Newlstter for
February - March 2000
by Jack Rosberg,
Executive Director of the Anne Sippi Foundation

Understanding in the Treatment of  Schizophrenia

In my last Newsletter, I made mention of some of the important steps in reaching that individual who is schizophrenic.  I believe it’s worthwhile repeating.  What is the first step in treatment with this person.   Making contact with some substance to it, is the first step.  If you don’t make the first step, if you don’t make contact with these people in a meaningful way, there is no second step.  The first step, has to prepare the patient for treatment.  Treatment does not happen without this first step.  In the beginning of psychotherapy and other forms of treatment, there isn’t any relationship and even though the person may want something from treatment, they are also skeptical, doubtful, that this will take place.  There has to be some relatedness between you and that person.  In the majority of cases the long term schizophrenic has been through many treatment efforts that have not succeeded and which understandably makes that person wary.  These individuals feel like they have failed, they also feel like the mental health system has failed them.  They have been disappointed and they are ashamed of their condition.  We have to make contact that leads to a therapeutic alliance.  Treatment cannot be successful without the therapeutic alliance.  Even when you effect the therapeutic alliance, it is of great importance for the therapist to be aware that any number of things can break that alliance and treatment will not succeed until the break in that alliance is repaired.  This is not only true of the psychotherapist, in my opinion, it is also true of the psychiatrist prescribing medication and those people involved in psychosocial rehabilitation and in fact all the people who are part of the treatment effort. 

It is important to acknowledge the fact that treatment is an influence process.  It’s not merely a platform to gather some information and understanding of that person’s past.  We are dealing with the reality of today and are attempting to make changes in the reality of today because that person doesn’t feel good enough and has a very poor image of them selves.  Even though they may have delusions of grandeur, they feel ashamed of their condition.  This sense of shame is continuous during the course of their illness and I think that it needs to be looked at and brought to the surface so they can take a look at themselves beyond the pathology.  We focus on the pathology because it appears to be so interesting that we forget that no one, to quote Harry Stack Sullivan, “is utterly schizophrenic.”  They have healthy parts to themselves and if we can find these parts, if we can bring them out and reinforce it, it sometimes tends to modify the pathology. Then the healthy parts begin to emerge and the individual’s self image improves and there is a reduction of course, in this feeling of shame that I mentioned. 

If a psychiatrist says to the patient, “you have a brain disease” what is a disease, what does this mean to the individual who has schizophrenia?  Eugen Bleuler, who coined the word schizophrenia, called it a group of related disorders.  When we talk about looking for the cause of schizophrenia, Manfred Bleuler stated that there could be a hundred different causes.  There is some reason to be concerned about the direction that research is taking in respect to the causes of schizophrenia, however, as treators that should not be our primary concern.  We need to concern ourselves as treators in developing better treatment methods including psychotherapy, psychosocial rehabilitation and perfecting the art of prescribing medication.  I believe that it’s folly to think of these treatments, as being scientific, they are art forms and are as good as is the person who uses these forms of treatment.  For that reason alone, it is not difficult to understand why treatment has not been more successful.  We need to find better ways of dealing with this problem.  If a psychiatrist looks at a patient and the patient says “what’s wrong with me” and the psychiatrist says “well you have schizophrenia.”  What is that?  The word itself certainly is frightening.  It produces all kinds of erroneous thoughts.  Or what is schizophrenia?  The psychiatrist may say, “it’s a brain disease.”  If that happens, the patient is armed with another defense mechanism.  If the psychotherapist sits down with that individual and states that he or she is there to help that person understand how to change their behavior so that they can live more comfortably and the patient says “they can’t because the doctor says I have a disease.” 

If the reader thinks that I am spending too much time on this thought, let me explain to you that this individual with schizophrenia is looking for a way to explain to themselves what their condition is.  If they become convinced it is a disease then they are often unwilling to assume any responsibility in overcoming this condition.  This is all too common in the mental health profession, especially with psychiatrists, who can be in total disharmony with the psychotherapist and other treatment speacialists.So consequently,  that individual doesn’t have a shared believe system with his therapist.  How can you treat a person who thinks so very differently than you do and how can you persuade that person what they have is not a disease.  They have to understand what they have is a condition or a disorder which can respond to the right kinds of treatment and help make the kinds of changes that lead to a better lifestyle, a lifestyle with a sense of freedom and dignity and self respect.  That’s where therapy has to lead that person who has schizophrenia. 

If a patient thinks that he/she has a condition that is beyond their control, then they feel no responsibility for joining the treatment effort, because they have a brain disease.  There are no demands made of them, we don’t expect things of them and consequently they don’t do anything.  In how many institutions do we find patients sitting around doing very little or lying in bed endlessly?  This happens to be a response to our expectations.  If we are hopeful, so are they, gradually.  If we don’t have hope, they don’t have hope. 

In order to understand how we arrive at the place where there is a growing feeling of hope, I think it would be useful and productive to make an effort to define schizophrenia beyond the symptoms and characteristics, which come as a result of the incredible fear that happens with the early onset.  This fear leads to a feeling of disintegration and there are fears of annihilation, the fears of destruction that pushes the individual away from his or her attachments, the most meaningful aspects of their life.  They feel like death is close and there has to be some relief from this terrible feeling of destruction.  There is a retreat towards a place where there is a feeling of greater safety and the fear is processed into the symptoms that we view as being schizophrenic.  There is a logic and language that develops that is part of this process that has as its design, survival.  It is our task to breach these defenses so that we can make the contact that leads to some resolution of the schizophrenic condition.

