Intensive psychoanalytic psychotherapy of schizophrenia

1. Introduction

Version followed: the Chestnut Lodge tradition as written by Frieda Fromm-Reichmann ("Transference problems in schizophrenics" 1939; Principles of Intensive Psychotherapy 1950; "Psychotherapy of schizophrenia" 1954; Psychoanalysis and Psychotherapy: Selected Papers 1959) and Harold Searles (Collected Papers on Schizophrenia and Related Subjects 1965, especially "Phases of patient–therapist interaction in the psychotherapy of chronic schizophrenia" 1961; Countertransference and Related Subjects 1979). It is adapted here for a present-day clinician who treats psychosis alongside antipsychotic medication and multidisciplinary team care. McGlashan's Chestnut Lodge follow-up is mentioned only as historical context.

What it is. Intensive psychoanalytic psychotherapy of schizophrenia is a long-term, high-frequency, face-to-face individual therapy. It was developed at Chestnut Lodge (Rockville, Maryland) from the 1930s to the 1960s, drawing on Sullivan's interpersonal psychiatry and on classical psychoanalysis. It is not a manualised treatment. It is a body of clinical principles, case-based recommendations and (in Searles) a descriptive phase model. Where this guide turns those into explicit procedures, the procedure is tagged [synthesis]. [source: Fromm-Reichmann 1939 via Spanish translation; Fromm-Reichmann 1954 abstract; Searles 1961 via Spanish translation; AJP 1998 profile of Fromm-Reichmann]

How change happens. Fromm-Reichmann held that the patient's symptoms both express and defend against overwhelming anxiety. In her account, the ordinary human conflict between needing others, fearing their loss, withdrawing and hating them is magnified in psychosis. She also held that the person with schizophrenia can form a usable transference. Change comes from a reliable, respectful, non-intrusive relationship in which the patient risks contact again. Within that relationship, anxiety, hostility and dependency can be experienced, understood (dynamically, not only by content) and linked to the person's history. Searles added that the therapist's own feelings are the main instrument. On his account, recovery moves through a period of mutual emotional symbiosis with the therapist, which then resolves into individuation. In effect, the developmental differentiation that never happened is lived through again in reverse. [source: Fromm-Reichmann 1954 abstract; Searles 1961; Searles 1958 "The schizophrenic's vulnerability to the therapist's unconscious processes"]

Modern frame (required). Current practice combines this kind of psychotherapy with antipsychotic medication prescribed and monitored by a psychiatrist. It also includes team care: nursing, case management or care coordination, family work and psychoeducation, vocational and social rehabilitation, and crisis and risk planning. Many Chestnut Lodge patients of the 1940s–60s were treated with little or no medication. Do not reproduce that. Use this guide as the relational and psychodynamic layer of a multimodal plan, never as a substitute for medical care. [synthesis; historical point: Psychiatric News 2014]

2. Framework

Format (historical). Chestnut Lodge practice used face-to-face sessions with no couch and no requirement to free-associate. The patient could sit, lie on the floor, walk about or choose any seat. A long preparatory period of daily meetings came first. The recommended frequency was 4–6 sessions a week of an hour or more, with flexible length (Fromm-Reichmann reports sessions of several hours). She advised against rigidly scheduled hour-long sessions for the most disturbed patients. Each inpatient had an administrative psychiatrist (ward management, privileges, medication, emergencies) who was separate from the psychotherapist. Administrative intervention was mandatory for suicide attempts, violence, escape and sexual relations between patients. Treatment usually ran for years. Searles speaks of many years for chronic patients, and of several years for the late phase alone. [source: Fromm-Reichmann 1939; Delahanty review (Indepsi), citing Fromm-Reichmann and Stierlin 1977; Searles 1961] [uncertain: the exact frequencies and durations come from a secondary review and a translation, not from the English originals]

Format (today, adapted). The following is a reasonable adaptation, not a historical standard. See patients face to face, 2–4 times a week where possible (more often in inpatient or early phases), for a planned duration measured in years. Use a split model: you are the psychotherapist, and a named psychiatrist or prescriber holds medication and risk management, with agreed communication. Keep shorter or flexible contacts available when the patient cannot tolerate 45–50 minutes. [synthesis]

Phases. Searles's five phases of patient–therapist interaction (chronic schizophrenia) are set out below. Fromm-Reichmann's preparatory period overlaps with phase 1. Searles stresses that the phases overlap and fluctuate constantly, and that individual cases cannot be cleanly delineated. Use them as a map for reading the relationship (mainly through your own countertransference), not as a protocol. [source: Searles 1961; Prieto Silva 2022 abstract]

[source: Searles 1961 (Spanish translation, CeIR 2016); Fromm-Reichmann 1939; Fromm-Reichmann 1954 abstract] [uncertain: Searles's phase durations as given in the translation are roughly: phase 1, months and often the first years; phase 2, several months; phases 3 and 4, a few months to one or two years each; phase 5, several years. These are illustrative for 1950s inpatients on long stays, not targets]

Transition criteria in practice. Neither author gives operational criteria. Searles reads the phase mainly from the therapist's dominant feelings and from the patient's mode of relating. Use the "Signs of moving on" column and your countertransference, and review both in supervision. Expect regressions to earlier phases after separations, medication changes, discharges and family crises. [source: Searles 1961; Prieto Silva 2022 abstract] [synthesis for the review practice]

Termination. Fromm-Reichmann recommends discussing the illness and its treatment openly after recovery, so that the patient can connect the recovered self with the psychotic past. Searles places termination after the late phase. Principles (1950) has chapters on how to begin and end an interview and on termination of treatment. [source: Fromm-Reichmann 1954 abstract; Delahanty review; UChicago Press table of contents] [uncertain: the content of those 1950 chapters]

3. Guiding principles

• Difference of degree, not kind. The patient's experience differs from yours only in degree. Practically: look for the understandable human anxiety inside every symptom. [source: Fromm-Reichmann 1939]
• Respect and dignity. Practically: treat the patient as an adult partner. No condescension, no psychiatric jargon, no talking about the patient in their presence. [source: Fromm-Reichmann 1939; Searles 1961]
• Professional, not friendship. Practically: offer understanding and reliability, not love, friendship or substitute parenting. Affection cannot repair early deprivation, and offering it can increase dependency and the sense of rejection. [source: Delahanty review, citing Fromm-Reichmann]
• Fear of intimacy and rejection sensitivity. Practically: approach slowly, never press closeness, and expect any lapse (lateness, schedule change, misunderstanding) to land as rejection. [source: Fromm-Reichmann 1939; Delahanty review]
• Do not hurry. Practically: do not judge progress by your own clock; weeks or months of apparent nothing can be work. [source: Fromm-Reichmann 1939]
• Listening is the basic instrument. Practically: attend to words, gestures, posture, silence and your own bodily and marginal reactions as communications. [source: Fromm-Reichmann 1950, table of contents; 1939]
• Nonverbal communication matters as much as verbal. Practically: show understanding by how you act, not only by what you say. [source: Fromm-Reichmann 1954 abstract; 1939]
• Interpret dynamics, not content, and only when the patient is ready. Practically: say less, later, more concretely; let the patient find the answer. [source: Delahanty review, citing Fromm-Reichmann 1950 and 1957]
• Symptoms are expressions of and defences against anxiety. Practically: ask what anxiety this symptom manages right now, often an anxiety about you. [source: Fromm-Reichmann 1954 abstract]
• The therapist's security and anxiety are clinical variables. Practically: the patient reads your involuntary signals, so attend to your own anxiety and keep sources of satisfaction outside work. [source: Fromm-Reichmann 1939; 1950 table of contents]
• Meet hostility without fear and without counter-hostility. Practically: stay calm and present, protect safety openly, do not retaliate or flee. [source: Fromm-Reichmann 1939]
• Mistakes are inevitable and usable. Practically: acknowledge and repair misunderstandings; they often become turning points. [source: Fromm-Reichmann 1939]
• Countertransference is the main source of data. Practically: your feelings (boredom, rage, tenderness, confusion, wish to rescue) indicate the phase and the transference. [source: Searles 1958, 1961, 1977]
• A kernel of reality in every distortion. Practically: before interpreting a perception of you as distorted, find and acknowledge what is accurate in it. [source: Searles 1958]
• Emotional participation over detached neutrality, but neutrality has its place. Practically: be a real, feeling person, and know when calm neutral investigation serves the patient better (Searles's phase 1 and his 1963 paper on neutral responses). [source: Searles 1961] [uncertain: the 1963 paper]
• Avoid compulsive rescuing. Practically: notice the urge to relieve suffering at once; it often defends the therapist and blocks the patient. [source: Searles 1961]
• Symptoms are part of identity. Practically: expect anxiety about change and loss of self as improvement comes; do not treat it as ingratitude. [source: Searles 1961; title of Searles 1961 "Anxiety concerning change"]
• The patient's therapeutic striving. Practically: recognise the patient's wish to help you and others as healthy, not only as pathology. [source: Searles 1975, via Wikipedia summary]
• The institution is part of the treatment. Practically: expect staff splitting, envy and exclusion around an intense dyad, and work with the team rather than in isolation. [source: Searles 1961; Delahanty review on the administrative and therapist split]
• Supervision is essential, and resistance to it is a signal. Practically: when you want to keep the case private, take it to supervision. [source: Searles 1961; title of Searles 1955 "The informational value of the supervisor's emotional experiences"]
• Integrated medical care (modern). Practically: medication, physical health monitoring and risk management run in parallel, with a named prescriber and regular liaison. [synthesis]
• No blame of families (modern). Practically: explore family experience as the patient lived it, but do not adopt historical causal theories that blamed parents, the "schizophrenogenic mother" in particular. Work with families as allies. [synthesis; historical context: Fromm-Reichmann 1948]

4. Intervention inventory

The inventory below comes from what the founders actually describe. Interventions A1–A20 come from Fromm-Reichmann, B1–B17 from Searles, and C1–C3 are present-day integration tasks ([synthesis]). Unless a line is marked otherwise, every Example language line is illustrative wording written for this guide (marked "(illustrative)"), not the founders' words. The founders give no fixed steps for any of these interventions; the steps are an operationalisation and are [synthesis] unless a source is given. Section D covers historical practices that should not be reproduced.

