VOL 15, NO.
2, 1989
Schizophrenia and the
Self: Contributions of
Psychoanalytic
Self-Psychology
by William S. Pollack Abstract
This article explores the unique
contribution of psychoanalytic self-
psychology to an indepth under-
standing of the subjective
experience of the self in schizo-
phrenia. The author makes the
argument that with creative adapta-
tion Kohut's experience-near
concept of the primacy of the self—
its development and vicissitudes of
fragmentation/cohesion—and the
salience and legitimacy of self-
object needs in all human relation-
ships can be applied to psychotic
and schizophrenic experience.
When so applied, there is reason to
suspect that an important bridge to
the subjective inner life of the
schizophrenic patient will be
achieved.
Psychoanalytic theories about the
etiology and phenomenology of
schizophrenia have, for the most
part, mirrored the ontogenesis of
psychoanalytic metapsychology
itself. Beginning with Freud's drive-
based (id) analysis of psychotic dys-
function, psychoanalytic
conceptualizations of schizophrenia
then moved toward a more ego/
defense-oriented approach
(Hartmann 1952, 1953), more
recently incorporating the theories
of interpersonal (Fromm-Reichmann
1948; Sullivan 1953), object relations
(Jacobson 1954, 1964; Kernberg
1976)—and to a more limited
extent—self-psychology schools of
thought. Theorists have only varia-
bly, however, addressed the true
subjective inner experience of the
schizophrenic patient, tending at
times to focus more upon the
experience-distant and esoteric
"inner world" of defenses or inner
structures; or, alternatively, aban-
doning the patient altogether in
search of pristine theoretical
311
debates over etiology. What has
been all too often ignored, then, are
the subjective, actual feelings,
Downloaded from http://schizophreniabulletin.oxfordjournals.org/ at Pennsylvania State University on March 2, 2014
thoughts, and experiences of the
affected individuals.
All this must give us cause to
reflect, with humility, upon the as
yet sadly uncharted territory of the
subjective experience of the schizo-
phrenic patient (with some notable
exceptions such as Sullivan,
Semrad, Stanton, Searles, and Will).
On the other hand, it should
encourage us to use the broad
depth of psychoanalytic knowledge
to investigate this area more fully.
It will be the central thesis of this
article that the modern psychoana-
lytic concepts of narcissism and
self-psychology are especially
salient for this task of an indepth
empathic understanding of the sub-
jective experience of schizophrenia.
Self-Psychology and the Sub-
jective Experience of
Schizophrenia
A full review of the more classic
psychoanalytic, ego-psychological,
and object-relations approaches to
the mysteries of schizophrenic
experience is beyond the scope of
this article and, indeed, has been
adequately dealt with elsewhere
(see, e.g., Hartmann 1953; Modell
1956; Jacobson 1964; Kernberg 1976;
Day and Semrad 1978). Suffice it to
say, however, that already present
in the original work of Freud were
to be found not only the classical
theoretical formulations of drive
overstimulation as a cause of psy-
chotic illness, but also the seeds of
ideas for both a structural theory
and, indeed, even a self-
Reprint requests should be sent to
Dr. W.S. Pollack, Director, Continuing
Education in Psychology, McLean Hos-
pital, 115 Mill St., Belmont, MA 02178.
312
psychological understanding of
schizophrenia. Although Freud
began by focusing his conceptual
understanding of the schizophrenic
patient's experience upon shifts in
libido, he soon began to understand
that certain inner experiences were
better explained by shifts in the
cathexis to the self, or in what he
came to call vicissitudes of "narcis-
sism" (Freud 1911/1948; see also
Modell 1956). Indeed, by the end of
his career, Freud had moved, gen-
erally, to a more structural
definition of psychosis, seeing it,
unlike neurosis, as not being so
much a conflict from within but a
conflict between the self (ego) and
the environment or outer world
(Freud 1924/1948).
Fascinatingly, the theoretical
works of Kohut and his followers in
self-psychology build upon the
earlier Freudian concepts of narcis-
sism and branch from them. Most
notably, Kohut came to disagree
with Freud's single developmental
line in which autoerotic and nar-
cissistic concerns were concep-
tualized as the earlier precursors, in
a direct developmental trajectory, of
later interpersonal relations or
object love. Specifically, Kohut
came to argue theoretically for a
paradigm of dual developmental
lines: one, for the self (narcissism)
and another for interpersonal or
object love. Kohut believed strongly
that the line of self-cathexis, or the
so-called narcissistic line of develop-
ment, did not necessarily mature
into object love:
As I crudely outlined ... long
ago, narcissism is not as Freud
had taught, a precursor of object
love, to oe relinquished and to be
supplanted by the latter—it has
its own line of development.
[Kohut 1980, p. 453]
According to such an approach,
the narcissistic or "self" line will
undergo maturation or transforma-
tion, but it need not necessarily
branch into love for another inde-
pendent person. For example,
earlier developmental forms of
narcisstically (self) gratifying inter-
action between parent and child,
such as "mirroring" or "twinship"
relationships (see below)—if things
go well—may later mature into
higher level se//-capacities for
empathic immersion of a caring
sort, or a quality for humor,
vicarious introspection, artistic
creativity, wisdom, or empathy
(Kohut 1971, 1977; Kohut and Wolf
1978).
Such an approach also legitimizes
and enhances the salience of
observing our relationships/
interactions with others, not only
from the perspective of the recogni-
tion of, or respect for, their
independent locus of function,
but—especially—from the purview
of their subjective meaning to the
self. In turn, this led Kohut to the
conclusion that even normal
development does not rest upon
too rigid a need for the complete
sense of separation of self and other
(object). Rather, the creation—at
different developmental levels—of a
supportive matrix between the self
and others, enhancing the function-
ing of the self, is a significant
maturational task. Such interactions
may lead to the growth of inter-
nalized structures, but may also
continue to require ongoing support
from significant others for self-
function. Hence, the recognition
that a more semipermeable bound-
ary between what is the self and
what comes from the significant
objects around us should not only
be tolerated, but in some cases
expected and/or encouraged, viz:
the idea of the self-object.
Central to Kohut's new psychol-
ogy of the self is the concept of the
SCHIZOPHRENIA BULLETIN
self-object, a theoretical and practical
approach to the treatment of
patients that may broaden and
Downloaded from http://schizophreniabulletin.oxfordjournals.org/ at Pennsylvania State University on March 2, 2014
deepen our understanding of their
inner experiences. Kohut described
a self-object as an object that we may
experience as part of ourselves.
