Psychotic Spectrum Disorders page two

When does psychosis typically manifest?

For males, probably between ages 16 and 30. And a little later in women, maybe around 24 to mid-30s.  There's also childhood schizophrenia, and there are older people who have late in life onset schizophrenia, but the predominant onset is around late adolescence early adulthood, right when people are making the move to leave home, go to school, and function independently.

 Tell us about the treatment for this condition in psychotherapy and in the therapeutic community at Riggs? How is this different from treatment in other contexts?

Certainly one of the things we do at Riggs that patients won’t get in other settings is 4-times a week individual psychotherapy. Some of the more biologically-based people might say that’s a waste of resources on these people, or that can make them worse.  There is controversy in the field about the value of insight oriented psychotherapy with psychotic people.  The thinking is that, it is an illness to be managed, rather than a person to be understood. The research in this country is very much biological and behavioral.  Psychotherapy can include crucial learning, for example, when someone speaks to you, what do you say back? You know, basic training for how to live in the world. That can be extremely helpful to patients

The research in Europe is very different. Americans often are not well-versed in the research from  Scandinavian and Finnish treatment studies, but they have substantial positive outcome data on integrative treatment approaches using biological, psychological,  family and  social-based treatment interventions delivered in a cohesive system.

 Our treatment at Riggs closely parallels what the Finnish researcher Yrjö Alanen calls, “need-adapted treatment.” The idea is that you work with the needs of the individual with schizophrenia using psychodynamic psychotherapy, family systems work, medication, and community support. That’s basically what we do at Riggs. His research used a treatment model very similar to ours, though our residential treatment is longer term. Their treatment is both in the hospital and in the home.

 I should say that psychoanalysis has a tarnished reputation in the history of diagnosing and caring for schizophrenia. In the late 1940s, the term of the “schizophrenogenic mother” came into the psychoanalytic literature. This was unfortunate, and it put families on the defensive. Groups mobilized to fight what was perceived as “mother-blaming” or family blaming, insisting that these disorders were purely biological. What we now know about mental illness is that the etiology and phenomenology is extremely complex with many variables interacting to produce the symptom picture and the meaning structure of the experience.  At this point, it is not possible to simplify these illnesses  in terms of cause or treatment.

What we know from research, particularly from Scandinavia, is that family environment does play a role. If people have the genetic makeup or markers for schizophrenia, environment does make a difference in whether it’s expressed or not. The research is clear that there’s an interaction.

 We need to take these people and their lives seriously. They not only have problems with their brain receptors, but also problems with meaning. Even if the trouble begins in an organic dysfunction, they still need to learn to manage their lives. By loose analogy, if you have diabetes, you have to reconfigure your life to take care of yourself and make some recalibrations. It is not optimal to surrender your life to the disease but some changes are necessary. People have to live a life that has purpose and meaning and need a lot of help to understand what’s happened in order to put together a life that works.

So we provide the opportunity for social interaction and feedback , medication, and skills acquisition — but also, four times weekly psychotherapy.  That’s radical in this day and age.  Many mainstream psychiatrists would think it’s unwise to engage in intensive psychotherapy with severely disturbed patients. I think that’s a shame. Why would you designate a category of people not to talk to the way you would talk to anyone about the symptoms in their lives and to assist in the development of insight to facilitate adaptation or change?

The therapeutic community program at Riggs is also unusual becauseour patients have such a range of psychopathology and difficulty. We have very high functioning patients and some very low functioning patients, and we don’t segregate them by diagnosis or symptoms. What is remarkable to me is the humanity that the patients show each other; even the most crazy acting schizophrenic person gets feedback. They will hear, “That’s not okay.” Or, “You’re scaring other people.” Or, “I think you’re doing that because you’re scared.” Individuals get a lot of engagement around their social presentation, and this is helpful.

It’s also helpful that they can determine their own course. In many treatment programs, patients are required to go to groups. At Riggs, patients have freedom to choose their level of involvement, which will differ from others. Our patients with Borderline Personality Disorder are often very smart, savvy, and highly engaged in their interpersonal environment. They benefit from interpersonal contact and may have, (as well as generate in others) intense emotions. For schizophrenic patients, that’s often too much stimulation. We have an environment where patients may have as much contact with others as they can tolerate.  Then, when they’ve had enough, patients aren’t pressured to remain in groups if it is overstimulating.  They are free to self-regulate and titrate their stimulation, which is  useful self-knowledge and self-management.

