Division of Psychoanalysis (39), American Psychological Association,
New York, NY, April, 2002.
THE EFFECTS OF MEDICATING OR NOT MEDICATING ON THE TREATMENT PROCESS
Bertram P. Karon, Ph.D.
Michigan State University
It is my view for any psychopathology that everything goes best if medication is not used at all. If the patient, the therapist, or the setting -- hospital, family, board and care home, job -- require it, medication can be used, but the patient should be withdrawn from medication as rapidly as the patient can tolerate.
I have never medicated a patient who was not on medication when they came to see me. It has never been necessary. I tell patients that I will never ask you to give up anything you need, but the odds are that you will eventually be off medication if you continue to work with me.
The Michigan State Psychotherapy Research Project compared medication used appropriately, with psychoanalytic therapy without medication and with psychoanalytic therapy accompanied by medication in the treatment of severely disturbed center city schizophrenics. Our major finding was that even an average of 70 sessions of psychoanalytic therapy, with or without medication, was far better than medication alone, most markedly with respect to the thought disorder, but also led to a more human way of life in a variety of ways, and to earlier discharge from the hospital and approximately half the probability of readmission within two years. Consequently, it even saved money. All of that I have written about in my book, Psychotherapy of Schizophrenia: The Treatment of Choice (Karon & VandenBos, 1981).
The comparison of psychoanalytic therapy without medication with psychoanalytic therapy accompanied by medication looked quite different depending on the experience level of the therapists. The experienced therapists, who had over 10 years experience in treating schizophrenics and were considered good therapists by their colleagues, were both very helpful on all criteria, even though I used no medication, and Dr. Tierney used medication. I am not usually too bothered by disorganized people, but Dr. Tierney was. The medication was helpful to him in relating to the patient initially, but he was very clear with his patients that the medication did not cure anything, the only thing that would cure them was their understanding, but that the medication made things bearable so they could work together. He then withdrew the medication as rapidly as he felt the patients could tolerate. Much to my surprise that turned out to be a good way to work.
The inexperienced therapists (graduate students in Clinical Psychology or psychiatric residents) showed more difference in results. Those who did not use medication at all tended to have patients whose thought disorder improved remarkably, but they had trouble in getting sufficient behavioral control so that their patients could be discharged. (This was the '60's when long hospitalizations were readily available.) However, when their patients were discharged, they tended to stay out. The inexperienced therapists who used medication as well as psychotherapy tended to maintain the level of medication and not withdraw it. Behavioral control improved quickly in their patients and they were rapidly discharged from the hospital, but their thought disorders tended not to improve more than medication alone. Their patients spent the least time in the hospital in the project period (the first two years), even less than the patients of their supervisor. But in the two year follow-up period their patients were rehospitalized as much as those who had received only medication. In other words, long term follow-up hospitalization was related not to how fast the patient got out of the hospital initially, but to whether or not the thought disorder improved. And the thought disorder improved most if the therapist did not use medication at all, or used it initially but withdrew it as quickly as the patient could tolerate.
At the time I understood this as probably due to the fact that the medications which are of some use with schizophrenics all decrease affect; schizophrenia is basically a chronic terror syndrome, and all of the symptoms of schizophrenia are either manifestations of terror or defenses against terror, and anything which decreases the terror will be useful.
However, one of the things that changes patients in psychoanalytic therapy are patients' affective reactions within the therapeutic hour. So that medications which decrease affective reactions in general will decrease it during the hours and remove one of the curative factors. It is like talking to a drunk friend or drunk patient, for that matter; they talk freely but they do not change.
Since then, however, we have learned that most, if not all, neuroleptic medications are also neurotoxic. (Breggin, 1997; Breggin & Cohen, 2000). The older generation of neuroleptics cause tardive dyskinesia in 40% of patients within 10 years, according to the American Psychiatric Association's committee on Tardive Dyskinesia. The newer atypical antipsychotics are not free from this, most, but not all, have a lower but not zero risk. There has been a large judgement recently in Philadelphia against a psychiatrist because Resperidol caused tardive dyskinesia. And the drugs which have a lower risk of tardive dyskinesia have other risks, like agranulocytosis. There are also recent MRI studies showing intracellular damage from neuroleptic medication (e.g., Gur et al.,1998).
As you probably know, the most important research findings on schizophrenia in the last 20 years have been the long term follow-up studies. Contrary to Eugen Bleuler's original description, his son Manfred Bleuler found that approximately one-third completely recover within 25 years and another one-third have social recoveries. There have been at least a dozen studies all of which are consistent with this finding. There has not been any change with so-called modern medications (Ciompi, 1980; Harding, 1995; Harding, Zubin & Strauss, 1987). There were better results in the era of moral treatment in the early 1800's (Bockoven, 1972) and better results in the U. S. during the mid-twentieth century (Hegarty et al, 1994) when psychotherapy was more likely to be offered. In the best of the American studies Courtney Harding (1988) found that 50% of patients stopped taking their medication, despite the fact that most psychiatrists insist that it must be taken for life. What is fascinating is that all of the 30% who completely recovered in Harding's study were among the 50% who had stopped taking their medication. This could mean that the healthier patients felt freer to stop or that the medications helpful in the short run, interfere with full recovery. I think both are true.