Consequently, the expected control
over such an object is closer to the
sense of control that an adult usu-
ally expects to have over his or her
own body and mind rather than to
the kind of control we usually
expect to have over others (Kohut
and Wolf 1978). Accordingly, there
are two types of self-objects, each
with a variety of developmental
levels:
Those [selfobjects] who respond
to and confirm the child's innate
sense of vigour, greatness and
perfection; and those to whom
the child can look up and with
whom he can merge as an image
of calmness, infallibility, omnipo-
tence. [Kohut and Wolf 1978,
p. 414]
The first type of self-object consists
of the parent's and later significant
objects' response to the child's or
patient's grandiose self and is com-
monly referred to as a "mirroring
self-object." The other type
responds to the child's or vulner-
able patient's projection of
omnipotence and omnipotent fan-
tasies onto an idealized other or
parent, and is commonly referred to
as the "idealizing transference" or
"idealized parent imago."
Embedded in this seemingly sim-
ple definition is an empathic,
experience-near understanding, I
believe, of the schizophrenic
patient's endopsychic life. It differs
significantly from classic psychoana-
lytic object-relations concepts of
"part-objects," etc., which Kohut
sees as dominated by a maturity
moralitv, in which the continued
VOL. 15, NO. 2, 1989
need to be satisfied by others is
maligned as a primitive or develop-
mentally immature use of the
therapist or significant object.
Rather, Kohut understands a self/
self-object relationship to be the
expression of a phase-appropriate
and legitimately expressed need in
patients for necessary psychological
and functional support from others,
which a fragile or incomplete inter-
nal self-structure cannot provide for
itself. As he has stated:
The essential psychopathology ...
[in these patients] is defined by
the fact that the self has not been
solidly established, that its cohe-
sion and firmness depend upon
the presence of a self-object and
that [such patients] respond to
the loss of a self-object with sim-
ple enfeeblement, various
regressions, and fragmentation.
[Kohut 1977, p. 137]
The self-object and set of self-object
responses, then, may make up for
and may be developmentally "the
precursors of [internalized] psychic
structure" (Tolpin and Kohut 1980,
p. 442). Such an understanding of
self-pathology, or of normal human
development—as the sense that to
some extent or another we are
incomplete without the presence of
another person to provide impor-
tant psychological functions for our
own selves —provides, I believe, an
important bridge for understanding
the internal subjective experience of
the psychotic patient. The self-
object concept goes far toward
explaining the psychological equilib-
rium and stability that can be
achieved in the psychotherapy of
such states of pain and dysfunction
when the need to be used as a
functional part of the patient's self
is accepted by the therapist (e.g.,
the need for mirroring or idealiz-
ing). It also aids us in experiencing
empathically the internal struggles,
fears, concerns, ideas, and wishes
of the person diagnosed as having
schizophrenia.
Such a shift in theory and treat-
ment focus also suggests a different
pathway to mental health. Kohut
argues that it is more important to
create an ongoing therapeutic
environment in which supportive
self-objects help to maintain the
cohesion of the patient's self than
to exhort patients to become inde-
pendent. Separation-individuation,
then, become less salient than affec-
tive connection or the subsequent
storing of such positive memories
of holding, soothing, caring, and,
indeed, of merging. Kohut explains,
that even the most mature and
healthy adult will seek:
[a] self-object environment that is
in harmonious contact with them
until, ... they ultimately attain
what they need ... when they
have securely inserted themselves
into the empathic matrix that
they require, they are then not
only able to receive freely, but
also to deal with themselves in
abundance. [Kohut 1980, p. 453]
For schizophrenic patients, the
empathic matrix of intensive indi-
vidual therapy, or adjunctive
interactions with supportive self-
objects, becomes a psychological
necessity to maintain emotional
equilibrium and self-cohesion, to
forestall further psychotic regres-
sion or fragmentation, and
eventually to internalize a more sta-
ble sense of the self. It is more than
a cultural need. It is, from a psy-
chological perspective, a life or
death struggle.
This is particularly the case for
psychotic patients who are often in
deep conflict between the need to
protect the self from others and the
extreme need for real dependency
upon others for emotional and
actual survival. Kohut's nonjudg-
313
mental theory—that self-objects are
the precursors of later internal
Downloaded from http://schizophreniabulletin.oxfordjournals.org/ at Pennsylvania State University on March 2, 2014
structure, and that many individ-
uals with disorders of the self may
borrow structure from others
because their own psychic structure
is not yet fully formed (Tolpin and
Kohut 1980)—goes far toward
relieving the burdens of guilt car-
ried by both patient and therapist.
Now patient and therapist (or sig-
nificant other) alike may accept the
legitimate need for emotional
merger and recognize that the
therapist is often experienced not as
another dependable, separate
object, but as an actual part of the
patient's narcissistically expanded
self.
Kohut (1977) explains that in the
course of normal human develop-
ment, we all need the opportunity
to merge with a calming, soothing,
and/or idealized object as a precur-
sor to creating self-capacities for
affective regulation, psychological
stability, and growth. When early
parental environments fail, we see
patients who have never achieved
such a cohesive, internalized psy-
chic structure, or for whom the
structure is extremely shaky. Their
selves are, therefore, vulnerable to
disintegration anxiety, fragmenta-
tion, or a sense of chronic
depressive boredom termed
"enfeeblement." In turn, such
patients may seek out or require the
provision of a flexible self-object
matrix or holding environment, first
to maintain the homostatic balance
of internal healthy ego functioning
and only later to allow for its
internalization.
In Kohut's work, and in the field
of self-psychology, there is a great
empathic sensitivity to the patient's
inner experience of the self as well
as to the treatment environment,
with its intermittent crises. He sug-
gests that patients with disorders of
314
the self who must depend upon
others, to some extent, to provide
self-equilibrium are likely, at times,
to demand a more perfect "in-
tuneness" or empathy. When, of
course, these needs cannot always
be met, rage may ensue. From this
perspective, however, anger is not
necessarily an untamed primitive
drive or a congenital biological ill-
ness, but rather the expression of a
lost connection—the pulling of a
life-sustaining plug for psychologi-
cal equilibrium, the loss of an
important self-object glue which
leads to a crisis or to regressive
fragmentation as a signal of dis-
tress. Kohut is also clear, however,
that this does not mean that the
psychotherapist or the significant
self-objects have necessarily erred.
