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There is so much
material that needs to be discussed about the
treatment of schizophrenia, that I hope each month I
will be able to select a topic of discussion that
will clarify some of the treatment issues and share
with you some of the thoughts or ideas that I think
are basic to the understanding of what treatment is
with this population.
The word schizophrenia stimulates fear and
misconceptions in many people, including
professionals. They, the patients with this
condition called schizophrenia, are often viewed as
unpredictable in their behavior and dangerous to
others. This is far from the truth. These human
beings who are afflicted with this condition are
usually not dangerous to others, in fact, they are
far less homicidal than those who do not have this
diagnosis, they are, however, more suicidal. The
etiology of the condition remains unknown, even
though there are many speculations as to its causes.
To quote the distinguished Psychiatrist Manfred
Bleuler, the son of Eugene Bleuler, "as for the
origin of the schizophrenic psychosis we must openly
confess that even the considerable research of the
last hundred years, has not produced the discovery
of a specific cause. It seems probable that such a
cause does not exist" . Eugene Bleuler, who coined
the word schizophrenia, defined it as a group of
related disorders. Psychiatrist Leopold Bellak and
others view it as a syndrome. More than thirty years
ago, Silvano Arieti, a major figure in the field of
schizophrenia, summarized the outcome of sessions at
the Second International Congress for Psychiatry,
devoted entirely to this disorder. "There was not a
single concept of schizophrenia advanced by any
attendant psychiatrists that was not rejected or
challenged by some other authors. Even the name
schizophrenia was disapproved by several people".
The above, certainly reflects much confusion about
this condition even among those opinion leaders. In
my opinion, it is our responsibility to find ways of
educating professionals as well as the general
public in order to explain this process in an
understandable and less bewildering way. These
patients are terrified human beings who are as
confused about their condition, as is most of the
world. They want help, but what they usually
experience is not effective enough. They do not know
how to help themselves - so the professional world
must continue its struggles to find better solutions
to these problems and to make it a more
understandable condition.
Schizophrenia is very often seen as a condition that
is chronic and unchangeable. At best, it is seen, as
having periods of remission, but will always be a
part of the individual and prevent that person from
functioning productively. The word chronic, does not
fit all patients. Loran Mosher, the American
Psychiatrist, writes that the word is disturbing in
that it becomes a negative fulfilling prophecy and
substitutes the word "veteran" for the patient with
a long tern history, which suggests an attitude of
hope. Sylvano Arieti and many other distinguished
contributors speak in optimistic terms about the
patients potential for change and some degree of
recovery. Robert Liberman states there is no longer
any question of these patients being able to make
good social recoveries. The big question is how
quickly can it happen.
The focus of treatment is usually on symptom control
and that seems to be a common objective of treatment
in many parts of the world. However, many years ago,
Harry Stack Sullivan stated . There are healthy
parts in the individual who has that condition which
are not commonly regarded and/or separated from the
pathology and reinforced.
In the process of deinstitutionalization, patients
with this condition are warehoused in board and care
facilities that do nothing more than house, feed and
medicate them. A majority of these facilities go no
further than meet these minimal requirements. The
ratio of staffing with patients, is usually low and
the staff commonly has little or no training.
Psychiatrists visits meet legal requirements, but do
not allow enough time to have more than a
superficial understanding of the patient. As a
consequence, patients are often medicated beyond
their needs. Unfortunately, there are few
alternatives to board and care facilities at this
time.
It is important to point out that medication can be
harmful, as well as helpful. With many of the
phenothiazines, there are side effects that can
cause irreversible neurological damage yet in these
facilities - there is usually no treatment, besides
medication. Even the newer medications that have
fewer side effects can pose some serious dangers if
not properly monitored.
The state hospital system has been and is a costly
failure for those patients who have schizophrenia.
They are unable to provide their residents with any
more treatment than that which exists in the board
and care environment. Yet, their cost of treatment
is incredibly high. Perhaps the state system is
justifiable for high risk patients that pose a
threat to others and themselves - yet - one should
question - what methods do they use to reduce these
risks? It seems to me that they do no more than hold
patients in closed wards and use medication, which
does not help these patients overcome the dangers
their condition poses.
County psychiatric hospitals are beleaguered with
patients whose insurance is inadequate and those
without any financial support. They are understaffed
and often, meet only minimal requirements.
