Psychosocial Treatment of Schizoprenia

Second Regional Hospital of Novosibirsk, Russia April 4, l994
 I'm happy to be here and that people here are interested in hearing about my work. As I  understand it, some of you are psychiatrists and some of you are nurses. I want to talk  about things that are important to you, which goes further than individual psychotherapy,  which is what I do in the treatment of schizophrenia. I think it is important to understand  that before the introduction of the neuroleptic drugs in l954, psychotherapy was one of the  few treatment methods that was used in the treatment of schizophrenia in the United  States.

 Just a brief history so that you can understand the direction the mental health field is  taking. Before l923, there wasn't any treatment for schizophrenia besides the physical  methods of treatment in the United States. These included methods such as electro-shock  treatment and insulin-shock treatment. I know that they still are being used in Russia. I  personally see no value in any form of shock treatment, with patients who have a diagnosis  of schizophrenia. I consider these methods to be a barbaric approach to human beings.  They create confusion in individuals who are already confused. They do not overcome the  symptoms and characteristics of schizophrenia, such as delusions, hallucinations and/or  thought disorders, they cause brain damage and they increase the fear and terror in the  schizophrenic patient.

 In l923, the psychotherapy of schizophrenia was introduced in the United States by a  European Psychiatrist, by the name of Adolph Meyers and it captured the attention of  many professionals who treat people who have schizophrenia. Psychiatrists became very  interested in this method of treatment and many professionals began using psychotherapy  with this treatment population. I remember a story that was told in the literature about a  president of the American Psychiatric Association, who became excited by the fact that  psychotherapy was a useful method of treatment with schizophrenic patients. But one of  his associates said to him "my friend, that's very good, a psychotherapeutic hour with a  patient who has schizophrenia can be worthwhile, but what about the other 23 hours of  the day". What happens with patients after they have a therapeutic session? What are  their lives going to be like? That brought some more reality into the psychiatrists' mind.  It suggested the importance of seeing the patients actively involved in other therapeutically  related activities. However, these ideas, that is, methods of resocialization and  rehabilitation, as we now know them now, were not developed for many decades.  Though the realization that the schizophrenic patient needed more than a therapeutic hour,  it took more than seventy years to develop and effect these therapeutic modalities.

 However, even without the allied treatment modalities, the psychotherapy of  schizophrenia developed very well within the United States and also in parts of Europe,  until the neuroleptic drugs were introduced in l954. The medications are used in most  parts of the world as a primary treatment method. I've seen them in China, I see them in  Europe, including Russia and of course the United States. They became the treatment of  choice. It was promised, when they were introduced, that they would stop this illness  called schizophrenia by l970. However, the only thing that it stopped, was the  development of other treatment forms. I'm not against medication, you need to know  that, but we must be aware and face the reality of their limitations. Medication is simply a  treatment form, which makes people more comfortable and reduces some of the  symptoms. There has been a good deal of research on medication versus psychotherapy  that has pointed out that both psychotherapy and medication are more effective when they  work together.

 The medications produced quick results symptomatically especially with patients who  were acutely disturbed. So because of this, psychotherapy and psychotherapists began to  retreat from the schizophrenic patient, even though some psychotherapists continued using  psychotherapy with these patients. Since there were no other treatment methods  developed yet and psychotherapy by itself was not as dramatically effective, medication  became the major tool in the treatment of this condition called schizophrenia. But  medication, didn't overcome the problems and we found over a course of years, with a  great deal of research and outcome efforts, that psychotherapy, the way it was practiced  traditionally, wasn't good enough either. So many people were confused about what to do  with this difficult problem. However, in recent years, it has become clear that we can't  really underestimate anything that seems to suit the treatment of this very difficult  condition. Psychotherapy is important, medication is important, both of them are better  together, but that is not good enough. Psychotherapy was a very passive treatment  approach in the past. Over the years, outcome and research studies have concluded in  many parts of the world, that one of the factors in the failure of psychotherapy with the  schizophrenic patient was the passive treatment approach commonly used with these  patients. Those studies have determined that we have to be more actively involved with  these patients. We cannot wait for their invitation to join them in their world. We must  make an active verbal effort to establish a relationship with them that gives them a sense of  hope. Perhaps we don't have to explore the past so thoroughly, perhaps the best history  that exists, is between the patient and the therapist. We see other methods of treatment  developing in many countries. People all over the Western World and even in China for  an example, are beginning to realize the importance of other treatment methods. These  methods are not in competition with each other.

