apprehended fragment
of the patient, the patient comes together representationally, taking on a fuller,
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ISPS Life Honorary Members L. Bryce Boyer
more complete understanding in the therapeutic community and the work

becomes stronger. We were taught well by Dr. Boyer and his work lives on. We
are grateful.
Boyer, L.B. (partial bibliography)
(1967). Psychoanalytic Treatment of Schizophrenic and Characterological

Disorders, ed. L.B. Boyer and P.L. Giovacchini. New York: Science House
(1979). Countertransference with severely regressed patients. In

Countransference: The Therapist’s Contribution to the Therapeutic Situation,
ed. L. Epstein and A.H. Feiner, pp. 347-374. New York: Jason Aronson.
(1980). Psychoanalytic Treatment of Schizophrenic and Characterological

Disorders, ed. L.B. Boyer and P.L. Giovacchini, 2nd edition, revised and en-
larged. New York: Jason Aronson.
(1983). The Regressed Patient. New York: Jason Aronson.
(1985). Christmas “neurosis” reconsidered. In Depressive States and Their

Treatment, ed. V. Volkan, pp. 297-316. Northvale, NJ: Jason Aronson.
(1990). Master Clinicians on Treating the Regressed Patient, Vol. I, ed. L.B.
Boyer and P.L. Giovacchini. Northvale, NJ: Jason Aronson.
(1993). Master Clinicians on Treating the Regressed Patient, Vol. II, ed. L.B.
Boyer and P.L. Giovacchini. Northvale, NJ: Jason Aronson.
(1999). Countertransference and Regression. Northvale, NJ: Jason Aronson.

Boyer, L.B.
Sue von Baeyer
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Johan Cullberg
It is difficult to find a perspective that will catch the

scope of what has constituted Johan Cullberg’s
professional life – thus far. Every aspect seems to touch upon the other.
He started his career at the department of gynaecology at the Karolinska

Hospital: The psychological effect of contraceptive pills. Somewhat later he
interviewed 60 women who had lost their child during delivery, a study which
he used for his dissertation. These narratives from women in crisis helped
him to fully understand that it is not only a painful period that has to be lived
through. It is also, in fortunate cases, a starting point for a process of
maturation that opens up for insights not available previously. This
experience is described in his book: “Crisis and maturation,” which was
published in 1975, a book which has contributed to the general
understanding of the crisis experience. He points to the importance of
coming to a stand still to be able to look at the catastrophe in a personal life
context. Many unfortunate individuals will eventually come out as stronger
and more mature persons.
At that time Johan Cullberg also became the head of one of the outpatient
clinics in the Nacka project, one of the first areas in Sweden to focus on
psychiatric care outside the hospital. He took special interest in the
interplay between the individual patients and their close environment.
Medicine and hospital care came second, and normalization was at the
centre of his interests. Later he became the head of the research unit of the
project where he more systematically studied the environmental effects on
mental health. He wrote about the anomic milieu; its alienating effects and
how it tends to deprive people from getting enough confirmation of their
human dignity to allow them to go on. Most people who live in a suburban
environment find ways to overcome this, but it is harmful for those who are
vulnerable. Johan Cullberg wanted to understand what conditions in society
have to be changed to make the interaction more positive.
During these years he was also engaged in the situation for the patients who
had to be confined in the hospital ward – especially those who suffered from
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AND
psychosis. This had a special meaning for Johan Cullberg as one of his
brothers became schizophrenic and was locked in a hospital ward and
treated with hundreds of electroconvulsive shocks and insulin treatments.
Even if his brother in many respects faded away slowly as a person, he is still
active and recognized for his artistic painting. Having lived with this pain for
the main part of his life, Johan has fought for a more decent treatment of
psychotic patients. He has claimed the need for lower doses of antipsychotic
medicine and a reduction in the use of compulsory treatment. On the whole
he has wanted the psychiatric care to take a more humane direction.
Of course it has kindled a hope in many patients and their families, when a
person from the psychiatric establishment took sides with the patients: But
the disappointment has been equally strong, when it turned out that he had
kept his belief in neuroleptic treatment in adequate doses and in the
existence of biological factors as the main determinants of schizophrenia –
even if he is a psychoanalyst. For him the psychodynamic understanding is
indispensable, but it is not really an alternative when it comes to the
treatment of psychotic patients. What we read about in the literature are
single case reports that he believes are exceptional.
He has discussed his opinion that it is necessary to integrate the biological

with the psychodynamic approach in open debates and in the scientific
press. But the ambivalence to his integrative endeavours has appeared when
at times his contributions have been passed over in silence or have been
considered unrealistic. This was particularly clear when they were
nominating a candidate for a professorship, which according to many people
was intended for Johan Cullberg, and he was disregarded. Many were very
upset. When asked about it Johan himself thinks that the academic debate
in Sweden is polarized and simplified. (Some ten years ago, however, he was
awarded an honorary professorship).
During the eighties and the beginning of the nineties he worked clinically at
the same time as he continued formulating his experiences in writing. It was
for him a matter of course to convey to others what he had seen and thought
about psychiatric conditions, their background and treatment. First of all
medical students have been his target group, as he sees them as central
when it comes to a change of Swedish psychiatry. He wanted to write study
literature from the subjective and objective perspective as well as the
biological, the psychological and social, each being the necessary condition
for the others.
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ISPS Life Honorary Members Johan Cullberg
His next book, “Dynamic Psychiatry”, is a far-reaching textbook that covers

psychiatry as a whole. At the same time it introduced a personal vignettes
including empathy and understanding, it gives directions as to medication
and diagnostic considerations.
The following book, ”Psychoses,” is as exciting as a novel, and has surely
tempted many students to start working in psychiatry. He gives
psychodynamic explanations of the background to the psychotic condition,
and demonstrates how the compulsory measures can be replaced by respect
and kindness. But it also leaves space for much that is still to be understood
about these conditions, especially the vague concept of schizophrenia, which
probably covers a lot of different states of mind.
Later he widened his perspective to the literary field and has written two so-
called psychobiographies. In his eagerness to try to understand more about
the psychotic process, he grappled with three Swedish authors: Stig
Dagerman, who committed suicide, and August Strindberg and Gustaf
Fröding both of whom became psychotic. From a psychodynamic perspective
he reads their texts, supplementing them with outside information about
their lives and excerpts from their psychiatric files. In describing their
existential situations he digests it into portraits of human beings of flesh and
blood, who in their literary works have tried to understand their problems.
The last ten years of research have been dominated by his work with the
”Parachute Project” – an expression of his wish to understand what factors
are of importance for the psychotic break down and for the outcome. First of
all, however, he wanted to demonstrate that it is possible to make
psychiatric care more humane by considering the patients’ individual needs.
Important research questions have been: What distinguishes those of the
175 patients who had a good outcome from those who never were able to
return to their prepsychotic life? And what did it mean to them that instead
of noisy and messy hospital wards they stayed in quiet, small, homelike units
– mostly outside the hospital? Especially he wanted to find out the
consequences of offering lowest effective doses compared to minimizing
symptoms by using high doses of antipsychotics, often with heavy side
effects. The project is going to be presented at the ISPS conference in Madrid
2006.
Johan Cullberg has said that more and more he has adopted a view of the
human being as one who has to take responsibility for her life, irrespective
of her psychological problems. After all, one has to believe that no one can
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AND
change another person who is not willing to change. What kind of life does
our patient want to live? What kind of person does she want to be? Those of
us who have chosen to try to help those who seek our help, first of all have
to support her in reaching the goals she has set for herself. We are not there
to cure or correct other people to make them fit our model for a normal
person.
Sonja Levander
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Stephen Fleck
Stephen Fleck died on December 19, 2002, maintaining

his friendship with Theodore Lidz to the end, both of them
living in the same retirement home in New Haven,
Connecticut. An emeritus professor in two departments at the Yale University:
psychiatry and the department of epidemiology and public health, he was the
epitome of a gentle yet firm mentor for his younger colleagues, maintaining
these ties as well, almost to the end. He and Ted Lidz began working together
in the late 1940s. They succeeded in pushing psychoanalytic orientations from
a two-person study of the individual to a perspective including social-
scientific methodology, medical, behavioral, neurological and public health
factors. They emphasized familial factors. Their research family was also
innovative in its diversity, including all the mental health specialties, and
avoiding narrow elitism. The papers issuing from this team’s work were
published in the landmark Schizophrenia and the Family, published in 1965
by International Universities Press, and edited by Lidz, Fleck and Alice
Cornelison. Number 7 in IUP’s Monograph Series on Schizophrenia, it
delineated the twelve years of conducting an intensive study of the
interfamilial environment in which schizophrenic patients grew up.
In 1980, he co-edited Psychotherapy of Schizophrenia, whose senior editor

was John Strauss, along with T. Wayne Downey. The book was published by
Jason Aronson. And in 1981, with Jerzy Henisz, he co-authored
Psychotherapeutic Management on the Short-Term Unit: Glimpses at
Inpatient Psychiatry. He participated in the writing of “Practice Parameters
for the Assessment and Treatment of Children and Adolescents with
Conduct Disorder,” issued in 1997 by the American Academy of Child and
Adolescent Psychiatry.
Fleck was born on September 18, 1912 in Frankfurt, Germany. As a medical

student in 1933, he and others were told by one of their professors that the
Nazis had marked them for arrest. He fled first to Holland and in 1935 he
moved to the United States. By 1940 he had graduated from Harvard Medical
School. There, he served as John Rock’s research assistant and thus
contributed to the basic research that led to the birth-control pill. Fleck
maintained an interest in this initiative, working on the American Psychiatric
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AND
Association’s Family Planning Position Statement, No 73007, in 1973,

chaired by Eugene Brody, M.D. “Individual choice as to whether and when to
become a parent and the prevention of unwanted pregnancy or birth is an
important way to promote and safeguard the health and welfare of
individuals, families, and communities. Birth control, including
contraception, medically safe abortion, and voluntary sterilization should
therefore be available universally to every individual on request to prevent
unwanted pregnancy or parenthood as a part of standard health care and
medical services.” He along with his wife, Louise, worked politically towards
the ultimate success on June 7, 1965 of the landmark case Griswold v.
Connecticut, which made the sale of birth control legal in the state. By a vote
of 7 to 2, the Supreme Court of the U.S. ruled that the Constitution protected
a right to privacy. Justice William O. Douglas, writing for the majority, ruled
that this right was to be found in the “enumbras” of other constitutional
protections. One can imagine the victory parties the Flecks hosted and
attended, and the joy they felt in a nation protecting its citizens so fully.
From 1942 to 1946, Fleck served in the Army Medical Corps stateside and in
Europe, sometimes also assisting Army intelligence. Following the Battle of
the Bulge, he was briefly in charge of 80,000 German POWs, most of them
medically ill. In May 1945, he helped evacuate and treat concentration-camp
prisoners and interrogate German prisoners. He also searched
concentration camp records for signs of his own family and friends who had
not escaped Nazi arrest.
Following the war, he completed a psychiatric residency at the Henry Phipps

Clinic of the Johns Hopkins Hospital in Baltimore, Maryland. He then served
from 1949 until 1953 on the faculty of the newly founded University of
Washington Medical School, where he received psychoanalytic training. In
1953 he joined the Yale Department of Psychiatry, helping begin the long-
term research project on schizophrenics and their families. At Yale, he
served in numerous administrative capacities, including Psychiatrist-in-
Chief of both the Yale Psychiatric Institute (1953-83) and the Connecticut
Mental Health Center (1969-83); Director of Residency Training; and Deputy
Chair (1969-83). His Yale obituary notes, “Despite an extensive research and
publishing record, he always maintained that clinical care and teaching
should be first priorities of any academic setting. He refused major
administrative positions at several junctures, preferring to concentrate on
those priorities,” as if thirty years heading the famous YPI were not a major
administrative post.
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ISPS Life Honorary Members Stephen Fleck
Fleck valued his role in the career development of many psychiatrists and
other mental health professionals; he took a deep fatherly interest in them.
Even when officially retired, he continued supervisory and professional
service until shortly before his death. He and his wife, Louise H. Fleck, who
predeceased him, were active community volunteers, focusing on projects to
strengthen the public schools as well as to promote reproductive choice. He
was survived by daughters, Anna F.J. Singer and Carra F. Rockwood, hi son,
Stephen H. Fleck, and four grandchildren, and by his brother, Edgar Fleck
and dear friend, Dr. Gertrud Hunziker-Fromm of Zurich, Switzerland.
I am grateful to Karen Peart for her internet posting of the Yale News
Release of Stephen Fleck’s obituary, which provided most of the information
included here.
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Murray Jackson
Murray Jackson has played a leading role over many

decades, in both Britain and Scandinavia, in
stimulating and maintaining the interest and skills of
many professionals in the contributions that
psychoanalytic approaches can make to the treatment of individuals with
psychotic illnesses.
Born in Australia in 1922, he graduated in medicine at the University of

