Some Bi

The

Observations

YE1ltl)-

and

FIUED,

authors

\I.I)..

\l)

Questions FRANZ

BRULL,

their observations of acute p.si’chiatric patients in a dat’ hospital. noting the universality ()fthe existential concerns that arise patient has confronted his illness. Thet discuss problem ofwhat determines a cure” in emotional disturbances andsuggest that theprimary issue patients to learn to live as healthy people within o/ their

in Intensive \1.I).

scribed

discuss

individual

Psychotherapy

once the

the

is for the limits

fact that mistakes

potential.

establish a day hospital as a part of an outpatient clinic for the treatment ofacute psychiatric patients in Israel was made by the Kupat Holim (Workers’ Sick Fund) in October 1968 at the Mental Health Clinic of Ramat Chen, Tel-Aviv (I). The day hospital is currently equipped to treat 15 patients for several consecutive hours each day. The staff consists of a psychiFIRST

atrist,

a

ATTEMPT

nurse,

tO

a

psychiatric

social

worker,

and

an

occupational therapist. To date, approximately 500 patients between the ages of 18 and 65 have been treated; the majority have displayed serious psychiatric conditions (half had psychoses and the other half displayed acute symptoms of neuroses and psychoneuroses). Eighty-five percent of these patients were discharged without requiring full hospitalization; the remaining 15 percent required transfer to residential hospitals. Treatment at the day hospital includes pharmacotherapy, individual and daily group psychotherapy, and occupational therapy, and usually takes place over a period of two months. In our intensive psychotherapy for these acute psychiatric cases, we employ the concepts originated by Frieda Fromm-Reichmann (2) in her work with psychotic patients at Chestnut Lodge, Rockville, Md.

a

OBSERVATIONS

Dr. Fried is Senior Lecturer and Dr. BrOIl is Clinical Associate Professor, Department of Psychiatry, Tel-Aviv University Medical School. Dr. Fried is also Director and Dr. BrOIl is Head of the Day Hospital, Kupat Holim Mental Health Clinic, 9 Hatzvi St., Ramat Hatayassim, Tel-Aviv, Israel.

of freedom.’ for

to existence of this complex

but We as

.

.

the

.

trist

or

the

classic

fathom

other

his

awareness fering seek vinced ily)

prevails, (6) of

a form

of de-

emerges.

We

state

generally accompanied

display a by slowness

of additional confrontation in which

hospital

condition

secondary circumofthe patient with suddenly becomes

he

In this

staff

and

ofhimself-the

need

for

depressive or retar-

from others and that ofa pattern ofan illness help.

state

expert

member)

help

“first

his recurwhich he of realiza-

with the unthe psychiawill

him.

be

able

Sometimes

diagnosis”

advice

dethe

condition.”

depressive

without

day

necessar-

Goldstein experience

situation

being and his desire to be advice of his own accord. by others (usually members of the

to

dearly for to this as

is not

tion, he usually agrees to seek expert advice, spoken hope that the expert (in this instance, diagnose

trying

anxiety

catastrophic

emotional

as a result refer to the a situation

to

freedom

complex situation. as the “subjective

aware that he is different ring symptoms are part is unable

in

have to pay (5) referred

nevertheless,

find that our patients mood, not necessarily dation. stances. himself

This

anxiety:

danger Out

unlike

believe

to err and may Kierkegaard

to an already this anxiety

pression

who

meaningful and are therefore concerned find ways of being (3, 4). of reference, the patient is aware of his in shaping his destiny and realizes that mainspring. He is also not blind to the

adding scribed

(7)-as

a suf-

like others cause More often, he ofhis immediate and

to

this him to is confam-

treatment.

This moment of confrontation between the patient and his illness is a moment of truth and of complex inner realization. It can perhaps best be compared to the struggle of Sisyphus, as expressed by Camus (8)-a struggle absurdity as which in this

of emotional the

Approximately four-fifths of our patients display marked symptoms of anxiety and two-thirds exhibit depression. This disproportionate incidence is not related to the actual signs and symptoms of these patients, who do not suffer from anxiety neurosis and/or depression (endogenous or reactive) in the classic sense of the words. Their anxiety tends to be more related to the state de-

existentialists,

he is likely in judgment.

cause

against absurd, ClINICAL

the

the “dizziness ily

THE

by

make existence with attempts to In this frame freedom of choice he himself is its

day

ThREE

the meaning case is the

despair

or insight

of life and against disease. It is at this

that

the

patient

hospital.

