Chapter Introduction

CHAPTER
15

Treatments for Schizophrenia and Other Severe Mental Disorders

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TOPIC OVERVIEW

Milieu Therapy

The Token Economy

How Effective Are Antipsychotic Drugs?

The Unwanted Effects of Conventional Antipsychotic Drugs

Newer Antipsychotic Drugs

Cognitive-Behavioral Therapy

Family Therapy

Social Therapy

What Are the Features of Effective Community Care?

How Has Community Treatment Failed?

The Promise of Community Treatment

During [Cathy’s] second year in college … her emotional troubles worsened…. Her thoughts about sex gradually bloomed into a fantasy about Steve Martin, the comedian. Unable to sleep through the night, she would awaken at four a.m. and go for walks, and at times, it seemed that Steve Martin was there on campus, stalking her. “I thought he was in love with me and was running through the bushes just out of sight,” she says. “He was looking for me.”

… The breaking point came one evening when she threw a glass object against the wall in her dorm room. “I didn’t clean it up, but instead was walking around in it. I was, you know, taking the glass out of my feet. I was completely out of my mind.” … She was … informed that she suffered from a chemical imbalance in the brain, and [was] put on Haldol and lithium.

For the next sixteen years, Cathy cycled in and out of hospitals. She “hated the meds”—Haldol stiffened her muscles and caused her to drool, while the lithium made her depressed—and often she would abruptly stop taking them…. The problem was that off the drugs, she would “start to decompensate and become disorganized.”

In early 1994, she was hospitalized for the fifteenth time. She was seen as chronically mentally ill, occasionally heard voices now … and was on a cocktail of drugs: Haldol, Ativan, Tegretol, Halcion, and Cogentin, the last drug an antidote to Haldol’s nasty side effects. But after she was released that spring, a psychiatrist told her to try Risperdal, a new antipsychotic that had just been approved by the FDA. “Three weeks later, my mind was much clearer,” she says. “The voices were going away. I got off the other meds and took only this one drug. I got better. I could start to plan. I wasn’t talking to the devil anymore. Jesus and God weren’t battling it out in my head.” Her father put it this way: “Cathy is back.” …

She went back to school and earned a degree in radio, film, and television…. In 1998, she began dating the man she lives with today…. In 2005, she took a part-time job…. Still, she remains on SSDI (Social Security Disability Insurance)—“I am a kept woman,” she jokes—and although there are many reasons for that, she believes that Risperdal, the very drug that has helped her so much, nevertheless has proven to be a barrier to full-time work. Although she is usually energetic by the early afternoon, Risperdal makes her so sleepy that she has trouble getting up in the morning. The other problem is that she has always had trouble getting along with other people, and Risperdal exacerbates that problem, she says…. “The drugs may take care of aggression and anxiety and some paranoia, those sorts of symptoms, but they don’t help with the empathy that helps you get along with people.”

Risperdal has also taken a physical toll…. She has … developed some of the metabolic problems, such as high cholesterol, that the atypical antipsychotics regularly cause. “I can go toe-to-toe with an old lady with a recital of my physical problems,” she says. “My feet, my bladder, my heart, my sinuses, the weight gain—I have it all.” … But she can’t do well without Risperdal….

Such has been her life’s course on medications. Sixteen terrible years, followed by fourteen pretty good years on Risperdal. She believes that this drug is essential to her mental health today, and indeed, she could be seen as a local poster child for promoting the wonders of that drug. Still, if you look at the long-term course of her illness … you have to ask: Is hers a story of a life made better by our drug-based … care for mental disorders, or a story of a life made worse? …

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Cathy believes that this is a question that psychiatrists never contemplate.

“They don’t have any sense about how these drugs affect you over the long term. They just try to stabilize you for the moment, and look to manage you from week to week, month to month. That’s all they ever think about.”

(Whitaker, 2010)

In many ways, Cathy’s clumsy journey is typical of that of hundreds of thousands of people with schizophrenia and other severe mental disorders. To be sure, there are other patients whose efforts to overcome such disorders go more smoothly. And at the other end of the spectrum, there are many whose struggles against severe mental dysfunctioning never come close to Cathy’s level of success. But in between, there are the Cathys.

This is today’s treatment picture for schizophrenia and other severe mental disorders. For some, it involves miraculous triumphs; for others, modest success; and for still others, heartbreaking failure. Treatment is typically characterized by medications, medication-linked health problems, compromised lifestyles, and a mixture of hope and frustration. Despite this, today’s treatment outlook for schizophrenia and other severe mental disorders is vastly superior to that of past years. In fact, for much of human history, people with such disorders were considered beyond help. Few returned to any semblance of normal or functional living. Indeed, few returned home from the institutions to which they were sent.

A graphic reminder During the 1800s and 1900s, tens of thousands of patients with severe mental disorders were abandoned by their families and spent the rest of their lives in the back wards of the public mental institutions. We are reminded of their tragic situation by the numerous brass urns filled with unclaimed ashes currently stored in a building at Oregon State Hospital.

Schizophrenia is still extremely difficult to treat, but clinicians are much more successful at doing so today than they were in the past. Much of the credit goes to antipsychotic drugs—imperfect, troubling, and even dangerous though they may be. These medications help many people with schizophrenia and other psychotic disorders to think clearly and profit from psychotherapies that previously would have had little effect for them (Miller et al., 2012).

As you will see, each of the models offers treatments for schizophrenia, and all have been influential at one time or another. However, a mere description of the different approaches cannot convey the pain suffered by those with this disorder as the various methods of treatment evolved over the years. People with schizophrenia have been subjected to more mistreatment and indifference than perhaps any other group of patients. Even today, at least half of them do not receive adequate care (Burns & Drake, 2011; Gill, 2010). To better convey the plight of people with schizophrenia, this chapter will depart from the usual format and discuss the treatments from a historical perspective.

As you saw in Chapter 14, throughout much of the twentieth century the label “schizophrenia” was assigned to most people with psychosis. However, clinical theorists now realize that many people with psychotic symptoms are instead manifesting a severe form of bipolar disorder or major depressive disorder and that such people were in past times inaccurately diagnosed with schizophrenia (Lake, 2012). Thus, our discussions of past treatments for schizophrenia, particularly the failures of institutional care, are as applicable to those other severe mental disorders as they are to schizophrenia. And our discussions about current approaches to schizophrenia, such as the community mental health movement, often apply to other severe mental disorders as well.

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