Sydney in 1945. After Military service in Occupied Japan and a period of
medical research in the US he moved to London where he trained in
psychiatry at the Maudsley Hospital. In the hey-day of psychoanalytic
influence in psychosomatics he was much influenced by the work of
psychoanalysts in the field of, in particular that of George Engel and John
Romano at the Rochester School of Medicine and of Franz Alexander in
Chicago.
Ten years as a psychiatric Consultant in a University Hospital led to a life-

long interest in the psychological factors contributing to certain physical
illnesses, in particular in those gastro-intestinal disorders which may
occasionally reciprocate with psychotic states. Writing about
psychosomatics, teaching medical students and trainee psychiatrists, and
interest in Jung’s work on psychosis led him to training first in analytical
psychology and later in psychoanalysis.
Appointed as Consultant at the Maudsley hospital in 1972, he directed a 10-bed

a unit on ‘Ward 6’ where psychoanalytic principles were applied to the
treatment of a wide range of the severely mentally ill, whilst continuing his
private psychoanalytic practice which focused on less severe borderline and
psychotic cases. The success of this unit depended on the integration of
pharmaceutical, psychological and innovative nursing approaches, together
with his psychoanalytically-based ‘ward rounds’ with patients and staff and
active support for the psychological containment offered by the staff –
particularly those nurses who went on to further training as ‘nurse-therapists’.
Although far from partisan within the psychoanalytic schools, he felt that
Melanie Klein and those who followed in her footsteps and developed her
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AND
ideas further offered a rich framework that greatly assisted the

understanding of the psychotic mind, and he profoundly admired the work of
pioneers such as Henry Rey, Donald Meltzer, Herbert Rosenfeld, Hanna
Segal and Wilfred Bion.
With the encouragement of Paul Williams, the co-authored book

‘Unimaginable Storms: A Search for Meaning in Psychosis’ (Jackson &
Williams 1994) was published. This outstandingly educative book was based
on edited transcripts of audio taped interviews of Murray with patients of the
ward. It has been a most important source book for a whole generation of
professionals seeking a contemporary psychoanalytic understanding of
psychosis, and of the ‘psychotic’ aspects of their mind.
Regrettably the in-patient unit at the Maudsley Hospital was not continued in
the same modality after his retirement from the British National Health
Service in 1987, but he continued his teaching at a number of centres in
Scandinavia over the next 15 years, recording his experience in a second
book –Weathering the Storms – Psychotherapy For Psychosis’ (Jackson
2001), a masterpiece of communication illustrating how selected psychotic
patients can benefit from non-intensive psychoanalytic psychotherapy
conducted by well-trained professionals was largely born out of this
experience.
He and his colleague Michael Conran succeeded in persuading younger

colleagues to work to bring the ISPS symposium to London in 1997 in order
to influence practitioners in the mental health field in the UK and to inform
them of the importance of developments in other parts of the world.
Although long retired from direct clinical work, he has sustained a great
interest in the subject of psychosis. He lives in rural France with his wife
Cynthia, his constant companion and support for the 49 years of their
marriage.
He was awarded a Life Service Award at the ISPS International Conference

in Washington in 1994.
Brian Martindale
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Jarl Jørstad
Jarl Jorstada development as psychiatrist and

psychoanalyst was influenced by three months
confinement in a solitary cell, and later 18 months
prisoner in Germany during the war, when many hundred Norwegian
students were arrested. His experiences in the concentration camps Pölitz,
Buchenwald and Neuengamme contributed to his growing curiosity about
the forces in human minds which create such cruelty and holocaust. He
luckily survived and started the medical school in Oslo in 1945, and
graduated as MD in 1950, psychiatrist 1958 and psychoanalyst 1972.
His interest in treatment of schizophrenic patients developed during his

work in two periods at Dikemark mental hospital, treating severely
disturbed and schizophrenic patients from Oslo. During the last 12 years
period, when he was head of the department 5 (Lien), together with a
dedicated staff, he managed to develop a pioneer institution, trying to
combine a therapeutic community with individual psychotherapy, including
many young schizophrenic patients. The experiences they had during this
period they published in many papers and in the Norwegian TV.
This was one background for the ISPS Symposium in Oslo in 1975. Another
important background was also his stay in USA in 1968 – 69, when his
main goal was to study the teaching of psychotherapy, at Harvard (Beth
Israel Hospital, John Nemiah, Peter Sifneos), Yale (Theodore Lidz), New
York, ,(a.o.Montefiore, Hillside, Jacoby, - Alberta Szalita), and NIMH,
Washington D.C. (Helm Stierlin). This created important networks of top
professionals in psychotherapy, family therapy and social treatment of
schizophrenic patients in USA. The following years many of them came to
Norway and gave seminars and taught in many places in Norway. Well
known psychotherapists from United Kingdom, Switzerland and Germany
(M.Jackson, D.Malan, G.Benedetti, H. Stierlin and many others) also had
important seminars.
The successful ISPS Symposium in Oslo in 1975, contributed to this process

of increased interest in psychodynamic understanding and treatment of
schizophrenic and other psychotic patients all over Norway.
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AND
In 1976 Jarl Jørstad was appointed as medical director of the psychiatric

university clinic 6 B in Oslo City Hospital Ullevål. This was also a pioneer
institution in developing a therapeutic community which included a mixture
of neurotic and psychotic patients, and had many groups. A basic condition
for their treatment program was that they could select the patients they
admitted into the ward, and they favoured more resourceful neurotic
patients.
During his leadership he recruited many excellent clinicians and

researchers, which developed a good and open research team together with
the clinicians, and were setting the main point in clinical research and the
results of institutional treatment. When the department in late 70ties
developed a crisis, caused by new obligations to admit immediately all
psychotic and suicidal patients as emergency cases from the catchment
area in the city, the number of psychotic inpatients increased rapidly, and the
more neurotic patients were treated in the out patient clinics. Many of the
nurses working in the acute unit developed signs of burn-out syndrome,
their organization of the therapeutic community did not work any longer. The
research witch included patients, staff and the ward atmosphere, showed
clearly that the milieu and the groups were now harmful for many of the
psychotic patients.
In 1981 the whole treatment program was then radically changed to an

individually oriented therapeutic milieu, where the psychotic patients were
separated from the more acting–out borderline patients, who got a special
organized, group oriented day unit. Now, the nurses now were more
caretaking of the psychotic patients and took more responsibility and
leadership. After one and two years the researchers found that the ward
atmosphere showed reduced aggression and was warmer, the patients said
they had a much better ward milieu, and the burn-out syndrome in the staff
was resolved. These results were published in a book and in several
Scandinavian and international journals, and resulted in a couple of
doctorate degrees.
The engagement and enthusiasm of Jarl Jørstad in promoting psychodynamic

understanding, modified psychotherapy and optimal milieu therapy for
psychotic patients, influenced many professional workers in psychiatry, both
in Norway, Sweden and Denmark. He was asked to give many seminars in
these countries, and delegations came from them to learn from the
experiences at Dikemark and Ullevål hospitals. He was also asked to be a
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ISPS Life Honorary Members Jarl Jørstad
consultant for institutions in crisis, which was a result of his interest and study
of irrational group processes which influence teamwork and leadership in all
organizations (Tavistock), and which gave him many tasks in Scandinavian
countries and in Switzerland.
Together with a large group of young psychiatrists he also contributed to a

radical change of the teaching and training of psychiatric residents in the
1970ties in Norway. In spite of resistance from most of the professors in
psychiatry, they managed to introduce obligatory supervision in the
therapist-patient relationship, and the basic principles of psychodynamic
psychotherapy, once a week in one year, later extended to two years. As
leader of the psychotherapy committee in Norwegian Psychiatric Association
he also formulated the qualifications of the supervisors: they should be
experienced psychotherapists, and should have had their own personal
psychotherapy or psychoanalysis. Later special courses in supervision were
also developed.
In his books and many papers he focused more and more on the early mother-
child relationship as background for vulnerability in later life, the unconscious
forces in human mind, and the transference/countertransference interaction
in therapeutic relationships of severely disturbed patients. His popular
psychiatric books were published in a couple of editions both in Norway,
Sweden and Denmark, the first also in Poland, and the last in UK.
From 1990 he has still had his private psychotherapeutic and psychoanalytic
practice in his home in Sandvika outside Oslo, but now only a few hours a
week.
Svein Haugsjerd
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Julian Leff
Julian Leff must be one of the best known of the few

contemporary psychiatrists who have made major
contributions to the psychological therapies of
psychosis that have gained acceptance within psychiatry. Though there are
plenty of psychiatrists well known within the psychological therapies field,
few from the latter territory have become household names in the wider
psychiatric field.
Julian Leff has researched in many areas during his thirty eight years with the
Medical Research Council, during which time he has always held clinical
appointments. He is surely best known for his now widely replicated research
demonstrating the possibility of substantially reducing relapse and
readmission rates in patients with schizophrenia by working with the families
to reduce ‘Expressed Emotion’ and excessive contact. Indeed, his 1982 paper
describing this work has become a classic, with over 500 citations in the
world literature. The research work also demonstrated the synergic effect of
combining psychosocial and pharmacological interventions.
In a psychological therapies field often beset by theoretical partisanship,

Julian Leff has staunchly maintained his role as a social scientist and much
of his work is rigorously empirical. He has gone on to demonstrate that
expressed emotion is not a particular characteristic of families with
psychosis and through research refuted the specificity of communication
deviance in families that was gaining hold in the 1970s and 1980s, a matter
that remains a source of scientific controversy. He has therefore played an
invaluable part in retaining the focus on the importance of aspects of the
family in psychosis. He has done this without re-evoking the complex
problem of family attribution which has led to many professionals
abandoning involvement with families who have considerable needs for help
both in their own right and in the specific professional assistance they often
need to provide domestic environments that will be maximally facilitating to
the recovery of their relative.
It remains a matter of international concern that, in spite of the long
acceptance of the concepts and the research evidence, few psychiatrists
learn how to engage families to the latter’s satisfaction when they have a
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AND
member prone to psychosis, let alone apply the specific interventions that
Leff and his colleagues demonstrated to be effective more than three
decades ago now. This is strong evidence that psychiatrists are quite
selective in the evidence they choose to implement.
Julian Leff has played an important role in supporting the development of

the roles of community psychiatric nurses through the many psycho-social
training programmes now present in many parts of the UK.
It may be interesting for ISPS members to know of some of his wider

contributions in social psychiatry. Some of Leff’s early research was on the
effect of sensory deprivation in the production of hallucinations in normal
persons. The role of culture in psychiatric disorders has always been
prominent in his research interests. One expression of this was his
contribution to the work clarifying different diagnostic practices towards the
psychoses on the two sides of the Atlantic. His work with Professor John
Wing and others in standardising assessment interviews and rating scales
has made international research work much more possible and relevant. He
also conducted cross-cultural studies of expressed emotion, demonstrating
the general reliability of his key findings of the association between high
expressed emotion and psychosis relapse rates in the different cultures.
There were also important studies highlighting the important fact that
mental health settings can contain professionals who themselves create a
deleteriously high expressed emotion atmosphere.
His research work on cultural commonalities and differences has involved

him in projects in countries far and wide in the world of which a few are
Barbados and Trinidad (in the West Indies), Aarhus (Denmark) Chandigarh,
(N. India), Chengdu, (China). It goes without saying that the importance and
interest in his expressed emotion work has led to invitations to speak all
around the world.
In more recent years, the research focus has been on the well being of long stay
patients when discharged thoughtfully into the community following the closure
of the hospitals that had been their homes for decades, demonstrating the
possibility of successful rehabilitation and relocation.
Another interesting and important research was into severe depression in one
partner in a couple relationship, comparing psychological treatments with the
best of medication management and showing the superiority of the former.
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ISPS Life Honorary Members Julian Leff
One could almost write a book just reviewing Julian Leff’s published life
work as this amounts to more than ten books authored, co-authored or
edited, some hundred or more chapters and more than 150 research or
review articles, nearly all in the world’s prominent journals.
Julian Leff’s family background included medical members of which his father
was one. Because of the war, his grandfather was an especially important
figure at home in a small Buckinghamshire village. Buckinghamshire is of
course well known for another pioneering schizophrenia study by Ian Falloon
and others. Julian’s empirical approach has withstood the fact that he is
married to a prominent UK psychoanalyst!
When Murray Jackson (another ISPS Life Member) retired from the
Maudsley in 1987, Julian Leff took over the in patient unit that Murray had
been the consultant to.
Professor Leff has now substantially retired and spends a considerable

amount of time developing his longstanding skills with the piano where - to
quote “I delight in playing with other instrumentalists and singers, and feel that
achieving unison in a small chamber group is akin to working skilfully with a
family. As his tutor says, ‘the most important thing is to listen, listen, listen!’ “.
Those of us who have encountered Julian at ISPS conferences and

elsewhere will probably have similar images of him as a quiet, friendly
modest man in social settings, but an eloquent and powerful communicator
and teacher when lecturing. His international contribution to the social and
psychological well being of those vulnerable to psychosis and their families
has been immense and we have little doubt that this influence will continue
for the decades to come as the scientific, profession and lay public are
increasingly convinced of the relevance of the importance of the interplay of
the psychological and social with biology in psychosis. We are delighted that
Professor Julian Leff has accepted Honorary Life Membership of ISPS.
Brian Martindale
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Theodore Lidz
Theodore Lidz, the Sterling Professor Emeritus of

