Psychosocial Treatment of Schizophrenia

A Lecture on the Psychosocial Treatment of Schizophrenia at the 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 being's 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 toward 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 toward 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 toward 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 patient's 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.