 In order for treatment to reach its maximum effectiveness, we need to have a series of  treatment modalities that act in a compatible manner with each other. The psychotherapy  of the past is no longer the psychotherapy of the present. It has changed, it's more active,  it's more involved, it's more humane, it's more personal, it's not so secretive, it isn't  necessarily based on psycho-dynamic or psychoanalytic principles. The use of medication  in the past is not the use of medication in the present. What I'm saying is not a subjective  opinion but is a function of research results. However, we have a schism in the treatment  world, which is really tragic. Patients find it hard to change and so do people who treat  them. Without changing our treatment approach, patients do not change. I think all of us  know that up until the present time, the treatment results with schizophrenic patients have  not been good enough.

 I'll give you an example of people who are very rigid in their attitudes about treatment. At  another hospital in Novosibirsk, I did several days of lecturing and demonstrating with  patients and I was told that one psychiatrist there was angry at another psychiatrist,  because he came to my lecture. His idea was that psychotherapy is absolutely useless with  these people who have been diagnosed as schizophrenic. Well that's his opinion, but it's  more than an opinion. It shows a mind that's very rigid. It's apparent that the man doesn't  have any understanding of what is schizophrenia. But it's even worse than that, a man  with such a terribly closed mind, to new thoughts and new ideas does not have the best  interest of his patients in mind, when he closes his eyes to other important treatment  efforts. His patients will be sick for a very long time and I will tell you even more without  knowing his practice, that he probably uses more medication than patients need. That his  patients live in what we call "chemical straight jackets", they are dehumanized. Research  points out that if you reduce medication carefully by 40%, therapy is much more effective,  providing you have a good treatment relationship.

 What is psychotherapy today? This is something that I hope I'll be able to show you in  some of the demonstrations that I do with patients here. The psychotherapy that you see  me do will not be the psychotherapy that you see other people do. It's based on a very  important principle, that is anything that is sensible and useful should be used to help  these very sick human beings. I believe you should use any means at your disposal to  effect changes in those individuals with schizophrenia, excluding the old physical methods  of treatment mentioned, that is shock treatments. We know in recent years, other methods  have developed, like resocialization and rehabilitation. We have a treatment package  today. A treatment approach that embraces every aspect of that human beings' life. We  know that medication has a purpose and a point to it, but it doesn't cure anybody, as a  matter of fact, there is no medical cure for schizophrenia, which doesn't mean that people  with schizophrenia can't change. There are many qualified research studies in Europe and  also in the United States, which point out very accurately, that patients who have a history  of ten or more years of schizophrenia, can make social changes. These studies are not  suppositions, they are definitely accurate and valid studies that have been replicated in  many different countries. This is a time of change, whether you like it or not. These  human beings deserve the best we can give them. We certainly can do better than we've  done, there is no question about that, if we have the right attitude.

 We know that psychotherapy is different today. What is it? What are people looking for?  Are we talking to patients with a hope that as they understand themselves better, they will  change their behavior? That was a method that was practiced for many decades. But  patients with a long history of that condition do not respond to that form of treatment.  You see this in your own practices, I'm sure. If somebody is hearing voices, will they stop  hearing voices because you talk to them? If somebody doesn't know how to take care of  their hygiene and clean themselves, and take showers and baths, or eat properly, will they  change, if you tell them these things? Psychotherapy has to produce change in that  person, without which there is no treatment. Many of the patients that you treat here need  patient management, because they change their behavior as a result of what you do with  them and what you expect of them. Then perhaps they begin to understand themselves a  little better. So instead of insight, we're looking for behavioral change and that really is  the purpose of any form of treatment. Also we are looking at another aspect of treatment  which is very important, and that's rehabilitation. I think that's where some of you come  into the picture, in the area of rehabilitation and resocialization. We found without any  question, that some kind of work, some kind of effort is critically important in helping  these people gain a sense of self respect.

 It's not good enough to allow patients to lie in their beds all day long and to look at  television and to drink coffee and to smoke. They have to be exposed to things that will  help them regain their will to live. They have given up hope, because they have failed so  much. Also, we have given up hope because we find it so difficult to really stimulate them  and get them involved in activities that are useful and critically important for their  development. If we have no hope, they have no hope. If we don't change, they won't  change. Atmosphere is a very important issue, it's more than technique, it's more than  methods, it's the attitude of the individual person and the attitude of the entire hospital of  people working with these patients. If you don't have the optimism, if you don't feel the  warmth towards these human beings, what you expect of them will not be fulfilled.