Psychiatry at Yale, lived to be 90 years old, dying on
February 16, 2001. He lives on through his book, The
Person, His and Her Development Throughout the
Life Cycle which probably can be found on the bookshelves of essentially all
mental health professionals who trained during the decade after its
publication in 1976; it is still in print. He dedicated his career to
understanding the interpersonal causes of schizophrenia, focusing on
family, community and cultural factors, and the details of the person’s life
history. He was convinced of the continuity between health and psychosis.
Ted Lidz was born in New York City and grew up on Long Island. He received
his B.A. and M.D. from Columbia University. He completed two years of
medical internship at the Yale-New Haven Hospital and then became an
assistant in Neurology at National Hospital, Queen’s Square in London. His
psychiatric residency, at the Johns Hopkins Henry Phipps Clinic, was under
the leadership of Adolf Meyer. There, he met his wife, Dr Ruth Maria
Wilmanns, who had fled Germany in 1934 and arrived at Hopkins in 1937.
They married in 1939. She died in 1995.
Lidz enlisted in the Army in January, 1942 and served in New Zealand, Fiji
and Burma. His Fiji tour left him caring for hundreds of psychiatric
casualties from Guadalcanal, he the only psychiatrist. Years later, he and
Ruth returned there to study the culture, and the book, Oedipus in the Stone
age: A Psychoanalytic Study of Masculinzation in Papua New Guinea, grew
from their studies.
On his return to Hopkins in 1946, he served as the psychiatric liaison clinician

and began research on psychosomatic conditions. He and Ruth trained in
psychoanalysis in the Washington-Baltimore Psychoanalytic Institute,
learning from Harry Stack Sullivan and Frieda Fromm-Reichmann. They
studied the psychiatric difficulties of parents of children hospitalized with
schizophrenia, and this launched Lidz’s later extensive studies.
The Lidzes moved to Yale in 1951 when Ted became professor and chief of
clinical services. Along with Stephen Fleck and others, he launched a long-
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AND
term study comparing 17 schizophrenic patients and their families with 17

non-schizophrenic hospitalized patients and their families. The book he co-
authored with Stephen Fleck and Alice Cornelison, Schizophrenia and the
Family, 1965, International Universities Press. He was a fellow at the Center
for Advanced Studies in the Behavioral Sciences at Stanford, a great honor
and opportunity.
Lidz was a lifelong principal fighter against biological reductionism and the
view that schizophrenia is incurable, and for the benefits of psychotherapy.
He formally retired in 1978, but continued treating patients. He yearned to
write one more book, refuting biological reductionism.
His fierce loyalty is reflected in a telling exchange of letters with Gore Vidal in the
New York Review of Books published on June 13, 1985, “Caring for the Bird.”
To the Editors:
“I was not enlightened by Gore Vidal’s review of the two books about
Tennessee Williams [NYR, June 13], and found the review distasteful, if not
repugnant. However, the question of what is suitable for publication is a
matter for the editors of the Review. I write because of what he has to say
about Dr. Lawrence Kubie. Dr. Kubie is dead and cannot defend himself and
he was a friend and colleague of mine.
I do not know what transpired in Dr. Kubie’s therapeutic work with

Tennessee Williams as Dr. Kubie kept such matters to himself. However, Dr.
Kubie was a leading psychoanalyst and psychoanalysts do not order patients
to do anything and it seems highly doubtful to me that Dr. Kubie “ordered
him to give up both writing and sex so that he could be transformed into a
good team player.” Also in the light of Tennessee Williams’s dismal last
years, why does Vidal write, “happily the Bird’s anarchy triumphed over the
analyst.” Throughout his article Vidal quotes a number of instances in which
Williams distorted or altered the truth and certainly there is ample reason
not to accept Williams’s version of what went on in his analysis.
Dr. Kubie did not take down his shingle and retire from shrinkage. When he
left his practice in New York, he did so to accept the position as Director of
Psychotherapy at the Sheppard and Enoch Pratt Hospital in Towson,
Maryland, a very important position in one of the country’s major
psychotherapeutic institutions.
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ISPS Life Honorary Members Theodore Lidz
I did not agree and still do not agree with Dr. Kubie’s concepts about
creativity, but I find Vidal’s snide comments about a man who devoted his life
to the care of patients and the promotion of mental health highly offensive.”
Theodore Lidz, M.D.; Yale University; New Haven, Connecticut
Gore Vidal emeritus replies: “I am saddened that Dr. Lidz was not
“enlightened” by my review, but not all darkness is penetrable, particularly
that generated by, if I may say so, his own peculiar calling. Perhaps
“ordered” was too strong a verb. Certainly Dr. Kubie gently hinted. ... Is that
better? God knows Tennessee dramatized his own life; and he certainly got
things wrong, but he was never a liar. As for Dr. Kubie, I draw the readers of
this review to his appearance, under the name Dr. Sanford Kubie, in a
forthcoming novel, October Blood by Francine du Plessix Gray. Here they will
see Kubie as many people at the time did—a slick bit of goods on the make
among the rich, the famous, the gullible.
Lidz is survived by three sons, eight grandchildren and five great-

grandchildren.
I am grateful to the Yale Bulletin and Calendar for posting the March 2, 2001
Volume 29, Number 21 issue on the internet, which provided most of the
information in this summary.
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Christian Müller
He was born in 1921 in Münsingen near Berne/

Switzerland where his father, Prof. Max Müller, was
medical director of a great psychiatric hospital. His
grandfather, too, was a psychiatrist. Christian Müller achieved his studies of
medicine in Berne in 1946 and habilitated in psychiatry and psychotherapy
under Manfred Bleuler in Zurich in 1957. From 1960 through 1982, he was
ordinary professor of psychiatry and director of the psychiatric university
clinic of Cery/Lausanne, Switzerland.
On the base of a classical medical, psychopathological and psychanalytic-

psychotherapeutic education, he developed a deep interest in the long-term
dynamics of the main mental illnesses, especially schizophrenia. Already
since the fifties of the last century, he was an engaged reformer of
institutional psychiatry in Switzerland and one of the world’s first pioneers of
a psychoanalytically oriented psychotherapy of schizophrenia. In 1956, he
founded with Gaetano Benedetti from Basel/Switzerland an international
working group on this topic which organised periodical international
symposia on the psychotherapy of schizophrenia first in Zurich and
Lausanne, and then abroad. This group marked the very beginnings of the
later International Society for Psychotherapy of Schizophrenia.
Christian Müller’s main research focus was on long-term evolution of mental

illnesses until old age. His catamnestic long-term investigations on all main
psychiatric illnesses which he inaugurated in the sixties under the name “The
Lausanne Enquête” are among the longest in the world. After his retirement in
1982, he mainly worked on historical psychiatric themes. He has published a
great number of scientific papers and books, covering different fields of
psychiatry. As member of several national and international scientific societies,
he was also influential in reforming psychiatric care structures and promoting
community-related networks for rehabilitation. Furthermore, he was as a core-
member of the editor-board of “Psychiatrie der Gegenwart”, the leading
German psychiatric encyclopaedia. As co-founder of an European working
group for geriatric psychiatry, he was also one of the earliest European
psychiatrists who developed a special interest in old age psychiatry on which he
published the first textbook. He earned several internationational scientific
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AND
awards and was promoted Doctor honoris causa of the University of Heidelberg
in 1980. On the international as well as on the national level, where he is
looked at as “the grand old man” of Swiss psychiatry, he is highly estimated
for both his professional and his human qualities. He currently lives in
Berne/Switzerland where he continues to be an active psychotherapist and
psychoanalyst.
Honors: Hermann-Simon Award (Germany) 1971, Theodor Nägeli Award

(Switzerland) 1976, Member of the Akademie Leopoldina (Germany)
Main books:
Mikropsie und Makropsie (Karger, Basel 1956)

Über das Senium der Schizophrenen (Karger, Basel 1967)
Alterspsychiatrie (Thieme, Stuttgart 1967) / Abrégé de psychogériatrie (Masson,
Paris 1981)
Lexikon der Psychiatrie (Springer, Berlin 1973)
(with L. Ciompi as first author): Lebensweg und Alter der Schizophrenen (Springer,
Berlin 1976)
Les maladies psychiques et leur évolution (Huber, Berne 1981)
Les institutions psychiatriques (Springer, Berlin 1982)
Etudes sur la psychothérapie des psychoses (Privat, Toulouse 1982)
Die Gedanken werden handgreiflich (Springer, Berlin 1992)
Vom Tollhaus zum Psychozentrum (Pressler, Hürtgenwald 1993) / De l’asile au cen-
tre psychosocial (Payot, Lausanne 1997)
Wer hat die Geisteskranken von den Ketten befreit? (Psychiatrieverlag, Bonn 1998)
Paul Dubois (1848-1918) (Schwabe, Basel 2001)
Rorschach, Briefwechsel (Huber, Bern 2004)
Luc Ciompi
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Barbro Sandin
“With all my might I wanted to fight for the

restoration and renewal of at least one of these
forgotten persons.” This is how Barbro Sandin
describes her first meeting with schizophrenic
patients at Säter Mental Hospital in January 1973. Barbro was at that time
40 years old, a former housewife and the mother of three children. She was
a newly educated social worker, but still not a trained psychotherapist. She
was deeply familiar with philosophy and literature and – since she was
brought up in a religious environment – with the language of the Bible, which
she used in her own independent way.
The result of this first meeting was a powerful and devoted commitment –
continuing to date.
Barbro ‘s report on the work with her first patient in The Swedish Medical
Journal 1975 was a light in the dark for many of us who could not see how
we would be able to help psychotic patients. However, major part of the
Swedish psychiatric profession was sceptical and critical – for many years
even resistant and hostile. As a psychologist, I soon got in contact with
Barbro and had the advantage of being supervised by her.
I would like to highlight what I believe characterise her long-lasting work.
Shortly, Barbro became a source of inspiration and she set the tone within
psychotherapy of psychoses, not only in Sweden but in Scandinavia as a
whole. She contributed to drawing attention to the conditions of the patients
and to reducing the taboos and fears that surround schizophrenia. The
patients themselves, and not least their relatives, got new hope and the
strength to forward new demands on public healthcare. However, this was
not well received everywhere.
The first patient who Barbro worked with was Elgard Johnsson. He
describes his time at the hospital, his meeting with Barbro and his path
towards health in the book “Tokfursten” (“Prince Madness”), published in
1986. The book by Barbro, “Den zebrarandiga pudelkärnan” (“The zebra-
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AND
striped nucleus of the poodle”), was published the same year. In the book
she gathers her experiences and thoughts about schizophrenia and
psychotherapy from the first ten years of her work. The book formed the
basis of her doctor ‘s thesis, which she defended in Tromsö in 1986. A few
lines from the summary of the opponents (S. Haugsgjerd and V. Rosvaer) are
illuminating: “Her theory about human experience is fundamentally
applicable and may enrich several more specific subject-oriented theories.”
“She moves the concepts of transference–countertransference from the
interpretational position of psychoanalysis towards the active and engaged
position to fellow humans in existential philosophy – a shift from a neutral to
a loving understanding.”
The importance of Barbro is of course due to the encouraging good results that
she and her team achieved in their work with schizofhrenic persons. Barbro
also has a unique and engaging ability to share her experiences. In her lectures
she always departs from case-studies. Her starting point is the existential
perspective – the genuine meeting with the patient, keeping in contact with the
common human conditions of good and evil, life and death, loneliness and
sense of community. With her common language Barbro also creates a
“meeting room” when she delivers lectures or talks, with sincerity and humor
in harmony. She helps us to “hear” the patient ‘s actual situation. Over the years
she has also convincingly shared her experiences from a large number of
patients ‘ radical journeys towards health and freedom from psychosis.
Barbro has always emphasized that psychotherapy with psychotic patients is