Often, people with psychosis need an environment with low levels ofexpressed emotion, with less interpersonal stimulation and opportunities for quieter engagement.  The Riggs community has enough people to provide a lot of life and spark and energy, but our psychotic patients can move in and out of that environment as they need to. They’re not required to be overstimluated, or stay in a situation that’s too overwhelming. 

It’s also important to get medication right. At the outset, we see some patients with positive, active symptoms — hallucinations, delusions, extreme paranoia. The thrust in these cases is toward identifying effective medications. It is extremely traumatic to lose your mind, and at some point, patients need a place to face and think about what’s happened to them. Families need a similar opportunity.

The levels of medication used to treat positive psychotic symptoms can leave a person quite sedated in the beginning. It’s hard to do psychotherapy with someone who is half asleep. So we try to find an effective dose that treats the symptoms but allows a person to engage in the therapy. Psychopharmacology is both an art and a science; it’s very individualized. An effective drug for one person may cause intolerable side effects for another.

 What other activities have you seen help people with this condition?

Keeping patients engaged is really key—for example, learning to paint, or working in the greenhouse.  Exercise is particularly important if you’re going to be on antipsychotic medications because they cause weight gain. Also, informal activities with peers, such as going to the movies and going to dinner together are extremely important. The benefit of the open setting at Riggs is that people can be out in the world, not cloistered and locked up in a hospital. For schizophrenic people who are often so socially isolated, to be out in the world can be quite beneficial.

 What positive outcomes have you seen from sufferers of this condition after treatment at Riggs?

There’s a wide spectrum of outcome. These are often notoriously difficult conditions to treat. I have seen people do extremely well, and I’ve seen people get worse and deteriorate, so the outcome possibilities are hugely different. I’ve seen people go to school, work in a part-time job, and live independently in a community.  I’ve also seen people who really couldn’t manage in the open setting, and have left treatment here in a terrible way, sometimes going to locked settings.       A major part of recovery is some supportive, social relationships. And if you can tap into people’s creative potential, that’s a huge boost to their self esteem and ability to express themselves. Certainly engaging the creative side of any person in this situation is very important.  For our patients, to go the shop and take instruction from another person is a really big deal.  Some people have a hard time allowing themselves to try something new and fail  -- and then to try something else, which is what the creative process demands. 

What do people who recover have in common?

A lot of our patients are very bright to start with, and they have good family support, so they can take their time and find their wayMany people who recover find a creative pursuit, something that engages them, or a kind of work they can tolerate that gives them a place in the world of dignity and self-respect.

One of the things that is astonishing to me is that the recovery rate for people with schizophrenia in third world countries is reported to be higher than in the U.S.--often these countries have no access to medication. This points to ‘village mentality’, where there is more social support, a place for people with psychosis in the community. They don’t get shipped off or hidden from the to-and-fro of community life. The social environment may support persons with psychosis better in different cultures.  In a fast-paced, so called “advanced” country, mentally ill people may become dehumanized problems to be managed rather than people to be understood. Our prisons are perhaps the largest mental health system in the country, full of people with psychotic disorders. And, of course ,many sick people are living on the streets.

 What books, or other resources, would you recommend for lay people who want to learn more about psychosis?

For an academic treatment of the history of psychotic disorders, I’d send people to Andrew Scull’s book Mad House: A Tragic Tale of Megalomania and Modern Medicine. Its an historical account of what went on in the Trenton state hospital in the early 1900s.    I’d recommend The Center Cannot Hold: My Journey Through Madness, by Elyn Saks, a professor, attorney, and MacArthur Grant recipient who has suffered from remitting and relapsing schizophrenia for a number of years.  She recounts the experience of her symptoms, her various treatments including psychoanalysis and the important role of medication for helping her maintain her mental health.  She does not romanticize schizophrenia and speaks to the profound effects of the course of her illness on her life and work.