Psychotherapy of schizophrenia the treatment of choice
Bertram P. Karon , Ph.D., is a Professor of Clinical Psychology at Michigan State University, where he has taught since 1962. He is a past President of the Division of Psychoanalysis of the American Psychological Association, and President of the Michigan Psychoanalytic Council. He was selected by the New York Society for Psychoanalytic Training for their 1988 Distinguished Psychoanalyst Award, and their 1982 Outstanding Publication Relevant to Psycho-analysis Award for Psychotherapy of Schizophrenia: The Treatment of Choice. He was also selected for the 1990 Fowler Award for Distin-guished Graduate Teaching by the American Psychological Association Graduate Students and for the 1990 Master Lecturer Award by the Michigan Psychological Assoc-iation. He has over 100 publications in American and European journals of Psychoanalysis, Psychology, and Psychiatry. Dr. Gary R. VandenBos received his doctorate in clinical psychology from the University of Detroit. He has held positions as the director of the Howell-Area Community Mental Health Center in Michigan and professor of Clinical Psychology at the University of Bergen in Norway. He is a diplomate of the American Board of Forensic Psychology, and he is a licensed practicing clinical psychologist in the District of Columbia. He has been associate editor of the American Psychologist since 1984 and a contributing editor to Hospital and Community Psychiatry since 1982. He received the Early Career Award for Contribution to Psychotherapy from Division 29 (Division of Psychother-apy) of the American Psychological Association in 1983.
Given the temper of the times, the title of this book is brave and somewhat provocative. In the current world of general psychiatry, and even in psychoanalytic circles, few would agree with the authors that psychotherapy is the treatment of choice for schizophrenic people. The conventional wisdom is that schizophrenia is an illness with a biological, probably inherited, cause and that psychological approaches have not proved effective in its treatment…But Karon and Vandenbos have a different view. It istheir belief that in the hands of a skillful, experienced, and motivated therapist, psychotherapy can be dramatically helpful to schizophrenic people, more helpful and even less expensive than alternative treatments stressing medication management. Thisbelief is supported by their vast clinical experience and by the findings of the Michigan State project, in which they compared the efficacy of psychotherapy and medication. Neither that project nor this book settles the question once and for all, but they have written an extremely useful volume which should convince anybody open to their argument that there is a great deal to say in favor of their position… This book will stir strong feeling. In spite of its shortcomings, it is well worth reading.
— James P. Frosch, M.D.; Review Of Psychoanalytic Books
Given the temper of the times, the title of this book is brave and somewhat provocative. In the current world of general psychiatry, and even in psychoanalytic circles, few would agree with the authors that psychotherapy is the treatment of choice for schizophrenic people. The conventional wisdom is that schizophrenia is an illness with a biological, probably inherited, cause and that psychological approaches have not proved effective in its treatment…But Karon and Vandenbos have a different view. It is their belief that in the hands of a skillful, experienced, and motivated therapist, psychotherapy can be dramatically helpful to schizophrenic people, more helpful and even less expensive than alternative treatments stressing medication management. This belief is supported by their vast clinical experience and by the findings of the Michigan State project, in which they compared the efficacy of psychotherapy and medication. Neither that project nor this book settles the question once and for all, but they have written an extremely useful volume which should convince anybody open to their argument that there is a great deal to say in favor of their position… This book will stir strong feeling. In spite of its shortcomings, it is well worth reading. Whether or not the authors are correct in their belief that schizophrenia is a purely psychological phenomenon best treated by psychotherapy, they have demonstrated that psychoanalysis has much to contribute the understanding of schizophrenic individuals.”