A1. Preparatory period of daily contact (Fromm-Reichmann)

• Purpose / when: Build the minimum trust needed for any work with a withdrawn, suspicious or newly admitted patient. It is the opening move, comparable to the first stage of child analysis. [source: Fromm-Reichmann 1939]
• Steps: (1) Agree a predictable schedule, daily if possible (inpatient) or as frequent as feasible. (2) Arrive on time, every time, and announce any change in advance and in person. (3) Make no demands: the patient need not talk, lie down or free-associate, and may move or choose a seat. (4) Say briefly why you are there and that you will keep coming. (5) Expect weeks to months of testing (absence, insults, refusal, silence) and keep showing up. (6) Note everything the patient does in your presence as communication.
• Example language: "I'll be here at ten each morning. You don't have to talk; I'd like to get to know how things are for you, at whatever pace suits you." (illustrative)
• Watch for / working: Working: the patient waits for you, comments on your lateness, chooses a place to sit, starts complaining, asks a question. Watch for: your own discouragement and wish to shorten the period. Fromm-Reichmann warns that patients cannot be hurried and that progress must not be judged by the therapist's standards.

A2. Silent companionship (sitting with the patient)

• Purpose / when: For mute, stuporous, catatonic or deeply withdrawn states. The aim is to offer non-intrusive presence. Fromm-Reichmann describes a patient for whom simply being allowed to breathe and exist in company was the relief. [source: Fromm-Reichmann 1939, which reports sitting beside a mute patient for an hour every day for weeks]
• Steps: (1) Sit at a comfortable distance and angle that the patient can tolerate; let the patient adjust it. (2) Stay for the agreed time, attentive and unhurried (Searles allows the therapist to read or think quietly in out-of-contact phases [source: Searles 1961]). (3) Make occasional low-demand remarks about the shared here-and-now, with no questions. (4) End on time with a statement of when you will return.
• Example language: "I'll sit with you for a while. I'm not expecting anything." … "Our time is up for today; I'll be back tomorrow at the same time." (illustrative)
• Watch for / working: Working: slight orientation toward you, eye contact, a gesture, a word, later recall of your visits. Watch for: catatonic states with medical risk (not eating or drinking, autonomic instability). These need urgent medical review and are not a matter for psychotherapy alone [synthesis].

A3. Judging when to break the silence

• Purpose / when: Silence can be companionable, hostile, resistant, or a breakdown of communication that has become a source of anguish. Break it when it turns into torment. [source: Fromm-Reichmann 1939; Delahanty review]
• Steps: (1) Track your own tension and the patient's signs (fidgeting, distress, rising agitation, hallucinatory preoccupation). (2) Ask yourself which kind of silence this is. (3) If it is anguished, offer a short observation about the shared moment rather than a question. (4) If it is companionable, leave it.
• Example language: "It seems to be getting harder to sit here quietly today." (illustrative)
• Watch for / working: Working: tension falls, or the patient speaks. Not working: you break silence to relieve your own discomfort. Check this in supervision.

A4. Listening as the basic instrument

• Purpose / when: Always. Fromm-Reichmann treats listening as the core psychotherapeutic instrument. It includes the therapist's associations, marginal thoughts and physical sensations as data. [source: Fromm-Reichmann 1950, table of contents; 1954 abstract on nonverbal communication]
• Steps: (1) Attend to content, form, gesture, posture, timing and silences. (2) Note your marginal thoughts, images and bodily sensations during the session and write them down afterwards. (3) Let the patient know, mostly by demeanour, that you are trying to understand everything they produce. (4) Ask what anxiety the material might be managing, especially anxiety about you.
• Example language: "I'm following, even where I can't yet make sense of it." (illustrative)
• Watch for / working: Working: the patient elaborates, corrects you, tests whether you remember. Watch for: listening for content to argue with rather than for meaning.

A5. Restraint with questions and interpretations when you don't understand

• Purpose / when: Fromm-Reichmann advised against asking questions just because you don't understand, since you may break into a thought sequence or hallucination. She also advised against interpreting merely to show that you understand, because the patient often grasps the unconscious meaning better than the therapist. [source: Fromm-Reichmann 1939]
• Steps: (1) When lost, hold the not-knowing. (2) If you must say something, say that you are trying to follow, not what it "means". (3) Save questions for moments when the patient seems to invite them. (4) Note your confusion as data (see B13).
• Example language: "I don't fully understand yet, and I'd rather not pretend I do." (illustrative)
• Watch for / working: Working: the patient explains further or seems relieved not to be decoded. Not working: the patient treats silence as indifference. In that case, say more about your effort to follow.

A6. Following the patient's pace and waiting for patient-initiated proposals

• Purpose / when: Respect autonomy and avoid repeating intrusive control. Fromm-Reichmann generally waited for the patient to ask for suggestions and in one case acted on a catatonic patient's own conditions for contact. She also suggests tolerating some unusual behaviour until the patient is ready to discuss it. Her example is accepting a patient's refusal to bathe. [source: Fromm-Reichmann 1939]
• Steps: (1) Distinguish behaviours that are only unusual from those that threaten health or safety, which need team and medical response [synthesis]. (2) For the former, hold off on correction. (3) When the patient proposes how contact should go, take it seriously and agree where safe. (4) Return to the behaviour when the patient shows readiness.
• Example language: "You've said you'd talk if we walk outside instead of sitting here. Let's try that." (illustrative)
• Watch for / working: Working: increasing initiative from the patient. Watch for: self-neglect or physical risk being left unaddressed for the sake of "pace". Coordinate with nursing and the prescriber.

A7. Communicating understanding through action (nonverbal)

• Purpose / when: When words are too threatening or unusable, a small, fitting action can show that you have understood a wish for closeness or distance. [source: Fromm-Reichmann 1939; 1954 abstract]
• Steps: (1) Read the nonverbal bid (moving closer or away, offering or refusing something). (2) Respond in kind, minimally and within professional boundaries. (3) Do not comment on it unless the patient does. Fromm-Reichmann's own example, lighting her cigarette from the patient's, belongs to its era. Today's equivalents are modest acts within boundaries: adjusting distance, walking alongside, accepting a drawing [synthesis].
• Example language: Often none. If needed: "I'll sit here, a bit closer, if that's all right." (illustrative)
• Watch for / working: Working: the patient relaxes or makes a further small bid. Watch for: actions that become physical intimacy, gifts or special favours (see D).

A8. Meeting hostility without fear and without counter-hostility

• Purpose / when: For threats, insults, aggressive gestures. Fromm-Reichmann describes facing the patient's hostility without fear and without hostility in return as the ideal. A recovered patient told her that the therapist's fear would have confirmed the patient's belief in their own dangerousness. She also advised against silently accepting violence. [source: Fromm-Reichmann 1939; Delahanty review]
• Steps: (1) Ensure safety first: positioning, an exit, staff nearby, and the team's violence-prevention procedures [synthesis]. (2) Speak calmly and stay put if it is safe. (3) Say plainly that you want to work with the patient and will protect yourself, and stop the session, if attacked. (4) Afterwards, play the incident down rather than holding a grudge. Fromm-Reichmann regained a patient's trust by showing she attached little importance to an incident of milk being thrown at her. (5) Later, explore what the hostility was about, especially in relation to you.
• Example language: "I'm not going anywhere, and I'm not angry with you. I also won't let either of us get hurt. If you come at me, I'll leave and we'll meet again tomorrow." (illustrative)
• Watch for / working: Working: hostility becomes verbal and then discussable. Watch for: your own fear, which the patient will detect, and retaliation disguised as "limits".

A9. Protecting against disappointment: schedule changes and lapses

• Purpose / when: Each disappointment can repeat earlier frustrations and trigger rage, anxiety or regression. Fromm-Reichmann describes a stupor after an appointment change that lifted once she explained the change in person. [source: Fromm-Reichmann 1939]
• Steps: (1) Give advance notice of absences and changes, in person where possible, with the reason at a level the patient can use. (2) Name who covers. (3) After any lapse, ask about the effect and accept responsibility for your part.
• Example language: "I wanted to tell you myself: I'll be away next Thursday and Friday. Dr X will be on the ward. I'll be back Monday at the usual time." (illustrative)
• Watch for / working: Watch for: delayed reactions such as withdrawal, symptom flare or missed sessions after a change. Link them gently to the change.