It is not possible to "perform super-
human feats of never failing, per-
fect empathy" (Kohut 1977,
p. 93). These therapeutic "derail-
ments" or empathic failures are
unavoidable in treatment and inter-
action, especially with extremely
disturbed fragmentation-prone
patients. Nonetheless, it is impor-
tant for the self-object or therapist
to persist with efforts to provide
empathically, during these periods
of hurt and disillusionment, the
opportunity for patients to soothe
themselves without either having to
attack or blame themselves or in
turn to be attacked by others.
Especially the therapist (self-object)
must take care to do no further
harm through experience-distant
"interpretations." Indeed, when
handled properly, these "derail-
ments" may lead to inner structure-
building experiences and alliance-
enhancing opportunities for greater
mutuality between patient and
therapist—Kohut's concepts of opti-
mal disillusionment and transmuting
internalization.
The majority of Kohut's work, as
well as the development of self-
psychology itself, was founded
upon the analytic understanding of
narcissistic personality disorder
rather than psychosis. And like
many of the classical analysts who
came before him, Kohut, unfor-
tunately, remained somewhat
gloomy in his view of the prospects
for therapeutic application of these
techniques to persons with schizo-
phrenia and the other psychoses.1
However, with creative adaptation,
we can use both Kohut's theory of
self-object development (his sense of
the self) and his experience-near,
empathic listening concept with
good results in working with
seriously disturbed psychotic
patients. Moreover, these concepts
can become an important spring-
board for a more complete
psychoanalytic understanding of
the subjective experience of
schizophrenia.
In his earliest monograph on The
Analysis of The Self, Kohut (1971)
actually expressed his belief that
through the indepth understanding
of narcissistic disturbance from the
point of view of depth self-
psychology, one might gain a
•There have been some earlier
attempts to integrate self-psychology
into psychoanalytic treatment paradigms
for schizophrenia. Adler, in an essay on
Semrad's contributions, attempted a link
to Winnicott and Kohut's work
(especially self-object transferences). Yet
a major thrust remained in the sphere of
borderline disturbances and pre-
schizophrenic conditions (Adler 1979).
Magid (1984) also made an attempt to
use Kohut's theories in treating very
disturbed patients, but again with a
mixed emphasis on borderline disturb-
ance. The field of self-psychology as
applied to the experience of psychosis,
per se, remains exceedingly under-
developed.
SCHIZOPHRENIA BULLETIN
greater subjective sense of the inner
experience of schizophrenia:
Downloaded from http://schizophreniabulletin.oxfordjournals.org/ at Pennsylvania State University on March 2, 2014
Although the essential psycho-
pathology of the narcissistic
personality disturbances differs
substantially from that of the psy-
choses, the study of the former
contributes nevertheless to our
understanding of the latter. The
scrutiny of the specific thera-
peutically controlled, limited
swings toward the fragmentation
of the self and the self-objects
and the correlated quasi-psychotic
phenomenon which occur not
infrequently in the course of the
analysis of narcissistic personality
disturbances offers, in particular,
a promising access to the under-
standing of the psychoses
[Kohut 1971, pp. 5-6]
In the development of his own
nosology of disorders of the self,
Kohut grouped psychoses under
the primary disturbances of the self,
which also include borderline
states, as well as the narcissistic
personality and behavioral disor-
ders. He distinguished psychotic
disorders, from the others,
however, by describing them as
involving "permanent or protracted
breakup, enfeeblement, or serious
distortion of the self" (Kohut 1977,
p. 192). He went on to differentiate
further and to describe subjectively
the nature of the psychoses, from
the perspective of the sense of the
self:
If serious damage to the self is
either permanent or protracted,
and if no defensive structures
cover the defect, the experiential
and behavioral manifestations are
those that are traditionally
referred to as the psychoses. The
nuclear self may have remained
non-cohesive (schizophrenia)
either because of an inherent bio-
logical tendency, or because its
totality and continuity were not
responded to with even mini-
mally effective mirroring in early
life, or because of the interplay
between or convergence of bio-
VOL. 15, NO. 2, 1989
logical and environmental factors.
It may have obtained a degree of
cohesion but because of the inter-
action of inherent organic factors
and a serious lack of joyful
responses to its existence and
assertiveness, it will be massively
depleted of self-esteem and
vitality ("empty" depression). It
may have been almost totally
deprived during the crucial peri-
ods of its formation of the
repeated wholesome experience
of participating in the calmness of
an idealized adult (i.e., of a merg-
er with an idealized selfobject),
with the result, again decisively
influenced by inherent biological
factors, that an uncurbed tend-
ency toward the spreading of
unrealistically heightened self-
acceptance (mania) or self-
rejection ("guilf'-depression)
remains a serious central weak
spot in its organization. [Kohut
and Wolf 1978, p. 415]
Kohut argued that psychoses, as
well as narcissistic personality dis-
turbances, could no longer best be
understood as a regression along a
single developmental line, from
object love back to narcissism and
then autoerotic fragmentation or
delusional restitution. Rather, he
insightfully applied his dual line
developmental theory to argue for a
developmental line of narcissism
itself, with higher and lower levels
of transformation and vicissitude:
Instead it is especially fruitful to
examine the psychopathology of
the psychoses—in harmony with
the assumption that narcissism
follows an independent line of
development—in the light of trac-
ing their regression along a partly
different path which leads
through tne following way sta-
tions: (a) the disintegration of
higher forms of narcissism; (b)
the regression to archaic narcissis-
tic positions; (c) the breakdown of
archaic narcissistic positions
(including the loss of the nar-
cissistically cathected archaic
objects), thus the fragmentation
of self and archaic self-objects;
and (d) the secondary (restitutive)
resurrection of the archaic self
and of the archaic narcissistic
objects in a manifestly psychotic
form. [Kohut 1971, p. 6\
Such an approach allowed Kohut
to outline diagrammatically the
transformations of self-experience
on a developmental continuum
from emotional health to severe
self-disturbance. From such a per-
spective, we would see under the
pole of the development of the
grandiose self, in normal individ-
uals, mature forms of self-esteem
and self-confidence. When minor
failures of development affecting
cohesion occurred, narcissistic per-
sonality disorders would ensue
with excessive claims for attention
and partial fragmentation of the
grandiose self manifest in symp-
tomatic hypochondriasis. Within
frank psychosis there would be a
delusional reconstitution of a gran-
diose self in a type of cold paranoid
grandiosity, acting as though no
one else were necessary. So, too, in
the normal phase of the idealized
object development there would be
admiration for others, a sense of
enthusiasm, and important self-
goals. With narcissistic disturbance
we would see a compelling need for
merger with a powerful idealizable
object or some self-fragmentation,
disjointed inner experiences, exces-
sive religious feeling, and/or vague
awe for the omnipotent. In the
inner psychotic experience, the
need for the omnipotent object
might again be experienced from
within the self as a sense of a power-
ful persecution, influencing
machine, or delusions of
persecution.
