The self in connection to others is a second area that is central to our recovering patients. This is the area in which skill deficits are the most apparent. At MMHC we have an ongoing clozapine(Drug information on clozapine) support group that serves as a forum where patients further along in their recovery teach those patients who are in an earlier stage of recovery. Pragmatic skill-building groups, along with role-playing in a dyad, help patients with this aspect of recovery. In the individual sessions, attending to the therapeutic relationship as an interpersonal process is also important.
A 52-year-old man with paranoid schizophrenia, who had been hospitalized more than 10 times, had been living a profoundly isolated life while conventional antipsychotics poorly controlled his positive and negative symptoms. He lived marginally in his own apartment and refused offers of group living or day programs. Following a 14-month trial on olanzapine(Drug information on olanzapine) his grooming improved, as did his ability to describe his affective experiences, and he became romantically involved with a woman at a day treatment center.
After living 20 years without an intimate relationship, he felt overwhelmed with the newfound stresses of this connection. He discussed the pressures of being in this relationship and twice switched back between his old medications and the newer medications. Most recently he chose to move to a living situation that gives him more access to other high-functioning members of the MMHC community. He now has a pet for the first time in his life and cares for it lovingly. He reports pleasure in these connections and reports that for now, at least, he is not yet ready for a more intimate relationship.
A 38-year-old woman, who had a diagnosis of schizophrenia with long-standing paranoid symptoms, had been hospitalized more than five times. She talked about her difficulty finding a peer group now that she had become more social:
"I don't have a lot of friends, but my parents are with me. They stood by me through all the illness I had. I want to meet normal people...[but] I've been with so many mentally ill people that it's hard for me to make up things to talk about. I used to know a lot of people from church, but now I know nobody. I never had my teenage years. That's why I don't seem mature."
The loss of a sense of continuous development or uninterrupted narrative is a common sorrow for these patients. Time spent in the "sick role" with an active illness may limit the development of mutual relationships. The patient describes a nether world of relationships that is neither well nor sick. We know of no magic formula to aid in this process but would rely on her support group, clinician and her own strength to experiment with different kinds of connections, learning from each one.Sense of Purpose
We observe that people often search for a sense of purpose and spirituality as their symptoms remit to a substantial degree. A large number of them understandably yearn to return to their former hopes of what they had wanted to become, but instead must grieve this loss and attempt to find meaning and purpose in their reconfigured lives. As they work through their grief, rehabilitation and/or occupational training can solidify a sense of purpose and competence in these patients (Arns and Linney, 1993).
A 46-year-old married woman diagnosed with schizoaffective disorder more than 25 years ago, who survived more than 10 suicide attempts and a long history of cocaine abuse, talks about how her beliefs have changed over the years since she started taking clozapine:
"Every night in the past when I went to bed, I would ask God to take away my life. Things have changed now that I am better. Now I feel that there is a God. There is a divine spark in all of us...He has His own agenda. My life is only tragic if I am not on clozapine. When I was on the other antipsychotic, my thinking was slowed. I couldn't concentrate on my writing. My purpose in life is to do God's will. He gave me a gift for language and writing. I have to use them to help those still suffering to write about their...our...suffering."
There's little doubt that the growth of therapies for schizophrenia will continue to open complex psychological doors for our patients. Convincing payers that these developmental and existential issues are worthy of payment will become a policy challenge for caregivers.
Research demonstrating the cost-effectiveness of psychotherapeutic efforts for this population (e.g., in terms of improved medication compliance), coupled with data indicating that clozapine is a cost-effective intervention (Meltzer et al., 1993), could help to establish the need for individual psychotherapy, support groups and intensive vocational training for these patients. With or without such data, we believe that this study upholds the notion that the psyche in persons with psychotic disorders warrants psychotherapeutic care. By learning from the people who have managed this transition well, we can better utilize the next wave of pharmacological successes.
(Dr. Duckworth wishes to acknowledge his coauthors--Vijaya Nair, MMed [Psych]; Jayendra K. Patel, M.D.; and Stephen M. Goldfinger, M.D.--and especially the patients of MMHC who shared their experiences with us--Ed.)