ESSENTIAL

QUESTIONS

We have noted that three questions invariably when the patient reaches the stage of confrontation his condition and the resulting despair. First, the seems preoccupied with the question, “What know?” This this in general “second

the

stage reaches

is a question medicine

(7).

diagnosis”

Am

of limitation. and termed

The

J Psychiatry

patient’s

132:7,

the

arise with patient can I

Balint referred to essence of it the

efforts

July

to find

1975

the

707

INTENSIVE

PSYCHOTHERAPY

ion. This pretation

answer to this nagging problem are often hidden in other questions such as “Do I have cancer?” “Is it heart disease?” These questions refer to the chronicity of the disease. The patient may approach the question indirectly by asking, “How severe is my illness’?” “Is it hereditary?” “Is it a recurring condition’?” Such questions are not necessarily

directed

sarily

be

called

“

to

conclusions. The second tion tion.

disease. [There untrue.] What a vital, serious, considers the one

general

emerges

need

mere him

or

not

presence to draw

at this

chronicity asks, “Suppose

rather

than

most

important

of the and

and

him. The may lead

stage

recurrence I really

neces-

of sohis own of realiza-

of the do have

condisuch a

is still some disbelief or hope that this is can I do about it? How can I live’?” This is and difficult moment in which the patient possibility of living with the disease as a

person

haps

psychiatrist

question

of the possible The patient

healthy

the

answered by repeat” patients

tory

will

as a sick

person.

aims

be discussed

later

This

is per-

of psychotherapy

in greater

in

detail.

When this moment passes. the third question arises. “What can I hope for’?” In the absence ofconfidence that he will recover and with only feeble hope remaining. the patient

may

find

himself

in a moment

lead to suicidal tendencies. We find that almost all of our questions

in some

form

or

ofdespair

that

patients

refer

--sonic

directly.

another

can

to these These

questions - “What can I know’?” “What ought I to do’?” “What can I hope for’?” -have a history in our cultural heritage and were posed previously by Immanuel Kant (9). As they appear in the course of intensive psychotherapy, the questions are linked with the patient’s confrontation with the disease during a stage of insight into his condition, which results in despair and anxiety or depression along with an awareness of the possible implications of being in such a condition.

INSIGht!

ANI)

CURE

We wish to report an incident that haps the crux of the problem facing tensive mate

psychotherapy goal

At the with

the

and

of our

day

completion passing

what

is also

what who

perhaps

is peruse inthe

ulti-

hospital.

of a term of

raises those

her

of treatment,

psychotic

cycle,

which

ended

a patient

said,

“Doctor, you did not cure me, but now it is different. It is not any easier-in fact, it is more difficult ---but it is different.” This statement (which the patient did not clarify) emphasizes and exemplifies the lack of finality at the end of a course of treatment. The patient was not cured, but it -

was

“different.”

The

question

that

naturally

arises

at this

point is, What is “cure,” and what are its goals’? The ideal situation is one in which a patient suffering from a specific complaint (such as a toothache) is relieved of the ther

symptom filled

and

or extracted.

suflers

no

more,

i.e.,

if fashion

However,

the

tooth

decrees

is ei-

that

a

gap in the teeth is unattractive, a replacement for a pulled tooth will he sought in the form of an artificial tooth. In the latter sense, cure is dependent on the whims of fash-

708

Am

J Psychiatry

/32:7.

July

1975

(10).

zeitgeist of man’s Von

is also responsible image at a particular Gebsattel

(I I)

said,

for the moment “The

interin his-

paranoiac

patient’s point of view becomes paranoiac if the patient stops living in a world where ‘Selbstverstandlichkeit’ [that which is self-evident] is self-evident and not dangerous.” In such a world, insignificant happenings take on meaning. Von Gebsattel added, “It is only due to paranoiacs that we are able to appreciate the inner peace of our world, in which there are happenings which are accidental in nature, without personal reference” (p. 128). Binswanger said, “The manic world appears to be a changeover from ‘steigen’ [to climb] to ‘versteigen’ [to climb

too

high.

too

far]”

(12).