Especially significant for our pur-
poses is how this emphasis on the
primacy of the self (particularly
upon its firmness [cohesion] or the
frightening vicissitudes of its
fragmentation-prone nature) may
315
give us a better bridge toward an
understanding, from within the
Downloaded from http://schizophreniabulletin.oxfordjournals.org/ at Pennsylvania State University on March 2, 2014
psychotic patient's own experience.
This comprehension surpasses
other psychoanalytic or experiential
approaches—which continue to
emphasize the role of an external
observer/object. In fact, one very
important conclusion to be drawn
from the work of self-psychology as
applied to the psychoses is that the
focus upon interpersonal loss, or
object love, per se, tells us less
about the precipitants of psychotic
phenomena than focusing our
attention on the hurt, loss, or injury
experienced from within the exclu-
sive purview of the self—the
narcissistic wound or danger. As
Kohut remarked,
The precipitating events which
usher in the decisive first steps of
the regressive movements [in
psychosis] lie frequently in the
area of narcissistic injury rather
than in that of object love. [Kohut
1971, p. 8]
In the schizophrenic patient's
world, we are often experienced as
a functional part of the patient's
self—pushed away or drawn closer
within this internal locus—during
struggles to maintain a psychologi-
cal balance of the self. Our self-
object presence, then, is used as a
type of internal "glue," helping a
fragmenting self to cohere or a
debilitated self to function. To
accept and truly listen to the subjec-
tive experience of psychosis, we
must be attuned to our use as part
of another, and be accepting of the
denial of our significance or,
indeed, even of our existence as sep-
arate people, selves. From such a
vantage point of empathic immer-
sion within the patient's self, the
need for merger represents not a
bizarre unacceptable experience of
the world of objects, but merely a
more extreme modification of legiti-
316
mate self-object use, present on a
continuum. This is a continuum of
self-object relationships where,
even in normal development, we all
at times continue to depend upon
the functional presence of signifi-
cant others (self-objects) to bolster
the experiences within ourselves of
positive self-worth, self-esteem, and
self-cohesion. Psychotic inner life,
then, need not be so far from our
own inner experience if we remain
empathic to these needs of the self.
Clinical Vignette
A single young male in his twenties
was admitted in transfer from
another hospital to a more secure
facility for fear of his hostile com-
ments, potentially aggressive
behavior, and self-referential, quasi-
delusional paranoid stance vis-a-vis
his fellow patients. He had recently
begun a therapy and was explain-
ing to the therapist his ideas of
"sexuality":
Patient: At the other hospital, the
doctor asked me about masturba-
tion and that scared me, Dr. P.,
because everything seemed sex-
ual. Like that tree over there is
sexual and my father is sexually
interested in me, I think. And I
worry about you and me being
sexual you know, like inside
me . . . .
Therapist: I wonder if what you
told me about being depressed
and scared before you came to
the hospital means you were feel-
ing very alone and insecure.
When you feel the whole world is
sexual—even though you are
scared again—you must feel stim-
ulated and very alive.
Patient: Yeah, you're right. I'm
scared to think of sex and you,
but I don't feel so down and in
pieces when I do. How about my
father, though?
Therapist: It's scary not knowing
who is who ... but you need him
to be there and support you, I
guess—why feel so Dad about
that, and so scared?
Patient: Like I'm a little baby
sometimes. I'm not so sure what
to do about all of this reality
stuff.
Therapist: Reality?
Patient: 1 feel like I can change it
when I want to, like changing the
channels on the TV.
Therapist: When it hurts too much
you invent things or people or
ideas about yourself to feel more
comfortable inside.
Patient: Anything's better than
feeling like you're falling apart.
Therapist: Yes, you need these
ideas to hold yourself together.
Patient: And I like using you that
way too.
Therapist: Feel free, if it helps,
using me is part of our work.
Patient: (Laughs) Like you're a big
teddy bear, or like my father, but
that's crazy.
Therapist: Crazy?
Patient: To think of you that
way
Therapist: That way?
Patient: Like a part of me.
Therapist: I guess a part that
keeps things comfortable and
glued together.
Patient: Yeah . . . .
Treatment Recommendations
In analyzing the early psychoana-
lytic work of Tausk, Kohut stresses
this analyst's experience-near con-
cept of a psychotic patient's
subjective world:
... Tausk's empathic or introspec-
tive recognition that the
schizophrenic's ... [sense] of
being influenced by a machine
was the revival of an early form
of self, a regression to painful
and anxious body experiences
after the contact with the
"you"—experience is lost [was a
great discovery]. Persistent intro-
SCHIZOPHRENIA BULLETIN
spection in the narcissistic
disorders and the borderline
states thus leads to the recogni-
Downloaded from http://schizophreniabulletin.oxfordjournals.org/ at Pennsylvania State University on March 2, 2014
tion of an unstructured psyche
struggling to maintain contact
with an archaic object or to keep
up the tenuous separation from
it. Here, the analyst is not the
screen for the projection of inter-
nal structure (transference), but
the direct continuation of an early
reality that was too distant, too
rejecting or too unreliable to be
transformed into solid psycholog-
ical structures. The analyst is
therefore introspectively experi-
enced within the framework of an
archaic interpersonal relationship.
He is the old object with which
the analysand tries to maintain
contact, from which he tries to
separate his own identity, or
from which he attempts to derive
a modicum of internal structure.