Accuracy is not of major importance in creating a bridge between therapist and patient.  You have to want to help, not just pay lip service.  You have to involve yourself emotionally in the life of the individual in order to persuade the person that there is hope.  You must give that person some reasons to join forces with you in an effort to overcome the condition that has become an integrated part of his or her life.  You see that in the mind of that person with that condition it is a way of staying alive in a world that is perceived as being dangerous.  The condition represents a certain degree of comfort and we have to understand that in order to make the relationship worthwhile.  The fallacy of treatment with this condition is that so many people who work with this problem, are not really that skilled in establishing an alliance and as a result, the distance between the two parties is never overcome. 

When we speak of auditory hallucinations, delusions, paranoia and other symptoms of this condition, what does this really mean and where does this come from.  I have stated above that this comes as a result of the fear being processed into symptoms as a way of the organisms effort to heal itself.  If you work with a patient who is suffering from auditory hallucinations, how do you deal with it?  If you ask that person, about what the voices say you will frequently find that it is comparable to what the individual feels about themself. The following has been said to me many times by individuals who are hearing these voices.  “They are saying bad things about me.  They swear at me, they call me dumb, stupid.”  When you explore with the individual what he or she feels about themselves you will frequently find that it is in common with what “the voices state.”  It is possible to distract that person from hearing the voices.  The following is an example of two patients, both of whom heard voices.  I asked one of them, “ what’s the first thing you do when you wake up in the morning?”  He said, “I look for my voices.”  The second one, told me that he “woke up with an enormous appetite.”  We spent some time talking about food, from different lands and the voices left him.  I had succeeded in training him to distract himself. 

I had a patient that I worked with in Krasnayarsk, Russia, which is a very large and attractive city.  The patient was a young man about 22 years old, who had been hearing voices for several years.  He told me that he heard voices and the voices said terrible things about him.  He also admitted that he said those “bad words.”  With some urging on my part, I was able to persuade him to say these bad words in front of an audience, who were watching the demonstration and whom he felt were able to read his mind.  I had him pick up a chair and hold it up until he was exhausted and the voices temporarily disappeared.  This was a young man with all the natural feelings that all people have and I suggested that he think of beautiful women.  After a period of training he was able to dismiss the voices by thinking of these attractive women.  I saw him for a number of weeks, his therapist observed my efforts and was able to take up where I left off and in a follow up communication, I heard that his voices were eliminated. 

What do you do with a patient who is aggressive and violent as a result of responding to internal cues or command hallucinations, which urge that person to act in a way which could be harmful to others.  If it is a person who you have no or little experience with, I think that caution is not to be thrown to the winds.  You must regard this person with the utmost seriousness.  People can get hurt by those individuals who are frightened and responding to internal cues.  In reference to those individuals who you are familiar with and at least recently have had a treatment alliance with, there are methods, psychotherapeutic methods that can be utilized to dissuade that person from being aggressive.  In all my experience as a psychotherapist, I have never been attacked by a person that I had a treatment alliance with.  There are strategies that can be utilized as I mentioned of refusing to retreat from the person’s aggressive gestures.  However, I do not recommend that for therapists who are not skilled or in fact anybody who has not enough understanding of this dynamic.  The best plan is to protect yourself, but bear in mind that this can be a tactic utilized by the patient to put you at arms length because your treatment efforts have become threatening.  It’s important to emphasize that these are not dangerous people and when they are suffering from poor impulse control there is a wish on their part to have someone take charge and help them through this very difficult time.  In other words, one should be realistic and not become overconfident in being able to handle this kind of episode.  It’s not so terrible in that sense to say to that person “you make me anxious, or you frighten me, but I want you to know that I really want to help you and you are not going to drive me away.  But in view of the fact that you are scaring me now, I am going to walk away from you and come back tomorrow.”  This is perfectly good treatment, it’s an honest appraisal of how you feel and the patient needs to know you feel this. 

One of the tragedies related to this is that there are times when mentally ill individuals do commit capital crimes, like homicide and the news media tends to place emphasis on the mental illness.  This is of course always a tragic happening, but from a statistical point of view, mentally ill individuals are less homicidal and yes even less dangerous than the average population.  They are however, more suicidal.

Schizophrenics are frightened human beings, they want to be left alone.  If we understand that these are terrified people and/or anxious individuals who want to be left alone then we will not be so frightened of them.  One of the failings of our culture is that there is a great deal of ignorance about the serious mentally ill and there is such great stigma that they are mistreated in so many different ways.  In a way, they are like lepers of years gone by and we have an obligation that we haven’t met yet, to educate the average person about these unfortunate victims of schizophrenia.  Change in treatment will not come as a result of ignorance, change will come about as a function of increased awareness and enlightenment.

When we think of crazy behavior, is it only a product of mentally ill individuals?  How about the countless crimes and crazinesseses committed by the so called normal population.  There is spousal abuse, child abuse, drive by shootings, robberies, hate crimes, racial prejudices, just to name a few.  So what is the difference?  There is a great difference.  Our culture is populated by the above.  Of people who are of far greater harm than those individuals who are mentally ill and it’s time to recognize this and to help those people who are not responsible for their condition to gain some freedom that they deserve so much and have been deprived of by our failure to understand what they are as human beings. 

I close this Newsletter and will continue talking about schizophrenia and treatment in the following Newsletter of March.

Until we meet again,
Jack Rosberg