In the private sector hospitals, because of
insurance limits and the absurd restrictions of
managed care, the acutely disturbed schizophrenic is
stabilized with medication and perhaps some
supportive therapy and then is discharged.
Frequently, there is no after care treatment that
they accept or fits their needs.
There are few programs that give these human beings
the opportunity of regaining personal, interpersonal
and productive skills lost in the process of their
condition. There is a sense of futility and
hopelessness that pervade this massive population of
human beings, even though many have qualities that
can lead to change given the opportunity.
When we look at the most
frequently used treatment methods, medication,
psychotherapy, psychosocial rehabilitation, we can
see that separately and even together, they have
succeeded and they have failed. I believe we have to
be aware of what happens between patients and
therapists, to better understand why so much failure
and why so little success. Methods are very
important, but only as good as the people who
deliver them. The attitude, emotions, effort and a
mutual attachment, are at this point, in my opinion,
the determining factors in effective treatment.
The disparity in the belief system of the patient
and the psychotherapist can create insuperable
barriers to successful treatment. Unfortunately this
happens with some frequency, unless the
psychotherapist in making contact and establishing a
therapeutic level of communication, with the
patient, can find some agreement as to what is the
definition of the patients condition. If no
agreement is concluded and the psychotherapists
views are not shared by the patient then treatment
will not happen.
There are many viewpoints about the origin, nature
and meaning of schizophrenia. Some of these ideas
are within reason and some of these ideas are so far
apart from reality they add yet another dimension of
resistance to the overall treatment of this problem.
When we discuss what schizophrenia is, with patients
and non professional people, it is essential that we
come up with some understandable explanations of
this condition. Does it make sense or is it logical
to talk in terms of schizophrenia being a brain
disease!
Many mental health professionals have specified a
multitude of organic reasons that cause
schizophrenia. There is talk about genetic factors,
too many dopamine receptors, or other statements
related to parts of the brain. These statements are
made repeatedly, yet there is no conclusive
confirmation. However, even if there is some truth
to the above, this does not explain this condition,
we call schizophrenia in understandable terms to
patients, relatives and even to many professionals.
These ideas of schizophrenia as a disease or a
medical illness can and often does make the patients
perception of his/her condition incompatible with
psychotherapy or other non-medical treatments and
may lead the patient to believe that these treatment
modalities are not applicable to his/her problems.
In that context, the incompatibility of both parties
evaluations prevents the development of a
collaborative treatment effort.
When schizophrenia is seen and described as a
disease, then the primary model of treatment becomes
medical. Medication is the treatment focus and
patients, relatives and many professionals
throughout the world see this modality as the only
way to approach this condition.
When the anti-psychotic medications were introduced
in 1954, they were heralded as the "wonder-drugs"
miracles that would overcome schizophrenia by 1970.
They did not turn out to be the miracle cure, but
they did make a contribution. I have no doubt that
medication is a useful tool in treatment. However,
we cannot permit it to grow or become something it
isn't. It is not the only treatment method of
importance, nor does it, when used by itself, lead
to some degree of recovery. It is primarily used to
offer some relief from symptoms, therefore, the
symptomatic relief lasts as long as the medication
is used.
In 1968, the English Psychiatrist, Phillip May did a
research study at Camarillo State Hospital,
comparing medication with psychotherapy and his
study, in brief, discounted the usefulness of
psychotherapy. His research design and methods were
widely criticized and in 1976 he published another
research study done at Camarillo, which found both
psychotherapy and medication combined, were more
effective than when used separately. However, his
initial study discouraged many professionals in the
use of psychotherapy with schizophrenia for years.
Today, even though research throughout the world
have reached the same conclusions, psychotherapy
continues to be discounted by many of those involved
in the treatment of schizophrenia. This attitude is
either a function of biological beliefs, which
excludes the importance of other treatment methods
or these professionals who are unable to effectively
use psychotherapy.
