714 BOOK SECTION

categories, e.g., self/nonseIf. It is apparent that Lidz and his co-

workers have made a giant effort and have persisted in following u p
their observations despite changing clinical and research fads. Their
contributions continue to bear fruit in rational treatment ap-
proaches and increasingly sophisticated research methodologies,
and the author has been successful in demonstrating, even to many
“organically” oriented psychiatrists, the value of a psychodynamic
approach to schizophrenia.

Johns. Kafka, M.D.

Washington, D.C.

SCHIZOPHRENIA AND THE NEED-FEAR DILEMMA. By D. L . Burnham,

A . I Gladstone and R . W.Gibson. New York: International
Universities Press, 1969, xv 474 pp., $15.00. +
Respectable as it has become again in recent years, the notion of
schizophrenia is acceptable to most of us, clinicians and researchers
in the field of mental illness, as something of a compromise. As Burn-
ham, author of the theoretical chapters of this book points out,
schizophrenia is but a conventional label, a diagnostic umbrella for
“diverse and far-reaching” phenomena, difficult if at all possible to
account for by means of unitary theory. Burnham and his collabora-
tors actually prefer to speak of “the schizophrenic person” rather than
of “schizophrenia,” making use of the more operational, Meyerian
notion of a “schizophrenic reaction” or “disorganization,” which
official psychiatry decided to do away with not too long ago.’
Burnham’s thesis is that a deficient psychological differentiation
and integration in early life results in a vulnerable personality struc-
ture, one that predisposes to a schizophrenic reaction. According to
this thesis, the person who is predisposed to such a reaction suffers
from an “inordinate need and fear of the influence of other persons’’
-a “dilemma” that not only creates a morbid predisposition, but
also accounts for the specificity of the psychotic reaction. All this is
in line with the traditional Freudian view of mental illness, the
1 I understand that thecommitteecurrentlyat work to revise APA’sDiagnosfic &
SfafrjficalAfanunf ofAZenfal Disorders (DShl-11) is in favor of changing again the
oyer-all label. this time from “Schizophrenia”to “Schizophrenic Disorders.”

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 BOOK REVIEWS 715

“conflict model,” according to which schizophrenia is a defensive

reaction to anxiety, on the same continuum of pathology as the
neuroses.
The far-reaching assumption of such a view is that some schizo-
phrenics may be born normal. As Burnham puts it, “We believe that
among the various types of schizophrenia there is at least one group of
persons whose inborn psychic apparatus is normal but whose dis-
ordered early object relations interfered with normal development”
(p. 15). In support of this contention, the authors point to the fact
that psychological treatment can help schizophrenics become more
or less normal. There is a “deficit,” but it is acquired and reversible.
Burnham elaborates this thesis in the opening chapters of the
book by using findings and arguments from a wide variety of sources:
Sherrington, Coghill, Werner, Allport, Rapaport, Piaget, Wynne,
Searles,. and many others. The emphasis, however, is on psycho-
analytic-ego-psychologyand object-relations theory as developed by
Erikson, Jacobson, and Mahler.
Faulty differentiation between the self and the environment
(mothering object in particular) leads to a blurring or loss of self/
nonself boundaries, body-image uncertainty, as well as general in-
ner/outer uncertainty or confusion and hallucinations, (deriving
from disintegration of the superego), difficulty in distinguishing one’s
own thoughts from those of others, and selective interpretation of
reality to fit one’s own emotions of the moment. Faulty integration,
on the other hand, leads to schizophrenic ambivalence, splitting,
dissociation-drive impulses come to dominate the entire psychic
apparatus: affects become all engulfing, with uncontrollable floods
of feeling; action loses its purposiveness, control, coordination, and
continuity.
Poor differentiation and integration make for an unreliable in-
ternal structure and an excessive need for external guidance and
control. Excessive dependence on objects make for a special vulner-
ability to rejection or abandonment. The schizophrenic person per-
ceives love objects as dangerous because he is so susceptible to their
influence, which can literally dominate or appropriate his self as well
as his ego and superego systems.
The book itself is rather loosely organized around a research
project that set out to study the kind of relationships schizophrenic
persons are capable of developing, dyadic ones in particular, under
the controlled conditions of a psychiatric hospital. For, as the authors
put it, “[su~hrelationships]may become either the tenuous bridge to