a teamwork. What became known as the “Sandin model” requires, that
around the patient there is a group of staff, who work continuously and
reliably for many years in enduring everyday contact, with outpatients as
well as with inpatients. The treatment is built on a long-term perspective
with a focus on every patient‘s unique personality and circumstances. Barbro
holds that the person who suffers from schizophrenia withdraws from life
and development in his attempt to get away from destructive anxiety. The
patient thereby looses the communication inherent in a relation, which is
precisely what he needs to be able to develop. He suffers from not being able
to exist, he needs above all our co-existence. The patient must obtain faith in
life and in its possibilities from his human environment until faith in life
becomes his own solid experience. Consequently, the human relations in the
treatment milieu are of crucial importance for the ability of the patient to
develop his own confident self. Barbro often refers to Martin Buber: The Self
is created in the meeting with Thou.
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ISPS Life Honorary Members Barbro Sandin
The supervision by Barbro on the basis of these premises was innovative in

the late seventies. Every member of the team participated and no one
prevented the patient himself from dropping in. Old structures were thus
broken and human resourses, not least those of the patients themselves,
were used. Everyone became aware of one‘s own importance, maybe as a
“life line” to which the patient chose to attach himself until his contacts
could safely be widened to others – or as a”container” of those feelings that
the patient was not yet able to contain himself. The respect for the patient
increased while the respect for the sickness or madness decreased. A non-
sentimental, open and prestigeless atmosphere developed, where humour
and enjoying life became resourses of great value. Since everyone during an
extended period of time got to know the patient as a person and his life
history, as it became visible in the therapy work, everyone involved also
came to understand the former “patterns of sickness.” Many were those
patients who thereby got radically changed opportunities in life.
Barbro ‘s far-reaching work as a lecturer and supervisor has been important

not only for the patients, but it also changed many people‘s view of
schizophrenia and its treatment – even their view of their own lives.
Psychotherapeutic work with psychoses is overwhelming and enriching for
everyone involved.
In 1987 Barbro received a donation of one million SEK from a private person.
She then left public psychiatry and was, together with her co-workers who
all joined her, able to start the Walla Foundation Clinic in Ludvika – a
beautiful and “homelike” treatment environment, which is beneficial for
those who need enviromental confirmation that they are appreciated and
valuable. At Walla the work continued with patients, various educational
programmes was organized and an annual conference on psychotherapy of
psychoses was held. We are hundreds of participants who over the years
have gotten the opportunity to listen to and be inspired by prominent
international lecturers with compehensive experience from treatment of
psychoses. We acquired increased knowledge, a broader perspective on our
not very glamorous daily duties and the joy in our work was reinforced. We
will remember the jolly conference parties for many years.
In her work and in her view on schizophrenia and treatment, Barbro

separates the existential aspects of human life from other fields of
knowledge. I have understood her main point in her work with patients in the
following way: we must seek to confirm their courage to live and the creative
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AND
power inherent in all of us, but which the patient suffering from
schizophrenia lacks a firm experience from. The originally “created illusion
of paradise” must be able to grow into the world, with sufficient security, in
order to maintain faith in life and the creative ability.
When it comes to psychological and psychotherapeutic influences, Erich

Fromm, Donald Winnicott and Jean Piaget among others are important for
Barbro ‘s thinking. Personally, I am pleased to note that modern research on
infants, for instance by Daniel Stern, confirms many of the thoughts
developed by Barbro. This applies, for example, to her ideas about the needs
of the infant in its growing into an individual and to what is needed in
psychotherapy of psychoses in order to bring about a lasting maturity.
Walla still works in the spirit of the “Sandin model” and although Barbro
retired in 1993 and later moved to Gothenburg, she continues to supervise,
for example at Walla.
In 1993 “Crossing the borders” was published, a book on psychotherapy of

schizophrenia, to which Barbro contributed. Together with Lisbeth
Palmgren, Barbro has written the book “Galenskap som risk och
möjlighet”,(“Madness as a risk and possibility”) in 2000, in which they reflect
on authors with mental suffering
The writings of Barbro are unfortunately mainly available in Swedish only.
Barbro Sandin will however be represented with an essay in the book that
the ISPS intends to publish in 2007.
Kia Sjöström
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Harold F. Searles
Harold Searles, now living in retirement with his wife

and former nurse Sylvia in Davis, California, is 87 years
old. He had loved California since his Army years
there, and had kept his California license updated, although he has not
practiced there during this past decade. Born and raised in Hancock, New York,
a bucolic little town nestled in the Catskill Mountains and on the banks of the
Delaware River, Searles came very naturally to write his first monograph on
The Nonhuman Environment: In Normal Development and in Schizophrenia.
However, family life was idealized but was filled with complicated and chronic
anxieties and depression, as Searles describes in his dialogue with Robert
Langs, Intrapsychic and Interpersonal Dimensions of Treatment.
Searles’s great contribution to the mental health field is his personal

honesty – his openness to his responses to the other person, and his ability
to articulate these responses. In his writings and in his many demonstration
interviews of patients (which he has said was his favorite clinical activity
after leaving the Lodge), he set a very high standard for all of us. The
boundary between the pre-conscious and the conscious moves back, when
we have the courage to face ourselves more fully. When we hide behind a
professional mask of warm-hearted dedication, aiming at being such good
and empathic people, we diminish our access to our patients, and find one
false self in pseudo-interaction with another person who then plays some
part in an unreal drama: “…a healthy hopefulness needs to be distinguished
clearly from an essentially manic repression of feelings of loss and despair.”
(Searles, 1979, p. 483) As Searles moves from clinical vignettes to theoretical
explication, the reader often has the feeling, “I almost thought that, myself,”
or, uncannily, “He knows me better than I know myself.”
Thus, Searles’s writings should be studied by each of us, aiming at

developing our clinical skills and emotional capacities in general. One’s
countertransference responses gradually become one’s strongest
therapeutic tools. He says, after detailing the grinding isolation he
experienced in years of work with a hebephrenic man, “To my enormous
relief I realized that I could now be related to him without having either to kill
him or fuck him.” (Searles, 1979, p. 431) Like reading the works of Ferenczi
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AND
and Winnicott, one senses his presence as a gifted supervisor of one’s

ongoing clinical struggles; he is thus a perpetual vibrant supervisor and
therapist. A prolific writer, he gathered his many papers into books which
have remained in continual print. The topics include many aspects of
psychoanalytically oriented work with patients suffering from schizophrenia,
from manic-depressive illness and from the borderline condition. While his
books sold excellently, they do not turn up often in used book stores; their
owners cherish them. And when psychiatrists get together, recalling their
residency training, they very often recall Searles’s “one-shot interviews”
which so often revealed pivotal events in the interviewees lives, which their
therapists had known nothing of, and which evoked volcanic emotional
outpourings, which the therapists had thought were beyond the capabilities
of their seemingly frozen and hopeless patients.
Searles obtained his B.A. at Cornell University, in 1940, and his M.D. at
Harvard Medical School in 1943. He began his residency training at the New
York Hospital and then served as a Captain in the Army’s medical corps,
serving at the Washington DC Veterans Administration Mental Hygiene
Clinic. He began his psychoanalytic training while there, at the Washington
Psychoanalytic Institute. His analyst was Ernest Hadley. Searles became a
training and supervising analyst there and served as President of its Society
from 1969 to 1971. He was on the medical staff of the world-famous
Chestnut Lodge Hospital from 1952 until 1964, working closely with Frieda
Fromm-Reichmann. His office was in the Frieda Fromm-Reichmann Cottage
after her death in 1956. Colleagues at the Lodge included Marvin Adland,
Dexter Bullard, Sr., Donald Burnham, John Cameron, Beatriz Foster, John
Fort, Robert Gibson, John Kafka, Ping-Nie Pao, Alberta Szalita, Otto Will and
many others, all sharing their ideas, friendships and competitiveness.
Searles served as a Clinical Professor of Psychiatry at the Georgetown

University School of Medicine, and contributed significantly to the residency
training program at the Sheppard and Enoch Pratt Hospital in Towson,
Maryland, and the Columbia University residency program in New York City.
Additionally, he was a consultant at the National Institute of Mental Health,
working on the project studying the Genain quadruplets.
In each issue of the ISPS-US Newsletter, edited by Brian Koehler, PhD, this
quotation from Searles is in the banner: “Innate among man’s most powerful
strivings toward his fellow men…is an essentially psychotherapeutic
striving.” (Searles, 1979, p. 459) “More and more during the past several
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ISPS Life Honorary Members Harold F. Searles
years, I have come at last to see something of how frequently the analyst has
cause to feel gratitude toward the patient.” (Searles, 1979, p. 437)
References:
Langs, R. and Searles, H. (1980) Intrapsychic and Interpersonal Dimensions of
Treatment: A Clinical Dialogue. Jason Aronson. New York and London.
Searles, H. (1960) The Nonhuman Environment: In Normal Development and in

Schizophrenia. International Universities Press. New York.
———-. (1965) Collected Papers on Schizophrenia and Related Subjects.

International Universities Press. New York.
———-. (1979) Countertransference and Related Subjects: Selected Papers.

International Universities Press. New York.
———-. (1986) My Work with Borderline Patients. Jason Aronson, Northvale, NJ and
London.
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Helm Stierlin
Helm Stierlin was born in 1926 in Mannheim. He lost

his father rather early. Whereas his brother became
an engineer (living in Malaysia for many years), he
himself was caught between philosophy and medicine. He studied both
subjects in Heidelberg, Freiburg and Zurich. In Heidelberg his academic
teachers were Karl Jaspers, Alfred Leber, Alexander Mitscherlich and Victor
von Weizsäcker. Jaspers became his “Doctorvater” for his philosophical
dissertation.
After finishing medical school, in 1953 he went to Munich. He was

disappointed by German post-war psychiatry, as it was practiced at the time
in Munich’s “Universitätsnervenklinik”. Through the literature of Harry Stack
Sullivan’s writings he became curious about modern psychiatry and earned
a scholarship for the Sheppard-Enoch Pratt Hospital in Towson, Maryland
near Baltimore. From there he changed to Chestnut Lodge, the legendary
center for psychoanalytic treatment of psychosis. Even though Frieda
Fromm-Reichmann had already died in 1957, he met Otto Will, Hilde Bruch
and others. At that time family therapy began to evolve rapidly throughout
the United States. Soon Stierlin came into contact with Gregory Bateson
(who had also worked at Chestnut Lodge before), Ted Lidz, Murray Bowen,
Nathan Ackerman, Lyman Wynne, and Ivan Boszormenyi-Nagy. This opened
the family perspective for the treatment of schizophrenia and was from then
on a decisive turning point in Helm Stierlin’s until then psychoanalytically
oriented professional life. After the short interlude in Europe from 1963 to
1965 (Bellevue Sanatorium, Bellevue-Kreuzlingen, Switzerland) and two
shorter study periods in New Zealand and Australia, Helm Stierlin returned
to the United States and became a member of the National Institute of
Mental Health, where he worked together with Lyman Wynne and Margaret
Singer, famous developers of family psychiatry. As head of the adolescent
unit, Stierlin worked on young runaways, and his first well-regarded book
was on separating parents and adolescence.
A new period began after Walter Bräutigam brought Helm Stierlin back to
Heidelberg to the Department of Psychosomatic Medicine, where Stierlin
became director of the Department of Psychoanalytic Research and Family
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AND
Therapy in 1974. From then on his theoretical and clinical work rapidly
expanded. The Heidelberg concept grew, especially in cooperation with the
Milan group (Mara Selvini Parazzoli, Luigi Boscolo and Gianfranco Cecchin).
Stierlin also dealt with psychosomatic issues from then on and with family
dynamics and treatment of severe physical illness (i.e. cancer patients).
Stierlin rapidly became a fixed point in Germany’s professional and cultural

scenery. He was founder of the famous journal “Familiendynamik” and author
of thirteen books translated into twelve languages, e.g., Separating Parents and
Adolescents, Conflict and Reconciliation, Psychoanalysis and Family Therapy, The
First Interview with the Family, Unlocking the Family Door, Demokratisierung der
Psychiatrie. The number of his scientific articles is approaching 300.
Helm Stierlin is also a family man at home. His wife, Satuila Stierlin,
also a recognized clinician, teacher and family therapist, and his
daughters, Larissa and Saskia, build the most important frame in his
life.
Today almost 80 years old, Helm Stierlin is still busy in teaching,