A10. Acknowledging and repairing errors

• Purpose / when: Misunderstandings are inevitable. A therapist who cannot accept misreading the patient loses security. Fromm-Reichmann reports a patient who refused to see her for months after she failed to meet a request. When he returned, he described her errors, and both learned from them. [source: Fromm-Reichmann 1939]
• Steps: (1) When the patient signals hurt or withdrawal, consider your contribution first. (2) Name the specific error without excessive apology. (3) Invite the patient's account. (4) Keep the door open through any period of refusal (notes, brief visits, messages through staff).
• Example language: "I think I got that wrong yesterday. I didn't take seriously what you asked for. Tell me how it was for you." (illustrative)
• Watch for / working: Working: the patient returns or elaborates the grievance. Watch for: defensive explanation.

A11. Interpreting dynamics rather than content, briefly and when ready

• Purpose / when: Interpretation becomes central once contact exists. Fromm-Reichmann favoured interpreting dynamics and genetic links over symbolic content, at the moment the patient can receive it. She wanted interpretations concise, concrete, meaningful and unambiguous, offered one at a time, and often delayed so the patient can find the answer. [source: Delahanty review, citing Fromm-Reichmann 1950 and 1957; 1950 table of contents: "Contents or dynamics", "Timing of interpretations"]
• Steps: (1) Wait until the patient shows curiosity or has come close to the link. (2) Formulate one link: here-and-now anxiety, then the defence or symptom, ideally connected to the relationship with you. (3) Say it in one or two concrete sentences. (4) Stop and observe. (5) Return to it repeatedly over time (working through).
• Example language: "When I told you I'd be away, the voices got louder. Maybe being left feels dangerous." (illustrative)
• Watch for / working: Working: the patient adds material, corrects you, or anxiety visibly drops. Not working: confusion, a surge of symptoms or compliance without engagement. If so, the interpretation was too early, too long or too abstract.

A12. Interpreting security operations, resistance and parataxic distortions

• Purpose / when: Address the protective manoeuvres (Sullivan's "security operations") and transference or parataxic distortions before deeper content. [source: Fromm-Reichmann 1950, table of contents headings] [uncertain: chapter text; steps are synthesis from the headings and her 1954 emphasis on anxiety]
• Steps: (1) Identify the moment anxiety rises in session. (2) Notice what the patient does next (changes topic, becomes vague or grandiose, withdraws). (3) Describe the sequence without judgement. (4) Wonder aloud what was frightening. (5) Where the patient sees you as an earlier figure, describe the shift before linking it to history.
• Example language: "Just as we got near your brother, you started talking about the radio signals. I wonder if that was getting too uncomfortable." (illustrative)
• Watch for / working: Working: the patient begins to notice their own shifts. Watch for: sounding accusatory, which increases paranoid anxiety.

A13. Working with delusions and hallucinations

• Purpose / when: Neither collude with nor argue against psychotic content. Attend to its emotional and interpersonal function. Fromm-Reichmann notes that delusions and hallucinations that do not trouble the patient much can sometimes be left alone. She also questions whether multiple-meaning communications must be translated into descriptive terms at all. Searles treats delusions as attempts at restitution with a core of reality, and responds to the despair, fear or loneliness they carry. [source: Delahanty review; Fromm-Reichmann 1954 abstract; Searles 1961; 1950 table of contents "Hallucinations and delusions"]
• Steps: (1) Listen for the feeling and the relational theme (persecution means danger from others; grandiosity means fragile worth). (2) Acknowledge the experience as real to the patient. (3) Respond to the feeling. (4) Look for the kernel of reality, including anything about you (B4). (5) Interpret function only once there is a working relationship. (6) Inform the team and prescriber about content that indicates risk (command hallucinations, persecutory beliefs about specific people) [synthesis].
• Example language: "Whether or not it's the neighbours, it sounds like you feel watched and judged all day. That's exhausting and frightening." (illustrative)
• Watch for / working: Working: the patient talks about feelings and relationships alongside the delusion, and conviction or preoccupation softens over time. Watch for: pseudo-agreement, and arguing.

A14. Not naming positive feelings too early

• Purpose / when: Pointing out the patient's emerging attachment before the patient is willing to discuss it can freeze it. [source: Fromm-Reichmann 1939]
• Steps: (1) Notice signs of attachment (waiting, small gifts, distress at endings). (2) Receive them without comment. (3) Discuss them only when the patient raises them.
• Example language: If the patient raises it: "You've noticed you look forward to our meetings. What's that like for you?" (illustrative)
• Watch for / working: Watch for: retreat after you comment on closeness. Repair (A10).

A15. The initial interview

• Purpose / when: At first meeting. Allow ample time, gather the history and precipitating circumstances, and understand what preceded the psychosis. With consent, interview a significant other, sometimes jointly. [source: Delahanty review; Fromm-Reichmann 1950, table of contents]
• Steps: (1) Book extra time. (2) Explain who you are and how you work in plain language. (3) Let the patient tell it their way. Collect the history of onset, life events before it, relationships and prior treatment. (4) Agree the frame (frequency, place, role split with the prescriber, confidentiality limits) [synthesis]. (5) With consent, meet a relative or significant other. (6) Complete or obtain the standard psychiatric and risk assessment [synthesis].
• Example language: "I'd like to understand what life was like before things got so hard, in whatever order makes sense to you." (illustrative)
• Watch for / working: Watch for: overloading a suspicious patient with questions. Spread history-taking across several meetings if needed.

A16. Using the therapist's associations, marginal thoughts and bodily sensations

• Purpose / when: As data about the patient's unspoken states. [source: Fromm-Reichmann 1950, table of contents] [uncertain: chapter]
• Steps: (1) Notice stray thoughts, images, sensations. (2) Ask what in the session evoked them. (3) Use them to shape a tentative hypothesis; disclose rarely (see B6).
• Example language: Usually none to the patient. In notes: "Felt suddenly exhausted when she described her mother's visit." (illustrative)
• Watch for / working: Distinguish your own life's intrusions from patient-evoked states; bring both to supervision.

A17. Contacts with relatives

• Purpose / when: The 1950 book has a chapter on contacts with relatives. [source: Fromm-Reichmann 1950, table of contents] [uncertain] Modern practice adds family psychoeducation and support, usually delivered by the team [synthesis].
• Steps (synthesis): (1) Agree with the patient what may be shared. (2) Meet relatives with the patient's knowledge, ideally with the patient present. (3) Listen to the family's burden. (4) Refer to family intervention services. (5) Keep therapeutic content confidential except for risk.
• Example language: "Your son has agreed I can explain how our work runs and hear your worries. I won't share what he tells me in sessions." (illustrative)
• Watch for / working: Watch for: the patient feeling betrayed, and you being drawn into family alliances.

A18. Responding to intercurrent life events (including suicide attempts and requests for advice)

• Purpose / when: When major events occur in the patient's or therapist's life: suicide attempts, bereavement, pregnancy, marriage or divorce, illness, requests for advice. [source: Fromm-Reichmann 1950, table of contents] [uncertain: her specific guidance]
• Steps (synthesis): (1) For suicidal behaviour, carry out or arrange standard risk assessment immediately and involve the team. Psychotherapeutic exploration follows safety, not the reverse. (2) For other events, give them priority in the session and explore their meaning. (3) For requests for advice, consider what the request means and whether the patient can reach the answer. Give practical information where withholding it would be unhelpful.
• Watch for / working: Watch for: using "neutrality" to avoid necessary action.

A19. Beginning and ending sessions

• Purpose / when: Openings and closings carry separation anxiety. [source: Fromm-Reichmann 1950, table of contents "How to begin and how to terminate a psychotherapeutic interview"] [uncertain]
• Steps (synthesis): Begin by letting the patient lead. Give a brief warning before the end. End on time and restate the next meeting.
• Example language: "We have about five minutes left. I'll see you tomorrow at ten." (illustrative)

A20. Post-recovery review of the illness

• Purpose / when: As psychosis remits and in the late phase. Discuss the illness and its treatment openly so the patient can connect the recovered self with the psychotic past and make it part of their life story. At termination, establish continuity between morbid and healthy processes. [source: Fromm-Reichmann 1954 abstract; Delahanty review citing Weigert 1958]
• Steps: (1) Invite the patient to recall the psychotic period. (2) Explore what it meant and what it protected against. (3) Link it to current vulnerabilities and early warning signs. This links directly to relapse-prevention planning with the team [synthesis]. (4) Revisit it at termination.
• Example language: "Looking back at last spring, when you were sure the staff were poisoning you, what do you make of that time now?" (illustrative)
• Watch for / working: Working: a coherent narrative and recognition of early signs. Watch for: shame or sealing over. Go slowly and respect a wish not to revisit.

B1. Calm, neutral investigative stance, and resisting the urge to rescue (Searles, out-of-contact phase)

• Purpose / when: Phase 1, and whenever the patient is unreachable. Searles recommends a serene, neutral, inquiring attitude. He regards the urgent wish to relieve the patient's suffering as often defensive on the therapist's part and as an obstacle. He allows the therapist to sit through long silences, think, read, or even let irritation show, and he does not believe this harms the patient. [source: Searles 1961]
• Steps: (1) Commit to the time, not to producing change. (2) When you feel a pressing need to reassure, fix or explain, note it as information. (3) Stay curious about what the patient is doing and why. (4) Make sparse, low-key observations. (5) Do not set yourself up as the loving antidote to the patient's parents.
• Example language: "You've been watching the door a lot today. I'm curious about that." (illustrative)
• Watch for / working: Working: the first reproach, scorn or anger aimed at you for not helping. Searles reads this as the dawn after the long night. Watch for: cold withdrawal passing as neutrality.