[Kohut 1978, pp. 218-219]
The rationale for understanding
the patient's subjective experience
and the psychotic person's exquisite
sensitivity to our self-sustaining role
within the self, then, follows:
A schizophrenic patient, for
example, arrives at the analytic
session in a cold and withdrawn
state. In a dream of the preceding
night he was in a snow-covered
barren field; a woman offers him
her breast, but he discovers the
breast is made of rubber. The
patient's emotional coldness and
his dream are bound to be a reac-
tion to an apparently minute, but
in reality significant,' rejection of
the patient by the analyst. Reac-
tions to realistic rejections by the
analyst, of course, also occur in
the analysis of transference neu-
roses In the analysis of
psychosis, ... however, archaic
interpersonal conflicts occupy a
central position of strategic
importance that corresponds to
the place of the structural conflict
in the psychoneuroses. [Kohut
1978, p. 219]
Despite Kohut's own caveats con-
cerning the use of self-psychology
in the analysis of psychotic states,
VOL 15, NO. 2, 1989
he has, nonetheless, created a
metapsychology of the self which
comes closer to putting the psycho-
analytic clinician introspectively
near to the inner experiences, the
subjective sense of the schizo-
phrenic patient. What then, in
summary, are some of the central
concepts that can inform our work
as clinicians, in struggling to grasp
the subjective experiences of a psy-
chotic patient?
• Schizophrenic and psychotic
experiences, in general, are best
understood from the perspective of
the self (narcissism) rather than
from that of drives, ego structure,
or actual object (interpersonal) rela-
tions, per se. Viscissitudes in the
level of comfort and cohesion of the
self must be listened to empathi-
cally (from within the context of the
patient's self), and paid serious
attention in understanding the psy-
chotic patient's inner experience.
• The primary disturbance in psy-
chosis, therefore, is one of a
protracted fragmentation or
enfeeblement of the self. This is a
self, then, which in its attempts at
repair is "glued" together through a
legitimate and psychologically life-
sustaining interaction with signifi-
cant self-objects. Such self-objects in
the interpersonal social networks of
preschizophrenic and schizophrenic
patients, and such self-object func-
tions as provided by the psycho-
therapist, must be available to "fill
in the blanks" of missing or frag-
menting structures. Consequently,
the therapist must be comfortable in
being used not only as a piece of
the patient's inner world, but in
being experienced as a part of the
patient's own self, sometimes
merged into the patient's body-
mind-self in a fragmented and con-
fusing way. Following from Kohut's
work, it would be important not to
force the reality of one's external
existence too prematurely upon the
patient who is presently requiring
the inner experience of the therapist
to provide self-soothing, self-
esteem, and self-cohesion.
• Inner fears, frights, and acutely
anxious complaints of the schizo-
phrenic patient may be best
understood as the expression of
threats to the cohesive intactness of
the self—the self's stability of
homeostatic psychological
equilibrium—rather than the
resurgence of drives or the loss of
external objects. (One apparent
exception to this would be the loss
of self-objects, which again should
be understood as a loss of internal
function rather than a "classical
loss" of another.) Such anxiety sig-
nals of fragmentation or impending
fragmentation are a central part of a
schizophrenic person's inner life.
• An experience-near way of listen-
ing and talking to patients with
schizophrenia is to accept
empathically much of the
discussion—both concrete and
symbolic—as an expression of the
vicissitudes of an inner sense of
self: including the longing for
merger; the fear of distortion,
enfeeblement, destruction, and
fragmentation; and the urgent need
for the self-soothing of such frag-
mentation anxieties. The patient's
arrested needs for archaic mirror-
ing, for the exhibitionistic
expression of the self, and, at
times, primitive idealization of the
other must be sorted out slowly.
They should not be labeled or
treated merely as "delusions"; and
they must not be confronted pre-
maturely. Rather, they are best
understood as the expression of a
struggling self.
• Of paramount importance is the
fact that Kohut's work teaches that
we must—whenever possible—
accept the patient's subjective inner
317
experience as the present reality for
the patient, and focus our under-
Downloaded from http://schizophreniabulletin.oxfordjournals.org/ at Pennsylvania State University on March 2, 2014
standing, interpretation, and
involvement primarily on that level
of reality. Significantly different,
therefore, from "ego-supportive"
techniques of reality testing or more
classic analytic techniques of drive
interpretation, such an approach
enhances the patient's sense of self-
cohesion by recognizing the legit-
imacy of his or her needs, at
whatever point, for either archaic
merger with omnipotent self-objects
or for the mirrored reflection of
early grandiose needs. This
approach need not collude to dis-
tort reality, so much as to accept
the patient's inner experience of the
self and its world without any con-
frontation that might be likely to
fragment further an already inse-
cure self and force the "objective"
too prematurely upon a subjective
world still in confusion and chaos.
• Given reasonable concerns
about the use of psychoanalytic
techniques with patients experienc-
ing such chaotic fragmentation of
the self, as the schizophrenic
patient, it is important to use such
a respect for the experience-near,
empathic, and intersubjective
approach described here, in com-
bination with great activity, rather
than passivity, on the part of the
listener or therapist. Indeed, for
patients who cannot form stable
self-object transferences merely
with the provision of the presence
of an informed empathic therapist,
it behooves the listener to do more
than observe, but also to partici-
pate. I believe, from my clinical
experience, that one can use all the
therapeutic techniques gleaned
from the psychoanalysis of nar-
cissistic patients in the psycho-
therapy of more disturbed individ-
uals. However, they must be
actively brought into play during the
318
treatment session by an informed
and attuned therapist (see also Pol-
lack 1986a, 1986/;).
• Anger, aggression, and regres-
sion must be understood primarily
as secondary to self-hurt or nar-
cissistic injury. The significant self-
object or therapist, then, must take
on the task of minute reconstruc-
tion of the situation that led to the
hurt, usually including exploration
of the expressed and unexpressed
poignant narcissistic wishes, and
often requiring the recognition of
the legitimacy or validity of such
needs. This process would also
involve recognition of the legit-
imacy of the need/wish for "perfect
intuneness," while understanding
the impossible nature of its actual
achievement.
It is beyond the scope of this arti-
cle to go further into the nature of
the application of self-psychological
technique to the treatment of schizo-
phrenic patients: rather, we are
looking at how it enhances our
understanding of the subjective
experiences in psychosis. Suffice it
to say, however, that treatment
would aim toward facilitating the
process of "transmuting
internalization"—the slow accretion
of the self-object functions into the
internal structure of the psychotic
patients' selves. The probable
requirement for ongoing self-object
support would not be seen as
failure, but rather as the achieve-
ment of greater and greater choice
on the patient's part over how to
sustain an inner experience of self-
comfort, self-cohesion, self-esteem,
and joy.
Clinical Vignettes
Two additional case vignettes illus-
trate how Kohut's concepts of self-
psychology—most notably those of
experience-near metapsychology,
self-object functioning and trans-
ferences, and empathic intro-
spective approaches to inner life of
a psychotic patient—deepen the
clinician's capacity to listen to and
understand the subjective world of
schizophrenia. The first example
involves brief selective quotations
from a published letter by a suc-
cessfully treated schizophrenic
patient. The second presents the
poignant descriptions given by a
young woman in her late thirties
who had been involved in inpatient
and outpatient treatments at several
academic psychiatric settings for
many years and whose treatment,
at that time, had been under my
supervision.