travelling and writing. He is a critical reviewer of development, not only
in family therapy, but also in our society in general. Coming from a
psychotherapy of schizophrenia, which heavily influenced clinical and
theoretical thinking, he has expanded to become one of the prominent
thinkers and workers in today’s fast-expanding world of psychotherapy.
Michael Wirsching
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John S. Strauss
John Strauss is a warm and gentle man and a

scholar, a prolific psychiatrist researching persons
suffering from severe mental disorders. His over 200
scientific papers address issues of diagnosis, course of disorder, and the
processes of improvement. He emphasizes the role of the person with
mental disorder as a person in the struggle to recover, and understanding in
depth the subjective experiences of people with severe disorder. These
experiences provide crucial data for understanding and treating the basic
processes involved in disorder and recovery.
John Strauss represents the best in phenomenological research into severe

mental disorders. He does not turn his research subjects into the objects of
study, but tries unstintingly to feel his way into their way of being, to imagine
his own struggle to regain sanity, to imagine the moment-to-moment pain
caused by these alienating afflictions. Thus he sets an example not only as a
prolific researcher but as a strong therapist. Listening to his talks (he was
the keynoter for the ISPS-US annual meeting in Philadelphia in 2004), we felt
we had known him for a long time, a valued friend for years. He let us into
his thinking and feeling. He described the time when at a large conference
he had role-played a patient and found himself utterly deflated and sullen,
unable to continue talking with the interviewer. The interviewer had asked
him about work, and John started telling about his new job at McDonalds.
The interviewer wasn’t interested in the details but moved on to the next
question. It took a while for John to realize that he became silent because he
felt hurt and angry. The few patients in the audience all responded that they,
too, had had such experiences. As the discussion evolved, John felt that he
and the “other” patients were allied against the defensive professionals, and
that there never was resolution.
John was born in Cleveland, Ohio in 1932. He earned his B.A. degree with high
honors at Swarthmore College , majoring in psychology (Swarthmore’s t-
shirts read “A ‘B’ here would be an ‘A’ anywhere else.”) He earned his M.D. at
Yale and then was a special student with Jean Piaget in Geneva, Switzerland.
He then studied community psychiatry at the Washington School of Psychiatry.
He was a resident in medicine and then in psychiatry at the McLean Hospital
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AND
and Beth Israel Hospital in Boston, then worked at the National Institute of
Mental Health from 1964 to 1972. After a stint at the University of Rochester,
he settled in at Yale, where he has worked since 1977. Since 1985, he has
served as Director of the Center for Studies of Prolonged Psychiatric Disorder,
Connecticut Mental Health Center, New Haven, CT.
He was a Collaborating Investigator in the World Health Organization’s

historic comparative research in schizophrenia, and has served on many
scientific councils including the Veterans Administration on Rehabilitation
Research in Mental Health, the Scientific Council of the National Alliance for
Research on Schizophrenia and Depression (NARSAD) and the Society for
Life History Research in Psychopathology. He has received many grants from
NIMH and other granting agencies, mostly on schizophrenia, including the
processes of improvement. He has never lost sight of the person struggling
with the disorder.
John Strauss is worldly, living part of each year in France, traveling often
to Scandinavia, his works translated into French, German, Norwegian and
Japanese. He says he has combined French phenomenology with
American pragmatism in his views on effective research into
schizophrenia. He stresses that occupational rehabilitation is not an
ancillary part of treatment but is a central part of the recovery process.
Patients often tell him, “When I work, I don’t hear voices.” As people
recover from psychosis, they talk about reintegration and the sense of
finding out who they are; they talk about resolving conflicts about goals.
Relationships are central to the recovery process, not just relationships
with professionals, but with their fellow humans in general. He chides the
profession, reminding us that recovering patients routinely say how rare it
is to find a doctor who took them seriously. He still is working over a
patient’s challenge to him: “Why don’t you ever ask me what I do to help
myself?” He says, “This is a very heterogeneous disease with a very
heterogeneous outcome. There’s been a tendency to dehumanize and
depersonalize schizophrenics, but that’s bad science, and bad for
everyone involved. I’ve interviewed many patients, and I can tell you that
we’re talking here about people with goals who are struggling to make
sense of life. I don’t know any basket cases.”
For over a decade, John has hosted writing groups in various countries,
supporting people writing about their work with patients. His one strict rule
is that negative remarks are forbidden; he finds that the problems in the
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ISPS Life Honorary Members John S. Strauss
writing drop out by themselves. This would be a great rule by which all
therapists of psychosis should abide.
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Endre Ugelstad
Endre Ugelstad was well known for his work to

promote psychotherapy for persons with psychoses,
and especially for encouraging long term supportive
psychotherapeutic approaches. He inspired many by his skilled supervision
of staff to do such dedicated work. He had psychoanalytic training, but he
believed that good therapeutic work could be carried out by all clinicians
who had the capacities to form relationships with the psychotically
vulnerable and that this in itself could lead to considerable improvements for
the patients.
He received his MD in medicine at the University of Oslo in 1948 and worked

as a resident in psychiatry at Gaustad Hospital and Ullevål Hospital in Oslo
from 1950 to 1956. He then worked a few years in private practice. Later he
worked for many years as a psychotherapy consultant at Gaustad Hospital,
where he was one of the first in Norway to give group psychotherapy to
persons with psychosis. He was a member of the Norwegian Psychiatric
Association and of the Norwegian Psychoanalytic Association.
Endre was one of the founders of the Institute of Psychotherapy in Oslo in

1962. He took active part in the development of the institute and later
became an honorary member. The Institute was established to make training
in psychodynamic psychotherapy more available and to make psychotherapy
more available for patients with more severe disorders. The Institute has
continued to develop this vision and is organising training in psychotherapy
throughout the country.
Even though Endre did not pursue an academic career and never got a high
academic degree, he saw the value and importance of research and took
initiatives to studies on psychosocial treatments of psychoses. Within the
framework of a comparative study he and his co-workers at Gaustad
implemented alternative treatments for long term patients with chronic
severe mental illness. He later presented this at the 5th International
Symposium in the Psychotherapy of Schizophrenia held in Oslo in 1975, and
in 1977 he received the King’s Gold Medal for his thesis on “Psychotic Long
Term Patients in Psychiatric Hospitals.” He became increasingly aware of
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AND
the need to do research also in order to get politically strong arguments in

claiming the need for adequate resources for therapy.
Together with other Nordic colleagues Endre focused on interventions for

first time psychoses in the NIPS study (Nordic Investigation on
Psychotherapy of Schizophrenia) carried out in the1980s and 1990s. Their
book “Early treatment for schizophrenic patients” was published in 1994.
This work also led to a Nordic network for research on early treatment of
psychosis.
In 1990, almost thirty years after being a co-founder of the Institute for
Psychotherapy, Endre was one of the co-founders of SEPREP - Centre for
Psychotherapy and Psychosocial Rehabilitation of Psychoses, which is a
non-commercial foundation and a network of clinicians and researchers
promoting psychological treatment of psychoses in Norway. Endre was
engaged in all the three types of activities in SEPREP: training therapists,
disseminating information on psychoses and treatments and stimulating
research. He was involved in starting a two year seminar on psychotherapy
for psychoses and in the early phase of a national multidisciplinary training
program for treatment of psychoses. The bulletin Dialog was started for
communication between people interested in psychotherapy and
psychosocial rehabilitation of psychoses. A couple of years after Endre died
the new society ISPS made an agreement with SEPREP to get secretarial
services from SEPREP.
Endre attended some of the earlier symposia and served on the organising
committee of the 5th International Symposium on the Psychotherapy of
Schizophrenia in Oslo 1975. He was one of the editors of the book published
in 1976 with proceedings from the symposium. At the ISPS 1994 in
Washington Endre took the initiative to form the ISPS network and became
the chairman of the board. He was one of the driving forces to develop the
ISPS network into an international society, and he was arguing that ISPS
should develop a broader range of activities and promote a wider range of
psychosocial treatments. He also started to publish the ISPS newsletter for
the network. At that time he knew of his cancer. During the next years with
preparation of the ISPS 1997 in London and of the ISPS as an international
society, he gradually had to withdraw from the ISPS board.
Endre met his first wife Signe when they both worked at a psychiatric
hospital before he started his education to become a physician, and in their
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ISPS Life Honorary Members Endre Ugelstad
marriage for twenty years they had three children. His second wife Harriet
also worked in the mental health services, and they shared the interest in
the work for persons with psychoses. They had two children.
Endre died quietly at 76 years old on September 6, 1996 after four years of
cancer. During the whole period of the illness he was open about the
development to his family and friends, continuing to be very much present in
life and including death as a natural part of it.
Endre Ugelstad made important contributions to psychotherapy and

psychosocial rehabilitation for psychoses in Norway, the Nordic countries
and internationally. All of us, who continue the work in ISPS and the other
organisations that were initiated by him and other co-founders, are grateful
to him and remember him as an inspiring example and a good friend. But
also many therapist and patients who did not know Endre have been
positively influenced by his work through the impact he made on those who
met him and worked with him.
Torleif Ruud
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Lyman C. Wynne
In 1923, Lyman C. Wynne was born into an

impoverished but intellectual Danish family in a
Southern Minnesota village. A farmer and
businessman, Lyman’s father supported the family on
$350 per year and crops, though he discussed Spinoza and Kant with his
children. Lyman’s mother was bedridden with uterine cancer for four years. At
age 11, while his mother was dying, Lyman decided to become a medical
researcher. At age 12, he was sent to live with an aunt and uncle in Duluth and
from there obtained a full scholarship to Harvard. During the WWII, Lyman was
assigned by the army to attend Harvard Medical School. In 1945, with the war
ending, Lyman became a protégé of Erich Lindemann. That experience
changed Lyman’s career path from cancer researcher to psychiatrist and
ultimately, family therapist. Lyman’s first participation in psychotherapy was
with Lindemann, not meeting with individual patients but with what Lindemann
called the “social orbits” of highly disorganized families that included psychotic
and psychosomatic members. During that period, Lindemann was publishing
and discussing his pioneering studies of normal and unresolved grief.
After a medical internship at the Peter Bent Brigham Hospital, Lyman

postponed psychiatric residency to return to Harvard for research training in
the newly formed interdisciplinary Department of Social Relations. With Dick
Solomon, he began research on the role of the autonomic nervous system in
traumatic avoidance learning in dogs; it was a biopsychosocial study. He also
participated in small seminars with Talcott Parsons who was writing his first
book on social systems, with Clyde and Florence Kluckhohn in anthropology,
and with Freed Bales working on the first research on coding group interaction
processes. After completing his Ph.D., Lyman participated with Lindemann in
setting up the first community mental health center, took time out for
neurology training in London, and finally began psychiatric residency at the
Massachusetts General Hospital with Lindemann and Stanley Cobb. During the
1952 call-up of doctors for the Korean War, he was sent by the Public Health
Service to take part in beginning the new research program at National
Institute of Mental Health (NIMH) in Bethesda, Maryland.
The early years at NIMH were free-wheeling and creative. Lyman earned
further psychiatric residency credit at St. Elizabeth’s Hospital and completed
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AND
full psychoanalytic training as well. He experimented with innovative

deviations from psychoanalysis, especially interviewing and “treating”
families with schizophrenic members, with Murray Bowen doing the same
across the hall. During the 1950s and 1960s, the NIMH program brought,
courtesy of the doctors’ draft, such psychiatric stars as David Reiss, Will
Carpenter, John Strauss, Bill Pollin, Stuart Hauser, Roger Shapiro, together
with many interested visitors and colleagues, most notably Helm Stierlin,
Margaret Singer, and Pekka Tienari. In the early 1960s, Lyman took a
sabbatical to conduct an anthropologic study of extended families in the
Bekaa Valley of Lebanon. He also began a long participation in World Health
Organization research on schizophrenia. However, managing the
increasingly bureaucratic NIMH programs became onerous, and Lyman left
to become Chair of Psychiatry at the University of Rochester in 1971 where
he initiated the Division of Programs as an environment to house
interdisciplinary training, clinical services, and research; the Division
flourishes to this day. After two 3-year terms as Chair, Lyman stepped down
to focus more fully on family therapy and family research, especially the
Rochester High-Risk Longitudinal Family Study and the Finnish Adoptive
Family Study of Schizophrenia with Tienari. Clinically, he was active as a
family psychiatrist, frequently seeing challenging cases with his favorite co-
therapist, his wife, Adele.
In 1997, Lyman and Adele gave an endowment to the University of Rochester

to start the Wynne Center for Family Research. The mission of the Wynne
Center is to support family research and train new family researchers. Its
first Director is Susan H. McDaniel.
In 1998, Lyman retired to Emeritus status to spend more time with Adele,
their five children, and five grandchildren. He has continued to publish the
results of the Finnish Adoption Study with Pekka Tienari and Karl-Erik
Wahlberg. These studies document the interplay between family
environment and genetics in the development of schizophrenia spectrum
disorders.
Susan McDaniel
422
AND

