What Happened to the Pioneers?

3rd Quarter 2001

Newsletter

When I began my career in 1954, just prior to the introduction of the neuroleptic drugs, I felt a sense of excitement about what seemed to be happening in the professions that were responsible for the treatment of schizophrenia. I had the good fortune of working with a world renowned psychiatrist-psychotherapist by the name of John Rosen. He invented a treatment method that he called Direct Psychoanalysis. In the beginning of his experience as a resident psychiatrist at Brooklyn State Hospital in New York, he found after a while that he was able to enter into the delusional systems of patients who were dying of catatonic excitement. In those days, there were no methods of reducing the fear and the fever in that condition and patients expired. He was able to overcome the extreme agitation and patients survived.

Let me point out to you that later research regarding his methods did not find that his theories were instrumental in overcoming some of the symptoms in the patients he treated. It was more his personality, his warmth and compassion. He had the capacity to make rapid contact with patients which is the first step in treatment. And that gift made it possible for him to deal more effectively with the patients he treated. Remarkably, he was criticized by the administration of that hospital for not staying with some of the physical methods of treatment, such as electro shock treatment, insulin coma treatment, etc. Rosen was considered to be one of the earliest contributors to the psychotherapy of schizophrenia along with Harry Stack Sullivan and Frieda Fromm Reichmann. They were pioneers that attracted many other remarkable men and women in the U.S.

Even before their contributions, there were pioneers in Europe who made great strides in treatment, such as Eugen Bleuler who coined the term schizophrenia and was using psychotherapy and other treatment efforts that resembled psychosocial methods. He did his work in Switzerland. Other pioneers in Europe such as Paul Federn, Gertrude Schwing, Karl Abraham, Sandor Ferenzci, Margaret Sechehaye, Franz Alexander. A host of other professionals were influenced by their works and were able to successfully treat patients with non physical methods of treatment such as psychotherapy.

In the United States, the Menninger brothers in Topeka, Kansas developed that great hospital that attracted so many creative therapists who successfully treated this condition, we call schizophrenia.

At Chestnut Lodge, in Rockville, Maryland, individual professionals were influenced by Fromm Reichmann such as Harold Searles, Otto Wills, Jr., Salvano Arieti also made great strides in the psychotherapy of schizophrenia. We can’t forget the wonderful efforts of Carl Whittaker and Thomas Malone and the ground breaking research efforts of Gregory Batson and associates on Communication Theories in the Palo Alto, California study.

Some of these pioneers as it were, worked before and after medication was introduced, but they were not really affected by the medical treatment models, even though many of these individuals were medical doctors. They did not, as Rosen did not, believe that the primary approach to treatment was to put patients in psychiatric hospitals where they needed to be stabilized and then maintained with medication. Even though many patients were treated in psychiatric hospitals, they put their efforts into treatment which was composed of the therapist, the patient and the treatment milieu.

Today, we know that the heavy tranquilizing effects of those drugs, that were introduced in 1955, made management of patients easier, but they only masked the symptoms and many acknowledge they caused serious side effects including the familiar facial disfiguration known widely in the 1960’s and the 1970’s as "the thorazine look".

In the final edition of the Journal of NAMI, California, Calvin Flowers, M.D. Assistant Clinical Professor of Psychiatry at the University of Southern California and Medical Director at the Anne Sippi Clinic, states "that nine out of ten patients being treated with anti psychotic medications have significant physical illnesses requiring routine follow up, that are not addressed, lack of coverage, lack of access and lack of integration are all cited as further barriers to adequate health care in patients with mental illness. With the arrival of a second generation, of anti psychotic medications for treating mental illness, it now appears there are new factors contributing to physical illnesses; the very medications patients take to control the symptoms of their mental illness, yes, the new wonder medications that so importantly advanced the treatment of psychotic symptoms, negative symptoms, mood symptoms and cognitive symptoms are now being implicated in producing additional physical illness. Several decades ago medical investigators documented, in large state hospitals, that psychiatric patients with the diagnosis of schizophrenia were at considerably increased risk for cardiovascular disease, pulmonary disease, digestive disease, metabolic disease, and neurologic disease. It was also noted that patients with schizophrenia suffered from higher mortality rates, both natural and unnatural. People with schizophrenia have an overall mortality rate about twice that of the general population."

Now it is only fair to say that in quoting Dr. Flowers, the central part of his article had to do with the fact that patients with schizophrenia are not treated in a complete sense and they are neglected physically as well as psychologically and one must wonder how useful medication is without the other aspects of treatment.

In the same Journal the Editor, Dan E. Weisburd states and I quote "it seems that the marvelous new atypical medications significantly elevate both cholesterol and triglycerides in most patients that take them."

I wonder how many psychiatrists who advocate and prescribe medication are aware of these dangers and make an effort to do something about it. Too many psychiatrists are intent on relieving psychotic symptoms and do not make an effort to take the whole person into consideration.

