January 2000
Newsletter for the first of the Millennium
A History of Treatment and Current Ideas
I reread a book recently that was published in 1908 in German by Eugen Bleuler. The title of the book is Dementia Praecox. Bleuler coined the term schizophrenia. This book was not translated from German to English until 1950 and it was an epic volume on classifying this condition. It is as reciteful as the DSM codes. It is important to be aware of the monumental struggles that the earlier contributors made in their efforts to understand this very difficult human process, we now call schizophrenia. I think that it is very important for us to be aware of the history of the field in order to understand why we are, where we are at, today. We should be aware that some of Freud’s earliest followers began treating schizophrenia with a more active psychotherapy. This includes Sandor Ferenczi, Gustav Bychowski, Karl Abraham, Franz Alexander and others. In those early days the work was creative and exciting. Freud himself did not like this condition we call schizophrenia and made an effort to avoid treating it even though in fact he did, but he called it another condition.
When I began my career as a trainee learning Direct Analysis under the guidance and supervision of John N. Rosen, M.D., I felt a great sense of excitement being allowed the privilege of working with patients diagnosed with schizophrenia. That was prior to the introduction of the medications. We worked without any medication and because we believed that patients could recover, we poured our energies and our hopes into the treatment process and people did make behavioral changes that allowed them to function outside of institutions. This was not far from the works of Harry Stack Sullivan and his theories of interpersonal relations. Though Rosen was theoretically much more Freudian than Sullivanian, I began to utilize some of the direct methods of psychotherapy with some of the ideas of Harry Stack Sullivan. This happened to me intuitively. It became apparent later on that there was no other direction to take for me at that time. However, even that changed over the years. This was also around the time of Frieda Fromm Reichmann, Bertram Lewin, Carl Whittaker, Thomas Malone, Sylvano Arieti, Otto Wills Jr. and Harold Searles. All these individuals were students of Fromm Reichmann and they made significant contributions to the understanding of psychotherapy with this population we call schizophrenic. There was the Palo Alto study with the distinguished anthropologist, Gregory Batson. Don Jackson, Jay Haley and a number of other contributors who were part of this study. These individuals did much to further the understanding of treatment with schizophrenia. People did change and recover from this condition. In Europe, there was Eugen Bleuler, Paul Federn, Gertrude Schwing, Manfred Bleuler, the son of Eugene Bleuler, Gaetano Benedetti, Christian Muller, Endre Uglestad and a host of other creative individuals who pushed the frontiers of knowledge further. It is a fallacy to think that work of any substance only began after the introduction of the medication.
There was much going on in the field but, there was the split between the biological and the psychological, that still exists today. Unfortunately, there doesn’t seem to be a significant rapprochement between the two entities. I recall vividly, my early experience working with the most regressed patients who responded to my enthusiasm and the efforts and enthusiasm of my colleagues. Certainly our work was not isolated. There was a growing trend amongst many professionals on an international level to share their experiences by their writings and also the meetings they attended. People shared there work and their ideas and there was a sense of growing hope that treatment was developing in a very positive way.
When the medications came out that did indeed turn some people away from furthering the understanding of how relationships between therapists and patients make the difference in the outcome of treatment. There was some research done by an English researcher by the name of Phillip May. His research was biased however, it pushed people away from psychotherapy with schizophrenia. I think that it’s imperative for us to understand that even though medication has a place in the treatment of this unfortunate condition, medication is developed and sold by pharmaceutical companies who gain a tremendous revenue from ‘pushing medication’. There is a place for medication, I am not opposed to it, but it is only one treatment method amongst many other important methods that should be integrated. Such as psychotherapy, and psychosocial rehabilitation. Psychotherapy is and can be successful. Psychosocial rehabilitation is and can be successful. However, both methods are not widely used enough and medication can be more successful, if it is integrated in the other treatment efforts. I must tell you that it took a considerable amount of time for me to appreciate the limited value that medication has because I saw what could happen with professionals who dedicated their efforts at helping the victims of schizophrenia even without medication. However, I began to realize after some time, that it is foolish to reject any useful treatment tool. I have worked with this population for 46 years. After years of effort, I began to understand enough of the process to be able to train and teach, in countries besides the United States. I saw the devastation wrought by professionals who didn’t care enough to put their best efforts into the treatment process and also who were untrained and basically not equipped to work with these individuals.
