Back from the Brink.

Psychological treatments for schizophrenia attract renewed interest

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.

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.

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.

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.

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 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 Yrjo 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.