Lecture in Barcelona, Spain; Treating the Veteran Schizophrenic

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.

Until we meet again,

Jack Rosberg