— James P. Frosch, M.D.; Review Of Psychoanalytic Books
Inevitably, every psychotherapist has some experience with severely disturbed patients. Consequently, they will turn with excitement to this important new book which is a stunning attempt by two knowledgeable, persevering psychotherapists to present their understanding and sound therapeutic approach to these difficult and challenging patients. The authors argue that the treatment of choice is clearly psychotherapy and that such treatment can be successful and as long lasting for schizophrenic patients as it is for neurotic patients, but the journey may be longer and it may take more time to traverse.The task of therapy is to untangle the past from the present to make the future conceivable. The volume provides a thorough historical overview of the theoretical and clinical approaches to the problem of schizophrenia, including the views of leading contemporary clinicians on the topic. In general, the major clinical controversies have been regarded as issues of whether to focus on past, present or future; reality or fantasy; affects; exploration or relationship; whether the therapist should be active or passive; and how to handle regression. The authors argue that these are the wrong issues. They say that the task of therapy is to untangle the past from the present to make the future conceivable. Reality and fantasy are intertwined and must both be dealt with. Affects are central to all therapy, and emphasis on anger, despair, loneliness, terror, and shame are all necessary, as is the clarification of affect, and the acceptance of positive affect. Activity versus passivity is again in the wrong question; the right one is what action is helpful, when it is helpful, and when is not doing anything helpful? Regression is inevitable; should one accept it fully or try to limit it? This has no general answer other than do what is necessary (i.e., unavoidable) or most helpful to a particular patient at a particular time.
Diagnosis of schizophrenia involves ruling out other mental health disorders and determining that symptoms are not due to substance abuse, medication or a medical condition. Determining a diagnosis of schizophrenia may include:
- Physical exam. This may be done to help rule out other problems that could be causing symptoms and to check for any related complications.
- Tests and screenings. These may include tests that help rule out conditions with similar symptoms, and screening for alcohol and drugs. The doctor may also request imaging studies, such as an MRI or CT scan.
- Psychiatric evaluation. A doctor or mental health professional checks mental status by observing appearance and demeanor and asking about thoughts, moods, delusions, hallucinations, substance use, and potential for violence or suicide. This also includes a discussion of family and personal history.
- Diagnostic criteria for schizophrenia. A doctor or mental health professional may use the criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association.
- CT scan
Schizophrenia requires lifelong treatment, even when symptoms have subsided. Treatment with medications and psychosocial therapy can help manage the condition. In some cases, hospitalization may be needed.
A psychiatrist experienced in treating schizophrenia usually guides treatment. The treatment team also may include a psychologist, social worker, psychiatric nurse and possibly a case manager to coordinate care. The full-team approach may be available in clinics with expertise in schizophrenia treatment.
Medications are the cornerstone of schizophrenia treatment, and antipsychotic medications are the most commonly prescribed drugs. They’re thought to control symptoms by affecting the brain neurotransmitter dopamine.
The goal of treatment with antipsychotic medications is to effectively manage signs and symptoms at the lowest possible dose. The psychiatrist may try different drugs, different doses or combinations over time to achieve the desired result. Other medications also may help, such as antidepressants or anti-anxiety drugs. It can take several weeks to notice an improvement in symptoms.
Because medications for schizophrenia can cause serious side effects, people with schizophrenia may be reluctant to take them. Willingness to cooperate with treatment may affect drug choice. For example, someone who is resistant to taking medication consistently may need to be given injections instead of taking a pill.
Ask your doctor about the benefits and side effects of any medication that’s prescribed.
These newer, second-generation medications are generally preferred because they pose a lower risk of serious side effects than do first-generation antipsychotics. Second-generation antipsychotics include:
- Aripiprazole (Abilify)
- Asenapine (Saphris)
- Brexpiprazole (Rexulti)
- Cariprazine (Vraylar)
- Clozapine (Clozaril, Versacloz)
- Iloperidone (Fanapt)
- Lurasidone (Latuda)
- Olanzapine (Zyprexa)
- Paliperidone (Invega)
- Quetiapine (Seroquel)
- Risperidone (Risperdal)
- Ziprasidone (Geodon)
These first-generation antipsychotics have frequent and potentially significant neurological side effects, including the possibility of developing a movement disorder (tardive dyskinesia) that may or may not be reversible. First-generation antipsychotics include:
These antipsychotics are often cheaper than second-generation antipsychotics, especially the generic versions, which can be an important consideration when long-term treatment is necessary.
Long-acting injectable antipsychotics
Some antipsychotics may be given as an intramuscular or subcutaneous injection. They are usually given every two to four weeks, depending on the medication. Ask your doctor about more information on injectable medications. This may be an option if someone has a preference for fewer pills and may help with adherence.
