Gratification and Activity in Schizophrenia...

Gratification and Activity in Schizophrenia. Some Curative Factors in Two Dynamic Psychotherapies

B.S.Rogovoy (Orel)  Ph.D.

The article deals with the healing forces in two methods of dynamic psychotherapy developed by Bettelheim and Sechehaye. The author compares common and different features of these methods and tries to discover their fundamental principles which were not always formulated by their inventors in an explicit form. He believes that the main curative factor in these methods of psychotherapy is gratification of patients with the aim of re-building and training those functions of the ego which were incapacitated and weakened by the illness. The activity of patients seems to be a conditio sine qua non in these treatment methods,  gratifications being  used as a reinforcement of  activity and its gratifying background. The author supposes that in the final result gratification becomes interiorized in activity, which helps to make the latter stable in the face of internal and external obstacles.

   The inventor of one of the first really successful methods of psychotherapy in schizophrenia, M. Sechehaye, relates, among others, the following case: A young  schizophrenic girl named Paulette had  among  other peculiarities of behavior a strong liking of chocolate . Seeing weeks gluttony, insatiability, agitation and screams at the sight of chocolate the psychotherapist ordered to give her chocolate unrestrictedly. Several weeks passed by, Paulette consumed vast quantities of chocolate, with no good results. Not  only her cries streams and gluttony continued, but her general mental state aggravated further. Then  a new psychotherapist , Sechehaye appeared on the scene. Having learned that while being a nursling Paulette had received in her bottle orange juice mixed with milk, Sechehaye cancelled the giving of chocolate and began to give to the girl a daily bottle of orange juice and no more of it. Sechehaye gave the juice personally in the role of a substitute mother, and not as the previous psychotherapist, who placed the chocolate on a table and went off, while Paulette would stand for an hour or more alone before the chocolate, struggling with her ambivalence. The results of the gratification giving in this manner were quite satisfactory, and led to the improvement of the mental state of the girl who finally grew well (Sechehaye 1956).
   And now the second case, this time from the psychotherapeutic practice of another children's psychotherapist, Bettelheim. As usual at Bettelheim's Orthogenic  School, the girl named Mary (who at first did not appear a very severe case, but  later proved to be a schizophrenic) was gratified in every possible way, with much cultivation of passive dependency, as for example, a counselor (= nurse) systematically dressed Mary, tied her shoes , held  her  in her lap for prolonged time etc. At first Mary asked for litter gratification and seemed satisfied with whatever was given her. But soon she became greedy, demanded more and more and was never satisfied. After some general improvement of the condition of the girl, a severe regression, with the growth of passivity, occurred. Mary's attitude to her favorite counselors changed from attachment to aloofness and then again to extreme attachment (when Mary would go to her favorite nurse as ten times nightly). Nevertheless the therapeutic process of Bettelheim did not swerve in the least from its gratifying course, and at last recovered completely (Bettelheim 1955).
   These two examples from two psychotherapies of schizophrenia seem to be representative of their psychotherapeutic processes. Both psychotherapies lean on the psychoanalytic theory, which emphasizes the importance of the past psychological history of the patients but both of them systematically use much gratification of the patients in the present context of the treatment.
   The gratificatory tenor of the psychotherapies of Bettelheim and Sechehaye is not an exception in modern psychotherapy but is approved and adhered to, with more or less modifications, by many modern psychotherapists. At the same time, the curative value of gratification in schizophrenia has not been sufficiently explored, and it is not always quite clear how to use gratification to get positive results.
   We see that gratification is rather a mysterious force which sometimes to worsens the mental state of patient and sometimes improves it. If there is a worsening caused by gratification, it seems advisable sometimes to limit or modify gratification and sometimes to continue it without variation.
   These paradoxical qualities of gratification are not limited to schizophrenia and appear - in milder forms - in many clinical and even non clinical situations (Rotenberg; Arshavsky 1984).