B2. Offering hypotheses rather than firm interpretations, and interpreting in the here-and-now of action

• Purpose / when: Phases 1–2, especially with paranoid patients. Searles preferred tentative hypotheses and interpretations tied to immediate shared experience over explanatory statements. [source: Searles 1961, Spanish translation] [uncertain: wording reconstructed from a translation]
• Steps: (1) Anchor what you say in something that has just happened between you. (2) Phrase it as a possibility. (3) Leave room for the patient to reject it. (4) Do not press for agreement.
• Example language: "I could be wrong, but when I closed the window you went quiet. Maybe it felt like I was shutting you in." (illustrative)
• Watch for / working: Working: the patient argues, amends or plays with the idea. Watch for: a paranoid patient treating certainty as an attack.

B3. Acknowledging feelings rather than pushing the patient to own them

• Purpose / when: Throughout. Searles avoided pressing the patient to recognise a feeling. He acknowledged it instead and did not confront denial head-on. [source: Searles 1961, Spanish translation] [uncertain]
• Steps: (1) Name the feeling as present in the room, without insisting the patient "admit" it. (2) Accept denial without arguing. (3) Return to it later.
• Example language: "There seems to be a lot of anger in here today." (illustrative)
• Watch for / working: Working: the feeling becomes speakable over time.

B4. Acknowledging the kernel of reality in the patient's perceptions of you

• Purpose / when: When the patient perceives (often distortedly) something real in you: hostility, boredom, sexual feeling, fear. Searles held that people with schizophrenia are acutely sensitive to the therapist's unconscious processes. In his view, a psychotic ego cannot bear perceptions that no one confirms, and without confirmation the patient may resort to hallucination. He advised finding "a kernel of reality" in distorted responses. In one case, hallucinations lessened after he firmly said that the patient's enraged outbursts were really directed at him. [source: Searles 1958, "The schizophrenic's vulnerability to the therapist's unconscious processes"]
• Steps: (1) When accused, first ask yourself honestly what is true. (2) Confirm the accurate part briefly and without self-flagellation. (3) Distinguish it from the elaborated or delusional part. (4) Where the patient displaces feelings meant for you onto voices or others, consider saying they may be aimed at you. (5) Use supervision to check what you are bringing.
• Example language: "You're right that I was irritated a moment ago. I wasn't planning to harm you. The irritation was real, though." (illustrative)
• Watch for / working: Working: less need for delusional explanation, and more direct complaint toward you. Watch for: flat denial, which Searles warns can be unhelpful (his example is a reflexive denial in response to a delusional accusation), and confessional over-disclosure.

B5. Monitoring countertransference as the phase indicator

• Purpose / when: Every session. Searles reads the phase and the transference mainly from the therapist's dominant feelings. Shifts and deviations from your usual style are valuable clues. [source: Searles 1961; Searles 1977, "The analyst's participant observation as influenced by the patient's transference"; Prieto Silva 2022 abstract]
• Steps: (1) After each session, note your dominant feelings, fantasies and unusual behaviour (warmer, colder, more talkative than usual). (2) Compare them with the "What you typically feel" column in section 2. (3) Ask which role the patient's transference is casting you in (absent, bad mother, good mother, teacher). (4) Bring recurring patterns to supervision.
• Example language: Mostly not spoken. In notes: "Third week of murderous irritation after she mocks me, so ambivalent symbiosis is likely; check staff splitting." (illustrative)
• Watch for / working: Watch for: feelings you avoid recording (shame, desire, hatred). These are usually the most informative.

B6. Selective expression of the therapist's own feelings

• Purpose / when: Mainly in ambivalent symbiosis and later. Searles argued that the therapist must eventually and gradually express some of his anger, reproach and other real feelings, though far less often than he feels them. He did this so that the patient meets a separate, real, surviving person. He also suggests that later in treatment such data can be shared with the patient. [source: Searles 1961; Searles 1977; Searles 1958, which gives the example of telling a patient firmly not to do something in his office]
• Steps (modern limits are [synthesis]): (1) Express feelings only after reflecting on them, not in the heat of the moment. (2) Disclose in brief, owned "I" statements tied to specific behaviour, never as verdicts on the person. (3) Never disclose sexual or romantic feelings to the patient (see D). (4) Never use disclosure to punish, shame or relieve yourself. (5) Check the patient's response and repair if needed. (6) Discuss in supervision first when you are unsure.
• Example language: "When you spit at me, I get angry, and I don't want that here. I'm still coming back tomorrow." (illustrative)
• Watch for / working: Working: the patient experiences you as a separate, durable person and starts differentiating your feelings from theirs. Watch for: escalation, a paranoid reading of the disclosure, or a pattern of venting.

B7. Surviving hostility in ambivalent symbiosis without retaliating or withdrawing

• Purpose / when: Phase 2. The patient may direct intense hatred at you, fear you as dangerous, and seem to want to drive you mad. Searles describes a life-or-death struggle in which the therapist must endure the attack without retreating into defensive neutrality. Mutual survival builds the trust that leads into the next phase. [source: Searles 1961]
• Steps: (1) Keep the frame utterly reliable: same times, same place, no punitive cancellations. (2) Let the hatred be spoken. (3) Maintain safety (A8). (4) Notice and tolerate your own hate. Do not act on it, and do not deny it to yourself. (5) Get more supervision during this phase. (6) Brief the team on the likely splitting.
• Example language: "You can hate me in here. I'll still be here on Monday." (illustrative)
• Watch for / working: Working: hatred alternates with moments of warmth and the patient checks that you survived. Watch for: your own wish to transfer the patient, to cancel, or to have them discharged.

B8. Recognising and withstanding "the effort to drive the other person crazy"

• Purpose / when: Searles (1959) described ways one person can undermine another's trust in their own perceptions and emotional reactions. He saw this as part of the family experience of some people who later develop schizophrenia. He also saw it re-enacted in therapy, where the therapist can feel himself going crazy. [source: Liberman 2016 review of Searles 1959; Wikipedia summary] [uncertain: the 1959 paper lists six modes. As recalled, they include calling attention to aspects of the other's personality at odds with their self-image, simultaneous stimulation and frustration, relating on unrelated levels at once, and switching emotional wavelength or topic abruptly. Verify against the original] This is a recognition tool, not something the therapist does.
• Steps: (1) When you feel confused, doubting your perceptions or pulled between contradictory messages, name the experience to yourself. (2) Re-anchor in what you actually observed. (3) Avoid retaliating with your own contradictory messages. (4) Where useful, describe the contradiction plainly and without blame. (5) Avoid answering only one side of the patient's ambivalence, which Searles warns can itself make the patient feel driven crazy.
• Example language: "You're telling me to leave and you're also holding the door shut. I think both are true for you." (illustrative)
• Watch for / working: Working: you stay clear-headed and the patient experiences a person who keeps their own perceptions. This is a model for the patient's own reality-trust.

B9. Allowing therapeutic (pre-ambivalent) symbiosis

• Purpose / when: Phase 3. Searles regarded a period of mutual, largely pleasurable emotional symbiosis as central. It has play, humour, looser boundaries and maternal-type devotion on the therapist's side, and the patient may experience something like a happy early relationship with a good mother. He described accepting his own dependent and nurturing feelings, including bodily-felt fantasies, as necessary for real giving. [source: Searles 1961; theipi.org summary; Prieto Silva 2022 abstract]
• Steps: (1) When the relationship eases, do not rush to interpret it. Allow playful exchange, shared humour and shared imagery. (2) Keep all of it verbal and symbolic and within the frame: no physical intimacy, no extra-therapeutic contact, no gifts beyond the trivial [synthesis]. (3) Notice your own fantasies and dependency, and process them in supervision, not with the patient. (4) Protect the work from institutional envy by keeping the team informed of the rationale.
• Example language: "We seem to be enjoying ourselves today." (illustrative)
• Watch for / working: Working: the patient's hostility becomes less frightening to both of you. Watch for: collusive fusion that excludes the team, and boundary drift (see D).

B10. Receiving the patient's care and therapeutic striving

• Purpose / when: Phases 3–5. Searles (1975) held that the patient has an innate therapeutic striving toward the therapist. Psychological illness, in his account, partly involves frustration of that striving, so the therapist must genuinely experience the patient as helping. In the phases paper he accepts the patient's help and gratitude without shame. [source: Wikipedia summary of Searles 1975; Searles 1961]
• Steps: (1) Notice when the patient tries to help you (comforting, advising, noticing your tiredness). (2) Do not reflexively deflect or interpret it as only defensive. (3) Acknowledge it simply and truthfully. (4) Keep it within therapy, and never ask for actual help or favours [synthesis].
• Example language: "You noticed I was tired, and you were kind about it. That helped." (illustrative)
• Watch for / working: Working: rising self-esteem and initiative. Watch for: the patient becoming a caretaker of you at their own expense.

B11. Distinguishing real pre-ambivalent symbiosis from defensive pseudo-closeness

• Purpose / when: Transition from phase 2 to phase 3. Searles notes that idyllic closeness can be a defence (including a paranoid one) against hatred, and that there is no litmus test. [source: Searles 1961]
• Steps [synthesis]: (1) Ask whether hostility is still available (it can be spoken and survived) or has vanished abruptly. (2) Ask whether both of you can tolerate small disappointments. (3) Ask whether the team sees the same change. (4) Hold the question open rather than deciding early.
• Watch for / working: Abrupt idealisation followed by explosive rupture means the closeness was defensive. Return to B7.