Common medications that are available as an injection include:
- Aripiprazole (Abilify Maintena, Aristada)
- Fluphenazine decanoate
- Haloperidol decanoate
- Paliperidone (Invega Sustenna, Invega Trinza)
- Risperidone (Risperdal Consta, Perseris)
Once psychosis recedes, in addition to continuing on medication, psychological and social (psychosocial) interventions are important. These may include:
- Individual therapy. Psychotherapy may help to normalize thought patterns. Also, learning to cope with stress and identify early warning signs of relapse can help people with schizophrenia manage their illness.
- Social skills training. This focuses on improving communication and social interactions and improving the ability to participate in daily activities.
- Family therapy. This provides support and education to families dealing with schizophrenia.
- Vocational rehabilitation and supported employment. This focuses on helping people with schizophrenia prepare for, find and keep jobs.
Most individuals with schizophrenia require some form of daily living support. Many communities have programs to help people with schizophrenia with jobs, housing, self-help groups and crisis situations. A case manager or someone on the treatment team can help find resources. With appropriate treatment, most people with schizophrenia can manage their illness.
During crisis periods or times of severe symptoms, hospitalization may be necessary to ensure safety, proper nutrition, adequate sleep and basic hygiene.
For adults with schizophrenia who do not respond to drug therapy, electroconvulsive therapy (ECT) may be considered. ECT may be helpful for someone who also has depression.
- Family therapy
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Coping and support
Coping with a mental disorder as serious as schizophrenia can be challenging, both for the person with the condition and for friends and family. Here are some ways to cope:
- Learn about schizophrenia. Education about the disorder can help the person with schizophrenia understand the importance of sticking to the treatment plan. Education can help friends and family understand the disorder and be more compassionate with the person who has it.
- Stay focused on goals. Managing schizophrenia is an ongoing process. Keeping treatment goals in mind can help the person with schizophrenia stay motivated. Help your loved one remember to take responsibility for managing the disorder and working toward goals.
- Avoid alcohol and drug use. Using alcohol, nicotine or recreational drugs can make it difficult to treat schizophrenia. If your loved one is addicted, quitting can be a real challenge. Get advice from the health care team on how best to approach this issue.
- Ask about social services assistance. These services may be able to assist with affordable housing, transportation and other daily activities.
- Learn relaxation and stress management. The person with schizophrenia and loved ones may benefit from stress-reduction techniques such as meditation, yoga or tai chi.
- Join a support group. Support groups for people with schizophrenia can help them reach out to others facing similar challenges. Support groups may also help family and friends cope.
Preparing for your appointment
If you’re seeking help for someone with schizophrenia, you may start by seeing his or her family doctor or health care professional. However, in some cases when you call to set up an appointment, you may be referred immediately to a psychiatrist.
What you can do
To prepare for the appointment, make a list of:
- Any symptoms your loved one is experiencing, including any that may seem unrelated to the reason for the appointment
- Key personal information, including any major stresses or recent life changes
- Medications, vitamins, herbs and other supplements that he or she is taking, including the dosages
- Questions to ask the doctor
Go with your loved one to the appointment. Getting the information firsthand will help you know what you’re facing and what you need to do for your loved one.
For schizophrenia, some basic questions to ask the doctor include:
- What’s likely causing the symptoms or condition?
- What are other possible causes for the symptoms or condition?
- What kinds of tests are needed?
- Is this condition likely temporary or lifelong?
- What’s the best treatment?
- What are the alternatives to the primary approach you’re suggesting?
- How can I be most helpful and supportive?
- Do you have any brochures or other printed material that I can have?
- What websites do you recommend?
Don’t hesitate to ask any other questions during your appointment.
What to expect from your doctor
The doctor is likely to ask you a number of questions. Anticipating some of these questions can help make the discussion productive. Questions may include:
- What are your loved one’s symptoms, and when did you first notice them?
- Has anyone else in your family been diagnosed with schizophrenia?
- Have symptoms been continuous or occasional?
- Has your loved one talked about suicide?
- How well does your loved one function in daily life — is he or she eating regularly, going to work or school, bathing regularly?
- Has your loved one been diagnosed with any other medical conditions?
- What medications is your loved one currently taking?
The doctor or mental health professional will ask additional questions based on responses, symptoms and needs.