   We propose the following explanation of these apparent paradoxes. We may regard gratification, in one of its aspects, as a means of regression to the earlier stages ontogenesis, when all the demands of the growing organism were satisfied without efforts and strife. But when the lack of regression is too big, as it takes place in schizophrenia, the drive to regression becomes excessive and the regression itself uncontrollable and screening out any gratifying contacts with reality.
      Being regressive in one of its facets gratification is reality - bound ("progressive") in the other facet, and can therefore be used for the recovery of the contacts with reality, if these contacts have been severed by illness.
   These considerations permit us to understand why gratification as in the foregoing cases could be sometimes very useful and sometimes harmful, sometimes an instrument of recovery and sometimes a still more aggravating factor. Being a regressive agent, gratification might call forth an avalanche of uncontrolled regression, and then it would be very harmful. On the contrary, if the regression caused by gratification is limited ("closed"), the pleasure of gratification could be a mighty stimulus for a reconditioning and better adaptation to reality.
   And now, on the basis of the psychotherapeutical practices of Bettelheim and Sechehaye, we shall try to answer tentatively two important questions: What needs of the patients must be gratified primarily if at all and in what ways.
  As to the first of these questions, the answer of Bettelheim is simple and enticing: "provide the patient with the ample satisfaction of all, or almost all, of his needs", and not only the ones that are commonly accepted by other as legitimate (Bettelheim 1950). Only such profound gratification could overcome the feeling of fundamental insecurity lying, as Bettelheim says, at the basis of psychotic symptoms in schizophrenia.
    Some reservations are made by Bettelheim with respect to the limits of gratification, and first of all as concerns those desires of the patient the realization of which might bring harm to himself or to others. Other reservations are still more important. The patient preserves the right to decline a proposed gratification. Delusory desires leading away from reality ought not, as a rule, to be gratified.
   Bettelheim (1955) indicates as the most basic needs, which must, if possible, be gratified unlimitedly, the patient self-regulation of bodily needs, privacy and freedom to choose companions. The initial efforts in the therapy are invariably directed towards establishing relations wish other persons, which relations are considered by Bettelheim as the most important source of gratification. Much attention is payed to regressive gratificatory factors (e.g. Bettelheim 1950).
      If we turn now to Sechehaye, what she says on the subject seems to be very different from Bettelheim's view, at least at first sight. The needs of schizophrenics, Sechehaye maintains, are of two kinds: "essential" needs (as, for example, the need of Paulette for orange juice) and "compensatory" ones (as, for example, the need of Paulette for chocolate). Only essential needs must be gratified according to Sechehaye, and these often only in symbolic way, while the gratification of compensatory needs is not of help or even brings harm.
   Sechehaye indicates as the most obvious examples of compensations schizophrenic deliriums, hallucinations, and autistic reveries, while the essential needs are to be searched among such libido-laden processes as eating or other bodily pleasures, and they include significance regressive elements (e.g., orange juice for Paulette).
If we compare now the standpoints of the momentous therapeutic significance of gratification, and both agree that one ought not to gratify all the needs and desires of the patient in the lump. Other points of agreement of these two are the insistence on the primary importance of concern, care and empathy given to the patient, much attention to bodily pleasures and regressive factors, and dismissal of autistic tendencies as agents of gratification.
  Clearly Sechehaye is more inclined to limit gratification than Bettelheim, but this disagreement is significantly bridged up by two important reservations:  Bettelheim's acknowledgement that some of his patients were harmfully overgratified because of the institutional character of the therapy, with no great possibility to limit gratification individually according to the state of each patient (Bettelheim 1955); and Sechehaye's recommendation of an ever widening gratification of the patients in the later stages of the therapy (Sechehaye 1956)/ According to our hypothesis of the psychological role of gratification, it may be useful or harmful, dependent on the quantity and quality of regression and  "progression".  Too much regression would be dangerous and too little of it would not be therapeutic.
   As Sechehaye rightly insists and Bettelheim admits, some kinds of gratification leading, as we believe, to uncontrolled regression are harmful in any or almost any circumstances, while some of them (mainly with symbolic regressive meaning) may be especially salutary. But this does not remove the fundamental necessity of prolonged and sufficient gratification from various sources.
