SCHIZOPHRENIC REACTIONS (THERAPY)

The treatment of schizophrenic reactions has undergone a drastic change in the past fifteen years. Insulin coma therapy, widely accepted in the 1940s, has now been almost completely superseded by methods that are more effective and less risky, primarily electroshock therapy and psychotropic drugs. Psychosurgery is also rarely used except as a last resort in chronic regressed patients who appear to be hopeless. Studies show, however, that a substantial number of these patients can be returned to the community, and as many as 25 per cent can become self-supporting. In addition to the use of somatic therapies, there has been a considerable advance through the use of individual and group psychotherapy, milieu therapy, aftercare, and rehabilitation techniques, and the experimental use of behavior therapy.The two most widely applied techniques, electroshock (ECT) and drug therapy, vary in effectiveness with different types of schizophrenic reactions and different stages of the illness. ECT is particularly helpful in controlling the symptoms of catatonic excitement or stupor, somewhat less effective with paranoid patients, and least successful with patients of the hebephrenic andsimple type. The most commonly used drugs are (a) the phenothiazines, such as chlorpromazine, used to control excitement, agitation, and thought disorders such as hallucinations, delusions, and paralogical thinking; (b) antidepressants or energizers, aimed at elevating mood and increasing interest and alertness; and (c) antianxiety drugs prescribed to reduce tension and apprehension and promote sleep. These drugs may be used in combination with each other or together with electroshock therapy.Phenothiazines may be administered for months or even years, but the anti- depressants and antianxiety drugs are usually prescribed only for a short time or during periods of stress. In general, the tranquilizing drugs are more effective with schizophrenics than the energizers, and both types are more successful with acutely ill patients than with the chronically ill. One of their major values is that they render many patients accessible to psychotherapy. Another is that they enable a substantial portion of patients—possibly 50 per cent or more—to be treated in outpatient clinics or day hospitals; in some cases even acute psychotic episodes can be managed by medication without the necessity of hospitalization. See ELECTROSHOCK THERAPY, CHEMOTHERAPY, ENERGIZER, TRANQUILIZER, PSYCHOSURGERY, INSULIN SHOCK THERAPY.Electroshock therapy is seldom used with schizophrenic children, although it is sometimes administered to adolescents. The same applies to drug therapy. Some of the more widely applied techniques are play therapy, relationship therapy, and activity group therapy in hospitals or residential treatment centers. Reinforcements (rewards) are sometimes used to overcome tendencies toward apathy and withdrawal.Many attempts have been made to treat schizophrenics through individual and group psychotherapy. The results vary considerably from patient to patient as well as from therapist to therapist. The assumption is, as Arieti (1959) puts it, that the schizophrenic “is not happy with his withdrawal, as some psychiatrists used to believe, and he is ready to resume interpersonal relations, provided he finds a person he trusts, a person who is capable of removing that suspiciousness and distrust which originated with the first interpersonal relations.”Therapists who agree with this position adopt an accepting, understanding attitude toward the patient, though some therapists treat him as a mature adult when he behaves in an infantile way, while others assume the role of a benevolent and loving parent. In either case they realize that the schizophrenic is easily hurt and therefore tolerate his hostility while avoiding any show of anger. Many of them find it is best to proceed slowly, even by sitting and smoking in silence with the patient, or by bringing him presents such as food as a means of establishing a trusting relationship. The couch is usually avoided since a prone position encourages the patient to live in his fantasy world instead of relating to reality. His delusions and hallucinations are rarely directly challenged by the therapist; instead, he encourages the patient to question them himself. He may also attempt to bring the patient closer to reality by direct support and guidance in the regulation of his life, as opposed to attempting to increase his insight, since this often has the effect of arousing conflicts rather than diminishing them.Finally there is increasing emphasis on sociotherapeutic techniques. Where psychotherapy is applied, the group approach is often preferred to the individual, since it encourages the establishment of normal social relationships and group members tend to correct one another’s fantasies and bring one another closer to external reality. Socialization is also advanced by organizing the hospital as a therapeutic community offering not only occupational and recreational therapy, but discussion groups and patient government.While most of these techniques are applied to patients on the road to recovery, there has also been progress in bringing chronic, withdrawn patients into closer touch with everyday reality. One approach, termed remotivation, utilizes planned conversational groups conducted by psychiatric aides or other nonmedical personnel. In a typical session, the leader creates a “climate of acceptance” by warmly greeting and complimenting each patient, then establishes a “bridge to reality” by reading and having patients read familiar poetry and other material. This is followed by a discussion of a special topic, such as space flight, that arouses interest without touching on personal problems. After this the discussion is focused on the “work of the world,” during which the leader notes references made to former hobbies and occupations—and later sees that the patients have an opportunity to pursue them in the hospital. At the end of the session a plan is outlined for the next meeting, and each patient is thanked for his participation.In the past few years social psychiatry has extended beyond the hospital and now includes such approaches as involving the patient’s family, the planning of a rehabilitation program, halfway houses, ex-patient organizations, and aftercare in the community.