Case # 1 . The patient is a suc-
cessfully treated schizophrenic
young woman who had been in
intensive psychodynamic psycho-
therapy for many years and whose
comments (in letter form) on her
psychotherapy were published in
the American Journal of Psychiatry
(Recovering Patient 1986). This
patient frames the inner turmoil
and pain of the illness itself:
Like so many schizophrenic
patients I have my own history of
hospitalizations, medication
trials—good and bad, setbacks,
milestones, turns in the road,
light appearing and disappearing
at the end of the tunnel. I have
seen lights in the sky, heard cho-
ruses of people inside me—
taunting, tormenting me, pinning
me against the wall, driving me
into insanity. The drama is end-
less, and the agony and terror are
even more so. [Recovering
Patient 1986, p. 69, author's
italics]
Yet part of the terror that schizo-
phrenic patients must experience
and that becomes a part of their
SCHIZOPHRENIA BULLETIN
subjective lives involves the nar-
cissistic insults and injuries which
Downloaded from http://schizophreniabulletin.oxfordjournals.org/ at Pennsylvania State University on March 2, 2014
they receive from those around
them:
... the confusion I felt about
myself was compounded by what
seemed irrational or conflicting
actions directed toward me. A
child destined to become schizo-
phrenic must deal not only with
the seeds of illness within him-
self, but also with the attitudes of
others toward his "idio-
syncrasies," whether these
feelings are voiced openly or sub-
tly manifested in everyday life.
Even if medication can free the
schizophrenic patient from some
of his torment, the scars of emo-
tional confusion remain, felt
perhaps more deeply by a greater
sensitivity and vulnerability.
[Recovering Patient 1986,
p. 68, author's italics]
This patient became acutely aware
of the significance of the merger
with an understanding self-object
(therapist), and noted that such a
self-object connection could lead to
a greater sense of self-cohesion:
His persistence in talking about
"us made me curious and later
made me feel, despite a twinge of
guilt, that maybe it would be nice
to talk about us." The guilt
came from the fact that tnere was
an "us." For so long it had been
"me" and "them." [Recovering
Patient 1986, p. 69]
And then, in describing the success
and the inner growth, the patient
points out the need for a frag-
mented self to be empathically
understood from within his or her
own subjective stance:
This grew from years of our
working together to develop
mutual respect and acceptance
and a form of understanding, in
which I believed that he had the
capacity to comprehend what I
said and that I had the potential to
VOL 15, NO. 2, 1989
be understood. (Recovering Patient
1986, p. 70, author's italics]
Indeed, it was the continuity of
the self-object relationship that this
patient came to feel made for per-
sonal change; and suggests it is
necessary for other patients suffer-
ing from similar inner, subjective
experiences:
A fragile ego left alone remains
fragile. It seems there must be
some balance that can be
achieved so that schizophrenic
patients can receive the benefits
of psychotherapy with therapists
who are sensitive to their special
needs and can help their egos
emerge, little by little. Medication
or superficial support alone is not
a substitute for the feeling that
one is understood by another human
being. [Author's italics] For me,
the greatest gift came the day I
realized that my therapist really
had stood by me for years and
that he would continue to stand
by me and to help me achieve
what / wanted to achieve.
[Recovering Patient 1986, p. 70]
Case #2. The patient is a young
woman in her late thirties who has
been in and out of psychiatric treat-
ments for over 10 years, first more
intensively in psychoanalytically
oriented inpatient facilities and now
in more attenuated fashion through
day hospitals, halfway houses, and
active rehabilitation services. She
wrote a letter to a younger friend
who was recently hospitalized for a
serious psychiatric disturbance. She
began by explaining how a great
deal of one's inner experience can
be confused when one has under-
gone serious psychotic disturbance:
Did it occur to you that the
things which do not accurately
represent what they claim to,
which are "misdone,"
"misfound-as-true," in me, ...
for example—contribute to my
being, as of this present? They
are all I know, whether or not
they are true; they are my
appraisal of me and of living/ that
speaks to me of what existence is.
They are life's signature, to me,
the tracings of which I keep clear
whether I like some curves of it
or not. [Author's italics]
We all do this "keeping clear."
We cherish the ability to meet
and reckon, perceive, reality-life
in us and out us . . . and you
were doing that, perceiving and
reckoning intangibles in you on a
frontier, when you had your
troubles this fall
This young schizophrenic woman
then goes on to describe, quite
poignantly, the sense of fragile self-
equilibrium or "homeostasis" which
self-psychology alerts us to in the
inner experience of a psychotic
patient:
I have a metaphor about living
I thought up, recently.
Its image is "homeostasis,"
which—to frame it here—is the
head-bodies' ability to keep its
best temperature, 98.6 °F even
when the temperature goes up or
down outside it.
Think of holding a full coffee
cup on a saucer and going across
a room, keeping it level. That's
keeping the cup's homeostasis . . .
keeping its state as it might best
be, through your motions.
Tasks or accomplishments are
like this, too: one arranges
oneself to bring out one s best,
for the task's best, leaving aside
what doesn't fill that function.
The thing is, people sometimes
organize only for a series of
homeostases outside them: for
example, accomplishments; then,
being the right person for some-
body else— . . . which may not be
where one is in one's self at the
moment.
Then there is, and this is the
harder to read, the "homeostasis"
of the inside of the person her [self]
or himself [Author's italics]
Here, our patient describes the
inner subjective dilemma of the
schizophrenic person:
319
This is the self-homeostasis which,
in general, people don't include:
how one feels inside . . . [is] the
Downloaded from http://schizophreniabulletin.oxfordjournals.org/ at Pennsylvania State University on March 2, 2014
person cold, the stomach hungry:
things, when I fill them, which
give me a location in me, a sym-
pathy with my own being, which
makes me feel at home in it,
gives me as a prime, first, place
to be. [Author s italics]
Just so, the whole person.
Ignoring some prime parts of it,
and being ignored in them by
others, got us into this pickle
The difference between us and
other people is only that, where
they can scant their own consid-
ering of their own self-site
within, and get away with it,
even though at cost, . . . we . . .
can't. If we ignore living in/of
ourselves, we don't survive.
