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Treating the "Untreatable": Healing in the Realms of Madness

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Dr. Ira Steinman has exclusively focused on intensively treating severely disturbed patients for over four decades with a psychoanalytically-informed approach. What's most impressive is that he has done so throughout the era of managed care, which has defined and limited the role of mental health professionals in treating severely ill patients to the use of psychotropic medication, supportive psychotherapy, cognitive-behavioral treatment, group psychotherapy, or treatments that promote reality testing. Dr. Steinman's book, Treating the `Untreatable': Healing in the Realms of Madness, exemplifies his impressive work.

He chronicles his intensive treatment of a dozen patients. His delusional and schizophrenic patients gradually become aware "that they are the creators of their psychotic productions" and that their "projected and feared impulses that took the form of hallucinations and delusions become understandable and detoxified." The basis of his approach to treatment seems so logical and sensible, although he is one of very few mental health professionals who has continued to treat this population as though they are indeed treatable. He asks, "What happens if we genuinely try to understand the origin of such psychotic beliefs, even with the most disturbed, and attempt to put together an emotional and historical thread that describes how delusional beliefs or schizophrenic thought began?"

The therapist, according to Dr. Steinman, "must be able to see and gradually work therapeutically with delusions, hallucinations, unconscious meanings, resistances to insights, his own reactions and the patient's transference reactions from the past and to the current changing situation." Judiciously using medications for his patients as he helps them work through their traumas, Dr. Steinman has found the delicate balance between what symptoms are tolerable to his patients, and where they need a pharmaceutical shield.

Courageously gearing his book to the general public as well as to his colleagues, Ira Steinman illustrates the inner life of severely mentally ill patients, "articulates a rationale for the use of an intensive psychodynamic psychotherapy" for these patients, and "proves false the current belief that such an in-depth exploratory psychotherapy is of no benefit in such severely disorganized patients." He demonstrates, through case examples, that childhood trauma is "instrumental in the development of a certain percentage of people who are diagnosed as schizophrenic." Nearly all of the patients he described in his book have been off antipsychotic medications for up to thirty years, even after previous long courses of supportive psychotherapy, extensive antipsychotic medication, and repeated hospitalizations that left the patients in the throes of schizophrenic disorganization. Dr. Steinman's intensive psychotherapeutic work, as described in Treating the `Untreatable' led to healing and cure.

Dr. Steinman offers a compelling argument for the use of psychoanalytic psychotherapy in treating the severely disturbed. Over the long run, such treatment is likely to cost less than repeated hospitalizations and lifelong supportive psychotherapy. He concludes that as a field we "have lost our way in treating severely disturbed and delusional patients." Undoubtedly he is correct. And most importantly he demonstrates the efficacy of uncovering exploratory dynamic psychotherapy to treat the `untreatable'. Dr. Ira Steinman is an inspiration to graduate students as well as to established psychotherapists. Similarly, Treating the `Untreatable' offers hope--the possibility of having a fulfilling life--for those who suffer terribly from serious mental illness.

--Mary C. Lamia, Ph.D.

'Alongside psycho-pharmacological intervention and the benefits it brings,

the treatment of seriously disordered individuals requires that their

delusional beliefs be addressed psychotherapeutically; otherwise, there is

no significant and sustained symptom relief. Ira Steinman provides the

most thoughtful, well articulated account available of how such treatment

should be conducted, complete with captivating and instructive case

examples. I wish we could have used his book in our residency program when

I was Director of Training at the Department of Psychiatry, Mount Zion

Hospital, San Francisco. As Editor-in-Chief of 'The Psychoanalytic

Quarterly' for ten years, and Program Chair of the American Psychoanalytic

Association for two terms, I can assure you that clinicians from various

backgrounds and with all levels of experience will want to read "Treating

the 'Untreatable'" and will find it enormously useful when they do.'

- Owen Renik, M.D.

I have been searching for a book like this for the past ten years. I wish I could give it ten stars.