Concluding
WORDS

CONCLUDING WORDS
Manuel González de Chávez, Ann Louise Silver, Yrjö O. Alanen
This book contains a beautiful history account of the history of the

science and of the beginnings of psychotherapy dedicated to
schizophrenia . It discusses the pioneers who believed in it and who
wanted to carry it out, develop it and make it known. It contains the
history of the ISPS, now a half century old, beginning with small
symposia in which experiences were exchanged, of the therapists’
hopes, desires and concerns to help their patients in a closer, cordial,
more effective and more human way.
Step by step, Symposium by Symposium, decade by decade, page by

page, in this book we cover these fifty years of history of
psychotherapy and schizophrenia as well as that of some
professionals who demonstrated confidence in humans and in their
capacity to cope with and recover from their most unfortunate crises.
Few times in the history of humanity, and not only in recent history, has
madness had such a kind, careful and respectful approach as that received
by the persons referred to in this book. A history of affection, attention and
listening, of help, interests, dedication and hope, constructed piece by
piece, full of humane motivations, careful observations, rigorous studies,
constant reflections and especially of actions and continued relationships
with, by and for the persons who suffer psychotic disorders and those with
whom they live and who love them.
This trajectory was not easy nor did it produce rapid innovation of our
therapeutic practices. In the same decades, biological treatments,
presently obsolete ones, such as insulin coma, electroshock and even
the most brutal of them, psychosurgery, widely crossed all the
frontiers and were incorporated into most of the institutions. That
which occurs in other sciences of human relationships also occurs in
our field. The simplest, most superficial and most distant practices
and theories, those which require less movement towards and
dedication to others, those that treat persons as objects, extend
socially and professionally faster.
425

AND
It is true that our first Symposiums on Psychotherapy of Schizophrenia

began, as psychoanalysis itself, as closed forums only for those with
invitation and known experience, that was not open to others, and that
were made known through the books that included the interventions of
the participants. The young Yrjö Alanen, e.g., who wanted to attend
them at that time, could not do so. The organizers of the Scandinavian
Symposia in the 1970s broke with this initial elitism and opened the
doors of these meetings to all the professionals interested, aware that
the innovation of the treatment of schizophrenic patients was a task for
many professionals and should benefit many patients.
Even so, these were difficult decades for psychotherapy of

schizophrenia. Purely formal and biological concepts were
established, while there was greater use of neuroleptics and abundant
simplistic expectations of obtaining adequate ways to eliminate each
symptom with drugs. Only the most enlightened professionals were
aware of the limits of biologicism and knew how to see the persons
and their lives together with psychotic experiences.
Biological psychiatry in its reductionistic forms has been associated

with academic and institutional power since more than one century
ago. This also should not be surprising, since in our societies,
political, economic and social power widely favored and used biologic
ideologies to explain and justify the dominant social relationships.
Thus, the wall of silence surrounding us should also not be surprising.
In fact, in most countries psychotherapies of schizophrenia and even the

most integrating and global dynamic concepts of these disorders have
been surrounded by a wall of silence supported by the academic and
institutional power for decades. All the usual instruments, going from
publications to research funds, have been used abusively to intensify
and stress biological trifling matters within quantitative methodologies,
but qualitatively irrelevant, not at all elucidating and quite blindly.
In benefit of our patients, breaking this wall of silence should be one

of our main objectives in the coming years. They suffer this superficial
and distant practice, purely pharmacological, with pain and severe
consequences. It does not try to understand them and does not even
propose listening to them, because they are those who suffer the
silence in the first place.
426

CONCLUDING WORDS
As psychotherapists dedicated to these disorders, our organization

and our objectives have been, up to now, greatly lagging behind our
knowledge and the demonstrated benefits of our practice. These were
years in which the chairmen of the successive symposia formed the
only link between us, while the need for communications and
exchange of experiences grew unendingly. Our formal association is
very young. It is an incipient organization, that we need to reinforce
and strengthen in the near future, because it is the main international
reference for many thousands of therapists, and thus for severe dozen
millions of persons living with these problems worldwide.
The ISPS is a privileged place of intersection and meeting between

professionals dedicated to this field, who come to it with different
training, orientation or degrees. They may come from schools with
different perspectives and they have enriched us with their knowledge
and practical experiences. It also includes the complete range of the
modalities of psychotherapeutic and psychosocial help that our
patients may receive.
Our association can provide us with knowledge and know-how, the

most advanced knowledge and mutual understandings, always within
an innovating and open mentality, seeking common factors and
language, achieving a wider and global view of these disorders and
developing more effective and complete therapeutic programs.
The ISPS should play a key role in teaching and training of

psychotherapeutic interventions and in the spreading and generalization
of the integrated programs in all the countries. This is our task: create,
demonstrate, spread and organize the best possibilities of
psychotherapeutic help for those suffering these problems.
Organizational and economic growth of the local societies within a

large international society is the great challenge of the ISPS in the
oncoming years. To achieve it, we should find the adequate balance,
reinforcing a greater international society and stimulating the birth
and growth of many more or less small local societies.
Establishment and development of the local societies are important

for affiliation, motivation and direct knowledge of the members. Their
frequent meetings in close geographic settings may be accessible to
427

AND
many and stimulating and enriching for all. Furthermore, acquiring

specific skills and knowledge by many professionals may be easy and
continuous. This is also true for the closer and more fluid cooperation
with those in power of the health care and social services and with the
user and family associations.
A solid organization of the international ISPS is essential to favor the

cohesion of all the members within this great richness of our
extensive and valuable diversity. This organizational nucleus allows us
to join our forces and initiatives, achieve the most adequate scientific,
professional and social setting, profit by our resources to the
maximum, make our activities a priority, offer the same will to
perform and a common image to the others and give perspective of
the future to our task. Definitively, we should comply with our mission
and objectives in all the countries of the world.
The international organization should implement the electronic forms of

information and communication between all the local societies and
members of any place, organize meetings and international congresses,
potentiate exchange of experiences between different countries, obtain
funds to create stable networks of multidisciplinary research in our field
and design highly qualified programs of education and teaching.
Publishing our own works should also be one of the main activities
and priorities of ISPS in the coming years. Thanks to the books that
include the main interventions of the Psychotherapy Symposiums and
the fortunate live and vivid memory of their main leading figures, in
this book we have been able to reconstruct our half century of history.
Thanks to these books, we have gotten to know, meet and re-meet
each other. We have learned and taught. We have discovered many
aspects, keys and styles, interventions, techniques and strategies,
much experience and much generosity.
Furthermore, book by book and Symposium by Symposium, we have

been acquiring the fundamental values of the psychotherapeutic
practice with psychotic patients who make up the identity signs of
ISPS. On the contrary to other societies, more or less close, the ISPS
members have a larger humanistic interest, a more open listening
attitude, more horizontal communication and greater desire to share
and learn from the therapeutic experiences of others.
428
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CONCLUDING WORDS
In the next decades, ISPS should develop more and faster. We no

longer have to wait three years for the books of our congresses. We
have initiated a Collection of books of the ISPS that should prosper
with as many valuable books as we can publish. We should offer the
precise theoretical and practical instruments to the mental health
professionals who work in this field for their training, extension and
generalization of psychotherapies in psychotic disorders.
The international ISPS should acquire organizational and economic

force to allow us to decide, based on our own criterion and with
greater independence, which books we want to publish. This should
occur without being strictly subjected to sales estimation or survey
filters or to the biased commercial conditions imposed by publishing
companies. We should be our principal clients of a good part of the
editions of our books. Thus, we could finance them to offer them to
our associates under favorable conditions.
Being a member of ISPS and paying the annual fees should not only
be the decision made to contribute to the performance of altruistic
objectives, in accordance with our desires and professional practice. It
should also have some more benefits. Obtaining our books at a lower
price may be one of them, the same way as we register for our
Congresses and Meetings at lower fees.
Our publications will be the authentic networks that extend and join
us, as were, in the first decades of our history, the books of the
Symposiums of Psychotherapy of Schizophrenia. Now, decades later,
we have new computer instruments that facilitate direct and almost
immediate contact, with fluid exchange online of all types of
information and experiences. The ISPS e-mail lists make up an
important contribution for our associates. Web and newsletters also
contribute both to our mutual knowledge and to making us known in
other settings and to other interested professionals.
After a half century of history, we now need a periodical scientific

publication, an international scientific journal, that could be perfectly
the ISPS Journal, with several annual issues, in which we mainly
publish papers and articles on non-biological and more dynamic
aspects of psychotic patients and on psychotherapeutic treatments
and psychosocial interventions.
429

AND
This ISPS Journal is presently a growing need. This is because there

are only two international journals in the field of schizophrenia. These
are very traditional in their points of view, very classically clinical and
very biologicists. We could even say that they are often belligerently
biologicists.
At present, the papers and articles published on psychological

treatment in schizophrenia and other psychoses, including the many
ones written by ISPS members, are enormously dispersed in probably
more than twenty journals of all types, having varied circulation and
impact, and in different languages. The articles that interest us now
must be published or sought in very different journals, of different
schools, modalities and interventions, from psychoanalysis to family
therapies, those dedicated to rehabilitation or to those of group
psychotherapy.
In ISPS, we lack a publication that groups our field and provides as a

routine general and updated view of it. It would be an important step
ahead to be able to launch this scientific journal and be able to
consolidate it with regularity and quality. This would accelerate our
growth and increase our level, cohesion and internal coherence. It is the
platform that we are needing to have an influential and rapid incidence
in the renovation of the perspectives and practices in this mental health
field. Thus, it should be one of the future objectives of ISPS.
The future of the ISPS, after these first fifty years, will depend on us.
Our economy and development as an organization, with its meetings,
congresses and publications, our research and teaching activities, our
influence and extension of our practices and experiences in benefit of
a more human, complete and effective help to persons with psychotic
problems will depend on us.
The ISPS groups persons and professionals with characteristics,

activities, interests, tasks, motivations, values and knowledge that we
are very proud of, as we have seen throughout all the pages of this book
with emotion, admiration and gratefulness. It is exactly these common
characteristics, those that make it necessary for us to have our own
internal and international organization, which would be always a
comfortable space for our meeting and also a reflection of us.
430
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CONCLUDING WORDS
An organization that should be increasingly democratic, because we

give preference to our international society and our local societies to
those who are at the head of them at each time and because on this
50th Anniversary, we wish the ISPS to survive all of us, meeting its
foundational objectives, that it grows, evolves and advances
continually, is renewed over the generations and has a long historic
life.

General University Hospital “Gregorio Marañón”
C/Ibiza 43, 28009 Madrid, Spain

Columbia, MD 21044, U.S.A.

431
AND

BOOK
Next
!