   From this point of view it would have been quite possible to heal Paulette even without the expedient of feeding her with orange juice, however useful just this kind of gratification might prove to be. As to the chocolate feeding, Sechehaye herself admits that of done with correct approach it could have reached better results.
The lack of ability to experience pleasure one of the most common features of schizophrenia and pre schizophrenic states (Rado 1956, L;wen 1964, Dobrovich 1985). The re-education of this ability helps in creating the regressive atmosphere of the "lost paradise", which is indispensable for restructuring the personality of the patient.
   The use of therapeutic regression being one of the central principles of classical psychoanalysis, it is no less important in the psychodynamic therapies of Bettelheim and Sechehaye, although the ways of such use are different.
   To counteract excessive regression, sufficient "progression" (i.e. nearness to reality) must be introduced, which is achieved in the psychotherapies of Bettelheim and Sechehaye by the massive use of such regressive elements which are at the same time an inalienable part of the present reality, and therefore prevent the loss of contact with it. Cf. the therapeutic strategy of Dick Diver with regard to his schizophrenic wife Nicole in the novel of F. S. Fitzgerald (Fitzgereld 1983). Even classical psychoanalysis is not devoid of such "progressive" elements, but they are not introduced in it so purposefully and systematically as in the psychotherapies of Bettelheim and Sechehaye.
   In our example Sechehaye fed Paulette with orange juice and introduced her presence and help for the sake of feeding the girl. Bottle feeding has a significant regressive meaning, as corroborated also by the experience of Bettelheim, whose child patients often ask for a baby bottle to suck from at some stage of recovery (Bettelheim 1955). At the same time a baby bottle was not an autistic reverie, but a gratifying component of the present reality. A similar combination of increased regression and more nearness to reality refers to the personal participation of the psychotherapist in the matter of feeding. If regression had been administered without simultaneous increasing "progressive" elements and without the aim of overcoming the ambivalence of the child in her adaptation to reality (the ambivalence in eating), the results would not probably have been so satisfactory.
   We shall venture a guess that in our second example (the treatment of Mary) one of the causes why the harmony of regression and "progression" was discomposed at some stage of the treatment might be too intensive cultivation of passive dependency of the patient, which did not serve in a sufficient degree to the overcoming of the difficulties in the way of "progressive" gratification. Then the energy provided by regression was of not sufficiently utilized for some "progressive" aim (as, e.g., it was done for overcoming Paulette's ambivalence in eating), and could more easily direct itself into purely regressive channels.
One of the most potent means of introducing therapeutic regression intertwined with "progressive" elements are contacts with the psychotherapist and the other members of the psychotherapeutic team. "Isolation of the patient and his inability to enjoy positive relations (personal and in groups)" discussed by Ammon in another context (Ammon 1978) are very salient in schizophrenia. At the same time these relations with other people, as is shown by the experience of the psychotherapists of differing orientations have an outstanding significance as a curative factor. Therefore the primary task in the psychotherapies of Bettelheim and Sechehaye is to establish for the patients some at least rudimentary relationships with other people.
   As the Orthogenic School of Bettelheim personal contacts of counselors with the patients continue for many hours on end, often with some physical nearness. Sechehaye  also speaks about many hours of contacts on end, which lead to the growing attachment of the patients  to the psychotherapists, who becomes a substitute of mother and really calls herself "Mama" in her talks  with the patient (Sechehaye 1956).
   Warm empathy and understanding, active help and readiness to sacrifice are demanded from the counselors of the School. Bettelheim chooses the counselors very carefully, and those who are not ready to sacrifice to the patients and do not show sufficient positive counter transference are immediately dismissed. Sechehaye works alone, without the psychotherapeutic group, which makes the demands to the psychotherapist in her method extraordinary high.
