Meaning-Focused Therapy

Meaning centered counseling Lecture No 11

Depression and Schizophrenia

Paul T. P. Wong, Ph.D. C.Psych
Tyndale University College, Toronto, Ontario


Endogenous psychoses

  • Endogenous psychoses are primarily caused by constitutional or somatic disorders, but they may be triggered by extreme stress, sudden loss, and other critical psychological events
  • Endogenous mental illnesses include endogenous depression, schizophrenia, and bipolar disorders
  • Psychogenic refers to the psychological contents that contribute to delusion though processes

The role of logotherapy

  • The psychogenic aspects of endogenous psychoses are treatable by logotherapy.
  • Logotherapy can engage the spiritual dimension and appeal to their residual freedom so that they can realize attitudinal values.
  • The patient “can shape his destiny and decide how he will react to the constitutional disease” (p.200).
  • Psychoses require drug therapy to treat the underlying somatic causes or the symptoms.
  • Psychoses also require psychotherapy to help patients cope better and avoid secondary depression.
  • In-patient treatment may be needed when patients are at risk of committing suicide.

Checking for a suicidal intention

  1. Are you entertaining the idea of killing yourself?
  2. Why don’t you want to kill yourself anymore?
    Those who try to hide their suicidal intentions cannot answer question 2.
    Progression towards suicide: Thoughts – Intentions — Attempts

Endogenous Depression

  1. It is a somatogenic mental illness.
  2. DSM-IV calls it Major Depressive Disorder (MDD), or unipolar when compared with bipolar disorder.
  3. A subtype of clinical depression is called MDD with Melancholic Features.
  4. Symptoms (Triad of failure): An inability to work; an inability to feel pleasure, and an inability to suffer for a reason.
  5. The tension between what is and what should be is called the “existential tension.”

Symptoms of MDD according to DSM-IV

  1. Must either have a depressed mood or a loss of interest/pleasure in daily activities.
  2. This mood must be very frequent and intense, different from the person’s normal mood.
  3. Markedly diminished interest in all or almost all activities most of the day nearly every day.
  4. The symptoms cannot be accounted for by bereavement or medication and persist for longer than two months.
  5. Marked functional impairment in normal social and occupational situations.

In addition, there must be at least five of the following symptoms:

  1. feelings of worthlessness and excessive or inappropriate guilt nearly every day
    diminished ability to think, concentrate, or indecisiveness, nearly every day
  2. recurrent suicidal ideation
  3. psychotic symptoms
  4. significant weight loss or weight gain
  5. insomnia or hypersomnia nearly every day
  6. psychomotor agitation or retardation
  7. fatigue or loss of energy nearly every day

The psychogenic and existential component

  1. This irresolvable and unalterable distance becomes enlarged into an abyss
  2. “There is the sense of the falling away of the self and the world, of beings and meanings” (p. 206)
  3. “Steeped as he is in a feeling of his own insufficiency, the melancholiac becomes blind to the values inherent in his own being. This valuational blindness is later extended to the world around him” (p. 204)
  4. “The melancholiac feels himself as worthless and his own life as meaningless – hence the tendency towards suicide” (p. 204)
  5. Depersonalization in terms of attitude: “I am nobody – I am not in the world”

Psychotherapeutic Treatment of Endogenous Depression

Importance of acceptance

  1. Need to address anxiety. The existential anxiety of self-reproach and guilt feeling is a unique human condition “as a result of the interplay between the human and the morbid elements in the human being” (p. 200).
  2. “The melancholiac’s anxiety of conscience arises out of an intrinsically human experience: that of heightened tension between the need and the possibility of fulfillment.
  3. The patients need to accept the fact that they are sick and they need help.
  4. They need to accept their depression as an endogenous illness in order to counteract their tendency towards self-blame
  5. Reassure the patients that it is only human to accept the gap between what is and should be and their exaggerated reaction is due to their illness.
  6. It is not the existential tension that makes patients sick; it is the endogenous depression that makes the patient distort the tension.
  7. We need to relieve them of all duties in order to reinforce the message that they are sick.
  8. Sometimes recommend hospitalization.

Importance of belief and trust

  1. However, we need help them believe that mood disorder has a very good prognosis and they will become healthy again.
  2. They need to know that their inability to find meaning or value is due to their endogenous depression. Therefore, they need to refrain from making judgments and decision, when they are still ill.
  3. We want to relieve them of at least some work in the milder case of endogenous depression so that they not only realize they are ill, but that they are free from duties.
  4. We need to demand that they believe in their physician’s promise of recovery and be patient with themselves, waiting for the recovery.
  5. Supportive psychotherapy will help the patients navigate through the depressive phase, but they need to be committed to the regimen of medication, rest, trust and patience.
  6. Eventually, they will discover new insight and bestow new meaning on their illness; this will facilitate recovery and healing.

Prevention of secondary depression

  1. Psychotherapy cannot do much about endogenous depression, but can address the spiritual core of the patient and focus on her attitude towards her illness.
  2. Less suffering if patient learns not to be psychologically depressed over their endogenous depression.

The Symptoms of Schizophrenia

  1. Suffer from delusions and hallucinations
  2. Can’t tell the difference between real and unreal experiences
  3. They hear voices and think aloud as if their thoughts come from outside
  4. Inability to think logically
  5. Inability to show normal emotional or social responses to people or situations

Symptoms of paranoid schizophrenia

  1. Feel being persecuted or plotted against them
  2. Entertain grandiose delusions
  3. Want to protect themselves from the perceived plot
  4. They are tense, suspicious, and guarded
  5. Usually do not suffer from the disorganized speech and behavior

The psychology of Schizophrenia

  1. They suffer from a “film delusion” – they felt that they were filmed by an invisible camera and a hidden camera man.
  2. This feeling had no auditory hallucination – they did not hear any sound related to the filming.
  3. They claim that they could see themselves in the film or newsreel.
  4. Some with a paranoid basis maintain that their enemies or persecutors were spying on them by secretly taking pictures.
  5. The delusional feeling is primarily “experience of pure objectness”, which is an aspect of the central disturbance of the ego.
  6. In schizophrenia, the ego is limited or reduced in both consciousness and responsibility – two important existential factors.
  7. “The schizophrenic experiences himself as if he, the subject were transformed into an object” (p.209).
  8. The schizophrenics feel depersonalized to the point that their very humanness is affected.
  9. In depression, the human person can shape the disease process; in schizophrenia, the humanness itself is shaped by the disease process.

Existential analysis of psychoses

  1. Must make two points: (a) To objectify the illness as a fated occurrence, and (b) to distance himself from the illness.
  2. Help the patient to see the image of the real person apart from the subjective image of illness.
  3. Help the patient to see the spiritual core which is beyond neurosis and psychosis.
  4. Posits the existence of a spiritual core which cannot be injured by psychoses.
  5. Appeal to their diminished capacity for freedom and responsibility to awaken or discover the defiant power of the human spirit.
  6. Show that the patient is capable of shaping psychosis by bestowing some meaning on the illness.
  7. The life of psychotic patient is still worth living – he can still maintain the dignity of a suffering person (Homo patiens).
  8. The human spirit is still dependent on the service of its body, which may terminate its service.
  9. Therefore, existential analysis is considered only clinically light to moderate cases of psychosis.