October, 1997

What is schizophrenia? How is it treated? These are questions that perplex not only the beginning psychotherapist but experienced clinicians as well.

Schizophrenia is not a clearly understood disorder. Regardless of the causality there is a great need to understand, but more importantly is the need to help the schizophrenic obtain a reasonable level of functioning. How can schizophrenic patients be helped to lead more meaningful self sufficient productive lives in order that they no longer feel forced to cope by living in the world of insanity? For the psychotherapist, this is no small task.

Attempts to treat schizophrenia with psychotherapy by and large have not been adequate. While successful results have been described by psychotherapists, such as Federn, Klein, Fromm-Reichman, Rosen, and Sullivan,to name a few, the prevailing belief that the prognosis is poor for the long term (chronic) schizophrenics continues. Freud discouraged psychotherapy with schizophrenics because he believed a transference relationship could not occur with a schizophrenic patient. As psychoanalysis evolved, some psychotherapists began to treat schizophrenics with a modified psychoanalytic approach and received favorable results.

In this country, the three earliest contributors to the psychotherapy of schizophrenia were Harry Stack Sullivan, Frieda Fromm-Reichman and John Rosen. John Rosen was a very active and direct psychotherapist. In the 1940?s Rosen modified classical psychoanalysis and developed what he called, Direct Psychoanalysis. I spent more than two years in training with Dr. Rosen and over the years I expanded his approach into a method of treating schizophrenics that I call Direct Confrontation. This approach is a direct active emotion packed treatment which is designed to make quick contact with the most seriously regressed schizophrenic patients. Why Confrontation' This word frequently conjures up anxiety and skepticism by those unfamiliar with this approach. The increasing experience and body of the knowledge of the 1950's and 1960's show that schizophrenic patients were not as fragile as previously believed by the early Freudians. In fact, confrontation was found to be a necessary technique in breaking through the schizophrenic defenses.

The need for Direct Confrontation techniques in therapy are perhaps best explained by Berger, 1978. Confrontation has become perhaps the most significant concept of this decade as anxiety and alienation were the most common in the preceding one. Confrontational techniques became a necessity when it was realized that methods used in psychiatric training and treatment previously, were not adequate. In addition to the desire to reduce human suffering, by shortening the duration of psychotherapeutic treatment, there have been economic pressures to find ways to reduce the time and dollars spent for psychiatric treatment. The need to find more rapid ways to help patients gain understanding and insight leading to change, have also increased interest in confrontation approaches'. It has become clear over the past years that the word chronic is an anachronism. This is certainly evidenced by findings that have been replicated in many parts of the world that these unfortunate victims of this condition can, given the proper treatment formulae, make good social recoveries in almost every case.

 Years ago a distinguished psychiatrist, Loren Mosher, who was also concerned with the negative influence of that term substituted the word 'veteran'. Veteran is a term that describes eloquently the length of illness suffered by that individual with schizophrenia. The word 'chronic' has such a negative influence on those individuals who treat this disorder that frequently it persuades people not to utilize positive energies in treatment. Without a positive attitude, there cannot be any good outcome. Attitude is an extremely important part of the treatment no matter what the discipline.

 I think that it is important to realize that the treatment of schizophrenia has not been successful enough because we have not been sensitive to the needs of these very sick individuals. We have been complacent and comfortable with the older treatment methods and as a consequence, we have stopped the development of newer treatment directions. These people are reachable, depending what we have at our disposal and what we feel about treatment. Let me quote the eminent Karl Menninger who in 1957 wrote 'The psychology of schizophrenia is in my opinion as much in the mind of the observers as in the mind of the patient. We must change before he can change. He has long been incurable, because we have been hopeless'. Of course he is talking about the mental health profession, those professionals who have a negative attitude about this population. What he said at that time, in the history of treatment, has not changed in today's professional world.

 In 1955, a year after I began working with Rosen, the phenothiazines or neuroleptics were introduced. I began working with the long term schizophrenic without medication, with success. Certainly my efforts were not unprecedented. Many competent professionals in both the United States and Europe worked effectively without the use of medication. In Europe, the work of Federn, Schwing, Fenerczi, Alexander amongst many others and we should not forget the great contribution made by Eugene Bleuler who coined the term schizophrenia and was far more hopeful than his predecessor, Kraeplin. Bleuler worked as a psychiatrist and a psychotherapist at a small hospital in Switzerland. Then because of the illness of his parents, was compelled to move to Zurich where he continued his work at Burgholzi Hospital. Bleuler was very much influenced by Freud, with whom he maintained a correspondence. Some time later, he returned to that city where he began, the small town in Switzerland for a visit and was distressed to find so many sick patients. However, he forgot the patients that he worked with who prospered from the treatment that he gave them.