The psychotherapist (counselor) being a substitute of a parent figure, regressive processes, which are completely indispensable for rehabilitation, gather momentum. But these regressive processes must include also "progressive" elements. The psychotherapist and the members of the psychotherapeutic team do not simply represent the parent figures; they do it with a change. The real parents of the patient were "incapable of  responding to his basic needs" (cf. Ammon 1978), where as the substitute "parents" have the will and ability to do it and make it their task to help the patient in "corrective education" of the ego functions which were underdeveloped and perverted by the illness (cf. Ammon 1982). Thus, the contacts of the patients with the psychotherapist and other members of the psychotherapeutic team, without losing the atmosphere of spontaneity, must also be subtly directed towards more re-adjustment of the patients to reality.
   An example of the adequate introduction of "progressive" components into the contacts with the patients from their very beginning may be a case of the girl Marcia treated by Bettelheim. When Marcia first came to the Orthogenic School, she could not use her hands for eating as she had a habit to constantly using them for stopping her ears. After a long reflection, Bettelheim proposed to the girl that her counselor will stop her ears. This maneuver was successful to free Marcia' s hands for eating, and proved to be the first step of the girl on the road to recovery (Bettelheim, Karlyn 1975).
   The delicate balance of regressive and "progressive and "progressive" forces in interpersonal contacts may be easily discomposed, especially at the beginning. Bettelheim indicates that premature nearness may be very harmful, and casual contacts without any enforcement are recommended.
   Here is a proper place to dwell upon the significant difference between the therapies of Bettelheim and Sechehaye. Вettelheim basis his treatment on the use of a collective, i.e. many people, who could enter, in a greater or lesser degree, into interpersonal relations with the patient. This is very convenient, in particular as the patient may choose the objects and the intensity of transference, according to his demands. Sechehaye, on the contrary, insists that the psychotherapist must become a privileged person from whom the patient expects gratification (Sechehaye 1956).
The difference in the management of interpersonal contacts of the patients of Bettelheim and Sechehaye has a close relation to another, and probably still more important, dissimilarity. High level of dependency created by the exclusive contacts of the psychotherapist and the patient in the psychotherapy of Sechehaye is used by her to direct the patient in his behavior. Having evaluated the actual behavior, attitude and the former history of the patient, the psychotherapist herself chooses what gratification must be administered to the patient and in which ways. This is a matter of heavy responsibility, and there is some chance of mistake.
    Here is an instructive story related by Sechehaye. Having reached much success in the treatment of her patient Renee, Sechehaye inadvertently brought a relapse by saying to the nurse in the presence of Renee: "Give Renee a bath whenever she wants it; it will please her!" These words were followed by agitation and self-destructive behavior of the girl. Later, when Renee grew entirely well, she explained to the psychotherapist the nature of this mistake. It appears that Sechehaye should have taken the responsibility of the bath on herself and said to Renee: "Mama orders Renee to take a bath" (Sechehaye 1956). It would have been an order similar to that given to Paulette to drink orange juice. Gratification by orders from the "omnipotent mother" is easier for the patient to sustain in early stage of treatment by his own initiative.
   Therapeutic transference created with much spending of time and attention is systematically used by Sechehaye for the reeducation of her patients in the art of gratification by orders of the psychotherapist. Less intensive therapeutic transference cultivated in the Orthogenic School is also used for the aims of gratification but usually without any orders, on the basis of spontaneity of the patient. There are many striking examples in the books of Bettelheim of his extreme tolerance to different "unreasonable" manifestations of gratificatory spontaneous activity of his patients. For example, a schizophrenic boy took the habit to spit at his favorite counselor and later began to spit at other adults. He also tried to spit at other children but they could not stand it and the counselors had to limit his spitting to the range of the adults. This spontaneous and definitely gratifying activity continued for years before it finally stopped (Bettelheim 1955).
But the therapy of Bettelheim, especially in the later stages of treatment, is also not devoid of recommendations, suggestions and even orders to the patients. As Bettelheim says, "no child is expected to control himself beyond his ability just for our convenience, but... self-control and more socialized behavior will be expected of a child once he is ready and able to exercise them". (Bettelheim 1955).