 At the present time, these four methods of treatment that I discussed with you, really work  together, not separately, they are not separate categories of treatment. It's very important  for all these treatment methods to work with a sense of harmony. Let me be precise, it's  time to bring ourselves down to earth. Psychiatrists are one part of the effort.  Psychotherapists are another part of the effort. Resocialization specialists are another part  of the effort and the rehabilitation people are also another important part of the effort. To  me, it doesn't make any difference whether you are a psychiatrist, a psychotherapist or a  specialist in resocialization and rehabilitation, a nurse or one of the orderlies, you are all  equally important. People have to come to respect each other more as equal participants  in this creative and important environment in reference to these patients. It used to be, in  my country at least, that psychiatrists were the captains of the ship. They were respected  too much. The nurses and the other people in the treatment team were not respected  enough. The world has changed, in my opinion. Everybody has limitations, each  independent effort by itself is not strong enough, it's only when people mature enough to  realize that they need to collaborate with each other, in a harmonious way, can this  therapeutic force come together in a strong and powerful way to help these human beings.

 Let me tell you something, the train is moving and either you get on, or you get off. If it  doesn't happen now, it will happen next year, if not next year, the following year. It's  inevitable, because our great population of people who are very sick, are demanding we  change our efforts so that they can change their way of life.

 Many years ago, I developed a method of psychotherapy which is very untraditional. I  continue to practice it, yet making changes when indicated because no treatment method  can continue being effective without changing with the changing times. I think it's an  advanced method of psychotherapeutic treatment. However, no matter how good you are  or how great you are, by yourself you're not good enough, you need each other. If you  don't realize that, your professional life treating schizophrenia will be unsuccessful and  you will have deprived your patients as well as yourself of the rewards of effective  psychotherapy.

 For years, I worked in one hospital after another, as a psychotherapist and I really was  never satisfied with the atmosphere of the hospital, because it was so traditional. It really,  by it's resistance to new ideas, inhibited the creativity of people who developed innovative  psychotherapeutic directions. So in a evolutionary sense, my efforts were directed  towards alternative methods of treating this population. I have been treating  schizophrenia for forty years. Some learning is a very hard and painful process for all  human beings. What makes life interesting, is if we allow ourselves the freedom to learn  and to recognize our inadequacies.

 I will tell you something, most psychotherapists and psychiatrists just don't understand the  meaning of schizophrenia. Nobody knows what causes it, everybody's looking for a  magical answer to it. There is a lot of money directed toward research, which is  important, but not enough money directed towards treatment and rehabilitation centers.  Schizophrenia could be a result of a hundred different causes. Whatever the cause is,  whether it's biological or psychological, we waste too much time thinking about these  issues. Patients can and do change. That we have to concentrate on, helping them  change. That's the greatest challenge that psychiatry has today.

 Many of our mental health professionals assume a great deal about themselves. Do we  know that much about life, that we can put a fence around the human potential? Does  anybody have the right to call another human hopeless? What makes a person do that?  You hang a label around a person's neck and it follows them for the rest of their life. So  many people are really influenced tremendously by this negative attitude, that they give up  on life. Are we so great that we can make this pronouncement? Some people think they  know that much.

 We have a clinic in Los Angeles, which is named after a patient Anne Sippi, who was  considered to be hopeless because of her serious mental illness. At the age of two, she  acted very strangely and her mother took her to a doctor, who said that things would  change in time. At the age of four, she was very sick. It seemed, in retrospect, to be a  combination of autism and also childhood schizophrenia. Her first therapist told her  mother, that it was too late, she was hopeless. Her mother refused to accept that cynical  announcement and refused to abandon her to public mental health systems. She refused to  give up hope that she, one day, could have a better and more normal quality of life.

 I was working at a hospital in California and a psychiatrist asked me to have a consultation  with Anne Sippi. She was then 23 years old. Nineteen years of her life had been wasted  in schizophrenia. Her mother refused to accept the prognosis made by her first  psychotherapist. For nineteen or twenty years, she went from one place to the other, from  one doctor to another, because she refused to give her child up to mental illness.