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716 BOOK SECTION

hope, reorganization, and reintegration into shared reality or the

final disillusioning seal on a doom to irreversible despair, disorgan-
ization and alienation.”
What the authors describe in terms of interpersonal relations,
however, is but a function of the treatment program and the theory
that underlines it in the social system of a unique institution-not the
relationships that a schizophrenic person can develop in his natural
habitat. The treatment program was there, and the theory behind it
was more or less there, before the subjects of the study came under
scrutiny; and both the treatment and its philosophy were largely
constructed in terms of a long experience with hospitalized schizo-
phrenics-the way subjects diagnosed as schizophrenic are expected
to behave toward those who try to help them in a hospital-profes-
sional people who take over when close relatives and friends back
home concede failure. The theory of the hospital in which the study
took place was basically psychoanalytic, Harry Stack Sullivan’s inter-
actional, field-dependent version; the treatment method, Dexter
Bullard’s version of the psychoanalytic hospital that Ernst Simmel
developed in Tegel-Berlin during the late 1920’s and the Menninger
brothers adapted in Topeka in the mid-1930’s.
The decision to undertake the study was inspired by Stanton and
Schwartz’szclassic study of the social structure of the same hospital,
which scrutinized staff interpersonal relations and showed how im-
portant, often adverse, their influence is on patients. The present
study concentrated on the relations of patients with staff, as these un-
folded in a treatment program prescribed without concern for the
research as such, within the confines of a small locked unit. The
researchers managed to exclude borderline patients and,, in contrast
to other major studies of treatment with schizophrenics, made sure
that their population was likely to remain hospitalized for a long
period of time. In fact, they chose to study only chronic schizophren-
ic patients, whose illness is not likely to respond to the usual ap-
proaches of pharmacological treatment, outpatient psychotherapy,
or brief hospitalization. Such patients usually reach hospitals like
Chestnut Lodge following gradual deterioration or a crisis in.another
hospital. An important characteristic of such patients is their family
structure, not only as a major factor in the development of their
illness, but in contributing to the breakdown of all treatment pro-
grams.
* Stanton, A. H. & Schwartz, M.S. (1954), The MentalHospita1.-A Study of
Institutional Partic2’pation in Psychiatric Illness and Treatment. New York: Basic
Books.

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 BOOK REVIEWS 717

At least one of theresearchers (Gibson) both participated in and

observed the patients’ treatment. About a dozen patients at any
particular time were studied over a period of five years and by
methods that, because of the evolvingnature of the study, varied over
the course of these years. They came from socially affluent families,
ranged from late adolescence to middle age, and were overtly
disturbed long before admission. They were all men, presumably
because the subjects of Stanton and Schwartz’s study were women.
A wide array of patient relationships, representing various
aspects of the treatment and living circumstances on the unit, were
studied-with psychotherapist and unit administrator (a psychi-
atrist), social worker, chief nurse and several student nurses (all
women), nursing aides, activities therapists, housekeeping staff, and
fellow patients. For practical reasons, however, only certain relation-
ships were observed systematically and in detail, and these did not
include relations with other patients. All in all, each patient was
studied on the basis of fifteen to eighteen relationships with different
staff members at various periods of his career as a patient on the
unit. Besides the psychotherapist (who often saw his patient in his
own office out of the unit, usually four hours a week) and the unit
administrator, the most available staff members were the psychi-
atric aides (all men).
A major methodological problem was to define the “experi-
mental” variable “relationship” in the context of the schizophrenic
illness. A related issue was the need for a standard way to collect in-
formation concerning one patient’s relationship with those of an-
other, or with his own at another time. The wish to obtain such
private information about as large a number of diverse relationships
as possible and the scarcity of research assistants made the investiga-
tors decide to rely mainly on reports from participants in these
relationships-regular hospital personnel and patients-rather than
upon direct observations.
The data indicate some consistent aspects of patient-staff inter-
action, specific for the conditions prevailing on the “experimental”
ward. T h e most typical cluster of patient-staff behaviors reflected a
tendency in the patients to approach nursing personnel in a sociable
way and a reciprocal tendency on the part of the nursing staff. An-
other consistent pattern of interaction was €or the patients to engage
in objectionable behavior- “problem behavior”-and for the staff to
get annoyed or angered and try to control or change it. “Problem
behavior”brought to the foreground the issue of dominance and sub-
mission. Both kinds of behavior resulted in increasing patient-staff