   Bettelheim feels dissatisfied with the therapy of Sechehaye, and in his later book on autism he says, in some apparent contradiction with his earlier statements on the treatment of child schizophrenia: "Contrary to what is expressed in some works o "symbolic realization" (Sechehaye 1951), which consider the patient to be too passive and which attribute all the improvements to the actions of the therapist, we believe that neither these actions nor gratifications of needs (except the need to be active) lead to the return of these children to life. They returned to life only when we could create conditions or be catalyzing force which induces them to act on their own behalf" (Bettelheim 1985).
   In autistic children, in difference with schizophrenics, the ego functions have developed much more poorly before the onset of the illness and need more primary education than re-education, which can explain some differences in the course of the treatment itself. Therefore it seems justified to apply this therapeutic tenet to the treatment of schizophrenic children as well, and to check its correctness by the example of the aforementioned Mary.
   When Mary was treated at the Ortogenic School, the counselors did their best to satisfy all the needs of the girl and gratify her as possible. The result was a gradual growth of extreme dependency. Mary took to sitting on the lap of her counselors and would spend a full five hours on end in their society without any impatience, abuse or anger. Then, as we have mentioned earlier, a breakdown ensued, one of the main characteristic features of which was the inability of gratification. Mary became gloomy, her occasional smiles disappeared. She reacted to any perspective of gratification, to any necessity to be active or even to the slightest changes in her surroundings with dread, agitation of somatic symptoms. She became unable to express her real desires and complained for hours: "Do something for me! You never do anything for me!" At the long last the crisis was overcome, and bit Mary became mere able for gratifying activity on her own behalf.
   The example of Mary and virtually all the other cases of treatment by Bettelheim prove irrefutably that the appearance of the autonomous activity of the patient is bound to be preceded by the long and arduous practice of less active gratification. To state it by the words of Bettelheim himself: “We feel that before anything else a child has  to be utterly  convinced that- contrary to his past experiences – this world can be a pleasant one, before he can feel any impulse to get  along in it” (Bettelheim 1950). And this is also what Sechehaye does in her own ways with the aim to create for the patient a new reality, “a reality taking into account the patient’s needs and the fragility of his psyche” (Sechehaye 1956). This does not, as we believe it, contradict to the theoretical insistence of Bettelheim in his later book on the importance of activity of the patient as a corner- stone of any lasting improvement.
   The positive significance of the “effectance pleasure” connected with the results of activity has been indicated by some psychoanalytic ego-psychologists (White 1959, Spock 1963, Klein 1982). There is also “pleasure in functioning” differing from the “effectance pleasure” and connected with the effective use of functions and skills, irrespective of the results reached (Buhler 1930, Hartmann 1981, Klein 1982). Much contribution to the study of psychological importance of activity has been made by the physiologist Rotenberg, who emphasis the role of the so called “search activity”, without definite forecast of results, and affirms that the refusal of search activity is the most frequent and general form of regressive behavior (Roterberg 1982) and can be very harmful (Rotenberg, Arshavsky 1984; Rotenberg 1986).
   Bettelheim and Sechehaye lead, as we believe it, their patients in the way of the increase of the “effectance pleasure”, which inevitably gives rise to a subsequent increase of the  “ pleasure on functioning” and to a general  activating of the ego (cf. Hartmann 1981). In other words, much activity giving immediate pleasant results leads to the interiorization of the pleasure in activity. At a later stage, which is equivalent to recovery, the quantity of external gratification may be lessened harmlessly as activity itself becomes a significant factor of interiorized gratification, which is normal for mentally stable persons.
 We believe that the main therapeutic target in the psychotherapies of Bettelheim and Sechehaye is just this interiorization of pleasure in minimal activity, which mobilizes the ego functions in the direction of the readjustment to reality and is the main “progressive” factor of treatment. The processes of everyday life in the Orthogenic Scool demand continuous minimal activity of the patients for the sake of the gratification of their physiological and psychological needs, and Bettelheim does everything possible to make there activities  easy and certain to lead to gratification. But Sechehaye also did not suppress the activity of Paulett in her feeding but only made it more limited, secure and pleasant.