What happened that caused these pioneers that I referred to in the beginning of the article to stop influencing these young professionals from looking for new directions in treatment? Was it the concentration on medication? (I am not opposed to the judicious use of medication, providing it is part of an overall treatment approach). Was it poorly designed research? Another deterrent to good treatment and change are the HMO groups, (health maintenance organizations). These are insurance companies that have handicapped physical and mental health advances in treatment. Their primary interest is making money, no matter the cost to human lives and suffering. (See paper under "Articles" on "Managed Care"written by Jack Rosberg and Dr. Roderick Shaner).

Some years ago, I was a consultant to the president of an HMO group. My responsibilities were to help develop better treatment methods for individuals enrolled in this organization. I made a concerted effort to make this happen, but found that it was not possible. The organization was not receptive, my thoughts about treatment did not meet the HMO criteria. Treatment was in the hands of gate keepers whose job is to limit treatment, not provide what was indicated by the person’s condition. Patients with schizophrenia are restricted to psychiatrists who prescribe only medication even though the literature points out that this is hardly enough. They are a handicap to mental health.

When you look at the pioneers, when you look at their theories and when you regard the current theories of treatment, it is my considered belief, that the theories are not the criteria for a successful outcome in treatment. They may play a part in it, but success in my opinion, is a product of hope, concern, effort and addressing in a humanitarian way the needs of these individuals.

In Turku, Finland there is a respected Psychiatrist by the name of Yro Alanen, who has a belief system, that patients should be treated in the community and he certainly made it quite clear that all patients are different and in order to be successful in treating them, one must address them in a need specific way. I am not talking about patients who have early onsets and suffer an acute reaction and are met by treatment that is humane enough and qualified enough to overcome the initial onset. Contrary to popular belief, it is possible under the right conditions for most of these individuals to overcome the initial phase of that condition we call schizophrenia. Unfortunately, they are received by people, professional people who don’t know how and who are very far removed in a human way from the terrible fears that these individuals experience. I would hazard a guess that all people who suffer an acute reaction could overcome it and return to a normal existence, if treated competently. Unfortunately this does not happen. What happens over a period of time, is one episode leads to another, and consequently we have millions of people throughout the world who have become what is called chronic schizophrenics.

What happened to the pioneers? Where did they go? During my tenure with Rosen, beginning to learn the basics of treatment, I felt lost often, but I had the will and determination to help those suffering human beings who were then diagnosed as chronic schizophrenics. These were patients who were not medicated, however, even in those early days, my efforts met with some success because I wanted to and I cared and I was able to effect a relationship with these people and it became apparent to me that there were differences and similarities between all human beings including those who had a diagnosis of schizophrenia. Perhaps in that sense I could call myself a pioneer as well because I believed that people could change. I went on during the course of my career to develop an alternative to hospital treatment, the Anne Sippi Clinic, a residential care facility which at the time of it’s opening, was a prototype in the U.S.

In the U.S. there is apparently a sharp division between medical and non medical people. Most psychiatrists confine their practices to prescribing medication. Once again, I am not opposed to medication, it is one treatment tool. What I find to be harmful, is that people with schizophrenia too often are told, that their condition is life long. In that sense, we are creating self fulfilling prophecies. I have always said over the years, that we do not know that much about the human potential and we have no right to imply, suggest or state that people cannot recover or make changes in their lives. We do not know what causes schizophrenia, even though there is an immense concentration on the biological. There is a cliché today in reference to that which I find to be quite disturbing. There is much stated about this being the "decade of the brain". I believe that too much emphasis and hope is placed in this being the cause of schizophrenia. Thereby avoiding the responsibility of furthering treatment.

In the words of Manfred Bleuler, schizophrenia could be caused by a hundred different reasons. I believe that research must go on but isn’t it time that we spend more money training non medical people in the treatment of schizophrenia?

As far as recovery is concerned, there is no doubt in my mind and in the minds of many others in the world that a very large group of individuals have achieved remarkable recoveries. They have carved out a life despite the stigma of the past. They have goals, they make choices, they improve their situation, with the right type of interventions. If you talk to someone who is doing better he or she will tell you that someone, a friend, family member, therapist, reached out with warmth and gentleness and kindness. This is not what is typically done in the mental health system. One doesn’t have to be a pioneer actually to feel that way, but what happened to the pioneers? I know that the treatment world has changed, that there are other methods of treatment that exist today, such as the psychosocial efforts. Other forms of psychotherapy. Alternatives to hospitalization that could help the long term schizophrenic make good recoveries. But it takes a whole mind set. It takes an emotional expression of concern that makes treatment successful. We need to discover how to educate, not only the lay public, but also the professional world wherein these unfortunate human beings have a right to feel these pioneering efforts so that they can recover.

I welcome any comments that you would like to make. Also, anybody interested in submitting an article for publication, please inform me.

Until we meet again,

Jack Rosberg