 In the years between 1913 and 1952 before the introduction of the neuroleptics more than one hospital in the United States had discharges much earlier than had been reported in the literature. One has to assume that they effected better psychosocial treatment efforts that made it possible for those difficult treatment cases to be discharged much quicker than had been reported. I am not opposed to medication, however, we have to put the modalities of treatment at our disposal into a reasonable perspective so we do not give more credit to any treatment form than it deserves to have. Medication has not cured anybody, as a matter of fact, there is no medical cure for this condition we call schizophrenia. However, we can help these individuals recover partially, at least and improve the quality of their lives.

 When I was very young, I was drafted into the United States Army and was part of three campaigns in the European theater. The horror of war that I experienced, changed my life forever and much of what I had experienced is still with me to some degree and has influenced the direction that my life has taken. Compare that experience to the trauma of schizophrenia, those individuals who fall victim to that condition are similarly effected and their lives are inalterably changed. I think that it is so very important for those of us who do not have schizophrenia to understand how it effects those individuals by comparing it with some of the suffering that all human beings endure to some degree or another during the course of their lives.

 I make no effort to discount the contribution that the phenothiazines made to the treatment of schizophrenia. However, what happened was that the medications began to push the professional away from the development of psychotherapy. Also, when we look at the entire picture of treatment with this condition, it is quite evident that treatment is either inadequate, begun too late, or both. Some years ago at Chestnut Lodge a well known American institution, Thomas McGlashlan did a retrospective study and found that psychodynamic psychotherapy failed to resolve the schizophrenic episode in more than seven percent of the population that were treated there. In his study, he did not discuss partial recoveries and/or quality of life improvement, which in my opinion, constitutes a major contribution. I think that the efforts at that hospital have been quite successful but have been not discussed well enough to identify and define what represents success. As I mentioned, one of the significant issues in treatment failure has to do with not recognizing the need to institute treatment quickly enough when the early stages of schizophrenia are recognized.

 In a recent addition of the Schizophrenia Bulletin, which is published by the National Institute of Mental Health in the United States, McGlashlan stated, that current treatments for schizophrenia are extracting diminishing results, they are also limited and palliative, this includes biological and psychosocial treatment. Medications often fail to remove symptoms especially negative symptoms. It seems, he says, that all effective treatments are effective only as long as they are actively used. Once you remove the treatments, patients according to him, tend to regress. That is his point of view, I do not think that he is right. What he stated in his article appears to be in conflict with some other remarks that he made, to the effect that he has successfully treated schizophrenic patients with a long history of that condition using psychotherapy. It seems that McGlashlan's recent interest in concert with Faloon of New Zealand, along with a number of other distinguished researchers, from Australia and Norway who are making efforts to find the predictors of schizophrenia, could be responsible in further diluting the necessary concentration on better treatment and rehabilitation measures that will enable the professional world to focus their efforts on the many millions of patients throughout the world, who have been abandoned and forgotten because of the severity and length of their mental illness.

 I make no effort to dismiss the efforts of research, whatever the direction that research takes that might modify or lessen the numbers of schizophrenic patients with an early onset. However, in the words of Roy Grinker Sr., "We must have better more effective treatment and rehabilitation methods." We must not continue to overlook these people who have the right to receive the best possible treatment we can offer and we the professional treater, must accept the mandate handed down by the past and the present to improve and develop newer treatment methods that allow this large population of patients to improve the quality of their lives.

 To quote Dr. Marianne Farkas, at Boston University Center for Psychiatric Rehabilitation in a feature article of the W.A.P.R. Bulletin, October 1996, "A rehabilitation approach requires a series of interventions whether there are facilities or not and regardless of who performs them and that the focus is on the individual in his or her real world environment as well as focusing on changing that environment. Any psychotherapy is not rehabilitation or recovery. Any skills teaching is not rehabilitation, nor will it lead to recovery. Any facility is not rehabilitation, nor will it produce an atmosphere of recovery. The meaning of recovery, rehabilitation and integration is not about technique or facilities as the defining feature. It is about providing a comprehensive process that allows consumers to hope for a full life in their community, that takes that hope seriously and then figures out what approaches turns those hopes into a reality." This parallels the approach and philosophy of treatment of The Anne Sippi Clinic, The Anne Sippi Foundation and the A.P.S., International in its training of students and professionals and in program development.

