Working with Schizophrenia
and the argument for ongoing psychotherapy
By Michael Guy Thompson
What is schizophrenia? The fact is that none of us knows. It is a word, a label, that we confer on a person who we believe has lost his mind, or is acting crazy and perhaps dangerously so, and that in turn frightens us. Psychiatrists associate this condition with certain symptoms that are supposed to be obvious, such as delusional thinking — e.g., paranoia — or hallucinations — e.g., hearing voices — or speaking in a manner that is impossible to follow because it doesn’t make any sense, at least to us.
It can be scary to witness a person we have known all our lives begin to act crazy and accusing us of trying to put thoughts into his head, by insisting that he hears voices that are telling him what to do, and isn’t behaving the way he ordinarily does, or that we think is normal. When my communication with him becomes impossible to rely on, it’s as though all semblance of order has broken down and I don’t know what to do. Whom do I turn to for help, counsel, or advice?
Typically, we take this person to the hospital, to their crisis unit, and they will take control of the situation by effecting a mental status examination. And if this person is indeed exhibiting signs of schizophrenia or some other, similar psychotic condition, they will medicate him with the drug or drugs that they believe will diminish those disturbing symptoms by sedating him. Indeed, they will not release that person until those symptoms have abated.
Unfortunately, this is not the end of our story. This is when the heartache really begins. Medicating drugs, a misnomer if there ever was one, do not actually “treat” the condition they are prescribed for. Unlike, say, antibiotics, they do not eradicate the so-called illness that we believe schizophrenia is. They don’t cure anything. What they do, like narcotics, is mask the symptoms that are so disturbing to the person experiencing them, and the people around him. They act as sedatives, which is to say, they render us senseless. Granted, this may seem like an improvement over the delusions, hallucinations, or other disturbing behavior that this person was exhibiting. But as everyone knows who has had a loved one go through this, medication rarely returns this person to a normal, viable way of dealing with the world and other people.
Many of the people who complain about taking such drugs (e.g., Thorazine, Haldol, Abilify, Lithium, etc.) say that though their symptoms are diminished, they are left feeling in a haze, they have lost interest in their life, other people, and pleasurable activities. Most of all, they have lost their mental acuity and the sharpness required to engage in intellectual activity. Now what are they supposed to do? How do they get on with their life, if it has lost all meaning to them?
At the beginning of the twentieth-century there weren’t many drugs available for diminishing the symptoms of schizophrenia or bipolar disorder. Psychoanalysis — “talking therapy” — seemed to fill the breach and mental hospitals devoted to treating psychotic disorders employed psychodynamic therapy as their principal treatment regimen. Whereas psychoanalysis gained renown for alleviating less disturbing, neurotic symptoms, its success with schizophrenia was relatively mixed. The reason for this is twofold: 1) psychotic symptoms are much more difficult to treat and far more resistant to therapy, so it often takes longer to see any results; 2) expectations for complete remission of symptoms was unrealistic. As with neuroses, gains from therapy are always relative. No one, neither neurotics nor psychotics, has ever been completely cured of their condition. Success is typically measured by palpable improvement in one’s condition, that one is better off than one was before treatment.
In the 1980s a biochemical revolution in psychotropic medication occurred and powerful drugs appeared on the market that succeeded in masking the more disturbing symptoms in question: paranoia and hearing voices. If our criteria for success were to be measured strictly in terms of diminished paranoia and hallucination then this biochemical revolution would have to be deemed an astounding success. As we have learned, however, mitigating these symptoms does not, in and of themselves, result in a viable life. It does not necessarily mean that one’s capacity for intimacy with other people has been enhanced, that the person being treated enjoys his or her life, that the loss of self-esteem and self-regard have been restored to a normal, healthy condition. And what of the medication itself? The side-effects are often toxic and the patient being treated with them often complains about them. This is why most people taking such drugs resist taking them, only to see their more alarming — and noticeable — symptoms reappear. The game that then ensues — to devote one’s efforts to medication compliance at all costs — fails to address the problems that such medication is unable to address: to restore the patient to a life that is worth living, a viable and engaged existence.
For the past decade, psychotherapy and medication have been engaged in a sort of competition, one claiming to be better than the other. This is a false competition, because neither is a panacea to our problems. Most psychiatrists and psychotherapists nowadays have concluded that people suffering from schizophrenia benefit from both medication and psychotherapy.
In the 1980s a former patient of Chestnut Lodge Sanitarium, a psychoanalytic mental hospital in Rockville, Maryland noted for treating schizophrenia and depression with a strict regimen of psychoanalysis without medicating drugs, sued the hospital. The former patient, who had been admitted for severe depression, saw no improvement in his stay and his condition actually deteriorated. After his family removed him he was treated with medication and his condition improved. This was not unusual. Some patients respond to psychotherapy and some do not. Chestnut Lodge was famous for its commitment to psychoanalysis and patients typically sought treatment there because medication had not helped them. The case was settled out of court, but the patient who brought the suit then initiated a decade-long public campaign to discredit Chestnut Lodge and other hospitals that promoted psychoanalysis exclusively. This succeeded in turning public opinion against the psychoanalytic treatment of schizophrenia (though the patient who brought the suit was not schizophrenic) and subsequently virtually every psychoanalytic hospital in America (e.g., Menninger Clinic; Austen Riggs; Sheppard and Enoch Pratt, etc.) added medication to their treatment regimen in order to avoid potential lawsuits.
As often happens, the pendulum swung violently toward the use of medication as the “standard of care” for schizophrenia, whereas previously it has swung in the direction of psychotherapy alone. Many today would argue that without psychotherapy, drug treatment alone does little to improve the quality of a person’s life who suffers from psychotic symptoms. Given the costs of psychotherapy, most hospitals nowadays devote themselves exclusively to drug treatment. Moreover, most psychiatrists today insist that medication for schizophrenia is a life-long affair and that such patients should not expect to ever live without such medications.
I have been treating patients who suffer from schizophrenia, bipolar disorder, and other psychotic symptoms for the past thirty-five years, in Great Britain as well as the San Francisco Bay Area. I have done so in the context of mental hospital, residential milieu therapy households, and in out-patient private practice. Most of these patients began with medication, but over time, with the benefit of ongoing psychotherapy, they were able to wean themselves off of medication entirely. Psychotherapy works exactly the same with people suffering from psychotic symptoms as it does with milder neuroses. The objectives are exactly the same: improvement in one’s relationship with others, enhanced capacity for intimacy, increased self-esteem, better quality of life.
This is no silver bullet. Psychotherapy is not a panacea. Some people benefit from it more than others, and we don’t know why this is the case. The core benefit of therapy is that it entails a viable relationship with another person who does not sit in judgment, but is capable of being honest and compassionate. Over time, this usually provides an incentive to risk other relationships too, with friends, sexual partners, family members. Though one may never be entirely free of the sense of vulnerability that we associate with schizophrenia, one’s quality of life is usually significantly improved, over time.
If you, or a family member, is suffering from schizophrenia or other psychotic symptoms I would be happy to meet with you to discuss treatment options.