Back from the Brink

Leslie Greenblat learned she had schizophrenia long after she had begun to hear,

in her words, “thought-voices.” She heard them all the time, whether she was

driving, reading, shopping, or talking with friends. The disembodied remarks

seemed to come from someone whose intimidating and demoralizing pronouncements

couldn’t be ignored.

Greenblat’s condition first landed her in a psychiatric hospital in 1990. Over the

next 3 years, the young woman was briefly hospitalized another dozen times. After

each discharge, she took antipsychotic medications for a few months until the

thought-voices receded. Invariably, however, they returned.

Then Greenblat began psychotherapy with psychiatrist Ann Alaoglu at Chestnut

Lodge, a private psychiatric hospital in Rockville, Md. Although trained as a

psychoanalyst, Alaoglu didn’t have Greenblat lie on a couch and dissect her

childhood. Instead, Alaoglu provided a relaxed environment and gentle,

straightforward questioning to convince Greenblat that she finally had found a

partner in healing. In that atmosphere, the cacophony of thought-voices started to

ease.

“Before I met her, I didn’t trust doctors,” Greenblat wrote in an article last

year for Schizophrenia Bulletin (Vol. 26, No. 1) . “Doctors doped me up, locked me

in, and were generally distant. Dr. Alaoglu . . . was willing to put herself on

the line, sharing with me her sense of my progress and lapses.”

Alaoglu’s methods hardly represent the norm for schizophrenia treatment. But her

success with Greenblat and other patients helps explain why the search for

effective treatments has expanded beyond medication in the past decade.

Researchers are increasingly exploring ways to combine psychological and social

approaches with antipsychotic drugs, especially in the early stages of the

disorder. Techniques in the spotlight include family-education sessions, job

training, social rehabilitation, and several forms of one-on-one psychotherapy.

Hallucinated voices

Consider Alaoglu’s approach. She regards hallucinated voices as having meaning for

the person who hears them. Unlike Greenblat’s previous doctors, Alaoglu offered

Greenblat ways to make sense of the voices.

Before a flight home, for instance, Greenblat once told Alaoglu that the trees

were warning her not to go. “You seem a bit nervous about your trip,” the

therapist responded.

Such observations “gave me a sense of how I was communicating,” Greenblat says.

She was often conveying her feelings indirectly, through personally significant

symbols that seemed bizarre to others. Such realizations, Greenblat says, also

helped her develop intimate and safe contact with Alaoglu, easing schizophrenia’s

terrifying isolation and stigma.

“Psychotherapy doesn’t fix schizophrenia,” Alaoglu says. “But it can help to

improve a person’s functioning.”

As Greenblat’s condition improved over the next few years, she collaborated with

her psychiatrist in adjusting her doses of antipsychotic medication. She also

participated in a vocational rehabilitation program.

Greenblat, now in her 30s, is studying for a master’s in health science. The

rigors of school sometimes cajole her thought-voices out of hiding, but she pulls

through these rough times with the help of family members, friends, and Alaoglu.

No quick fixes

Greenblat’s ongoing struggle illustrates a bitter truth: There are no quick fixes

for schizophrenia. It’s a severe mental disorder that draws most of its public

attention in rare cases when a sufferer commits an act of violence.

Over the past century, schizophrenia treatments have included isolation in

pastoral settings or hospital wards, intensive psychotherapy, brain surgery,

dialysis, and a growing number of medications. The fiercest theoretical battle has

pitted psychoanalysts–some of whom have regarded schizophrenia as a product of

emotionally callous parents–against biological psychiatrists–who view

schizophrenia as a brain disease.

Psychoanalysts and other psychotherapists now emphasize the need to build healing

relationships in treating schizophrenia. More biologically oriented psychiatrists

stress the use of antipsychotic drugs.

Combining these approaches may take treatment to another level. “People aren’t

blaming families for schizophrenia anymore,” says psychiatrist Courtenay Harding

of Boston University. “But they’re also starting to realize that a pill doesn’t

reclaim a life.”