B12. Fostering individuation (resolution of symbiosis)

• Purpose / when: Phase 4. As the patient begins to separate, the therapist returns responsibility for symptoms to the patient. Searles lets the patient "stew in his own juices" rather than having the therapist feel things for them. He also expresses his own views as a separate person, accepts being one helper among many (nurses, family, fellow patients), and takes a request for a different therapist as a possible sign of individuation. [source: Searles 1961]
• Steps: (1) Notice your own detachment, sense of loss, or sudden outrage at long-standing regressive demands as signals. (2) Reflect choices and responsibility back to the patient. (3) State your own opinions as yours. (4) Support relationships and resources outside therapy. (5) Treat a wish to change therapist or reduce frequency as material, and support it if it is a move toward autonomy. (6) Keep risk management unchanged. Returning responsibility never means withdrawing safety planning; Searles's statement that he no longer minded whether the patient stayed ill is a historical stance that must not override risk assessment [synthesis].
• Example language: "I think you know more about what you want here than I do now. What do you make of it?" (illustrative)
• Watch for / working: Working: the patient takes initiative and tolerates your separateness. Watch for: guilt-driven re-merging, and family or staff pulling the patient back into dependency.

B13. Using perplexity, confusion and suspicion as data

• Purpose / when: When the patient or you are confused. Searles wrote on the psychodynamic function of these states, and in the phases paper describes confusion becoming constructive and even pleasurable once hatred is less threatening. [source: Searles 1961; Searles 1952 (title in Routledge table of contents)] [uncertain: the 1952 paper]
• Steps [synthesis]: (1) When confused, ask what the confusion might be doing (blurring a painful perception, merging, warding off conflict). (2) Note whether it is persecutory or playful. (3) Wonder about it aloud, lightly.
• Example language: "I've lost track of who's angry at whom. Maybe that's part of it." (illustrative)

B14. Late phase: staying the psychotherapist and working through identifications

• Purpose / when: Phase 5. More classical analytic work becomes possible. The patient selectively rejects harmful identifications and keeps useful ones, and recovers positive memories of parents. They may behave for months like a naive child or adolescent who needs teaching. Searles warns the therapist against being drawn into teacher or advisor roles at the cost of the psychotherapeutic function, though he accepts this can happen occasionally. [source: Searles 1961; Searles 1958 "Positive feelings in the relationship between the schizophrenic and his mother" (title only)]
• Steps: (1) Notice pulls to instruct or advise. (2) Explore what the patient wants from you before giving guidance. (3) Help the patient articulate which parental traits they want to keep or discard. (4) Welcome good memories of family. (5) Practical life-skills teaching belongs with rehabilitation colleagues [synthesis].
• Example language: "You'd like me to tell you how to handle your landlord. Before I do, what would your mother have said, and do you agree with her?" (illustrative)
• Watch for / working: Working: autonomous decisions and a more balanced view of family.

B15. Neutral therapist responses

• Purpose / when: Searles wrote a 1963 paper on the place of neutral responses in psychotherapy with schizophrenic patients. [source: Searles 1963, PEP citation only] [uncertain: From the phases paper, neutrality fits phase 1 especially, alongside emotional participation later]
• Steps [synthesis]: Use calm, noncommittal responses when emotional reactions would overwhelm, flood or confuse the patient, or when you cannot yet tell what you feel.

B16. Attending to concrete versus metaphorical thinking

• Purpose / when: Searles (1962) wrote on how the recovering patient comes to distinguish concrete from metaphorical thinking. [source: Routledge table of contents] [uncertain]
• Steps [synthesis]: (1) Notice literal readings of figures of speech, your own included. (2) Use plain language. (3) As recovery proceeds, explore the metaphorical meaning together and note the patient's growing capacity to play with it.
• Example language: If the patient says "my heart is broken" and means it literally: "It feels physically broken. Something has hurt you very badly." (illustrative)

B17. Supervision, consultation and work with staff

• Purpose / when: Throughout, and especially in phases 2–3. Searles describes therapists resisting supervision and treating the relationship as private territory, and the intense dyad dividing staff, provoking envy and exclusion, and becoming a channel for wider ambivalence. He also described the supervisor's emotional reactions as informative about the therapy. [source: Searles 1961; Searles 1955 and 1962 supervision papers (titles); Delahanty review on Lodge therapist groups and weekly staff meetings]
• Steps: (1) Keep regular supervision, increasing it in intense phases. (2) Bring the material you least want to show. (3) Meet the team regularly, explain the phase and rationale, and listen to staff observations, which are data about the patient's split relationships. (4) Track your feelings toward colleagues about "your" patient.
• Watch for / working: Watch for: secrecy, rivalry with the prescriber or nursing staff, or the team being cast as "bad" while you are "good".

C1. Coordination with the prescriber and team (modern integration) [synthesis]

• Purpose / when: From the start. It updates the Lodge's split between administrative psychiatrist and psychotherapist.
• Steps: (1) Name the prescriber and care coordinator, and agree roles in writing. (2) Agree what you share (risk, adherence, major changes) and how the patient will be told. (3) Explore the meaning of medication in therapy (being controlled, being poisoned, being cared for), but leave decisions to the prescriber. (4) Hold joint reviews at phase transitions and after crises.
• Example language: "Dr Y decides about medication. What we can do here is understand what taking it, or not, means to you." (illustrative)

C2. Family involvement (modern integration) [synthesis]

• Purpose / when: Alongside A17. Searles wrote on the contribution of family treatment (1964) [uncertain]. Current care offers families psychoeducation and support.
• Steps: Refer to family intervention; keep a non-blaming stance; protect therapy confidentiality; invite the patient's view of family meetings into sessions.

C3. Risk assessment and relapse planning (modern integration) [synthesis]

• Purpose / when: At intake, at every phase transition, and after separations, losses or medication changes.
• Steps: Use the service's standard structured risk assessment for suicide, violence, self-neglect and vulnerability. Keep a shared crisis plan. Link early-warning signs identified in A20 to the relapse-prevention plan. Act on risk regardless of the therapeutic phase.