 This woman, Anne Sippi, was a very difficult and sick person. She was violent 70% of  the time. She spoke three words. She hurt people by tearing their hair out, biting them  and kicking them. I approached her in the hospital and I'll tell you what I did with her, so  you will understand that I am not a traditional therapist. She was standing outside of her  restraints that day, looking up at the sky on the open patio in the closed unit and laughing.  I approached her and pulled her head down, and I said "young lady, I understand that you  bite people, you hit people, you kick people and you tear their hair out, that's fine with me  because that's exactly what I do." She noticed me then, she knew I was there. She was  not responding to the voices at that point. She realized that I had challenged her, that I  dared her to continue doing those destructive acts. Then came the tremendous battle  between her and myself. I was determined not to let her persuade me to leave her alone. I  chased her all over the hospital screaming at her. I shouted at her "stop being crazy" now  that's not really what is typically done. What happened after three weeks is that, she  began to control her impulses more effectively. I was determined that she would not go to  a mental hospital for lifetime custodial care. I had effected a therapeutic attachment and I  was determined to force her to change.

 I met with her mother and we decided we couldn't work in hospitals any longer, because it  just didn't have the right atmosphere for us. So we started an organization and we  thought it would be right to name it after her daughter. We raised enough money to buy a  residential treatment center, so that we could work freely and creatively. The Anne Sippi  Clinic has been in existence since l978. As a matter of fact, as a facility for treatment, it  has become an example internationally.

 We have 32 beds. We have staff psychotherapists, a psychiatrist and case managers. The  case managers are entrusted with the resocialization and rehabilitation procedures under  the supervision of each patients' psychotherapist. When people ask me for work, there are  certain qualities that I look for in that person. Whether they're experienced or not  experienced is not really the basic issue. It's whether they can cope with pressure.  Whether they have some sensitivity. A very important ingredient that most people never  talk about, is do they have any common sense. I would prefer that people use good  judgment and common sense, instead of trying to be very fancy creators and contributors.  I'm interested in people wanting to learn and wanting to work hard. I'm looking for  people who have respect for patients who have schizophrenia. I'm looking for people who  have some hope and for people who don't think that these people who have schizophrenia  are so very strange. Because they're not so much different than we are. They are born the  same way we are, they have similar needs for love and sex and they want things the way  we have them. Like all people, they die the way we do. So I'm looking for people who  really understand that there is some craziness in everybody's life.

 I'll tell you what the principles of treatment are, and I hope that you, as a treatment  person, can find them useful. I want to preface my remarks with the hope that you can in  a insightful and reflective way, take a good look at yourself, I think we all need to do this.  We need to be critical of ourselves, of each other, but not in a destructive way. But in a  way which will help us understand our faults, so that we can change in a positive manner.

 All of you are staring at me and wondering about my diagnosis. You know I could be  schizophrenic, for all you know. But just like you, I don't show it in public all the time.  But when I go home and I close the door, then it becomes a different story. I can be  depressed, I can be maniacal, I can be very paranoid, I can be grandiose, I can have  tremendous feelings of inferiority and inadequacy, doesn't it fit you too? Isn't that the way  of all people? Take a look outside of this hospital here in the cities, in the streets. Who is  more dangerous, your patients in the hospital, who have a diagnosis, or the people out  there? Because they have a diagnosis, does that make them sorry and unfit human beings?  The world sees them that way, for some reason, perhaps because all of us have a primitive  part to ourselves and contact with them stimulates it and exposes it. They defend  themselves and keep us at arms length because they are afraid of change. We, by our  attitudes, keep them at arms length, because we see ourselves as being like them. It's like  looking in the mirror and seeing just a little bit of yourself. It's really sad and tragic when  this condition prohibits people from living life with some quality attached to it.

 So at our clinic, the Anne Sippi Clinic in Los Angeles, if people are not optimistic, if  people are not hopeful, if people are not willing to work and change and learn, then they  don't belong there.

 Patients become feeble or enfeebled or weaker, because of our lack of expectations. Not  everybody is completely sick you see, not everybody is completely well. When you can  look at the healthy parts of these human beings, and see that they can be creative and  effective in doing things, then perhaps your attitude will change. If you see that they need  to form a relationship with you that is significant and meaningful, then their chances of  recovery are better. Words are not enough without the feelings attached to it. It has to be  an emotional relationship between you and that person. How can that person change if he  feels that there is nobody in his life? How can he get rid of the terror, the fear, the  tremendous fear, if he doesn't feel like somebody is trying to really help him? If he doesn't  grow to trust someone so that he can feel secure and safer in a world which he sees as  dangerous to himself, how can he achieve any degree of social recovery.

 The end result of schizophrenia is a process which is designed to keep the person alive. It  is a survival system. The initial fear, creates the symptoms. The symptoms reduce the  fear. Without symptoms, they couldn't live. So the symptoms have some sense, there is a  logic to it. If you listen to them well enough you will find out that they have developed a  language, a different language for each person. So what do you do? You have to learn  the language. You have to decode some of their metaphors. You have to understand the  logic and the language that they speak. The purpose is to stay alive in a world that they  see as dangerous to them. That's all it is. We have to find a way into their lives to start  with, so that they can come to believe, once again, that there is some sense of hope for  them.