Ann-Louise Silver, in a recent paper (Silver, 2000), said that when she first worked at Chestnut Lodge, her schizophrenic patients were not medicated. In more recent years, all of her patients were medicated as a matter of policy. In the premedication days, she had patients who got romantically involved, got married, had children, and related to their spouses and children. In the medication era, none of her patients developed stable marriages and stable relations with spouse and children.
There is a very useful book I recommend to professionals, Peter Breggin and David Cohen's (2000) YOUR DRUG MAY BE YOUR PROBLEM. The book lists the known side effects of almost all currently used psychiatric medications. Most of this is readily available in other sources. But what is unique is that the withdrawal effects of currently used medications are also listed, facts with which most medicating psychiatrists are unfamiliar, as well as advice on the optimal way to withdraw from these drugs. There is general advice, as well as specific suggestions for specific medications. Several medical psychoanalysts have told me the advice in the book is medically sound. The withdrawal effects are often misinterpreted as a return of the original symptoms, and, of course, any medication will suppress symptoms caused by the withdrawal of that medication. Breggin is a psychiatrist and David Cohen is a Professor of Social Work. They get their facts accurate. I first heard of Breggin when he was denounced by many of his psychiatric colleagues, because he was lecturing on the dangers of lobotomy and the dishonest data with which it had been justified. In the 1970's a blue ribbon panel of the American Psychiatric Association published a report endorsing lobotomy as safe and effective. They confined their panel to experts, defined as psychiatrists or neurosurgeons who had performed at least 12 of these operations in the previous year. Six months later, a court in Michigan reviewing the same data, but allowing Breggin and other professional critics to testify, came to a different conclusion, that despite its long history, there was no empirical evidence that lobotomies were helpful, and therefore it must be considered an experimental treatment which could only be performed with informed voluntary consent. Most importantly, involuntarily confined persons -- prisoner or mental patients -- could not give consent for experimental treatments because if you are not in a position to say no, you are not in a position to say yes. While this decision was never appealed and therefore was binding only in one county of Michigan, it immediately led to the abandonment of psychosurgery in public hospitals in Michigan and quickly to the abandonment of lobotomies throughout the country as psychiatrists and surgeons concluded that other courts would come to same conclusion. While this led to many of his psychiatric colleagues thinking of Breggin as a trouble maker, I have respected him every since.
The most general advice on withdrawing patients from medications given in that book is not based on psychopharmacology, which is generally unconcerned with optimal withdrawal procedures, but on recommendations from the general field of pharmacology where the subject has received serious attention. They recommend reducing the medication by 10% at a time, wait at least a week before the next reduction. The patient is the best judge of how fast one should go. Slow down when in doubt because the body and the brain have to adapt to the changing chemistry. The longer the patient has been on the medication, the slower it is usually necessary to go. It is also recommended that one consider subdividing the very last step into several steps.
As you know, some of our colleagues have been very lax about checking side effects, never consider withdrawing the medication, but add medications to control side effects. There are many settings where patients are automatically started on at least three medications -- an anti-anxiety or antipsychotic, combined with an anti-depressant, and either a mood stabilizer, or a drug that deals with extra-pyramidal symptoms. Additional medications are added as time goes by or as symptoms emerge. In the last six months I have talked to two patients who were being given more than 17 simultaneous medications. I doubt if anyone really knows the interactive physiological effects of more than three simultaneous medications.
As you probably know, the dopamine theory of schizophrenia comes from the finding that the neurones in the brains of schizophrenics have excess dopamine receptors. Dopamine is one of the better known neurotransmitters. We now know at least 500 neurotransmitters, but dopamine and serotonin have been paid the most attention by psychiatry. Since all the anti-psychotic medications block dopamine receptors, it was taken as proof that the basic problem was too many dopamine receptors, causing neural transmissions in out of control pathways. That anti-psychotic medication doesn't really cure schizophrenia was not noticed. However, when patients who had never been medicated were finally examined, they did not have excess dopamine receptors. And animal studies showed that giving anti-psychotic medication, which blocks dopamine receptors, led the animals to grow more dopamine receptors. There is more than one type of dopamine receptor, and the animals grew specifically the kind of dopamine receptor blocked by the drug (Porceddu. Giorgio, Ongini, Mele, & Biggio, 1986; Porceddu. Ongini, & Biggio, 1985).
It is still the case that none of the biological theories of schizophrenia hold up, except that the changes which occur in all of us under conditions of terror occur in schizophrenics. The viral theory of schizophrenia of Fuller Torrey is based on the fact that they found enlarged ventricles in monozygotic twins with schizophrenia as compared to their twin who were not schizophrenic. While their article summaries claim that the differences are not correlated with lifetime medication dosage, their data actually show an appreciable correlation (Suddath, Christison, Torrey, Casanova, & Weinberger, 1990). If you correct their data statistically for lifetime medication dosage, there are no differences between the schizophrenic and nonschizophrenic brains. In other words, the medications seem to have caused the differences. And the researchers are not developing anti-viral medications, which you would expect if they believed their own theories, but advocate current medications and the development of improved versions.
