Empirical Correction of 7 Myths about Schizophrenia: Lessons from Vermont Betty Dahlquist, MSW, CPRP California Association of Social Rehabilitation Agencies (CASRA)

Seven Myths of Schizophrenia At least 7 myths perpetuated about schizophrenia and other psychotic disorders discourage clinicians and case managers in promoting recovery 10 long-term studies show that consumers with severe and persistent mental illness can and do significantly improve over time Rehabilitation begins Day 1 of treatment Supportive psychotherapy is crucial for integrating the experience of illness and enhancing adult development There is no research evidence that consumers must stay on medications all of their lives People with serious mental illness can perform at all levels of work.

7 Myths about Schizophrenia They have been around for 100 years. Handed down from generation to generation of trainees across all the caring professions Have led to pessimism about outcome Significantly reduced opportunities for improvement Why we used to believe these myths What is the reality for each Treatment strategies

7 Myths about Schizophrenia Myth 1: Once a schizophrenic, always a schizophrenic Myth 2: A schizophrenic is a schizophrenic Myth 3: Rehabilitation only after stabilization Myth 4: Why bother with psychotherapy? Myth 5: Patients must be on medication on their lives Myth 6: People with schizophrenia cannot do anything except low-level jobs Myth 7: Families are the Etiological Agents

Myth #1: “Once a schizophrenic, always a schizophrenic” Background –Kraeplin - Good vs. Bad Outcome –E. Bleuler - “non restitutio ad integrum” –Cohen & Cohen - “the clinician’s illusion” Reality Wide heterogeneity Confluence of evidence across the world Impact of time changes everything Predictors lose power Set up programs “as if”

Results from Long-term studies The longer a cohort was followed, the more pronounced the picture of increasing heterogeneity and improvement in functioning Have consistently found that half to two thirds of patients significantly improved or recovered Universal criteria for recovery are: –No current signs and symptoms of any mental illness –No current medications –Working –Relating well to family and friends –Integrated into the community –Acting in such a way as to not being able to detect having ever been hospitalized for any kind of psychiatric problems.

Myth #2: “A schizophrenic is a schizophrenic” Reality: A rose is not a rose is not a rose Evidence Against Myth #2 –A group of schizophrenias (E. Bleuler) –substantial individual heterogeneity –Many genetic/environmental models (E.G. Kendler) Suggested Rx Strategies –Comprehensive assessments –Re-evaluate often –See the person behind the disorder –Collaboration

Myth #3: Rehabilitation only after Stabilization The Vermont-Maine Story –269 patients from the back wards deinstitutionalized in the 1950’s –A major follow-up study in the early 1980’s –Average of 32 years after first admission (22-62 years) –97% found 30 years later –68% achieved significant improvement or recovery –DSMIII diagnosis did not predict poor long-term outcomes as expected Rehabilitation, being out of the hospital combined with biological correction mechanism

Rehabilitation is Treatment Managing one’s symptoms Managing a budget Acquiring a job Acquiring a desirable housing situation Conducting social conversations Anything that raises self-esteem, lowers symptoms and improves functioning deserves to be called and reimbursed as “treatment”

Myth #4: Why bother with psychotherapy? Reality: Supportive psychotherapy is crucial for integrating the experience of psychosis & enhancing continuing adult development Evidence: –Surveys of consumers –Family interventions reduce relapse rates –Suggested Rx Realistic and practical Complementary to medication Working through trauma and grief Getting on with adult development

Suggested Rx Strategies continued Strategies continued –Longitudinal picture = halts and advances –Acquisition of skills –Biological and Environmental re-calibrations –True collaboration -Walking the path together What Vermont subjects said made the most difference in their struggles towards recovery –“Someone believed in me” –“Someone told me I had a chance to get better” –My own persistence –Translates to hope and hope connects with natural self-healing

Myth #5: Patients Must be on Medications all their Lives Background: –May be generated by MD’s in power struggles to promote compliance –or MD believes in myth #1 or its corollary: “once a broken brain, always a broken brain” Reality: It My be only a small percentage of folks who will need medications indefinitely –No supporting data (25-50% completely off) –American compliance rates (40-50%) –Denial of illness problems –Disorientation –Lack of knowledge –Side effects –No environmental engineering

Myth #5 continued. Suggested Rx strategies: –Strong patient-physician collaboration –Targeted psycho-education and skill building strategies –Built-in re-assessment strategies –Standardized side effects monitoring techniques –Training in non-pharmacological techniques to cope with symptoms

Myth #6: People with Schizophrenia cannot to anything except low-level jobs. Reality: People with schizophrenia can and do perform at every level of work –Symptoms do not predict work performance –Diagnosis does not predict work performance –Ability to function in a hospital or school does not predict ability in work environment –Best predictor are ratings of a person’s work adjustment skills in work settings –Best demographic is a person’s prior employment history. –Ability to get along socially with others is another predictor of work performance. “Employment is nature’s best physician and is essential to human happiness” (Galen, 172 AD)

Myth #7: Families are the Etiological Agents Reality: Families, as collaborators, can provide critical information to lower a relative’s vulnerability to episodes Evidence Against Myth #7 –Not causes of schizophrenia –Most families not high ‘expressed emotion’ (EE) –Family burden of care –Full of myths and misinformation Suggested Rx Strategies - Collaboration –Establish a relationship early –Education and emotional support –Triaging 1st v. long-term families –System Collaborators

“Schizophrenia does not seem to be a disease of slow progressive deterioration, even in the 2nd and 3rd decade of illness, there is still potential for full or partial recovery” (Huber et.al Finally, it is my hope that this presentation has excited and encouraged you to continue this very difficult work we do.