“PAST, PRESENT AND FUTURE OF PSYCHOTHERAPEUTIC

APPROACHES TO SCHIZOPHRENIC PSYCHOSES”
Yrjö O. Alanen, Ann-Louise Silver, and Manuel González de Chávez
(Editors)
This idea for this book came into being during the editorial work for the book
“ISPS and the ISPS Symposia,” published in connection with the 15th ISPS
conference in Madrid in June 2006 by the same editorial group, in honour of
the fiftieth anniversary of the ISPS symposia.
The history of psychotherapeutic treatment of psychoses now covers about
one hundred years. Still, the understanding and treatment of persons with
schizophrenic psychoses on a psychological basis has remained in a minor
position compared with biologically based treatment methods. In many
countries, this has led to a strict dominance of one-sided viewpoints of the
character of these psychoses as well as of the management and treatment
of patients fallen ill with them. Patients are encountered as objects, without
going more deeply in their problems. Still, the psychotherapeutic treatment
methods have continually developed and their versatility increased.
In this book, the beginning of psychotherapeutic approach to schizophrenic
psychoses is first described. The second part deals with the development of
psychotherapeutic activities in different countries around the world, and in
the third part, the present state and views for future of different treatment
methods and interventions is examined, followed by an integrating chapter
written by the editorial group.
We are most thankful for the distinguished psychiatrists and other authors
who have participated in the writing of different chapters of the book. We
hope that our book, with its comprehensive horizon, would be able to
increase more integrated and humanistic approaches to the treatment of
persons fallen ill with schizophrenic psychoses.
Yrjö O. Alanen, M.D. is Professor of Psychiatry (Emeritus) in the University of
Turku, Finland, a psychoanalyst and family researcher. Together with his co-
workers, he developed the comprehensive, both integrated and
individualized psychotherapeutic approach to schizophrenic patients
described in Alanen‘ s major work “Schizophrenia – Its Origins and Need-
Adapted Treatment” (1997), now published in six different languages. He is a
Life Honorary Member of the ISPS (International Society for the
Psychological Treatments of the Schizophrenias and Other Psychoses.
435
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AND
Ann-Louise S. Silver, M.D. (Columbia, MD, USA) is a psychoanalyst and

former staff member of the well-known Chestnut Lodge Sanitarium. She
is Professor of Psychiatry, Uniformed Services University of the health
science, Bethesda, MD, U.S.A. and chairperson of the American Academy
and Dynamic Psychiatry program committee. She edited the book
“Psychoanalysis and the Psychosis” (1989) and has written several papers
on psychotherapy as well as on the history of the psychotherapeutic
treatment of schizophrenic patients in America. She is a member of the
ISPS executive committee and the President of the U.S. Chapter of the
ISPS.
Manuel González de Chávez M.D. is Professor of Psychiatry, Complutense

Madrid University and the Chief of the Psychiatric Service of the General
University Hospital “Gregorio Marañón” in Madrid, Spain. He has organised
psychotherapeutically oriented Schizophrenia Courses in Madrid, very
popular both in Spain and Portugal for more than ten years. He is a
member of the ISPS executive committee and the organiser of the 15th ISPS
Conference in Madrid in June 2006. He also made the initiative for the book
“ISPS and the ISPS Symposia” published in honour of the fiftieth
anniversary of the ISPS symposia, 1956-2006, which will be published in
connection of the Madrid ISPS conference and is edited by the same
editorial group as this book.
PREFACE
PART I: THE PAST
Early history of the treatment of schizophrenic psychoses and beginnings

of the psychotherapeutic approach
In the first part of the book, the early history of the treatment of
schizophrenic psychoses is described, followed by the work of the pioneers
of the psychodynamic (psychoanalytivcally oriented) psychotherapy of
psychoses during the first decades of the 20th century.
What is schizophrenia? Is it possible to approach these patients on

psychological basis? (The editorial group)
In this chapter the character of the schizophrenia group disorders is described
and the problem of how to understand these patients psychologically is
examined in the light of history and present developments.
436

Past, present and future of psychotherapeutic approaches to schizophrenic psychoses
On early history of management and treatment of psychotic patients (The

editorial group)
Here, the early history of the psychiatric management and treatment of
schizophrenic disorders is examined.
The Schreber case and Freud’s two-edged influence on the psychoanalytic
approach to psychoses (Yrjö O Alanen).
Even if Freud himself did not work with schizophrenic patients, his
psychoanalytic approach, began at the 1890s, pioneered the history of the
psychodynamic understanding of schizophrenic psychoses. Especially
important was his treatise (published 1911) of the autobiography of Paul
Schreber, a German judge fallen ill with paranoid schizophrenia. On the
other hand, Freud’s pessimistic views about schizophrenic patients’ lacking
ability to form a transference relationship with the therapist had a notable
negative influence on the development of psychoanalytically oriented
psychosis psychotherapy. In this chapter, Freud’s ideas on schizophrenia are
examined in the light of later development.
The Burghölzli school: Bleuler, Jung, and others (Klaus Hoffmann).
The work in the Burghölzli psychiatric hospital in Zurich, Switzerland, had an
important role in the development of the psychological study on schizophrenia.
The name schizophrenia derives from Eugen Bleuler’s monography (1911). C.
G. Jung, worked in the same hospital led by professor Bleuler. He was one of
the first psychodynamically oriented schizophrenia psychotherapists. This
development is described by dr. Klaus Hoffmann (Reichenau, Germany) who
has even earlier published important treatises on this phase in the history of
psychiatry and psychotherapy.
The pioneering work of Paul Federn (Thomas Federn).
Paul Federn, a Viennese psychoanalyst, was the most important European
pioneer of schizophrenia psychotherapy. He began his work with these patients
already in 1906, even if he published the major reports of his abundant
experience during the 1940s, having moved to the United States. Federn’s work
is described by his grandson Thomas Federn, a psychiatric social worker. He
also deals with some of Paul Federn’s early European followers.
Adolf Meyer and other American pioneers. Beginnings of
psychoanalytically oriented treatment of schizophrenia in the United
States (Ann-Louise S. Silver).
During the first half of 20th century, the main centres of psychodynamic
psychotherapy with schizophrenic patients developed in the U.S.A. The first
important pioneer was the psychiatrist Adolf Meyer, who wrote papers on this
topic already during the first decade of the century. He had plenty of followers,
many of them working, like Meyer himself, in important university centres.
437
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AND
Harry Stack Sullivan and his influence (Ann-Louise S. Silver)

Dr. Silver also has the responsibility to describe the work of the most original
American psychosis psychotherapists in the U.S.A., Harry Stack Sullivan,
known of his interpersonal theory of psychiatry. Sullivan began his work with
schizophrenic patients in 1920s and had, during the following decades, a
large influence on American psychiatry, especially within the “Washington
School of Psychiatry,” represented by many important psychotherapists,
who - beginning with Frieda Fromm-Reichmann - continued his work
developing the core of psychoanalytically oriented psychotherapy with
schizophrenic patients.
PART II: FROM PAST TO PRESENT
Developments in different parts of the world from the 1940s to the present
In this part, the later development and present state of psychotherapeutic
approaches is dealt within a geographically extensive framework. This is in
harmony with the ISPS’s aspiration for local activities, on the one hand, and
global influence, on the other. It is also desirable and justified because of the
great variation in the development of psychotherapeutic approaches and
their practise between different countries, due to both theoretical and
cultural reasons. We also hope that this would have a positive influence on
the interest in our book in many of the countries considered.
Northern America (Ann-Louise S. Silver; with a team of interviewees

dealing with different approaches). Addendum: Interview with Joanne
Greenberg
United States formed the most important centre of psychoanalytic
psychotherapy with schizophrenic patients during many decades after
World War II. This is true both of individual and family psychotherapy.
During the last decades also cognitive-behavioural orientation gained a
growing foothold. Dr. Silver will describe the pioneering therapists and
their ideas and achievements, by help of interviews with representatives
of different therapeutic approaches. This chapter is supplemented by dr.
Silver’s interview with Joanne Greenberg, the author of the book “I Never
Promised You a Rose Garden” (under the pseudonym Hannah Greene).
Great Britain (Murray Jackson; David Kennard)

In Great Britain, the psychoanalytic orientation developed by Melanie Klein
found many followers. The “Kleinian school” proved to be especially fruitful
in the psychoanalytic understanding of schizophrenia and other psychoses.
The Kleinian orientation is described by one of its leading representatives,
438
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Dr, Murray Jackson, who also is a Life Honorary Member of the ISPS.
Another part of this chapter has been written by Dr, David Kennard, the
present chairman of the ISPS-UK, dealing with the strong cognitive-analytic
studies and practises in Great Britain.
German-speaking Central Europe (Klaus Hoffmann [Switzerland]; Stavros

Mentzos [Germany and Austria]
Another remarkable centre of psychoanalytically oriented psychotherapy with
schizophrenic patients developed in Central Europe, especially in Switzerland,
influenced also by existential analytic concepts (Daseinsanalyse). Especially
Gaetano Benedetti, an Italian-born psychoanalyst, had a wide influence not
only in the German-speaking area but also in Italy and, e.g., in the Northern
European countries. Together with Christian Müller, Benedetti also
established the first ISPS symposia in Switzerland during the 1950s. This
orientation and the later development of psychosis psychotherapy in the
German-speaking area is described by dr. Klaus Hoffmann (cf. Chapter 4) and
professor Stavros Mentzos (Frankfurt, Germany), one of the leading German
psychoanalysts and author of several books.
France and the French-speaking Central Europe (Francoise Davoin and

Jean-Max Gaudilliere)
French-speaking psychoanalysts also had an important part in the
establishment of psychosis psychotherapy in Europe after the World Wear
II. One of the pioneering figures was the Swiss psychoanalyst Marguerite-
Ann Sechehaye whose book “La Réalisation symbolique” (1947) attracted
great attention. In France, the interest in psychoanalytically oriented
psychotherapy of psychoses has been lively and many-sided if often
remained too insufficiently known outside the French-speaking linguistic
area. Its development and current trends are described by the
psychoanalysts Francoise Davoin and Jean-Max Gaudilliere (Paris), both
especially interested in psychosis psychotherapy.
Italy (Marco Alessandrini and Massimo Di Giannantonio)

In Italy, the most interesting feature has been the development of social
psychiatry, derived from the 1978 Law 180 (also called “Basaglia Law”),
requiring the closure of old-type mental hospitals. This led to a reform of
psychiatric care, with strong need to develop local open-care centred
services. In many areas, innovative activities were developed in the
treatment of psychotic patients, including an important role of given to
psychotherapy. These experiences and other psychotherapeutic trends in
Italy are described by dr. Alessandrini and professor Di Giannatonio
(University of Chieti).
439
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AND
Northern Europe (Jukka Aaltonen, Yrjö O. Alanen, Johan Cullberg, Svein

Haugsgjerd, Sonja Levander, and Bent Rosenbaum). Addendum (Barbro
Sandin)
Northern European countries have a long tradition of psychotherapeutic
approach to schizophrenia. This is also reflected in the history of the ISPS:
four of the international symposia on psychotherapy of schizophrenia have
been arranged here. Besides the individual therapy, the leading features
now include the development of family therapy and psychotherapeutic
approaches in the field of community psychiatry, as well as a
comprehensiveness of the psychotherapeutic orientation (e.g., the need-
adapted approach; state-wide schizophrenia projects). The principles and
results of the Northern European activities are described shortly separately
in different countries by Jukka Aaltonen and Yrjö O. Alanen (Finland), Johan
Cullberg and Sonja Levander (Sweden), Svein Haugsgjerd (Norway) and Bent
Rosenbaum (Denmark), with a common summary. This chapter also
includes a lively appendix written by Barbro Sandin, Ph.D,, a Honorary Life
Member of the ISPS, of her work with schizophrenic patients - which also
illustrates the other side of the coin: the resistance with which psychosis
psychotherapists often have to struggle in their working context.
Eastern Europe (Jacek Bomba)

This chapter includes a description of the psychotherapeutically oriented
work with psychotic patients performed in the often difficult circumstances
in Eastern Europe. This work, usually centred in family- and group
therapeutic approaches, is described by professor Jacek Bomba (Krakow,
Poland)
South-America (Jorge Gárcia Badaracco and Hernán D. Simond)

This and two following chapters are illustrating the editors’ striving for a
global dimension. In South-America, the psychotherapeutic approach has
already a long tradition, based on psychoanalytic viewpoints and including
also a strong interest in group psychotherapy. The writers, Drs. Garcia
Badaracco and Simond, are psychoanalysts working in Buenos Aires,
Argentine.
Eastern Asia (Lyn Chua; Dongshick Rhee)

Dr. Lyn Chua, Ph.D. (Singapore) is a member of the ISPS executive
committee. She is shortly dealing with the past and present of
psychotherapeutic activities including the influence of cultural background
in different Eastern Asian Countries (China, Japan, Korea, Hong Kong,
Indonesia, Malaysia) focusing then on her home country, Singapore. Her
contribution includes a culturally-relevant form of psychotherapy developed
for EPIP (Early Psychosis Intervention Programme) patients in a very
440
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interesting way, illustrated with a case report. Professor Dongschick Rhee,

a distinguished representative of the uniquely Korean brand of
Taopsychotherapy, describes this treatment specifically as used in the
treatment of psychotic and other seriously disordered patients.
Australia and New Zealand (John Gleeson; Jim Geekie, Dale Rook and
John Read)
Dr. John Gleeson (Melbourne) is describing the development in Australia,
known especially of pioneering projects in the area of prevention and early
intervention in schizophrenia. Dr. Jim Geekie with his co-writers (Auckland,
New Zealand) has written a highly interesting description of the development
of psychotherapeutic activities with the treatment of psychotic patients,
centred in early intervention services. Even here, the basic therapeutic ideas
include a specific attention to the cultural background of different patients in
this multi-cultural country.
Experiences of psychotherapeutic treatment in manic-depressive

psychosis (Brian Koehler)
Even if psychotherapy of schizophrenic psychoses is the main topic of our
book, we also found it relevant to include a chapter describing the
experiences of psychotherapeutic treatment in manic-depressive psychosis.
Dr. Brian Koehler (New York, N.Y., USA), is an American psychoanalyst very
well acquainted with this topic.
PART III: FROM PAST AND PRESENT TO FUTURE

