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Schizophrenia is a tragic condition which strikes
too many families throughout the world. But
schizophrenia is a diagnosis and we should not treat
a diagnosis, we treat human beings.
It is important to realize that the attitude of the
professionals who treat this very difficult
condition make a difference very often, between
success and failure in treatment. A positive
attitude becomes a self fulfilling prophecy. The
attitude is transferred to the patient and if you
feel a sense of hopelessness as a professional,
certainly the patient is not going to feel very
hopeful.
This lecture is going to discuss some of the issues
related to the lowest functioning individuals with
this condition. It is important to realize that
there are levels of schizophrenia, different degrees
of this condition which make treatment and the
effects of treatment certainly more positive with
the highest functioning group. That is not to say at
all, that lower levels of functioning cannot respond
successfully to an active and well established
treatment program. There has been a good deal of
research which points out very vividly that even the
lowest functioning individual with schizophrenia
given the right conditions, can make good social
recoveries. It is important, I believe, to focus
this Newsletter on those human beings who have been
largely abandoned by the mental health professionals
because they are very difficult to treat.
There are not many in the professional world who
want to put the effort into treatment, with the
poorer functioning patient that treatment with this
level of schizophrenia requires. These patients who
I consider abandoned by the profession are largely
treated by medication alone. I must insist that I am
not opposed to medication. However, it is quite
clear at this point in the literature and with much
research that medication by itself is not enough to
meet the needs of these unfortunate human beings.
Active psychotherapy, notice that I emphasize
‘active’ as opposed to the old traditional model of
passive and neutral psychotherapy. This is a very
important part of the treatment package. Also
included in this overall treatment approach is
psychosocial rehabilitation. One of the faults I
find with this effort is that psychotherapy has not
been integrated into psychosocial rehabilitation. We
should bear in mind that no matter how effective a
complete treatment approach is, it still requires
change and further development. Each modality that
we have needs to be examined and needs to be
understood not only in terms of what its purpose is,
but what are its limitations. It should be quite
clear that medication by itself is limited, by
itself, it is not effective in leading to recovery.
This is my opinion, based on my experience but it is
also supported by many research studies that have
been done throughout the world. We have to
understand the limitations of every effort that we
make with this very difficult disorder. We must be
honest with ourselves in order to further the
effectiveness of treatment for every level of this
condition that we call schizophrenic.
There are people who claim that anyone who has been
said to have schizophrenia and has been successfully
treated has been misdiagnosed. These are people who
are unable to work with this population and try to
justify their incompetence by saying it cannot be
done. If they can’t do it, that is, treat this
condition successfully, it doesn’t mean that it
can’t be done. If they do not want to do it, they
should not try. They do not have any right to state
that the people they cannot reach are hopeless. I
have heard this many times during the course of my
career and it is very unfair, even worse, to put a
label of this kind on any person. To quote Karl
Menninger who wrote in the late fifties that
"schizophrenics have been long incurable, because we
the treators, have been hopeless."
We often hear statements such as, you have to learn
to live with your schizophrenia. Why? The reasons
are quite apparent, if you look at it carefully
enough. There are not enough people in the world who
are trained or skilled enough in the treatment of
this very difficult condition. Why can’t they say,
that I just can’t do it? Or perhaps their egos won’t
permit them to say, I can’t do it, however, I will
recommend somebody who might be able to help. A
small example; if I was an automobile mechanic and I
couldn’t fix your car, would that mean that it is
beyond repair? This brings to mind a very important
point. Why is it that we have not developed better
and more training centers so that young
professionals can be stimulated and trained to work
with the schizophrenic person.
Another problem that comes to mind, which has
effected treatment remarkably is the rise and
dominance of the managed care system. They do not
allow for the treatment of schizophrenia with any
modality, besides medication. As a matter of fact,
they will not accept anybody that has that
condition. If it erupts while insured, then they are
sent to a psychiatrist who medicates them and there
is no end to this form of treatment, which leaves
them handicapped on a permanent basis. This is not
cost effective. This is also not humane and there is
not any consideration or feeling of concern beyond
the profit margin. Recent discussion in government
talks about the parity between the physical and the
mental, we can only hope that someday it comes to
pass. If it does, however, there needs to be
increased consideration for the development of
community based treatment centers and alternatives
to hospitals. It is quite clear that hospitals are
iatrogenic and not the best places to treat these
patients. That understanding began decades ago and
the enormous costs of hospitalization led to
deinstitutionalization without any adequate
preparation so that many of the patients who were
housed in hospitals were cast into the streets,
reside in jails and live in smaller institutions
that are called board and care homes. In order to
effectively treat this population and reduce the
misery of their existence and the cost of
maintaining them in non therapeutic environments we
need to, as I said, develop the correct methods of
treatment and housing.
A question occurs to me, what is better bad
treatment or no treatment. In my opinion, a person
with this condition would be better off not being
treated than being treated badly. I am referring to
non medical treatments and also the inappropriate
and over prescribing of medication by the
psychiatric world.
During the course of my experience, I had the
occasion of acting as a consultant in a Norwegian
Hospital in Molde, Norway. I found a ward of
patients who had never been treated by psychotherapy
or related treatment modalities easier to reach than
those patients who were treated with these methods
by professionals who were indifferent. In my
opinion, no treatment is better than bad treatment.
It has become apparent to me that bad treatment
leads to a greater sense of hopelessness and
characterological defects that prevent or handicap
even the best of treatment from helping those
individuals make good social recoveries.
I was responsible at the hospital that I mentioned
above with the consent of the Norwegian Government
in creating a program of treatment for young
schizophrenics in Norway. I worked with a number of
patients there and the easiest patients for me to
contact were the patients who never had any formal
treatment. Those patients who had treatment by
professionals who were really indifferent and I met
many of them, were the most difficult to make
contact with and treat. However, with much effort
contact was made and the patients responded
favorably and made good social recoveries.
In a follow up study recently in that ward where the
patients were housed, all of them had been
discharged from the hospital into their own
apartments or environments such as group homes and
were prospering with continued after care.
Everyone who reads this article is interested in
schizophrenia and over the years in the many
lectures that I have given, in the fifteen countries
that I have had the privilege of presenting my work
in, I have asked audiences this question, what is
schizophrenia? I have been constantly surprised that
almost no professionals had an answer for this
question. Is it important? I think that it is, that
having some understanding of this human process will
certainly make treatment much more effective and
give the therapist some greater understanding of
what he or she is trying to reach beyond the
symptoms and the characteristics. Anyone who has
seen the terror in an acute episode should realize
how desperate the individual is to overcome what
they perceive as a life threatening situation. They
lose track of their identity. There is a sense of
disintegration. They strike out at the fear that
surrounds them in an effort to find some relief.
Finally, there is some modification of this fear,
this great fear is processed into symptoms and
characteristics which reduce the fear. Then we see
that schizophrenia has become a survival system with
its own language and a logic that is more primitive
than what we use. If we understand this well enough,
the task of reaching the patient and the importance
of making contact and effecting a relationship
becomes more obvious and there is some better
direction to our efforts.
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