November - 1999

Some Notes on Schizophrenia

In reference to training interns and students interested in the psychotherapy of schizophrenia, one of the premises I present the students is that you don’t have to help anybody, just don’t hurt anyone and learn. When they integrate this idea, they don’t have an urgent need to "cure", which is usually a destructive exercise designed to impress and also to reduce some of the anxieties they feel about their competence. In that sense, without knowing it they are able to offer greater assistance to those patients with schizophrenia. I think that in a similar vein we all need to understand our limitations and forget that pressure or urgency, so that what we present is a much more sensible approach to treatment.

Many years ago, that fine psychoanalyst, Harold Searles, pointed out that people who have that urgent need to cure, really are made anxious by the condition of schizophrenia and want to rid themselves of the person who houses that condition. If you really want to help somebody, the question is, do you want to prove yourself and are more concerned with how people around you react to your efforts than you are with helping that person whom you are working with make progress.

Some years ago at an American Psychological Association Meeting in Toronto, Canada there was considerable concern that as medications like Prozac are marketed, psychologists worried that what they do might become obsolete. What some 15,000 were concerned that if what they do would be overcome by the introduction of more and more medications. One might say that one becomes obsolete if one does the same thing endlessly and doesn’t respond to the changes, the cultural changes that are brought about by the pressures of our society. In reference to that idea isn’t it important that all mental health workers find new directions in treatment?. Whatever the treatment is we cannot continue doing the same thing and expect to make a greater impact on those human beings who have this awesome condition called schizophrenia. It’s time for a change even though it’s hard for people to change.

Let me tell you about an experience that took place in Scandinavia. We began going to Sweden and Norway, in 1987 and have been there, adding Finland along the way, seven times. We went to many cities in Scandinavia, talking, training and working with patients to demonstrate an active treatment approach to the psychotherapy of schizophrenia. Even though the treatment in these counties, as far as psychotherapy was concerned, was from a historical point of view, psychoanalytic, we found that our presentations stirred up a great deal of interest in active approaches and were gratified in seeing that many of our Scandinavian colleagues began to see that passivity and neutrality were no longer useful. I must also state that some other professionals initiated their own active treatment approach and several developed training centers to help interested professionals and students learn some of these more active treatment techniques. So it is impressive to see people who have had a more traditional approach to treatment change their system of delivery after long periods of time.

Several years ago, in an edition of the Schizophrenia Bulletin, published by the National Institute of Mental Health, an article written by Thomas McGlashlan, a distinguished psychiatrist stated, "current treatment for schizophrenia are extracting diminishing returns, that are also limited and palliative. This includes biological and psychosocial treatment. Medications often fail to remove symptoms especially the negative symptoms of schizophrenia. It seems that all effective treatments are effective only as long as they are actively used. When you stop them the patient gets worse". However, McGlashlan does indeed talk about some of the successes he acheived as a psychotherapist. I wonder if he is referring to much of the treatment failures of inadequate treators.

How about psychotherapy? That isn’t mentioned very much. If you are familiar with the work of Robert Liberman, William Anthony, Julian Leff in England and a number of other contributors to the psychosocial rehabilitation efforts, no one in my opinion, has integrated any kind of psychotherapy with their psychosocial efforts. These are good contributors and in no way do I intend to diminish their contributions. However, psychotherapy in my opinion, is of critical importance in the armamentarium of treatment methods and yet it is not discussed very much. Why is that? Is it because people do not see it as a worthwhile approach? Or is it because there are few people who are willing and/or are able to use psychotherapy effectively with this treatment population called schizophrenic. If you do not have an active psychotherapy in my opinion, how can you in any sense of the words of Frieda Fromm Reichman share the illness with the patient. If you do not see that condition through the eyes of the patient, can you really understand what their life is like. We need to become part of their lives not just standing outside and looking at them in an arms length relationship and tell them, we know how they feel, when they are going through hell. Most of the time we don’t really understand how they feel. Implicitly, in the treatment relationship when we come face to face with that person initially, the message that comes from the treator is simple, it says change. Therapy of any kind is supposed to influence change. If that does not happen, there isn’t any therapy. It is just talk between two people that has no substantive meaning. So you look at them and they understand this, especially the veteran schizophrenic or that patient who has a long history of that condition. He or she looks at you, after receiving the same message from other therapists, thinks, and if you are sensitive to their cues, you can see in their eyes this thought, how about you, when are you going to change. When are you going to be something different. Then what comes forth is this question again implied, by the patient, you want to talk about my mother? What is it that you want to hear? I am ready to give you anything you want me to say. This is what they have experienced in the past with other therapists and they are prepared to deliver the same message because perhaps, they have lost hope and are unwilling to take a chance at failing again.

To give you an example, I had a patient some years back who when he sat down with me for the first time, a man of some fifty years of age with a 35 year history of schizophrenia, started crying. I said, "why are you crying"? He said, "because my mother treated me so terribly, it made me sick". I thought that this was a test on his part and I did not respond in a way in which he expected. Instead I said to him " how come when you go to the toilet you don’t zip up your pants when you are finished?" This surprised him. He looked at me and he was rather shocked. So he said to me, "don’t you want to hear about my mother?" And I said, "No." I said, "I just wanted to know why you don’t zip up your pants when you go to the toilet". That was the beginning of a better understanding of what I wanted him to do, which was that I wanted him to make behavioral changes and also to realize that this time, therapy, psychotherapy would be different.