 In 1993 William Anthony wrote the following: "Recovery is a deeply personal, unique process of changing ones attitudes, values, feelings, goals, skill and/or roles. It is a way of living a satisfying, hopeful and contributing life, even with limitations caused by illness. Recovery involves the development of new meaning and purpose in ones life, as one grows beyond the catastrophic effects of mental illness. Recovery does not mean that the suffering has disappeared, with all symptoms removed and/or that functioning has been completely restored. Recovery from mental illness involves much more than recovering from the illness itself. It involves recovering from the stigma people have incorporated into their being; from the iatrogenic effects of treatment settings; from the lack of recent opportunities for self determination. Both he and Farcus go on to question, is it possible to recover from serious mental illness? Both data and first hand experiences tell us that it is. Here we have an apparent disparity amongst some of the leading researchers in this country, the U.S.A. What I hope to do in the following is to point out with greater specificity ideas and treatment methods that not only re-examine our current ideas, but point out certain changes in thinking that should lead us into more effective treatment strategies.

 Jay Haley, who was one of the key players in the Palo Alto study on schizophrenia, headed by the distinguished scientist, Gregory Batson. (Out of this study developed an important theory on the effects of communication in schizophrenia), Haley recently published a book entitled, 'Learning and Teaching Therapy' published by the Guilford Press in 1996. In it he says, 'Learning to be a therapist doesn't mean merely learning a set of skills, as one would with carpentry. The instrument of change, in therapy, is the therapist'. He talks about the fact that he was never formally trained as a clinician. Since he had no investment in a particular therapy ideology, he found it easier to change his thinking about therapy. He was influenced by a number of distinguished contributors who helped him develop a posture for being a psychotherapist.

 I think that we can all learn from this point of view that while theories or theoretical positions abound practical solutions and therapeutic strategies become extremely limited or curtailed by theoretical rigidities. Even though theories can help us resolve some of our own confusions, they tend too frequently to inhibit our growth.

 Haley states in his book, a belief that I have held for many years, that insight doesn't lead to behavioral changes. My point of view which is in agreement with Haley, is that behavioral change leads to insight. It is quite clear that the psychoanalytic contribution has been instrumental in helping us understand dynamics, but it has not been very effective in producing changes in treatment. The primary reason, in my estimation, is because their direction is insight oriented. With the long term schizophrenic patient, gaining insight through interpretation does not lead to change. It is clear that so many of those victims of this condition are unable to process interpretations in a way which will promote behavioral changes. Psychotherapy needs to be adjusted to the capacity of the patient to integrate what comes from the therapist.

 Do we know what schizophrenia is? In 1950 Hans Seyles, at McGill University in Montreal, Canada, in a book that he wrote about stress made the following statement, 'Psychiatrists do not know what schizophrenia is and what is schizophrenia'. There are many reasons why the long term schizophrenic has not responded to treatment. We cannot arrive at a common understanding that allows us to create better treatment approaches. When we look at the literature today about schizophrenia and hear people speak about this condition, what we hear a good deal of the time is talk about the biological concomitants of this condition. When we hear the statement, that schizophrenia is a brain disease, does that help us understand the process, do we know what that means? Can you respond to a patient who asks what is wrong with me, by saying your have a brain disease? What does that mean to that person who is going through enormous pain and fear and looking for some answers to the conflicts that he/she feels and the fear and the loneliness and the shame and the depression and the hopelessness that they feel. As a psychotherapist, if you have a patient in treatment who sees a doctor who prescribes medication and informs the patient that they have a brain disease and they come to you for psychotherapy and you inform them of your wish to help them and they respond by saying all they need is medication, because 'my doctor told me I have a brain disease', that comes to represent another line of defense for that person. In order to successfully treat a patient to make some kind of contact with them which leads to a therapeutic alliance, there has to be a shared belief system. If you say that you have psychological problems, and they, the patient, responds by saying, I don't have any problems, I am perfectly fine, I have a brain disease and a chemical imbalance. Even if all these ideas were true, it wouldn't help us help these individuals with schizophrenia. There is enough evidence to conclude that there are biological factors involved in schizophrenia. There is a good deal of evidence about the genetic aspects of this condition, however, the genes have not been identified. One hears commonly, that this is the decade of the brain and that there is a strong effort to locate in the brain some of the features related to this condition. But nothing substantive has been concluded. You can't forget that this is also the decade of the mind. We have to find a much better way of understanding this process beyond the biological and also beyond the symptoms and characteristics of this condition.

 We are convinced that individuals who have a long history of schizophrenia, can improve dramatically, if we give them the level of attention that their condition demands. They can improve, they do improve, they do not necessarily need lifetime treatment.

 In the following issues, I will continue talking about the life of the person with schizophrenia and treatment directions that are more concise along with treatment strategies that will allow the therapist to understand how to approach this very serious condition in a more hopeful and meaningful way.

 Until we meet again, Jack Rosberg