D. Historical practices not to reproduce (described for context only)

• Treatment with little or no antipsychotic medication. In earlier Chestnut Lodge years, medication was often avoided because staff thought it dulled the feelings needed for therapy. McGlashan's follow-up of Lodge patients found that a majority of those with schizophrenia were functioning marginally or worse at long-term follow-up, and he concluded that treatment as then constituted had not changed the course toward lifelong disability. The Lodge later moved toward rehabilitation. Current limit: psychotherapy accompanies, and never replaces, antipsychotic treatment and team care. [source: Psychiatric News 2014] Harm account: treatment with little or no medication What was actually done. Chestnut Lodge was a 70–80-bed private psychoanalytic hospital in Rockville, Maryland. Each patient was assigned an individual analyst for intensive psychoanalytic psychotherapy, in which the therapist analysed "unconscious motives and transferences" and treated silence or evasion as resistance. Medication was routinely not given. McGlashan recalled that "drugs were viewed as the enemy because they dulled the mind", and staff believed many arrivals had been overmedicated. [source: Psychiatric News 2014] The best-documented individual case is Rafael Osheroff, a 42-year-old nephrologist with a severe depression. He was admitted on 2 January 1979 and diagnosed with narcissistic personality disorder, a diagnosis the experts later disputed. He received individual psychotherapy four times a week, and no medication was started. When his family complained, a case conference decided against major changes and kept the psychotherapy-only plan. He stayed about seven months. [source: Klerman 1990] A later account adds that his analyst pressed him to regress and give up a presumed narcissistic personality. It also says he was held on locked wards among long-stay patients with schizophrenia, that his self-esteem was intentionally attacked there, and that he lost contact with his sons. [source: Psychiatric Times, Osheroff obituary] [uncertain: that account gives 1977 as the admission year; Klerman gives 1979] How it caused harm. While at the Lodge, Osheroff lost 40 pounds, had severe insomnia and marked agitation, and paced so much that his feet swelled and blistered and needed medical attention. His family moved him to Silver Hill in Connecticut. There he was diagnosed with psychotic depressive reaction and treated with a phenothiazine and a tricyclic antidepressant. He improved within three weeks and was discharged within three months. [source: Klerman 1990] He sued the Lodge. A Maryland arbitration panel found in his favour, although not unanimously, and the award was later reduced. The case was settled in 1987, before a jury trial. [source: Klerman 1990] According to Klerman, his final diagnosis was partly chosen to avoid custody complications from a "psychotic" label. [source: Klerman 1990] The other account describes his economic losses as "impressive" but gives no figures. [source: Psychiatric Times, Osheroff obituary] Klerman framed the issue as "opinion versus evidence", not psychotherapy versus medication. Stone, by contrast, credited Osheroff's recovery partly to a better alliance with his new psychiatrist. [source: Klerman 1990; Psychiatric Times, Osheroff obituary] For patients with schizophrenia as a group, McGlashan's follow-up found about two-thirds functioning marginally or worse, against about one-third of the unipolar depression cohort. He concluded that the treatment "failed to alter the momentum of this disease toward lifelong disability". [source: Psychiatric News 2014] [uncertain: the follow-up is dated 1984 in this guide's Sources and 1986 in Psychiatric News; both may belong to the same series] The mechanism was untreated psychosis or severe depression lasting months or years, with physical decline (weight loss, sleeplessness, exhaustion from agitation). Meanwhile work, custody and social roles were lost, and the illness was reframed as character pathology or resistance. [synthesis] Recognising it today. [synthesis] Watch for a colleague or service that:
  • presents medication as incompatible with "real" therapy or as something that "dulls" the work;
  • treats a patient's or family's request for medication or a second opinion as resistance to be interpreted;
  • continues an unchanged plan while weight, sleep, self-care or psychosis worsen;
  • uses a personality-disorder formulation that displaces a treatable mood or psychotic disorder;
  • does not tell the patient about evidence-based alternatives.
  "Medication-free" programmes are not the same thing when the person has made an informed choice, alternatives are disclosed, and there is monitoring with a fixed review point. Klerman's tests are to disclose alternatives and, if there is no improvement in about three to four months, to reassess or get a consultation. [source: Klerman 1990] What to do instead / helping those harmed. Offer psychotherapy alongside medication and team care (C1, C3). Monitor objective markers (weight, sleep, self-care, risk), set review dates, and record informed consent that covers alternatives. [synthesis] For clients treated this way in the past, assess for demoralisation, shame about a "character" diagnosis, mistrust of therapists and grief for lost years. Acknowledge that the harm was real rather than interpreting it. [synthesis] If you see indicated treatment being withheld now, raise it with the treating team, seek consultation, and use your service's escalation or safeguarding route. [synthesis]
• Erotic or romantic disclosure. Searles reported telling recovering patients that he had fallen in love with them, believing this supported their self-esteem ("Oedipal love in the countertransference", 1959). Current limit: under present professional codes, disclosing sexual or romantic feelings to a patient is a boundary violation. Process such feelings only in supervision or your own therapy. [source: Wikipedia summary of Searles] [uncertain: the 1959 paper] Harm account: erotic or romantic disclosure What was actually done. In "Oedipal love in the countertransference" (1959), Searles described falling "in Pygmalionesque love" with patients as they recovered and telling them how he felt. His argument was that a patient's sense of being "capable of arousing such responses in his analyst" helps self-esteem. [source: Wikipedia summary of Searles] [uncertain: the paper itself is not drawn on; no source describes physical or sexual contact by Searles, so the practice documented here is verbal disclosure] The disclosure came from the therapist, inside a long, intensive, often years-long therapy with a patient who depended heavily on that one relationship. It was framed as therapeutic. [synthesis] How it caused harm. Gutheil and Gabbard (1993) separate boundary crossings, which cause no harm, from boundary violations, which do. Crossings can be repeated and develop into violations. The Royal College of Psychiatrists holds that harm depends on what the behaviour means to the patient, not on what the clinician intended. [source: Sarkar 2004] Romantic disclosure is one of the steps on the documented "slippery slope" to sexual exploitation (see the next section). Patients sexually exploited by a therapist show:
  • shame, fear, rage, guilt and self-blame;
  • isolation and emptiness, and disengagement from services;
  • cognitive distortion, identity confusion and emotional lability;
  • sexual dysfunction, mistrust of authority and paranoia;
  • depression, self-harm and suicide.
  The therapy usually ends abruptly. In one study only 20% of offending therapists made a referral, and patients are left keeping the relationship secret to protect the therapist. [source: Sarkar 2004] Gabbard and Lester found that most offenders are "lovesick" therapists who mistake transference love for real love and cannot see the harm. A hoped-for relationship after therapy ends also stops the patient from working through grief and loss. [source: Gabbard & Lester 2002, Metapsychology review] With psychotic patients, whose self–other boundaries are already fragile, a declaration of love can be taken concretely, can feed erotomanic or merger fantasies, and can make leaving the therapy feel impossible. [synthesis] Recognising it today. These are the steps of the slippery slope (Simon 1995): [source: Sarkar 2004]
  • neutrality is eroded in small ways, and first names are used;
  • sessions become social, and the patient is treated as "special" or as a confidant;
  • the therapist discloses personal problems or sexual fantasies about the patient;
  • touch progresses to hugs and embraces;
  • sessions are rescheduled or extended, and contact happens outside therapy;
  • drinks or dinner follow, then dating, then sex.
  Offending therapists share these features: grandiosity, sadomasochistic core issues, a tendency to act rather than reflect, seeing the patient as deficient in a way that calls for enactment, and overvaluing love as the cure. [source: Gabbard & Lester 2002, Metapsychology review] Typical rationales are "it's good for their self-esteem", "they need a real relationship" and "love is what heals". [synthesis] Erotic feelings toward patients are normal. Legitimate practice notices them early and processes them in supervision or personal therapy, never with the patient. [source: Sarkar 2004] What to do instead / helping those harmed. Take erotic countertransference to supervision. Be especially careful during personal stress or bereavement, which are common in offenders, and when working without supervision, which is also common in offenders. [source: Sarkar 2004] A former patient of an exploiting therapist may arrive with shame, secrecy, idealisation of the former therapist, or global mistrust of therapy. Ask directly and neutrally about previous therapies. Do not end the therapy abruptly or interpret their experience as fantasy. Expect the transference to the new therapist to be charged. [synthesis] On reporting: in the US, sexual misconduct findings go to the National Practitioner Data Bank. In the UK there is no consistent mandatory reporting, and patients often have to start proceedings with the regulator themselves. Know your own code and regulator, and support the client's choices about reporting. [source: Sarkar 2004] [synthesis]
• Open expression of hatred, contempt or indifference. Searles's advocacy of voicing hatred, and his late-phase stance of not minding whether the patient recovered, carry real risks with suicidal, paranoid or violent patients. Current limit: any disclosure is brief, reflected on, non-punitive and never compromises risk management (B6, B12). Harm account: open expression of hatred, contempt or indifference What was actually done. Searles held that the therapist of a chronically psychotic patient had to endure the patient's "effort to drive the other person crazy" without retaliating, and had to survive his own wish to kill the patient. [source: Wikipedia summary of Searles] In the Lodge tradition as this guide summarises it (B6, B7, B12), those feelings were sometimes voiced to the patient rather than only contained: hatred or exasperation said aloud, and in the late phase an avowed indifference to whether the patient recovered. [uncertain: Searles's primary papers on voicing hatred and late-phase indifference are not drawn on] The extreme form of the same move appears in Rosen's direct analysis, outside the Lodge (see the last item in this section). There, hostility was a deliberate technique, using threats of punishment, withholding of preferred food and threats to withdraw love. [source: Balbuena Rivera 2010] How it caused harm. [synthesis] With a suicidal patient, an expressed wish that the patient were gone, or not minding whether they recover, can be heard as permission. With a paranoid patient, it confirms the persecutory belief. With a patient prone to violence, it raises arousal in someone already fighting for control. And with someone who grew up with hostile carers, it repeats the original injury inside the therapy. Gabbard and Lester identify sadomasochistic core issues and a tendency to act rather than reflect as shared features of therapists who commit boundary violations. They list countertransference enactments among non-sexual violations. [source: Gabbard & Lester 2002, Metapsychology review] No named injury case tied specifically to Searles's disclosures of hatred was found. [uncertain] Recognising it today. [synthesis] Watch for:
  • "radical honesty" or "authentic" disclosure of contempt, disgust or boredom presented as a technique;
  • disclosures made in the heat of the moment rather than considered beforehand;
  • disclosures that leave the patient frightened, placating or caring for the therapist;
  • a therapist who describes a patient with relish as "impossible" or "hateful", or who stops minding about risk.
  Legitimate use, as in Winnicott-style "hate in the countertransference", is mainly internal. The feeling is noticed, used to understand the patient, and taken to supervision. Any disclosure is brief, owned, non-punitive and tied to something the patient can use (B6). What to do instead / helping those harmed. [synthesis] Contain the feeling first and process it in supervision. If you disclose, check the effect at once and repair. Never let a stance of indifference override risk assessment (C3). Clients who were on the receiving end of a therapist's contempt may present with self-loathing ("even my therapist hated me"), a fear of their own effect on others, or avoidance of therapy. Name the earlier therapist's behaviour as a lapse in professional conduct rather than as a truth about the client. A sustained pattern of contempt or punishment is professional misconduct and can be reported to the relevant regulator.
• Physical intimacy and informal contact. Era-bound acts such as smoking with patients, and any physical contact beyond ordinary courtesy, are outside current boundaries. Harm account: physical intimacy and informal contact What was actually done. In the mid-century treatment of psychosis, ordinary social distance was relaxed on purpose: therapists smoked with patients, sat close, and touched them in the hope of reaching someone "out of contact". [uncertain: no source documents specific Chestnut Lodge instances; the guide's existing wording is the basis] The documented version is Rosen's. He sat close to patients, held their hands and encouraged them to kiss him goodbye, as part of a deliberately "maternal" role. In the same treatment houses he used physical coercion (see the last item in this section). [source: Balbuena Rivera 2010] Gabbard and Lester list therapists "acting concretely in a mothering role" among non-sexual boundary violations. [source: Gabbard & Lester 2002, Metapsychology review] How it caused harm. Touch and informal socialising are early steps on the documented slippery slope to exploitation: first names, social sessions, being treated as "special", touch progressing to hugs, meetings outside therapy. [source: Sarkar 2004] Whether a crossing becomes a harmful violation depends on what it means to the patient. [source: Sarkar 2004] For a psychotic patient it can mean that the therapist is a lover, a parent, part of the patient's own body, or a persecutor. [synthesis] Patients with chaotic dependency needs or a history of abuse are at greatest risk. [source: Sarkar 2004] Recognising it today. [synthesis] Watch for:
  • touch rationalised as "reparenting", "holding", "corrective emotional experience" or "meeting unmet needs";
  • sessions moved to cafés, cars or the therapist's home without a clear clinical reason and without team agreement;
  • the therapist becoming the patient's main social contact;
  • shared cigarettes, food or gifts that create a sense of special friendship;
  • secrecy about any of these.
  Legitimate outreach (home visits, walking sessions, a handshake, practical help in early intervention or assertive outreach teams) is planned, documented, discussed in supervision, open to the team, and judged by its meaning to the patient. What to do instead / helping those harmed. Agree any departure from the usual frame with the team and record the reason. Review it in supervision, and ask how the patient experienced it. [synthesis] Clients who had intimate or informal contact with a previous therapist may not recognise it as a violation and may idealise that therapist. Explore it gently, check for escalation toward sexual contact, and follow the reporting guidance in the erotic-disclosure account above. [synthesis] [source: Sarkar 2004]
• Family-blaming aetiology. Fromm-Reichmann's 1948 notion of the "schizophrenogenic mother" and broader family-causation theories have been abandoned and caused documented harm to families through blame. Current limit: a non-blaming, collaborative family stance (C2). [synthesis; historical attribution: Fromm-Reichmann 1948] Harm account: family-blaming aetiology What was actually done. From the mid-1930s, clinicians studied the families of patients with schizophrenia as a likely cause. A 1934 study reported maternal overprotection in 33 of 45 patients. In 1948 Fromm-Reichmann wrote that the patient's distrust arose from rejection "mainly in a schizophrenogenic mother". Mothers came to be described as having given birth to healthy children and then "literally drove them mad". [source: Johnston 2013] One later psychiatrist recalled that "it became standard practice to believe that mothers were the cause of their children's psychosis". [source: Hahn 2020] In practice, parents were interviewed and assessed as the source of the illness rather than as partners in care, and the patient's treatment was organised around undoing the family's influence. [synthesis] Lidz and others argued that fathers' influence was as "noxious" as mothers'. For Fromm-Reichmann, the phrase was a passing remark in a paper about the therapist–patient relationship. [source: Hahn 2020] How it caused harm. In 1982, Parker's review found no evidence that distant, controlling mothers were more likely than others to have children with schizophrenia. The concept had already lost favour by the mid-1970s. [source: Johnston 2013] Blaming parents left them carrying guilt for an illness they did not cause, and it set clinicians and families against each other just when the patient most needed both. [synthesis] [uncertain: the sources do not give systematic data or personal testimony on parents' guilt; Johnston says only that "mother blaming helps no one"] Johnston adds a second, continuing harm. Clinicians now avoid environmental and parenting interventions in order to "stand apart" from mid-century psychiatry, so useful family work is lost. [source: Johnston 2013] Hahn warns that the opposite error is also harmful. Discrediting the "schizophrenogenic mother" has sometimes been used to divert attention from real abuse and trauma, and adverse childhood experiences are robustly linked to psychosis. [source: Hahn 2020] Recognising it today. [synthesis] Watch for:
  • formulations that locate the cause of psychosis in a parent's personality ("toxic", "engulfing", "double-binding" mother);
  • families shut out of information or care planning on theoretical rather than consent or safety grounds;
  • "expressed emotion" or attachment ideas used as accusations rather than as targets for support;
  • the patient being encouraged to see recovery as depending on cutting off the family, without evidence of actual abuse.
  Legitimate practice differs in two ways. It assesses actual abuse, trauma and current family stress without assuming the family caused the illness. And it treats family climate as something to work on together with the family. What to do instead / helping those harmed. Offer family intervention as set out in NICE CG178: at least 10 planned sessions over three months to a year, with the person with psychosis included if practical. Tell carers about their right to a formal carer's assessment. [source: HEE 2020, citing NICE CG178] Keep the collaborative stance described in C2. If a family member says they were blamed by earlier clinicians, acknowledge it explicitly, since this can unlock engagement. [synthesis] Where there is real evidence of abuse, follow safeguarding procedures. Being non-blaming is not the same as ignoring it. [synthesis] [source: Hahn 2020]
• Not part of this tradition: John Rosen's "direct analysis" (a different, confrontational 1940s–80s approach), which was associated with documented abuse of patients. It should not be confused with Chestnut Lodge practice. [uncertain] Harm account: John Rosen's "direct analysis" What was actually done. Rosen, who practised mainly in Pennsylvania, described direct analysis in 1947 and in his 1953 book Direct Analysis. [source: everybodywiki, John Nathaniel Rosen] It was an active therapy in which the therapist took a "maternal" role and delivered interpretations of the patient's psychotic material "directly and sometimes violently". Here is how it worked, as the sources describe it. [source: Balbuena Rivera 2010]
  • Setting: patients lived in a treatment unit, usually a rented house or flat, staffed by trained auxiliary therapists (typically two men and a woman). Rosen visited at least once a day.
  • Sessions: they lasted from a few minutes to several hours, averaging about an hour, four to five days a week. Rosen once claimed up to 10 hours a day for two of his cases.
  • Coercion: the units kept straitjackets, wrist and ankle restraints and locked doors, nominally for use only when other measures failed.
  • "Persuasion" techniques: Rosen listed 16 of them. Physical coercion was meant for flight, suicide attempts, destroying objects or demanding attention. Others included threats of punishment, withholding preferred food and threatening to withdraw love.
  • Physical closeness: he also sat close, held hands and encouraged patients to kiss him goodbye.
  Parents consented to and paid for these treatments. Alice Hammer's family paid more than $55,000, and her parents reportedly accepted beatings if they would help her recover. [source: Balbuena Rivera 2010] How it caused harm. [source: Balbuena Rivera 2010]
  • Hammer v. Rosen (1960): Alice Hammer, treated from 1948 to 1955, was struck repeatedly. A nurse who was barred from the room heard screams. A jury found Rosen liable for battery.
  • Sally Zinman (treated 1971–1973): she reported being undressed, struck on the face and breasts, sexually molested and tied to a bed.
  • Gay Claudia Ehrman (died 26 December 1979): one auxiliary held her while another hit her, to "break her silence" while Rosen was absent. The autopsy showed multiple bruises and a severely lacerated liver with massive internal bleeding. The aide who struck her received eight years for involuntary manslaughter, and the one who held her received a probated sentence for battery. Rosen's insurer settled for $100,000.
  • Other conduct: Rosen signed a death certificate for a patient who had in fact gone home.
  • Disciplinary outcome: about eleven patients filed complaints. The Pennsylvania licensing board prepared 67 charges under the medical practice act and 35 under its rules. On 29 March 1983 Rosen surrendered his licence, citing illness. He had also been practising in Florida without a licence.
  His results did not hold up either. A 10-year follow-up of 19 of his 37 original cases (Horwitz et al., Am J Psychiatry 1958) did not confirm his reported cures: many patients relapsed, and some had not been psychotic. Even a critic of the sensational accounts concludes that his physical methods violated basic ethical principles of psychotherapy. [source: Balbuena Rivera 2010] Recognising it today. [synthesis] Watch for:
  • therapy that "breaks through" psychosis by confrontation, shouting interpretations, shaming or physical force;
  • residential "therapeutic households" run by one charismatic clinician, with lay aides and no external oversight;
  • restraint or deprivation (food, contact, affection) used as therapeutic leverage rather than as a last-resort safety measure under legal safeguards;
  • staff barred from sessions;
  • families asked to accept harm "if it helps".
  Legitimate intensive or residential care for psychosis has transparent governance, uses restraint only under mental-health law and policy, and keeps the patient's dignity and consent central. What to do instead / helping those harmed. [synthesis] Use the integrated approach in this guide (C1–C3). Clients who survived coercive or abusive treatment for psychosis may show trauma symptoms tied to treatment settings, distrust of any therapist who is "active" or directive, and difficulty telling their psychotic experiences apart from what was really done to them. Believe and document the account, and assess for PTSD. Where current abuse is suspected, report it to the regulator and, for violence, to the police and safeguarding.