Merely defining the disease has evoked a century of controversy. Increasingly,

however, psychiatrists are agreeing on three general categories of symptoms known,

respectively, as positive, disorganized, and negative. Still, many researchers

suspect that there are different types of schizophrenia with different causes.

Positive, or psychotic, symptoms include delusions, such as believing that secret

agents are monitoring one’s thoughts, and hallucinations, in which a person

experiences imaginary but disturbing sights and sounds.

Disorganized symptoms include confused thinking and bizarre speech and behavior,

as well as inappropriate emotions, incoherent sentences, and wild gestures. Some

schizophrenia sufferers also have difficulty interpreting everyday sights, sounds,

and feelings.

Negative symptoms include apathy, a lack of verbal and emotional expression, and

an inability to hold down a job or interact with others.

Most cases of schizophrenia–which afflicts 1 in 100 people–are diagnosed in young

adults.

Brains and genes

The causes of schizophrenia remain unknown. In the past decade, researchers have

sought to identify problems in brain structure and chemistry, as well as genetic

mutations that underlie this mental disorder.

The scientific emphasis on brains and genes has accompanied a growing clinical

reliance on antipsychotic medications to treat schizophrenia. The first of these

drugs, chlorpromazine, appeared in 1954. One major consequence of this in the

1960s was the mass release of schizophrenia patients from state mental hospitals,

antipsychotic prescriptions in hand. However, few community-based mental-health

centers materialized to offer treatment to supplement the drugs.

A new wave of antipsychotic drugs has since raised expectations for improved

schizophrenia treatment. Even for the roughly one-half of schizophrenia sufferers

who clearly benefit from antipsychotic drugs, most face a long-term struggle with

disabling symptoms and poor social skills, according to psychiatrist Juan R.

Bustillo of the University of New Mexico School of Medicine in Albuquerque. These

same people stand a good chance of sinking back into a full-blown psychotic state

at some point, even if they dutifully take their medication, Bustillo adds.

Combination therapies

When drugs alone are not an answer, combination therapies of drugs and other

treatments show promise, argue Bustillo and his colleagues in a review of recent

schizophrenia-treatment research in the February American Journal of Psychiatry.

Family therapy and so-called assertive community treatment show particular promise

in preventing the return of psychotic symptoms and the need for hospitalization,

Bustillo’s group holds.

In family therapy, teams of clinicians meet regularly with patients and their

families. The primary goal here is to provide information about schizophrenia and

ways to cope with it. Another critical goal is to reduce the tendency of family

members to react to their schizophrenic relatives with expressions of exasperation

and discouragement. These negative responses don’t cause schizophrenia, but

research has linked the social stress that comes with them to renewed bouts of

psychosis.

Assertive community treatment consists of caregivers meeting with patients and

family members in their homes and providing practical advice on living

independently with schizophrenia. These programs also give advice to schizophrenia

patients on finding and keeping a job.

A combination of these approaches substantially improves the quality of life for

schizophrenia sufferers and their families, according to the research of

psychiatrist William R. McFarlane of the Maine Medical Center in Portland.

His approach employs teams of mental-health workers, each of which conducts

educational sessions with groups of six to nine patients and their relatives.

Families learn to help each other and get a big morale boost from expanded social

contacts, McFarlane says. The addition of multifamily sessions to assertive

community treatment improves the capability of schizophrenia sufferers to avoid

sinking back into psychosis and to stay employed, at least over the 1-to-2-year

periods studied so far.

Individual psychotherapy

Individual psychotherapy represents the most controversial form of schizophrenia

treatment, at least in the United States. Fifty years ago, psychoanalysts were the

primary purveyors of psychotherapy for all sorts of mental problems. Their

attempts to cure schizophrenia by untangling family conflicts met with little

success, however. To make matters worse, psychoanalysts left many parents feeling

unjustly blamed as the cause of their children’s schizophrenia.