I have a nephew who has been diagnosed with 'schizoaffective disorder'. He has been in and out of hospitals and jail and on and off anti-psychotic meds. He has a mother who would drive anyone, including me, insane. Every time I spend time with my nephew, within a couple of days, he starts to integrate, he feels better and better, and it seems obvious that he is not 'incurably schizophrenic' as his mother insists - because, of course, if he is not crazy, then she is the problem.

This book made me feel sane for insisting, against the opinions of dozens of psychologists, psychotherapists, social workers and counselors, that my nephew is reachable. I cried at the stories of abuse that Stein chronicles and the healing that is possible. His proscription for healing is exquisitely simple although not easy. His explanations are accessible for the layperson but aimed squarely at the field of psychotherapy, as well. He merely insists that the client confront and integrate the idea that the client is the inventor of their delusions, voices, other personalities, their break with external reality. Stein demonstrates that the delusions of his clients are understandable, that they are created out of the need to escape dire emotional pain. Merely giving clients supportive therapy does not work. Compassionate listening is critical for about three months, he finds, just the time it takes to compile an in-depth history of the client and, as much as he can, the history of the different delusions and voices. Stein invites the reader into the therapy room as he goes to work, gently but insistently, bringing the client into reality. Sometimes he talks directly to the delusions and different voices, making sense of who and what they represent to the client. He helps his clients learn to deal with their pain in other ways while reminding them over and over that they are the source of the delusions invented - and brilliantly so - for protection from a desperately painful reality. During this time, maybe a couple of years, it gets dicey for the clients as they let go of their defenses and confront sometimes horrible abuse. Stein writes of chasing clients as they flee his office, running for the Golden Gate Bridge to commit suicide. But he seems unfazed. Stein uses antipsychotic medications and short term hospitalizations for such episodes, but his clients progress. He has stories of clients in their fifties, with thirty years of derangement, hospitalizations, and heavy medications, who let go of their delusions, get off of medications and heal themselves.

I felt as if I were sitting in the room with Stein and his clients, as if I were a first-year student in psychotherapy, listening to a master. Stein has written a tribute to the power and brilliance of the human mind.

This book should start a revolution in the art of psychotherapy.

Now, Dr. Stein, please write a book about how to deal with the parents who interfere with the recovery of their adult children at every turn.

Ira Steinman's book is a beautiful forward development of Frieda Fromm-Reichman's seminal work. It's a creative confirmation of the virtues of psychodynamic psychotherapy in the hands of a virtuoso for the most disturbed patients many of us are reluctant to engage. For our residents who have little psychotherapy training and for seasoned clinicians, the book is an awakening!

Herbert S. Sacks, MD, Clinical Professor, Yale Child Study Center; Past-President, American Psychiatric Association

'What this book does is to demonstrate in a lucid and impressive way the

possibilities for the intensive psychotherapy of severely ill

psychiatric patients in a way that can lead to lasting benefit and

restoration of full life functioning much beyond the kind of systematic

management that can come with the use of psychoactive drugs (though of

course such medications are indeed part of Dr Steinman's treatments in

selected cases). This kind of treatment was once quite in vogue in

psychiatric and psychoanalytic circles back in the mid-2Oth century,

associated then with the names of Frieda Fromm-Reichman, Margaret

Sechehaye, Gertrud Schwing, Harry Stack Sullivan, and John Rosen, the

best known of that generation, but has since been largely eclipsed by

the rise of the use of psychoactive drugs, and this I feel has been a

major curtailment of the restorative possibilities of these patients.

Ira's manuscript is an effort - and a substantial one - to redress this

imbalance and to bring the intensive psychotherapy possibilities with

these very ill patients back into the foreground. As such it can serve a

very useful purpose for both the practitioner world and the world of

current and potential patients out there.'

- Robert S. Wallerstein, M.D., Past President of the International

Psychoanalytic Association

All too often some cases of health are simply written off as hopeless. "Treating the Untreatable: Healing in the Realms of Madness" is a look into the world of mental health, focusing on schizoprhrenia and delusions. Drawing from Ira Steinman's own vast experience in the field, she seeks to dispel the myth that some people are incurably crazy and must simply be put in a padded room for the rest of their days. With much to inspire psychiatrists dealing with these cases, "Treating the Untreatable" is something to be embraced for those who don't want to give up on their patients.