Attitude in reference to treatment is a very important part of the treatment process. Do you really want to treat this problem? Is it important to treat this problem? Because the person you are treating who has been long abandoned by the profession, deserves the best possible help that we can give them, which I believe they are not getting. I think that we can refer to the December 1999 report by the Surgeon General of the United States, which declares with emphasis how poorly organized current methods are and how many people with schizophrenia are denied proper care. Treatment has failed to answer the needs of the serious mentally ill. Has it failed because patients who have a long history of this condition can’t be helped? Or is it because we don’t want to work with them? It is acceptable if you don’t want to treat them, but at least make that clear. Don’t say it can’t be done because you don’t want to do it or you can’t do it. That’s completely unfair.
What we do determines the future of these human beings. They are not second class citizens they are just as good as anyone else despite their illness. All the symptoms and the frightening ideas that they have, may frighten people away from treatment and persuade them to say untrue things about that person with schizophrenia. That is not right.
As far as medication is concerned, I am opposed to the over utilization of it. I am opposed to medication being the center of treatment. It has become that, in the treatment world with some exceptions. I believe that it is very important to understand that schizophrenia is not primarily a medical condition and should not be seen as that, if we are to improve the results of treatment. There are some good people in the field however, but many are overwhelmed by those people who are looking for better medications. There is much research with respect to medication however, finding one that has better therapeutic value than some of the current medications is like looking for a needle in a haystack. Even if they find it, these human beings would still need other forms of treatment such as psychotherapy to help them understand, what happened, what it means and some understanding whether or not it has to happen again. So when we look at how medication is utilized in many institutional settings we wonder whether or not it’s for the patient or for the staff, because you often see offerings of medication that is beyond reason. If you look at medication and you come to some conclusion as to what is it’s purpose, if it is assumed that it will overcome that condition we call schizophrenia it is a fallacy, it can not do that. When you look at patients in institutional settings you see them with the symptoms and characteristics of schizophrenia however, they are modified by medication, which very often deprives them of the energies they require to go further in other forms of treatment. There are many reports that state when you reduce medication and you include other treatment efforts, then the effects of medication are more positive. So it is quite clear that there is a place for medication but it should not be the core of treatment. What we miss sorely are training centers that will help direct interested students and professionals into the area of treatment with this population. The universities do not provide that in their curriculum.
When we think of psychotherapy, what is the first step in treatment? Contacting that individual with that condition is imperative. Even the most regressed person can be contacted in a way which leads to a treatment relationship, if you are aware of its importance. These people can be reached, they are not beyond hope, there are chances for them to recover to some degree or another, depending on the consistency and the effectiveness of treatment. There are chances for them to recover to some degree at least, if the treatment is adjusted to fit their personal needs.
In my experience in other countries, like Russia, I was able to reach patients through an interpreter because I wasn’t overly concerned about language and cultural barriers. There are barriers that are much more difficult than that, they are our own feelings and our own fears and our own unwillingness to contribute and participate and be involved in this process with the patients that we treat. To quote Freida Fromm Reichmann who many years ago said, ‘treatment with these individuals is a shared experience’ it’s between two people, not you the therapist, just standing aside and reflecting back to the patient what you think they feel.
Making contact with this patient that has 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 for treatment, there is no second step. The first step has to prepare the patient, whether it happens quickly or not. You just don’t sit down with an individual and expect them to be open to treatment without the necessary preparation. There isn’t any relationship in the beginning of treatment. There has to be some relatedness between you and that person because that person has been through many therapists and has been disappointed by their lack of success and they feel like failures and are ashamed of their condition. Contact necessarily must lead to a therapeutic alliance, which is the context wherein all treatment takes place.
Until we meet again,
Jack Rosberg