Insight oriented psychotherapy does not necessarily lead to change. The psychoanalytic therapists, over the years have helped us understand about human behavior, however, their techniques of treatment have not lead to behavioral changes. And that is what therapy is supposed to produce. So my idea of treatment is to make demands on the patient to make behavioral changes they then impact the world around them in reference to the way they change and they gain insight because their behavior, produces changes in the way other individuals respond to them. Then the individual begins to understand why the world around them has changed and they begin to realize that that’s a function of their behavioral differences.

When we talk about psychotherapy I have had the opportunity to go to a number of different countries, Europe, Mexico and the United States and meet many mental health professionals. I found people wherever I have gone who were competent and good people and I also have found people who are not competent and not so very good. I guess this is characteristic of being human. Wherever you go, there are many similarities amongst all people. Wherever I have gone that there does not seem to be any real training in psychotherapy. The training that is done is the old fashion method which is didactic and is comparable of what analysts do with training student analysts. This is not my idea of training. I think training has to be a personal involvement of the supervisor and the trainee, so there is an exchange of information and they look at each other doing treatment. The supervisor demonstrates for the trainee and the trainee demonstrates for the supervisor.

At the Anne Sippi Foundation, which is a training institution I work with the patients with the interns observing and then have the interns and trainees work with the patients with me observing. I think that we have hidden ourselves too much and too long. We really do not get an accurate understanding of what people do with patients unless we can view it. I found this to be a very interesting way of training people and as a matter of fact, my experience began that way. I worked with one of the three earliest contributors for the psychotherapy of schizophrenia, his name, John N. Rosen who along with Harry Stack Sullivan and Frieda Fromm Reichman made the first impressive contributions of psychotherapy of schizophrenia.

Rosen worked in a very ideal way, in Bucks County Pennsylvania, where he rented houses in Bucks County for each individual patient and had them staffed around the clock and my responsibility was to go from house to house and work with the patients who lived there. We had to do treatment in front of the staff and also in front of Rosen and as difficult as that was, it helped me grow. There were no offices to hide in and that was the only way that treatment could take place. This was also good for the staff who had a better idea of what was going on in treatment, which I believe is necessary and should be a part of treatment today.

In fact, in 1989 I spent three months at a small psychiatric hospital in Molde, Norway on a project that was funded by the Norwegian Government. My job was to create an active psychotherapy program. Because there was so much disharmony amongst the staff, I had the staff assemble in the day room and in front of them, I treated all the patients on one ward which lead to greater cooperation and communication amongst the staff and that method was called ‘living room therapy’. Which lead to a paper written by the ward psychiatrist who read it at an International Meeting in Washington, DC in 1994. It is time, I believe that we come out of the dark and into the open so that we all can learn something together. Privacy in treatment comes with progress, when the patient requests a private audience because he or she does not feel like what they need to talk about should be shared with others.

The patients that I have focused on over the years have been the long term schizophrenic. They are typically called chronic, I don’t like that term because it’s such a negative description that becomes a negative fulfilling prophecy. The distinguished psychiatrist Loren Mosher also disliked the word chronic and replaced it with the word veteran, which is a description of the length of the illness and prior treatments. The veteran schizophrenic has the potential for change. Research that has been replicated in many parts of the world makes it quite clear that all people with schizophrenia can make good social recoveries under the right conditions. The word chronic has become an archaic term. Chronic suggests that the person will have recurrent episodes and can’t really recover to some degree or another. We need to take a look at ourselves, it’s time to do that. We are not so bad and we are not so good and even the greatest are not that great. As a matter of fact, I daresay that half the people that are practicing psychotherapy and other forms of treatment are incompetent.

Today, when we look at this problem, we call schizophrenia, the popular term in this country and other countries as well is what the biological psychiatrist call the decade of the brain. Psychologists in the recent past came up with the phrase the decade of the mind. What a peculiar disparity. People who talk about the decade of the brain state dogmatically that we now know that schizophrenia is a brain disease. Does that help you understand what it is? We know that people who talk in these terms are primarily products of the drug culture who are interested in using as much medication as they can. What is it? That is, schizophrenia. Is it a brain disease? Is it a biochemical disorder? A blood condition? A virus? Some people in Russia and also in this country suggest that it is a virus. Is it a function of too many dopamine receptors? A genetic predisposition? Strictly biological, strictly psychological, is this it? Does this explain it to you? Does it tell you what schizophrenia is? Is it more than a series of symptoms and characteristics? Perhaps one might see it as a process with stages.

By the way, when you speak about the causes of schizophrenia, Manfred Bleuler the son of Eugen Bleuler, said that it might come from one hundred different causes. However, when we treat human beings who have a diagnosis, we don’t treat the diagnosis, we treat the person. No matter what the diagnosis is there are both differences and similarities in people. Too often I have sat with psychiatrists who are biological minded and heard them prescribe medication based on the PDR and on a very brief evaluation of the patient which does not at all say what this person is like. And as a matter of fact in most cases, I do not see them as effecting any kind of relationship which might be construed as a therapeutic alliance. That relationship is the context of treatment, it helps to make medication more effective. The literature is quite clear in stating that medication is more effective if there is a strong relationship between doctor and patient. And also this is true in all treatment modalities.

I want you to know that the above is part of a series of notes on schizophrenia that will follow in the coming months.

Until we meet again.

Jack Rosberg