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 718 BOOK SECTION

contact. The kind of interaction that developed between patient and

therapist -a relationship that, in contrast to patient-nursing staff
‘interaction, was literally imposed upon the patient-was similar to
that described between patients and other staff members: “conven-
tional sociability” and “problem behavior” were the most important
determinants, patient relationships with therapists being more varied
and differentiated. These findings are in no way surprising and,
indeed, add little to what we know about patient-staff relationships
or to what we might expect under the circumstances.
A series of extensive case reports illustrate various aspects of
patient-staff relationships in terms of the “need-fear dilemma,”
describing the patients’ attempts to restructure reality in search of
constancy and security ties with the object world by means of
clinging, avoidance, object redefinition, splitting, displacement, etc.
These case reports afford an opportunity to revisit pathogenic factors
in the family and the environment in general -contradictions and in-
consistencies in the early child-parent relationship that prevent a
satisfactory self-object differentiation, sex and role identification-
as well as typical circumstances that lead to schizophrenic disorgan-
ization.
The treatment task was to break the cycle of desperate search for
objects and retreat to autistic relationships by attempting to contain
and integrate the patient’s need and fear of objects within actual
relationships in shared reality. The goal was to achieve genuine
object constancy.
Progress was assessed in terms of the patient’s ability to acknowl-
edge awareness of the inconsistency of his feelings, especially the
awareness that what he experiences as badness is within himself
rather than in the outside world. Such awareness is presumably
helpful in containing the patient’s “need-fear dilemma,” in particu-
lar, the need to avoid or destroy the “bad” outside world. As he is
able to engage in self-criticism, he tends to make less use of projec-
tion.
But improvement in terms of increased self-awareness and
objectivity is obviously hard to take and does not lead to a quick
recovery. A patient may know that he is not well, yet to know does
not make him well. In the case of most patients discussed in the book,
help went so far as to enable them to tolerate self-criticism and admit
their craziness: but, possibly because of a failure to internalize the
objects that helped them become less anxious and defensive, they
remained vulnerable to psychotic disorganization: once they lost the
supportive objects, their psychotic defenses returned and they be-
came as sick as ever.

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 BOOK REVIEWS 719

Treatment responsibility was shared by the psychotherapist and

a clinical administrator. The administrator’s function was the man-
agement of the patient’s daily schedule, physical health, and freedom
of movement; in this, he functioned also as an agent of social control,
protecting society from the patient’s potential destructiveness. He
exercised his functions mostly indirectly, through a team of nurses
and aides. But he delegated little in terms of decisions to anyone,
including the nursing personnel and activities therapist. The social
worker’s contribution to treatment was presumably to negotiate visits
with the family. Apparently, there was little work for a psychologist in
the team, either: in fact there is no mention of a psychologist at all.
The administrator’s efforts aimed at lessening the disruptive
effect of anxiety so as to facilitate relationships and maintain com-
munication, and at controlling behavior when it reached dangerous
proportions. It also sought to provide opportunities and chal-
lenges for ego growth, eventually fostering initiative, responsi-
bility, and independence. The long-range goal of treatment was to
modify the patient’s ego deficit, yet the definitive work in this direc-
tion was to be done by the psychotherapist “through the transference
relationship, genetic interpretations, and working through.’’ Indeed,
the clinical administrator’s primary goal was to provide a propitious
setting, congenial to the development of constructive relationships,
above all the relationship with the psychotherapist.
Gibson, the clinical administrator in the study, provides a clear
and detailed description of the techniques he used in trying to
maintain an optimal setting for the psychoanalytic treatment of his
schizophrenic patients. Some of these techniques had to do with the
patient’s defensive-regressivepatterns of behavior in response to the
reactivation or intensification of the “need-fear dilemma” brought
about by the therapist. The clinical administrator tried to mobilize
the patient’s human environment, mainly nurses and aides, and to
counteract the patient’s defensive responses, identified over and
again as object avoidance, object clinging, and object redefinition.
At thesame time, the clinical administrator tried to educate the staff
to the meaning of the patient’s behavior-an essential task if the staff
were not to behave in a rigid, thoughtless manner like guarding the
rules and keeping order with disorganized, assaultive patients, or as
servants of infantile needs, grotesque mother substitutes. Individual
supervision, group discussion, even group therapy, were used in order
to help the staff deal with the intense anxiety that a schizophrenic
patient’s needs tend to arouse.
An even more difficult problem was to help a patient give up a
relationship after a certain point as patient-staff relations became