5. Handling problems

Each item says whether the guidance is from the sources or is [synthesis].

• Prolonged non-response or mutism (the "stuck" out-of-contact patient). From the sources: keep coming, do not hurry, and do not measure progress by your own norms. Treat the first reproach as progress. [source: Fromm-Reichmann 1939; Searles 1961] [synthesis] Also: ask the prescriber to review medication and physical causes (catatonia, sedation, negative symptoms, depression). Try varied formats (walking, shorter and more frequent contacts, activity alongside). Set a review point with the team, for example every 3 months, to confirm the plan is still sensible.
• Testing and repeated rejection of the therapist. From the sources: expect weeks to months of testing and keep the door open. Fromm-Reichmann spoke through a closed door for months to one patient and waited out a long refusal from another. [source: Fromm-Reichmann 1939] [synthesis] Leave brief messages, keep your scheduled times, and let the patient know the offer stands.
• Hostility and threatened violence. From the sources: no fear and no counter-hostility; be honest that you will protect yourself; do not silently accept violence. [source: Fromm-Reichmann 1939; Delahanty review] [synthesis] Follow the service's violence-prevention procedures, never meet alone with a patient who has made a credible current threat, and debrief with the team. Return to the relationship once it is safe, as the meaning of the attack usually matters.
• Ruptures after the therapist's errors or absences. From the sources: own the error, explain changes in person, and expect delayed reactions. [source: Fromm-Reichmann 1939] See A9 and A10.
• Overwhelm and flooding (rising anxiety, fragmentation, symptom surge in session). From the sources: interpret less, later and more concretely; leave undisturbing delusions alone; break anguished silence. [source: Delahanty review; Fromm-Reichmann 1939] [synthesis] Shift to the concrete here-and-now. Lower the emotional intensity of your own responses (B15). Shorten the session if needed. Inform the prescriber of any sustained worsening.
• Therapist overwhelm (hatred, despair, confusion, fear of going mad). From the sources: Searles treats these as expected in ambivalent symbiosis and as data, to be borne and taken to supervision. [source: Searles 1961; 1959 via Liberman review] [synthesis] Protect your outside sources of satisfaction and security, which Fromm-Reichmann made a professional requirement [source: 1950 table of contents]. Limit how many intensive cases you carry at once, and seek your own therapy if feelings are spilling over.
• Non-adherence to medication or treatment. Not addressed by the founders, who largely worked before or without routine antipsychotic use. [synthesis] Explore what medication means to the patient (poison, control, proof of madness, loss of self, side effects), keep this distinct from the prescriber's role, and share adherence concerns per your agreement (C1). Do not make therapy conditional on adherence unless the team agrees that risk requires it. Missed sessions: keep the slot, reach out, and treat absence as communication. Do not discharge for non-attendance without team review.
• Collusive symbiosis and boundary drift. From the sources: Searles warns that the therapist can resist supervision, treat the relationship as private, and unconsciously keep the patient ill. [source: Searles 1961; theipi.org summary] [synthesis] Warning signs are extra sessions without rationale, contact outside the frame, gifts, secrecy from the team, physical contact, and erotic or rescue fantasies acted on. Respond with immediate supervision, a return to the frame, and transparent documentation.
• Defensive idealisation mistaken for progress. From the sources: there is no litmus test separating it from real pre-ambivalent symbiosis. [source: Searles 1961] See B11.
• Staff splitting and institutional envy. From the sources: the intense dyad divides staff, who may feel excluded, resentful or invested in the patient staying ill. [source: Searles 1961] [synthesis] Hold regular team meetings, explain the phase, take nursing observations seriously, avoid being the "only one who understands", and agree a consistent response to limit-testing.
• Family pulling the patient out at the point of individuation. From the sources: Searles notes that families often remove the patient just as individuation appears. [source: Searles 1961] [synthesis] Anticipate this with family meetings and psychoeducation, frame improvement as likely to bring temporary instability, and involve the care coordinator.
• Anxiety about change and loss of identity as symptoms recede. From the sources: symptoms are bound up with identity, so improvement can feel like losing oneself. [source: Searles 1961] [synthesis] Name it, slow the pace, and help build replacement sources of identity (roles, relationships, interests) with rehabilitation colleagues.
• Suicidality. From the sources: Fromm-Reichmann's 1950 book has a section on suicidal attempts [uncertain], and Searles acknowledges that his late-phase stance risked suicide. [source: Searles 1961] [synthesis] Professional standard: conduct or arrange standard suicide risk assessment at intake, at phase transitions, after losses or separations, around discharge, and with any change in hopelessness or command hallucinations. Maintain a shared safety plan. Act on risk over any therapeutic stance. Post-psychotic depression and the period after discharge warrant particular vigilance.
• Requests for advice and pressure to become a teacher. From the sources: Searles warns against routinely directing, advising or educating, especially in the late phase. Fromm-Reichmann generally waited for the patient to ask. [source: Searles 1961; Fromm-Reichmann 1939] [synthesis] Give necessary practical information. Refer skills training to rehabilitation, and explore the wish to be told.
• Therapist absence, illness or ending the relationship. Not addressed in the sources. [synthesis] Give long notice, arrange named cover, prepare a written summary for the team, and plan termination over months, with the A20 review included.
• Limited resources (public services cannot fund 4–6 sessions a week). Not addressed by the founders. [synthesis] Keep the principles (reliability, non-intrusion, dynamic understanding, countertransference use, kernel-of-reality acknowledgement) at 1–2 sessions a week inside team care. Use brief contacts between sessions where nursing or case management can provide continuity. Do not attempt the full symbiotic phase model without intensity, supervision and an institutional container.
• Choosing whether this is the right approach. [synthesis] This is a long-term, resource-intensive relational therapy. Use it as an add-on for patients who want an in-depth relationship and can be held safely by a team. Do not use it instead of first-line evidence-based psychosocial interventions offered in your setting.

Sources

Sources

• Searles 1961 "Fases de la interacción paciente-terapeuta en la psicoterapia de la esquizofrenia crónica" (Spanish translation, CeIR 2016)
• Searles, "The schizophrenic's vulnerability to the therapist's unconscious processes" (reprint, Wolstein ch. 12)
• Searles 1977, "The analyst's participant observation as influenced by the patient's transference"
• Fromm-Reichmann 1939, "Problemas de la transferencia en los esquizofrénicos" (Spanish translation)
• Delahanty, "Frieda Fromm Reichmann y la psicoterapia intensiva en la esquizofrenia" (secondary review)
• Fromm-Reichmann 1954, "Psychotherapy of schizophrenia", Am J Psychiatry (abstract)
• Principles of Intensive Psychotherapy, University of Chicago Press (table of contents)
• Frieda Fromm-Reichmann, 1889–1957 (Am J Psychiatry 1998 profile)
• Collected Papers on Schizophrenia and Related Subjects, Routledge (table of contents)
• Liberman 2016, "Harold Searles: algunas notas sobre un psicoanalista discreto" (CeIR)
• Harold Searles (Wikipedia)
• Harold Searles (theipi.org)
• Prieto Silva 2022, "El manejo de la contratransferencia en pacientes psicóticos según H. Searles" (abstract)
• Recalling Chestnut Lodge: Seeking the Human Behind the Psychosis (Psychiatric News 2014)
• Searles 1963, "Transference psychosis in the psychotherapy of chronic schizophrenia" (PEP citation page only)
• Searles 1963, "The place of neutral therapist-responses…" (PEP citation page only)

Books and papers cited (by author, year, title)

• Fromm-Reichmann, F. (1939). Transference problems in schizophrenics. Psychoanalytic Quarterly 8.
• Fromm-Reichmann, F. (1948). Notes on the development of treatment of schizophrenics by psychoanalytic psychotherapy. Psychiatry 11. [uncertain]
• Fromm-Reichmann, F. (1950). Principles of Intensive Psychotherapy. University of Chicago Press. [table of contents only]
• Fromm-Reichmann, F. (1954). Psychotherapy of schizophrenia. American Journal of Psychiatry 111. [abstract only]
• Fromm-Reichmann, F. (1959). Psychoanalysis and Psychotherapy: Selected Papers (ed. D. M. Bullard). University of Chicago Press. [uncertain]
• Searles, H. F. (1965). Collected Papers on Schizophrenia and Related Subjects. Hogarth / International Universities Press (incl. 1958, 1959, 1961, 1962, 1963, 1964 papers cited above).
• Searles, H. F. (1979). Countertransference and Related Subjects: Selected Papers. International Universities Press (incl. 1975 "The patient as therapist to his analyst"; 1977 participant-observation paper). [mostly not drawn on]
• McGlashan, T. H. (1984). The Chestnut Lodge follow-up study. Archives of General Psychiatry 41 (I and II). [cited only as historical context via Psychiatric News 2014]

[uncertain] The English full texts of Fromm-Reichmann's 1950 and 1959 books and of most Searles papers are not drawn on. Content attributed to them is drawn from Spanish translations, abstracts, tables of contents and secondary reviews, as tagged above.

Sources for the section D harm accounts

• Klerman, G. L. (1990). The psychiatric patient's right to effective treatment: implications of Osheroff v. Chestnut Lodge. Am J Psychiatry 147(4); reprinted in Focus (APA)
• "Belated obituary: Raphael J. Osheroff, MD" (Psychiatric Times)
• Recalling Chestnut Lodge: Seeking the Human Behind the Psychosis (Psychiatric News 2014), re-opened for the harm accounts
• Balbuena Rivera, F. (2010). J. N. Rosen: un pionero controvertido en el abordaje psicoanalítico de la psicosis. Revista de la Asociación Española de Neuropsiquiatría 30(105): 49–74
• John Nathaniel Rosen (everybodywiki; secondary, incomplete)
• Sarkar, S. P. (2004). Boundary violation and sexual exploitation in psychiatry and psychotherapy: a review. Advances in Psychiatric Treatment 10(4): 312–320
• Graves, M. (2003). Review of Gabbard & Lester, Boundaries and Boundary Violations in Psychoanalysis (2002). Metapsychology 7(45)
• Johnston, J. (2013). The ghost of the schizophrenogenic mother. AMA Journal of Ethics 15(9): 801–805
• Hahn, P. (2020). The real myth of the "schizophrenogenic mother". Mad in America (critical perspective)
• Health Education England (2020). National curriculum: Family interventions for psychosis and bipolar disorder (quotes NICE CG178)
• Further reading (not drawn on): Horwitz, W. A. et al. (1958). A study of cases of schizophrenia treated by "direct analysis". Am J Psychiatry (via Balbuena Rivera 2010); Gutheil & Gabbard (1993) and Simon (1995) (via Sarkar 2004); Parker (1982) (via Johnston 2013).