[Author's italics]
The hard thing is that culturally
eople aren't looking for this,
? hey are looking for spring-
releases of themselves, for
instance—rnaybe encounter
groups Tire medical model is, to
see yourself in order to correct an ill-
ness or pathology. That's too narrow,
I think. The need is more, to include
yourself in order to live, all the time.
In the culture we live in this
including is an invisible value,
not represented among honored
aims as making a worthwhile per-
son [Author's italics]
If locating yourself is important
for people to do, there should be
a point at which one can't do
without it, right? True, and we're
it: we are that point at which a
person can't do without
[Author's italics]
The trouble is—the full coffee-
cup spills over if you do not meet
its homeostasis right; . . . you can
tell when you don't do it right.
The self-homeostasis doesn t
show like that when ignored. It
has no external bad effects that
we've learned to gauge or have to
gauge until something goes very
wrong. Our crises are that noti-
fication; valuable, not soon
replicated, perhaps. I'm—some of
us [here at the hospital] are learn-
ing to find the smaller indices of
where we miss ourselves
[Personal communication,
 320
author's italics; see also Pollack
1983]
Summary and Conclusions
The metapsychology of self-
psychology both broadens and
deepens the clinician's understand-
ing of the inner experience of the
schizophrenic patient. In shifting
the focus from hypothetical internal
structures to a more experience-
near concept of the primacy of the
self, a self suffering from the pain
of fragmentation—an individual
seeking self-soothing, merger, or
idealization for the revitalization of
a sense of wholeness or cohesion—
Kohut's work creates a bridge
through empathic introspection into
psychotic subjectivity. Moreover,
recognizing the legitimacy and need
for self-object functions on the part
of significant others, especially on
the part of the therapist, diminishes
potential disharmony between the
therapist's sense of reality and the
patient's inner subjective experi-
ence. The patient's inner tension
states of enfeeblement and frag-
mentation, therefore, which require
use of another person to maintain
stability and relief (indeed, which
require the experience of the other
as a merged part of the self), may
then become more acceptable to a
therapist or significant other. Con-
sequently, we as self-objects may,
in turn, better tolerate the experi-
ence of being "taken in" in this
way—fused and at times apparently
incorporated—and thereby use our
role for greater indepth understand-
ing of the subjective inner life of
the psychotic patient.
The life or death psychological
struggle for self-honieoslnsis—as one
of our own schizophrenic patients
herself put it—is a central subjective
inner experience of the psychotic
person's disorganization and frag-
mentation-prone, fear-related self.
An understanding of this experi-
ence is mirrored in the theory of
self-psychology, which recognizes
the legitimate ongoing need for an
empathic matrix of self/self-object
connections for psychological suste-
nance, growth, and security.
The sphere of empirical research
on schizophrenia has expanded our
concept of the course of the illness
(Strauss 1982), as well as its capac-
ity for long-term amelioration and
cure when studied over time (Hard-
ing et al. 1987). The significance of
nonclassical therapeutic techniques
for inner (e.g., self-esteem)
changes—such as work therapy,
social skills training, or psychiatric
rehabilitation (Anthony 1979; Liber-
man et al. 1986; Harding et al. 1987;
Strauss et al. 1988)—has been dem-
onstrated.2 Demands must now be
put upon depth psychology and
psychoanalytic concepts of psy-
choses to follow suit. We must
expand our parameters to include a
more subjective, experience-near
comprehension of our patients'
lives.
Psychoanalytic self-psychology
offers a theoretical and practical set
of tools for better approaching the
inner boundaries of schizophrenic
patients' experience, as they see it. It
offers the opportunity for bearing
together with these people their
2
I have argued elsewhere that a hid-
den psychodynamic principle behind
rehabilitation therapy's clear success rate
and central meaning in psychiatric ill-
ness is its powerful effect on self-
functions: most especially, self-esteem
maintenance and self-definition or self-
cohesion. Analytic clinicians have unfor-
tunately continued to ignore the salience
of such "vocational" interventions, but
their growing success appears to be
forcing a reappraisal, and perhaps a
new look at their depth psychological
meaning (see Pollack 1986a, 1986b).
SCHIZOPHRENIA BULLETIN
pain: through open, flexible, and
therapeutic exploration of what
they, themselves, already know,
Downloaded from http://schizophreniabulletin.oxfordjournals.org/ at Pennsylvania State University on March 2, 2014
about their own selves—but need to
have understood, verified, and
empathically shared by us to make
them feel truly comprehensible,
truly comfortable. Such an experi-
ence-near concept of the self and of
its vicissitudes offers new hope,
both for the legitimacy of accepting
the significance of our patients' true
inner life as they experience it, and
for bridging the gap between their
experiential insight into schizo-
phrenia and our outsiders' view—
listening patiently and waiting to be
taken within.
References
Adler, G. The psychotherapy of
schizophrenia: Semrad's contribu-
tions to current psychoanalytic
concepts. Schizophrenia Bulletin,
5:130-137, 1979.
Anthony, W.A. Principles of Psychi-
atric Rehabilitation. Baltimore:
University Park, 1979.
Day, M., and Semrad, E.V. Schizo-
phrenic reactions. In: Nicholi,
A.M., ed. The Harvard Guide to Mod-
ern Psychiatry. Cambridge, MA:
Harvard University Press, 1978.
pp. 191-241.
Freud, S. A case of paranoia. (1911)
In: Collected Papers. Vol. III. London:
Hogarth Press, 1948. pp. 387-470.
Freud, S. The loss of reality in neu-
rosis and psychosis. (1924) In:
Collected Papers. Vol. II. L o n d o n :
Hogarth Press, 1948. pp. 277-282.
Fromm-Reichmann, F. Notes on the
development of treatment of schizo-
phrenics by psychoanalytic therapy.
Psychiatry, 11:263-273, 1948.
Harding, CM.; Brooks, G.W.; Ash-
ikaga, T.; Strauss, J.S.; and Breier,
A. The Vermont longitudinal study
VOL 15, NO. 2, 1989
of persons with severe mental ill-
ness: II. Long-term outcome of
subjects who retrospectively met
DSM-UI criteria for schizophrenia.
American journal of Psychiatry,
144:727-735, 1987.
Harding, CM.; Strauss, J.S.; Hafez,
H.; and Liberman, P.B. Work and
mental illness: Toward an integra-
tion of rehabilitation processes.
journal of Nervous and Mental Disease,
175:317-326, 1987.