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720 BOOK SECTION

symbiotic, reconstructions of infantile, mother-child relationships -

a necessary development in the patient’s course of treatment, but dif-
ficult for both patient and staff to give up.
Excerpts from therapists’ notes, however, afford a suggestive
glimpse of the method, which, psychoanalytic as it was in principle,
varied considerably from psychotherapist to psychotherapist. Ap-
parently determined by the therapist’s temperament rather than the
patient’s actual condition, it ranged from free association on the
couch even when the patient had to be forcibly held to it, to a face-to-
face confrontation that allowed for bodily contact and an occasional
exchange of blows. Working in close cooperation with the clinical
administrator, psychotherapists had the benefit of the supervision
with someone outside of the treatment team.
Schizophrenia and the Need-Fear Dilemma offers a panoramic
view of the hospital career of a schizophrenic person. But this is no
ordinaryhospital career. At the time this particular study was taking
place, Chestnut Lodgestill counted among its staff members some of
Sullivan’s most creative students, notably Otto Will and Harold
Searles. Frieda Fromm-Reichmann was still alive and, according to
the authors, contributed actively to their work. This was a hospital
where members of the staff took pride in developing an intense
personal involvement with their patients, and where such involve-
ment was, from the very start, expected to last for a long time.
All of which may make one wonder. This volume is already seven
years old, and the events it describes took place at least as many years
earlier. Are itscontents dated? The stated problem-object relations
in schizophrenia-is certainly not. But what about the theory and the
treatment that its authors advocatei
The psychoanalytic hospital was created with the understanding
that the patient would need to remain in treatment and specifically
within the hospital setting for a prolonged time. Such a condition was
easier to defend-if not to afford-in the days when antipsychotic
drugs were not yet available and custodial hospitalization was the rule
in most other places. It was easier to point out that in psychiatry, in
contrast with most other medical specialties, one “thinks in long-time
terms; treatment extends over a long period, prognosis considers a
long interval; the patient’s whole life is under consideration rather
than an acute episode or relatively brief illne~s.’’~ Things did not
change so quickly in those days, there were no third-party payers, no

3 hlenninger, K. A. (1936), Psychiatry and Medicine. Bull. Menninger Clinic,

1:l-9.

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 BOOK REVIEWS 721

patients’ lib movement, few if any government regulations. Times

were different for psychiatry, for psychoanalysis and psychoanalytic
hospitals-life, in general, was different then, not better or easier,
but simpler it seems.
Indeed, evidence from recent controlled studies4 suggests that
the hospital career of schizophrenic patients is more successful if
based on psychotropic drugs rather than hospital-based psycho-
therapy. Yet, in going over such studies, a thoughtful reader may ask:
What hospital and what psychotherapy? For that matter, what
success and what patients are we talking about?
The question is not to defend the psychoanalytic hospital and
psychoanalysisas efficient forms of treatment for schizophrenia, for it
is obvious that neither is more efficient than drugs in returning
chronic schizophrenic patients to the community. The present book
makes no claim to efficiency. The point is that there may be
something very worthwhile and hopeful in efforts such as the one this
book describes, beyond the mere pursuit of social expediency. In fact,
when it comes to results of hospital treatment based on psychoana-
lytic theory and method, this volume may suggest a more pessimistic
picture than is really warranted, paying, as it does, exclusive atten-
tion to very sick patients for the ostensible purpose of studying their
object relations, which are then consistently interpreted in terms of a
theory that seems to owe more to an encyclopedic grasp of the
literature than to the research data at hand.
As for the validity of the theory itself, I will let one of the authors
have the last word: “. . .
there is clearly a distance to go before we
arrive at a n adequate and generally accepted theory of schizophren-
ia, or more accurately, of the schizophrenias,” said Burnham5 in
summarizing the proceedings of a panel on the subject during a
recent meeting of the American Psychoanalytic Association. “As
theory-builders, we are like the would-be builders of the Tower of
Babel; we suffer a confusion of tongues” (p. 198).

Peter Hartocollis, M.D., Ph.D.

C. F. Menninger Memorial Hospital

4 May, P. R. A. (1968), Treatment of Schizophrenia. New York: Science

House. Also: Grinspoon, L., Ewalt, J. R. & Shader, R. I. (1972). Schizophrenia:
Pharmacology and Psychotherapy. Baltimore: Williams and Wilkins.
The Influence of Theoretical Model of Schizophrenia on Treatment
Practice, J. G. Gunderson, reporter. Th&Joumal(1974), 22:182-199.

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