A set of treatment recommendations in 1998 from the Schizophrenia Patient Outcome

Research Team (PORT), which was sponsored by the National Institute of Mental

Health in Bethesda, Md., advised against using a “psychodynamic model” in

psychotherapy with schizophrenia sufferers. In other words, it recommended to

health-care professionals that they offer support without probing for ostensibly

unconscious, family-related discord.

A revision of the PORT guidelines will make major changes, says psychiatrist

Anthony F. Lehman of the University of Maryland School of Medicine in Baltimore,

who directs the project.

Despite its marred reputation, psychoanalysis deserves consideration by the PORT

revisers, asserts Brian Martindale, a psychiatrist in London, who conducts

psychotherapy with schizophrenia sufferers. He says a psychoanalytic approach to

individual and group psychotherapy helps in establishing a working relationship

with these patients. Efforts to reclaim psychoanalysis as part of schizophrenia

treatment often get the cold shoulder in the United States.

Europeans currently conduct most of the research in this area. Updates on several

treatment projects that include a psychoanalytic perspective appear in Psychosis:

Psychological Approaches and Their Effectiveness (2000, B. Martindale et al.,

eds., Gaskell), a compendium published last year.

The British government plans to finance 50 early intervention teams that will

treat people soon after their first psychotic episodes, Martindale says. These

teams will include clinicians trained in a psychoanalytic approach much like that

employed by Alaoglu.

“The most essential requirements in psychosis therapy are persistence, honesty,

and an ability to convey to the patient hope for a better future, even if it’s a

distant one,” says psychiatrist Yrjö O. Alanen of the University of Turku,

Finland. He has done psychotherapy with schizophrenia sufferers for 40 years.

Alanen and his coworkers have organized schizophrenia-treatment teams in

communities throughout Finland. These teams offer a variety of services based on a

person’s particular symptoms and circumstances. Treatments include individual and

family therapy, vocational training, and antipsychotic medication.

Among patients tracked for up to 8 years after entering treatment, about two-

thirds remain free of psychotic symptoms and a majority hold down jobs.

Young adults who first became psychotic as part of an identity crisis and had warm

family ties at the time of their psychotic episode, have benefited mainly from

psychoanalysis, Alanen says. These individuals did best without antipsychotic

medication, he adds.

Young people who became psychotic in the context of stormy family relationships

and an unstable personality profited from drugs as well as family and individual

therapy. Particularly severe cases of schizophrenia, in which people had become

isolated and unable to maintain social contacts or to express emotions, required

both medication and basic forms of rehabilitation.

Bustillo’s group sees potential in two other forms of individual psychotherapy for

schizophrenia.

One technique, called personal therapy, attempts to reduce patients’ anguish by

helping them recognize their own psychotic symptoms. In combination with

medication, this technique has fostered social adjustment and reduced psychotic

relapses among schizophrenia sufferers (SN: 11/8/97, p. 293). U.S. therapists have

now expanded personal therapy to include computer and group exercises in abstract

thinking and social communication.

The second method that Bustillo deems potentially valuable is based on a treatment

for depression called cognitive-behavior therapy. Given help in problem-solving

and social-coping skills, patients with schizophrenia are encouraged to challenge

their own psychotic beliefs and experiences and to consider more reasonable

explanations for them.

It’s clear that a mix of psychological treatments and antipsychotic drugs

constitutes the best medicine for schizophrenia, Lehman says. However, most

schizophrenia sufferers can neither find nor afford community-based services and

experienced psychotherapists.

Nor will this situation change soon, Lehman says. To begin with, he notes,

antipsychotic drugs generate huge profits for pharmaceutical companies. Aggressive

marketing campaigns for these medications bombard psychiatrists, most of whom now

get little medical school training in psychotherapy. What’s more, drug

prescriptions and brief office visits are easier on managed medical care’s bottom

line than are more complicated and expensive psychological treatments.

“Our system of care for people with schizophrenia is inadequate,” says Harding.

Over the long haul, integrated treatment provided by clinicians who maintain close

ties to patients will save money and change lives for the better, she says.