We must also not lose sight ofthe fact that every physician anticipates cure according to his own individual concepts. Sartre(13) warned us against playing God. The question of how to be healthy replaces that of how to be cured. This question is also relevant when applied to anxiety and depressive states. Each individual is mainly be cause of what was. The most difficult task of the psychiatrist is to understand and attach the right amount of significance to what wasan evaluation of the past in terms of the present. This requires not only acute perception but also a great deal of involvement on the part of the psychiatrist in order to achieve total insight into the problem. The significance of the therapist-patient relationship cannot be stressed enough. Heaton ( 14) said of insight on the patient’s part that “reflection leads us to the fundamental phenomenological insight that experiencing is absolute: that essence or fundamental meaning is accessible only in and through the actual situation in which it appears.” He added, “Insight is developed by reflection on experience, and the more passionate the experience, the deeper the insight.” It is this experienced insight, on an emotional level, that is such an important and invaluable tool in intensive psychotherapy. In psychoanalysis. an attempt is made to make the unconscious conscious through words. Insight at this level, which is reached by patients at the stage of asking the three questions we previously discussed, seems to be the first positive sign on the long and difficult road to cure. Again we ask, What is cure in its totality’? It could be defined as the state that is reached when treatment terminates by mutual agreement of the doctor and the patient. In the case of general medicine, such a decision may be reached more easily when specific complaints are relieved. With mentally disturbed patients, whose symptoms are of an abstract nature, the decision is far more complex. Often, only in retrospect does a patient realize that he was once very ill. Alternatively, it may be that he has merely learned to live as a healthy person, attaching only secondary importance to his symptoms and living within the limits of his own potential. Perhaps this is what

our

patient

meant

when

she

described

her

condition

after a period of therapy as “different.” This seems to be the closest we can come to successful cure with the mentally disturbed --changing a sick person to one who is “healthy” but has a disease. The patient thus consciously

YEHUDA

accepts the bad and the good as part of the whole, and in so doing is able to lead a fuller and more meaningful existence within the limits of his ability and his own interpretation.

5. Kierkegaard Princeton. 6. Goldstein

7.

REFERENCES Fried Y. BrOIl F: Intensive psychotherapy for acute psychiatric patients in a day hospital setting in Israel. BrJ Psychiatry 2 12:635 639. 1972 2. From m-Reichmann F: Principles of intensive psychotherapy. Chicago. University Press, 950 3. May R: The Meaning of Anxiety. New York, Ronald Press Co. l950 4. Maslow A: Toward a Psychology of Being. 2nd ed. New York. Van Nostrand Reinhold Co. 1968, pp9- 15

8. 9. 10.

I.

II. 12. 13. 14.

5: Fear NJ, Princeton K: Functional

FRIED

AND

FRANZ

and Trembling. Translated by University Press, 1941 disturbances in brain damage,

BROLL

Lowrie

W.

in Ameri-

can Handbook of Psychiatry. vol. 1. Edited by Arieti S. New York. Basic Books. 1959, pp770 796 Balint M: The Doctor. His Patient and the Illness. 2nd ed. London, Pitman Medical, 1964 Camus A: La Myth de Sisyphe. Paris, Gallimard, 1942 Kant I: The Critique of Pure Reason. London. Kemp Smith, 1933 Schilder P: The Image and Appearance of the Human Body. New York, International Universities Press, 1950 Von Gebsattel VE, cited by Bendedetti G: Der Psychich Leidende und Seine Welt. Stuttgart, Hyppok rates Verlag, 1964 Binswanger L: Drei Formen nissgluckten Daseins. Tubingen, Niemeyer, 1956 Sartre JP: Being and Nothingness. New York, Philosophical Library, 1956 Heaton JM: Insight in phenomenology and psychoanalysis. Journal of the British Society of Phenomenology 3: 135 145, l972

Am

J Psychiatry

132:7,

July

1975

709