   Activity of the patients must remain minimal during a long period, and the patients, as indicates Bettelheim, must “be freed of all pressure to be active” (Bettelheim 1950). This prudence of Bettelheim with respect to the level of activity of his patients is echoed by the corresponding expressions of Sechehaye. Insistent and unremitting as she is in applying relatively passive gratification of her patients, she calls for prudence in the advanced stages of the therapy, when the patients become more active. “ It is imperative to await their spontaneous wish to progress, Sechehaye recommends not to compliment them too readily on their efforts, nor to rejoice too openly, but give them time to accustom to the new behavior (Sechehaye 1956).
   Thus we see must similarity in attitudes of Bettelheim and Sechehaye with respect to the activity of their patients. Both psychotherapists, with more or less clearness, see the profound significance of activity and both are prudent enough to avoid any hurry in stimulation it, although Sechehaye is  much more prudent in this respect than Bettelheim who inculcates spontaneous activity more and at an earlier stage of treatment.
   But why is such prudence necessary? What are the dangers of stimulating intensive will activity if it is really so important as a “progressive” means of the re-adjustment to the present reality? One may suppose that will activity as well as the other ego-functions are intimately bound in their development with aggression, which easily becomes “destructive” in the term of Ammon and turns against the subject himself. This self-destructive aggression seems to be especially strong in schizophrenia and autism, and Bettelheim reports of many cases of the appearance of the previously repressed manifestations of self-destructive aggression in his patients during the treatment (Bettelheim 1985).
   We will not elaborate the theoretical background of this hypothesis as there is no room here for that aim, and will limit our theoretical allusions to the consideration of the founder of the psychoanalysis,  that to fight the evil effects of harmful aggression, the ego “must be filled with libido itself and become itself a representative of the Eros” (Freud 1949, 1991).
   This filling of the ego with the forces of libido is just what is being done in the psychotherapies of Bettelheim and Sechehaye. The ego activities used for the sake of gratification become themselves sources of gratification in the course of the treatment. These processes of the re-education of the ego functions must begin at a level of minimal activities, because minimal activity gives less chance of the transfer of the newly awakened psychic energy into the still active pathological channels of destructive aggression. 
   The negative influence of excessive energization was clearly indicated by some authors  long ago (e.g. Freuf 1922), while the Russian physiologist Simonov has experimentally proven that weak stimuli of various kinds are able to prevent, suppress and cure pathological reactions caused by big doses of the same agent (Simonov 1962).
   These considerations permit us to understand some characteristic features of the psychotherapies of the Bettelheim and Sechehaye, which may be subsumed as limitation of the energization of activity. Thus, the psychotherapist must eliminate such highly energizing factors as ambivalence and excessive will efforts of the patients, as Sechehaye  did in feeding Paulette with her personal participation and insistence.
   Any ambivalence raises the level of energizing.  Therefore one of the causes why schizophrenic  delusions ought not to be gratified in their ambivalent character: “All mentally deranged persons believe is their delusions only partly and sometimes” (Bettelheim 1975.) It is understandable also why  anticipation and waiting, with their  increase of energization, may be harmful: “Waiting even for  pleasant experiences  creates tension” (Bettelheim 1950).
   In the same light, the insistence of Bettelheim and Sechehaye on the reliability and regular character of gratification is of paramount importance, as inconsistency and unreliability may heavily disturb the patient Sechehaye says: “The patient requires that the essential needs be realized many times, regularly and always in the same way, a work inevitably disrupted by loss of patience or hurrying the schizophrenic toward more adult behavior” (Sechehaye 1956). The institutional routine at the Orthogenic School also creates the habit of frequent low-intensity activity for gratification.