Hartmann, H. The mutual influ-
ences in the development of ego
and id. In: The Psychoanalytic Study
of the Child. Vol. 5. New York: Inter-
national Universities Press, 1952.
pp. 9-30.
Hartmann, H. Contributions to the
metapsychology of schizophrenia.
In: The Psychoanalytic Study of the
Child. Vol. 8. New York: Interna-
tional Universities Press, 1953.
pp. 177-198.
Jacobson, E. Contributions to the
metapsychology of psychotic identi-
fications, journal of the American
Psychoanalytic Association, 2:239-262,
1954.
Jacobson, E. The Self and the Object
World. New York: International Uni-
versities Press, 1964.
Kernberg, O. Object Relations Theory
and Clinical Psychoanalysis. New
York: Jason Aronson, 1976.
Kohut, H. The Analysis of the Self.
New York: International Univer-
sities Press, 1971.
Kohut, H. The Restoration of the Self.
New York: International Univer-
sities Press, 1977.
Kohut, H. Introspection, empathy
and psychoanalysis. In: Ornstein,
P.H., ed. The Sense for the Self:
Selected Writings of Heinz Kohut:
1950-1978. Vols. 1 and 2. New
York: International Universities
Press, 1978. pp. 205-232.
Kohut, H. Two letters. In: Gold-
berg, A., ed. Advances in Self-
Psychology. New York: International
Universities Press, 1980.
pp. 449-469.
Kohut, H., and Wolf, E.S. The dis-
orders of the self and their
treatment: An outline. International
journal of Psychoanalysis, 59:413-425,
1978.
Liberman, R.P.; Mueser, K.T.; and
Wallace, C.J. Social skills training
for schizophrenic individuals at risk
for relapse. American journal of Psy-
chiatry, 143:523-526, 1986.
Magid, B. Some contributions of
self psychology to the treatment of
borderline and schizophrenic
patients. Dynamic Psychotherapy,
2:101-122, 1984.
Modell, A. Some recent psychoana-
lytic theories of schizophrenia.
Psychoanalytic Revieiv, 43:181-194,
1956.
Pollack, W.S. "The Day Hospital as
a Therapeutic Holding Environ-
ment." Proceedings of the Annual
Conference on Partial Hospitaliza-
tion, #7. Boston, MA: AAPH, 1983.
Pollack, W.S. Borderline personality
disorder: Definition, diagnosis and
assessment. In: Keller, P.A., and
Ritt, L.G., eds. Innovations in Clini-
cal Practice: A Source Book. Vol. 5.
Sarasota, FL: Professional Resource
Exchange, 1986a. pp. 103-112.
Pollack, W.S. Borderline personality
disorder: Treatment considerations.
In: Keller, P.A., and Ritt, L.G., eds.
Innovations in Clinical Practice: A
Source Book. Vol. 5. Sarasota, FL:
Professional Resource Exchange,
1986b. pp. 113-135.
Recovering Patient. "Can we talk?"
The schizophrenic patient in psy-
chotherapy. American journal of
Psychiatry, 143:68-70, 1986.
321
Strauss, J.S. "The Course of Psychi-
atric Disorder: A Model for
Downloaded from http://schizophreniabulletin.oxfordjournals.org/ at Pennsylvania State University on March 2, 2014
Understanding and Treatment."
Hibbs Award Presentation, Annual
Meeting of the American Psychiatric
Association, New York, May 1982.
Strauss, J.S.; Harding, CM.; and
Silverman, M. Work as treatment
for psychiatric disorder: A puzzle in
pieces—Report of a conference. In:
Ciardello, J., and Bell, M., eds.
Vocational Rehabilitation of Persons
With Prolonged Psychiatric Disorders.
Baltimore: Johns Hopkins Univer-
sity Press, 1988.
Sullivan, H.S. The Interpersonal The-
ory of Psychiatry. New York: Norton,
1953.
Tolpin, M., and Kohut, H. The dis-
orders of the self: The psycho-
pathology of the first years of life.
In: Greenspan, S.I., and Pollack,
G., eds. The Course of Life. Rockville,
MD: National Institute of Mental
Health, 1980. pp. 425-442.
Acknowledgments
The author would like to acknowl-
edge the dedicated work of the late
Dr. Alfred Stanton in teaching him
how to listen to the inner experi-
ence of schizophrenia. Dr. Shervert
Frazier, the staff, and the patients
of McLean Hospital (and especially
the working group on Codman
House III) should be recognized for
giving the author the opportunity
to immerse himself in the lives of
psychotic patients, in depth. Dr.
Ray Greenberg first nourished the
author's interest in applying self-
psychology to understanding the
experience of psychosis. His help
and support are much appreciated.
Drs. A. Frank, J. Gunderson, M.
Padwa, and R. Waldinger are to be
thanked for their editorial assistance
and suggestions.
322
House 111, and Director, Continuing
The Author Education in Psychology, McLean
Hospital, Belmont, MA. He is also
William S. Pollack, Ph.D., is
Psychologist-in-Charge, Codman
What is schizophrenia? What
Schizophrenia: causes it? How is it treated? How
Questions and can other people help? What
is the outlook? These are the ques-
Answers tions addressed in a booklet
prepared by the Schizophrenia
Research Branch of the National
Institute of Mental Health.
Directed to readers who may
have little or no professional
training in schizophrenia-related
disciplines, the booklet provides an-
swers and explanations for many
commonly asked questions of
the complex issues about schizo-
phrenia. It also conveys something
of the sense of unreality, fears,
and loneliness that a schizophrenic
individual often experiences.
The booklet describes "The
World of the Schizophrenic Patient"
SCHIZOPHRENIA BULLETIN
Instructor in Psychology, Depart-
ment of Psychiatry, Harvard
Downloaded from http://schizophreniabulletin.oxfordjournals.org/ at Pennsylvania State University on March 2, 2014
Medical School, Boston, MA.
through the use of analogy. It
briefly describes what is known
about causes—the influence
of genetics, environment, and
biochemistry. It also discusses com-
mon treatment techniques. The
booklet closes with a discussion of
the prospects for understanding
schizophrenia in the coming decade
and the outlook for individuals
who are now victims of this severe
and often chronic mental disorder.
Single copies of Schizophrenia:
Questions and Answers (DHHS
Publication No. ADM 86-1457)
are available from the Public
Inquiries Branch, National Institute
of Mental Health, Room 15C-
05, 5600 Fishers Lane, Rockville,
MD 20857.