Different modalities of treatments and interventions: Their present state
and views for future
Part III deals with the development and present state of different
psychotherapeutic modalities and interventions in the treatment of
schizophrenic patients. Compared with the Part II, we hope that the main
focus in this part of the book will be on the present and future. Besides the
traditional therapeutic modes, important attention is given to newer
therapeutic methods and interventions, such as cognitive therapies,
prevention and early intervention, development of community psychiatry,
psychotherapeutic aspects in rehabilitation, the Soteria model and the
influence of deinstitutionalization movements,
Pharmacological treatments: Their basis and limits (Jarmo Hietala, Viljo
Räkköläinen and Jukka Aaltonen)
In this chapter the theoretical basis of pharmacological treatment is at first
examined, the focus then transferring on clinical indications and restrictions
441

AND
of neuroleptic treatment, as well as the questions dealing with the

combination of psychotherapeutic activities and pharmacological treatment
with each other, The authors are from Finland and have, e.g., studied
together PET (positrone emission tomography) findings in new
schizophrenic patients not received neuroleptic drugs. Professor Jarmo
Hietala is a biologically oriented psychiatrist known of his PET findings in
schizophrenia, professors Räkköläinen and Aaltonen psychoanalysts and
among of the developers of the comprehensive psychotherapeutically
oriented “need-adapted” treatment mode. They have also studied which kind
of patients can be best be treated without any neuroleptics at all in the
context of this orientation, and which kind of patients for their part get
benefit of the addition of neuroleptics in small or moderate doses in the
treatment schedule.
Individual psychoanalytically oriented psychotherapy (Ann-Louise S.

Silver)
Dr. Silver is here examining the development of psychoanalytically oriented
individual psychotherapy with special focus on its present state and
orientations, indications and context.
21) The family in schizophrenic disorders: Systemic approaches (Helm Stierlin)

Professor Helm Stierlin (Heidelberg, Germany) is one of the leading pioneers
in the field of family studies and family therapy with schizophrenic patients.
He began his work already during 1950s, first in Germany and, then in the
U.S.A., in the Chestnut Lodge sanitarium and the National Institute of Mental
Health near Washington, moved back to his home country in the beginning
of the 1970s and led the well-known centre for psychoanalytic basic studies
and family therapy connected with the University of Heidelberg. His
systemically oriented family dynamic concepts, presented in many books,
have had a far-reaching influence especially in European countries. In this
chapter, professor Stierlin gives an excellent summary of the development
of his views and the present state of family studies and family therapy of
schizophrenic patients, with a view of their further developmental needs.
Helm Stierlin is a Life Honorary Member of the ISPS.
Group psychotherapy and schizophrenia (Manuel González de Chávez)

Group psychotherapy and other group activities with schizophrenic patients
is one of the special interests of Dr. Manuel González de Chávez. He
describes the development and present state of these activities, their main
principles, important role, context, goals and results, and discusses future
views of the group approach in the treatment of schizophrenic patients.
442

Cognitive and behavioural therapies (Douglas Turkington and Rob Dudley)

Doctors Turkington (Nottingham, U.K.) and Rob Dudley (Newcastle, U.K.)
describe the leading methods, principles, goals and results of cognitive and
behavioural therapies in the psychotherapeutic approach to schizophrenia,
These principles have been applied both in the treatment of individual
patients, families and the activities of therapeutic communities.
Prevention and early intervention (Patrick D McGorry)

Preventive activities and different forms of early intervention have proved to
have an important key position in the treatment of schizophrenic psychoses
already because of the positive effect of early treatment to the outcome of
schizophrenia, indicated by several studies. Professor McGorry from
Melbourne. Australia, is one of the most important pioneers of these
activities. He has led pioneering projects on psychological treatment of early
psychosis and has written and edited several books dealing with these
topics.
Psychotherapy and rehabilitation (Courtenay Harding)

Professor Harding, now in Denver, Colorado, U.S.A. led the long-time follow-
up of an extensive rehabilitation programme carried out in the state of
Vermont during 1950es and 1960, with a matched control group. It was found
that the outcome of the rehabilitation group was better, even exceptionally
good compared with the usual outcome figures reported in schizophrenia
literature. Dr. Harding has written widely of the effects of social factors and
psychotherapeutically oriented understanding of schizophrenic patients on
their life and on the outcome of their disorder.
Community psychiatry, therapeutic communities and therapeutic setting

experiences (Johan Cullberg)
Professor Cullberg, a psychoanalyst and social psychiatrist from Stockholm,
Sweden, is one of the important pioneers of psychotherapeutic practises in
the field of community psychiatry, known of many books written on
psychodynamic psychiatry and psychoses (esp. Psychosis, Humanistic and
Biological Approach). He is the former chairman of the ISPS and a Life
Honory Member of this association. Cullberg has now led an extensive (17
centres, with a distinguished university department as the control)) project
(Parachute project) dealing with the development and results of the
comprehensive psychotherapeutic orientation in the treatment of new
patients from the schizophrenia group, so continuing the Northern European
studies in this area. One of the special features of this project is also the use
443

AND
of small treatment homes in many of the centres. On the ground of his wide
experiences, Cullberg will here examine the developing of community
psychiatric activities with schizophrenic patients on a comprehensive
psychotherapeutically oriented basis, including the results of the Parachute
project.
The Soteria model (Volkmar Aderhold)

Dr Aderhold, a psychiatrist from Hamburg, Germany, is specifically
acquainted with the activities of the Soteria model, established by the U.S.
psychiatrist Loren S. Mosher during the 1970s. The heart of the model are
the Soteria homes, small homes outside the hospitals functioning as centres
for a humanistic, psychotherapeutically oriented encounter of acute
psychotic patients, originally with specially selected lay staff, in professional
control. This treatment model has spread also in Europe (usually with
professional staff members), one of the most well-known representatives
being the “Soteria Berne”, established by professor Luc Ciompi. Dr.
Aderhold is describing the basic ideas, principles and activities of the Soteria
homes as well as follow-up studies of the patients .
The influence of deinstitutionalization movements (Robert Whitaker)

Mr. Whitaker is the author of the well-known book “Mad in America: Bad
Science, Bad Medicine, and the Enduring Mistreatment of the Mentally”, with
hard critic of the contemporary psychiatric treatment of psychotic patients.
In this chapter, Bob Whitaker is especially examining the shady side of
neuroleptic treatment, with its hidden violence and adverse side-effects,
also showing that the long-term results of the drug treatment seem to be
rather poor.
PART IV: ON FUTURE

Developing psychotherapeutic approaches today
29) Further development of our treatment approaches to schizophrenia: an
integrated view (The editorial group)
In this chapter the editorial group will present summarizing notions about
the developmental needs of the treatment of schizophrenic psychoses,
based on the views by the authors of different chapters as well as the
experiences of the members of the editorial group members themselves.
444

The relevant topics include:
• The heterogenic nature of schizophrenia: Implications for therapy

• The position of individual psychotherapy
• The position of family- and environment- centred activities
• The key position of prevention and early intervention
• On drug treatment and combining of drugs with psychological
treatment modes
• Health service organizations and psychotherapy. The quality and
dimensions of psychiatric care
• Obstacles to the development of psychotherapy with schizophrenic
patients
• The question of evidence
• The crucial importance of an integrated approach
445
Yrjö O. Alanen
ISPS ISPS
Editors
AND AND
ITS SyMPOSIA ITS SyMPOSIA


Yrjö O. Alanen
Editors
TECHNICAL SECRETARIAT SCIENTIFIC SECRETARIAT

Carmen Benavent, ISPS Project Manager Manuel González de Chávez, Chairman
Psychiatric Service I

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Yrjö O.

ITS SyMPOSIA ITS SyMPOSIA

FIFTY YEARS OF HUMANISTIC TREATMENT OF PSYCHOSES

In Honour of the History of the International Society for the Psychological

TECHNICAL SECRETARIAT SCIENTIFIC SECRETARIAT

FIFTY YEARS OF HUMANISTIC

First published in 2006, by Fundación para la Investigación

Copyright 2006 ISPS & Fundación para la Investigación y Tratamiento de la Esquizofrenia y

Depósito legal: M-23892-2006

List of Contributors .............................................................................. 7

Part I: HISTORY OF THE ISPS SYMPOSIA

2 Beginnings of the International Symposia for the Psychotherapy of Schizophrenia

11 The XIth ISPS Symposium June 12.-16.1994 in Washington, DC, U.S.A.

Part II: THE ISPS TODAY

The ISPS gets organized . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231

16 The Establishment of the International Society for the Psychological Treatments

Establishment of Local ISPS activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259

20.A United States of America

20.C New Zealand

Breaking the Covenant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301

21.A International schizophrenia research and the concept

21.B Commentary on “Breaking the Covenant: International Schizophrenia Research

Part III: VIEWS ON THE FUTURE DEVELOPMENT OF THE ISPS

22 My Views for the Future Development of the ISPS

PART IV: ANNEXES

I.- The ISPS Constitution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355

II.- History of ISPS Board members 1990-2006 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363

III.- ISPS Life Honorary Members. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365

Yrjö O. Alanen, Finland (1994- ) by Manuel González de Chávez . . . . . . . . . . . . . 367

Gaetano Benedetti, Switzerland (1994- ) by Brian Koehler . . . . . . . . . . . . . . . . . . . . 371

L. Bryce Boyer, U.S.A. (1994- 2000 ) by Sue von Baeyerer . . . . . . . . . . . . . . . . . . . . . 375

Johan Cullberg, Sweden (2003- ) by Sonja Levander . . . . . . . . . . . . . . . . . . . . . . . . . . . 379

Stephen Fleck, U.S.A. (1994-2003) by Ann-Louise S. Silver . . . . . . . . . . . . . . . . . . . . 383

Julian Leff, U.K. (2003- ) by Brian Martindale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393

Theodore Lidz, U.S.A. (1994-2001) by Ann-Louise S. Silver . . . . . . . . . . . . . . . . . . . 397

Christian Müller, Switzerland (1994- ) by Luc Ciompi . . . . . . . . . . . . . . . . . . . . . . . . . . . 401

Barbro Sandin, Sweden (1997- ) by Kia Sjöström . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 403

Harold F. Searles, U.S.A. (2003- ) by Ann-Louise S. Silver . . . . . . . . . . . . . . . . . . . . . 407

Helm Stierlin, Germany (1997- ) by Michael Wirsching . . . . . . . . . . . . . . . . . . . . . . . . 411

John S. Strauss, U.S.A. (2003- ) by Ann-Louise S. Silver . . . . . . . . . . . . . . . . . . . . . . . 413

Endre Ugelstad, Norway (1994-1996) by Torleif Ruud . . . . . . . . . . . . . . . . . . . . . . . . . 417

Lyman C. Wynne, U.S.A. (1994- ) by Susan McDaniel . . . . . . . . . . . . . . . . . . . . . . . . . . . . 421

NEXT BOOK! . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433

Gaetano Benedetti, Professor of Psychotherapy and Mental Hygiene,

Chris Burford, Consultant Psychiatrist, St Ann’s Hospital, London N15.

Tim Calton, Lecturer in Psychiatry, University of Nottingham, U.K.

Johan Cullberg, Professor of Psychiatry, Stockholm Center of Public

Pier Maria Furlan, Professor of Psychiatry, University of Turin, Italy

John Gleeson, Associate Professor, Department of Psychiatry, Melbourne,

Manuel González de Chávez Menendez, Professor of Psychiatry,

Svein Haugsgjerd, Professor, Psychiatrist, Psychoanalyst, Oslo, Norway

Jan Olav Johannessen, Professor, Chief Psychiatrist, Rogaland Psychiatric

Jarl Jørstad, Psychiatrist, Psychoanalyst, Sandvika, Norway

Brian Koehler, Ph.D., Psychoanalyst, Professor of Postdoctoral Program in

Lyn Chua, Ph.D., Lyn Chua, PhD. Assistant Professor, Department of

Brian Martindale, Consultant Psychiatrist, Psychoanalyst, South Tyne and

Patrick McGorry, Professor of Psychiatry, University of Melbourne,

Christian Müller, Professor of Psychiatry (Emeritus), University of Bern,

Bjorn Ostberg, Psychiatrist, Oslo, Norway