   In the same light, purely symbolic realization widely used by Sechehaye can be regarded as a kind of activity too, but with the level of energization brought down to the minimum. During the processes of symbolic realization” the patient is also active, although this activity is developing in his mental field. Gratification and activity- impossible for the patient because of his internal conflict – become possible after they have been modeled and rehearsed mentally, with corresponding therapeutic modifications.
   For example, feeling that her patient Renee was too delicate and too guilty to be addressed directly, Sechehaye each day in the presence of Renee picked up a rag doll called “Moses”, rocked him, cared for him and put him carefully in his cradle. At first Renee remained indifferent, then she dared to participate by furtive attention, and at long last Renee’s participation reached the degree of identifying herself entirely with the doll. Thereby Renee found new confidence in living. She agreed to eat from a spoon, but only after her Mama had fed Moses. Thus Renee “constructed her ego, step by step, on the proffered model” (Sechehaye 1956).
   Such re-construction of the ego demands internal activity of the patient as an indispensable condition, although in the symbolic realization of Sechehaye the patient remains relatively passive and the psychotherapist is more active than in the psychotherapy of Bettelheim. As has been already shown above, even in the psychotherapy of Sechehaye, symbolic realization ought to be followed, in the next stages of treatment, by activity and gratification of more externalized kinds. “One must… proceed by  steps, starting from the patient’s centers of interest, radiating out, and acquainting him with ever larger sectors of reality” (Sechehaye 1956).
   We look at both analyzed psychotherapies primarily as very ingenious methods to re-educate their patients in independent activity for gratification, with some direct or indirect limitations of activity and gratification to avoid unfavorable results. Both psychotherapies, and this is their main therapeutic paradox, create at first a new gratifying milieu, which does not directly stimulate activity and can even lessen it at some stage of the treatment, as we have seen in the case of Mary. But the final aim seen to be the ability of the patients for spontaneous independent activity with intensity, and also under the conditions when there is no immediate gratification and no certainty of results. Rotenberg writes about paradoxal methods of this kind: “This I not a call for passivity- this is a call for the refusal from an impasse, from such activity which is akin to neurotic worry… Personality indeed cannot be realized except in becoming and developing, and therefore when one says, “you have nothing to search”, - this is only an artifice to remove the obstacles in the way of such development, an assertion of the highest powers of man, of his transcendence”. (Rotenberg 1986).
   Our analysis of the psychotherapies of Bettelheim and Sechehaye deviates from the psychoanalytic tradition as we lay more stress on the present realities during the treatment than on the past psychological histories of the patients, and more stress on gratification and activity than on the other components of interpersonal relations. That is not say that the insight into the past and the interplay of the other components of interpersonal relations do not play significant part.  But we believe that these important factors would not, or would not be sufficiently therapeutic without the proper handling of gratification and activity.
   The psychotherapies of Bettelheim and Sechehaye have much in common with the dynamic psychotherapy as developed by Ammon, who understands it as “making up of the underdeveloped ego functions” of patients, which subsumes the development of “constructive aggression” and creativity (Ammon1980) as well as the education of  “the experience of success and of positive feelings with respect to one’s existence” (ibid.).  The direct relevance of these ideas and practices of Ammon to our scrutiny of the curative factors in two analyzed psychotherapies seems to be at hand.

W;nscherf;llung und Aktivit;t in der  Schizophrenietherapie: Heilend Faktoren in zwei dynamichen Psychotherapien.
B.S. Rogovoy (Orel)
Der Autor stellt die Frage nach den heilenden Faktoren in den beiden dynamischen Psychotherapien nach Bettelheim und Sechehaye.  Er stellt Gemeinsamkeiten und Unterschiede dieser beiden Methoden gegen;ber und macht einen verschiedene Besonderheiten dieser Methoden gegen;ber und macht einen Versuch, ihre grundlegende Prinzipien – von beiden nicht immer ausdr;cklich formuliert- herauszuarbeiten.  Er postuliert als im Vordergrund stehenden heilenden Faktor dieser beiden Methoden die Wunscherf;llung. Sie dient dem Wiederaufrichten und dem Umgang mit den durch die Krankheit geschw;chten Ich – Funktionen. Dabei ist die Aktivit;t des Patienten eine „conditio sine qua non“,  des therapeutischen Erlernen. Die Wunscherf;llung dient der Verst;rkung und einem Erlernen der F;higkeit, sich zu freuen. Der Autor nimmt an, da; schlie;lich die Freude an der Aktivit;t internalisiert wird.  Diese Internalisierung st;rkt  die Widerstandsf;higkeit gegen innere und ;u;ere Widerst;nde.