 So at the Anne Sippi Clinic, what the psychotherapists do is work with people in a  different way. That's in terms of helping the case managers effect rehabilitation and  resocialization of the patients for whom they are responsible. Perceptions of these people  can be very distorted. We've always underestimated their capacity to do things. They are  resistant to our efforts at involving them in productive activities. But with patience and  kindness and firmness, you can change their direction.

 Many of our patients are now doing things they haven't done for many years. Because of  their illness they have been deprived of education. We have a tutoring system, a teaching  system. It's just wonderful to see a person, who is actively hallucinating use a computer.  But I think it's simple to understand, that you can't hear voices and use the computer  accurately at the same time. But they like using their minds, they learn things they never  knew before. They learn how to spell, they learn mathematics and they show a greater  interest in reading. We have a women's group, which is designed to help women  understand how to take care of their personal hygiene. We teach men how to shave  themselves. They have lost certain social skills, we need to teach them those skills again.  What good does it do to sit down and and talk about whether or not they had problems  with their mother, if they don't take showers or baths. If they don't know how to use the  bathroom, or how to eat properly and most important or equally important, how to talk to  each other. They need to know how they effect other people in the world around them.

 As an example. A 57 year old man at the clinic came to me. I was the first therapist he  had at the clinic, he sat down, I sat down and he started to cry. He got sick with  schizophrenia at the age of l7. So he sat down and he started crying and said, "my mother  was so terrible to me, that's why I'm so sick". This insight must have been acquired in  some of his previous therapies. But I asked him a shocking question, I said, "why don't  you zip up your pants when you go to the toilet". Which surprised him because therapists  don't generally say these things. So I began working with him on these basic issues,  creating trust, effecting collaboration, creating a therapeutic alliance, so that we could  work together on his sickness.

 There are some people who like the easy road and instead of teaching him how to shave,  they shave him. I would never tolerate this, learning is slow but it's meaningful. How can  people feel good about themselves, if they feel they are helpless? It's difficult, it's hard,  but the end results make it worth while. We have patients who work. We have large  grounds and they have planted vegetables and flowers. They go out to work reluctantly or  with great resistance to begin with, but once the work begins, they feel good. Of course  there is a time for play too.

 We take our patients out into the world, we feel they belong there. They shouldn't be  hidden from the world, they are not a shame, it's not their fault they're sick. We take them  to museums, they may be a little peculiar, but it doesn't make us embarrassed. We take  them to musicals, we take them to the movies, we take them to the park, to the beach and  they paint and do other creative things in the clinic. Each person who has this condition is  an individual, they are not all the same. So when we do our staffing on these patients, we  create an individual program for each patient, because they all can't do the same thing and  they all cannot tolerate the same amount of pressure.

 We have a system as far as our psychotherapists are concerned, which I think is creative  and really to me, a wonderful expression of a human being meeting with another human  being. Our therapists do something different than most therapists do, they don't sit in their  offices. Each therapist must spend some time outside of their offices walking around the  unit and talking to each and every person. That's the world the patient lives in, you really  can't understand their behavior, if you simply sit in your office and tell them to "come on  in, let's sit down and talk ". But if you see them in their world, see how they behave, their  sense of belief in you grows and gradually they begin to feel good enough as human  beings.

 Many people have seen us as an example of treatment that should be replicated in different  institutions. If you do psychotherapy alone or medication alone, what you create is an  addiction to those two treatment methods. Change doesn't come about without those  other things that I discussed, such as resocialization and rehabilitation. Briefly it is my  understanding that this hospital is going in that direction, I hope so. It's necessary to  change.

 In our brief conversation, the chief psychiatrist of this hospital told me that rehabilitation  was one of the major directions. I wish you success, I think if you work together in  harmony, you will have success. Then you will feel the pleasure and the excitement of  your efforts. You will be able to know that what happened to that person is more than a  function of simply taking medication. The changes will be deeper and will be longer  lasting. My prediction is that with many of these patients, you won't assume that they will  regress and need re-hospitalizations. I know that's true, by the way, I've had the good  fortune and the privilege of seeing patients talking to staff in fifteen countries in the world  and I have seen this broader treatment development taking place for the last number of  years.

 So that is briefly what happens in treatment today. You should understand one idea,  which to me is exciting, that this also, these treatment modalities will be refined and they  will also change in time.