Synchronicity struck in my world again this week. Just as a discussion about why more Jungian therapists and analysts do not treat schizophrenics began on the IAJS discussion list, Furious Seasons posted a link to an article which challenged my assumptions.
For as long as I have been in practice, it has been the custom to treat schizophrenics and others with psychosis with medication and hospitalization and rarely if ever with therapy. I think in 35 years I have seen only one person carrying a diagnosis of schizophrenia and he did not stay in therapy long. Lacking experience working with people with this kind of problem, I admit I doubt my own ability to do so effectively, but I had really not questioned the conventional wisdom, surprising really given my general bias for therapy. Then I read of this study, reported in the Journal of Nervous & Mental Disease a year ago.
"This prospective longitudinal 15-year multifollow-up research studied whether unmedicated patients with schizophrenia can function as well as schizophrenia patients on antipsychotic medications. If so, can differences in premorbid characteristics and personality factors account for this? One hundred and forty-five patients, including 64 with schizophrenia, were evaluated on premorbid variables, assessed prospectively at index hospitalization, and then followed up 5 times over 15 years. At each follow-up, patients were compared on symptoms and global outcome. A larger percent of schizophrenia patients not on antipsychotics showed periods of recovery and better global functioning (p < .001). The longitudinal data identify a subgroup of schizophrenia patients who do not immediately relapse while off antipsychotics and experience intervals of recovery. Their more favorable outcome is associated with internal characteristics of the patients, including better premorbid developmental achievements, favorable personality and attitudinal approaches, less vulnerability, greater resilience, and favorable prognostic factors. The current longitudinal data suggest not all schizophrenia patients need to use antipsychotic medications continuously throughout their lives."
If I stop and think about it, the results make sense. Why should it be any more necessary for someone with schizophrenia to necessarily require medication forever than it is for someone with depression? Why have we assumed, with very little, if any, question, that those with major mental illness must always be medicated? What does it mean that we are in the process of "promoting" depression, ADHD and probably others into the category of major mental illness by expanding the definition of bipolar disorder?
It seems to me that for the most part the debate about the majors -- schizophrenia, bipolar, and other disorders involving psychosis, pretty much ended in a conclusion that they are primarily biological some years ago. At least I have not heard or read of anyone arguing otherwise for a long time. And somehow that came to equal chronic and requiring medication much the way diabetics require insulin.
But if there is a group of people with these disorders in whom they are relapsing and remitting in nature, then it would seem worthwhile to reconsider these assumptions. And why not therapy as part of treatment? If a patient is not floridly psychotic, why wouldn't therapy be both helpful and possible?
I am thinking that the person who raised the question in the IAJS discussion had a point.