This brings to mind an experience I had in 1975. I
was invited to make a presentation in Denver at a
meeting of the Ortho-Molecular Society by one of its
members, who had referred patients to me for
psychotherapy. The initial research in
Ortho-Molecular therapy was done by Doctors Abram
Hoffer and Humphrey Osmond in Saskatchewan, Canada
in the early 1950's. They used Niacin as a
tranquilizer and claimed good results. The initial
research was never replicated, however, many
psychiatrists and many mental health professionals
saw it as being useful and practiced Mega-Vitamin
therapy, for several decades. Linus Pauling, the
distinguished scientist and the sole recipient of
the Nobel Prize on two occasions was responsible for
the term Ortho-Molecular. This alternative treatment
method, claimed many followers during the years,
however, it is rarely heard of in these times. The
meeting, in Denver, was attended by several hundred
of these psychiatrists and I was pleased with their
response to my presentation. However, prior to my
presentation, the psychiatrist who made the
invitation to me said "take it easy with them, most
of them had tried to do psychotherapy with
schizophrenia, but did not succeed". I found their
position acceptable in view of the fact that they
admitted they were not able to use psychotherapy
with schizophrenic patients. This was an honest
representation of their experience without any
effort on their part to deny the effectiveness of
psychotherapy. Even though not all of the
psychiatrists agreed that psychotherapy was a useful
treatment method. There are also other professionals
and psychiatrists, who cannot or choose not to
practice psychotherapy, but do in fact find it a
useful treatment method with this condition called
schizophrenia. This rapprochement between methods, I
find to be reflective of mature and open minded
professionals.
The treatment of schizophrenia is a difficult
struggle for both the psychotherapist and the
patient. It requires a strong commitment and a
willingness of the psychotherapist to consistently
engage the patient in an effort to influence change.
The rewards of treatment are very slow in coming and
often difficult to perceive. In the heat of the
treatment struggle, for years, I have seen
professionals yield, because of the enormous
treatment demands. I believe that not understanding
what treatment basics are, can lead to an
overwhelming draining of energy, which can persuade
the psychotherapist to withdraw from being actively
involved in the psychotherapeutic part of treatment.
For example, the loss of concentration, on the
importance of making contact that leads to a
meaningful relationship that allows both the patient
and the psychotherapist to arrive at a shared belief
system, can be a dissuading influence on the
psychotherapists efforts in the active involvement
in the life of the patient. Also, we must be aware
that the schizophrenic condition can and does
frequently arouse many uncomfortable feelings in the
psychotherapist. The feelings of discomfort, also
may drive the psychotherapist away from continuing
any meaningful contact with the patient.
Should this occur, the psychotherapist may feel a
sense of defeat and retreat from the treatment
struggle and refer to medication as the more
important treatment method. This is then passed on
to the patient, who again believes that he/she has a
disease, which only medication can be of any use.
Psychotherapy is important as is medication. Of
course both modalities should be applied by
professionals who are aware of how important it is
to provide the patient with the hope that he/she can
improve the quality of their lives. Treatment forms
should not be separated from each other. We find, as
our understanding of the long term schizophrenic
grows, there are treatment modalities that need to
be utilized along with psychotherapy and medication
in a contiguous manner.
The psychosocial rehabilitation areas wherein
modules are designed to fit the level of the
patients condition are very important in helping us
arrive at the best outcome in treatment. Let me
emphasize that psychosocial treatment modules, need
to be adapted to fit the level of that patients
schizophrenic condition. The method must be adjusted
in order for the patient to understand and respond
in a satisfactory manner. The length and the
severity of their condition requires a strong effort
in the areas of resocialization and rehabilitation
to help the patient regain personal and
interpersonal skills and whenever possible, training
in productive labor.
However, I believe it necessary to return to the
major theme, the shared belief system. It is clear
to me that this begins with a concentrated
psychotherapeutic effort that helps the patient
understand that he/she does not have a 'brain
disease" or in fact any disease related to his/her
condition. Then it follows that the patient
understands their condition well enough and can
respond to a variety of treatment forms that
function as a whole and they can begin to act in
collaboration with in treatment. This shared belief
system is a major key to the patients collaboration.
Without this shared belief system the results may
very well be superficial.
IN CONCLUSION
Let me state that it takes a skilled and willing
psychotherapist to establish a treatment direction
that leads to a successful outcome. Psychotherapy
must be recognized as the integrating force in
treatment, without it, I believe, that medication
and psychosocial rehabilitation cannot sustain the
patients improvement in the quality of their lives.
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