  Die  Wunscherf;llung  hat nach Ansicht des Autors zwei Funktionen:  zum einen ist sie ein wirkungsvolles Mittel hinsichtlich der psychischen Regression;  wenn sie richtig eingesetzt  wird (s.u.), verbessert sie aber gleichzeitig die Realit;tsanpassung des Kranken. Diese letztere Funktion der Wunscherf;llung  nennt der  Autor „progressiv“ wirken kann, mu; sie integriender Bestandteil der aktuellen Realit;t sein. Beispielweise sollen deshalb die f;r schizophrene Erkrankungen typischen autistischen Tendenzen nicht verst;rkt werden, da die Patienten sich dadurch von der Realit;t entfernen. Der Autor erw;hnt zu diesen ;berlegungen zahlreiche veranschaulichende Fallbeispiele  aus Bettelheim;s und Sechehaye;s  Arbeit mit schizophren erkrankten Kindern und Erwachsenen.
   Der wesentliche Teil der Wunscherf;llung in beiden Psychotherapien umfa;t dabei die Beziehungen der Patienten zu den ihn umgebenden Menschen.
   Im einen unterscheiden sich die betrachteten Psychotherapieformen wesentlich: Bettelheim wendet die o.g. heilenden Faktoren innerhalb eines Therapeutischen Teams und auch innerhalb einer Patientengruppe an, w;hrend sich Sechehaye nur auf die dyadische Beziehung des Patienten und der Psychotherapeutin verl;;t. Demgem;; nutzt sie mehr ihren direktiven und modellierenden Einflu; auf die spontane Aktivit;t des Patienten.
   Eine notwendige Bedingung f;r die Entwicklung einer Wunscherf;llung Eigenaktivit;t scheint ein spezifisches Heilmilieu zu sein, das einerseits die Patienten von dem Druck, t;tig werden zu m;ssen, befreit, und anderseits eine milde Stimulation und gen;gende Unterst;tzung dieser Aktivit;t gew;hrleistet- was zur Entwicklung und nachfolgend der Transzendenz f;hrt. Die Aktivit;t der Kranken soll nach Ansicht des Autors f;r eine dauerhafte Periode in beiden Psychotherapien zun;chst minimal bleiben. Er erkl;rt die Behutsamkeit beider Psychotherapeuten in dieser Hinsicht damit, da; die mit jeder Aktivit;t verbundene  Energie das Potential an destruktiver Energie erregen k;nnte und somit sch;dlich w;re.
   Die theoretische Basis f;r seine Interpretationvon Bettelheim und Sechehaye  ist durch die Ich-Psychologen White, Spock, Klein und Hartmann, die sich ihrerseits auf die Werke des „sp;teren Freud“ ;ber das Ich und seine Funktionen berufen, erg;nzt.
Der Autor stellt bei seinen Betrachtungen ;ber Bettelheim und Sechehaye Verbindungen zur Dynamischen Psychiatrie nach Ammon her, der im Zusammenhang mit der Therapie archaisch Ich-kranker Patienten von einer nachholenden Ich- Entwicklung f;r nicht oder mangelhaft entwickelte Humanfunktionen spricht. Erfolgserlebnisse und das Empfinden positiver Gef;hle sind Aspekte dieser nachholenden Ich-Entwicklung und stehen im Dienste der Entwicklung konstruktiver Aggression und Kreativit;t.


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The article was published in the journal «Dynamische Psychiatrie” 27. Jahrgang 3./4. Heft 1994