For depressed patients, too, I have never medicated a patient who was not already on medication. I usually tell patients that medication is an option; most of them have tried it already. I summarize the scientific information as best I know it. In the NIH collaborative study of depression, either medication or two types of brief therapy were equally helpful during the first year. At 18 months they were still equally helpful but no better than placebo. In other words, medication or brief therapy help in the short run; but it takes work to change long term vulnerability. Of patients on maintenance medication for bipolar disorders who take their medication, 73% relapse within 5 years and 50% of those who do not relapse reported significant symptoms short of rehospitalization (Gitlin et al., 1995). If you are concerned about being sued, make sure that you tell them that medication is an option. I always say that if they want to try medication, I recommend Dr. A. He reads the scientific literature, and he will give them the right medication at the right dosage, and monitor side effects. If they want psychotherapy and medication, I recommend Dr. B, who also will give them the right medication at the right dosage, but who also talks to his patients. And if you want to work, stay here. "Won't you work with me if I take medication?" "No, but I'll be here after you've tried it, and you can call me." They get mad at me, but they almost always stay and work in real therapy without medication.
Of course, if the patient is already on medication, we begin and the patient has the option of going off. If you can, work with the prescribing psychiatrist or non-psychiatric physician. But they do not own you or the patient. In many cases, they are happy to work with you. In other cases, they deride psychotherapy and give the patient false information. Since you can readily tell the patient where he or she can read the facts for themselves, there is no problem. Further, you are not a cop and you should not enforce the taking of medication. You should inquire as to why the patient has stopped, started, reduced, or increased medication, and what effect it has had, just as you would about anything else.
When the drug companies advertize a medication as having no side effects, what they mean is that it does not have one side effect of the previous medication. Thus, the older anti-depressants, MAO inhibitors and tricyclics, made patients fat, Prozac was originally marketed as a diet pill and it does not make patients fat. However, SSRI's, like Prozac, do increase suicide and homicide. The NIMH panel which reviewed the evidence and concluded that there was no risk, consisted of individuals with large grants or on salary from the manufacturers. There has been a study in England comparing a population sample on the older antidepressants with those on SSRI;s and the rate of suicide and homicide is 2 to 4 times as high. If a patient is on an SSRI and starts talking suicide or homicide, they need to be told it is the drug, and get the drug changed. One of the shooters in Columbine was on an SSRI. The manufacturers have been successful in getting the newspapers not to mention the drug the patient is on when they go on a rampage. The most that is mentioned is that the patient was "depressed" or "under psychiatric care." The SSRI's, as a street drug user pointed out to me, are chemically very similar to amphetamines, which used to be used as anti-depressants and appetite pills, and had suicide and homicide as symptoms of overdose. Lilly is now advertizing Prozac II as not causing an increase in suicide and violence, while never admitting that Prozac I had this as a problem.
In Gunderson's study of the treatment of schizophrenia in Boston (Gunderson et al., 1984), it was concluded that supportive therapy was better than insight therapy because more patients who stayed in treatment went back to work, but the biggest finding was 3 out of 4 patients in both groups dropped out of the study. This was because the therapists, insight or supportive, were required to insist that the patients stay on medication, so the patients avoided the therapists (Karon, 1984).
It is my experience with schizophrenics that 60% of the patients who are believed to be taking maintenance medication have stopped and lie about it. Even when I tell them that I do not care or even prefer their not being on medication, they do not believe me, and continue to lie. They have had experience with mental health professionals and they assume I am like them. They have been threatened with hospitalization or shock treatment, or been hospitalized not for any increased symptom, but just for the act of stopping the medication itself. It is usually only after weeks of treatment they believe that I might mean what I say, and tell me that they have already discontinued.
I asked a Vietnam veteran who was supposedly irrational and uncooperative with treatment, what was wrong, how could I help him? He said he hurt people and he did not want to. It turned out that he beat people, stabbed people, and had even shot people. I said, "That's a real problem and I'd like to help you. But sooner or later you're going to feel like busting me."
"Oh, no, I"d never feel that way."
"Sure you will. Everybody who talks to me feels like busting me sooner or later. But you must tell me about it and not do it, and we will learn something valuable."
He relaxed and he continued treatment. He was supposedly on 400 mg of Thorazine three times a day. The third week of treatment he told me the truth; he hadn't been on medication for some time.
After several months of treatment he went for a check-up at the VA; he was on a 100% disability. They insisted he take his medication or be kept in the hospital. Reluctantly he took his medication, and, groggy, tripped and broke his ankle that evening.
His sister, who had arranged for him to see me, called the hospital to see why they were so unhelpful and was told he is disorganized and violent unless he takes his medication. She said, "He's in therapy. He is more coherent and less violent than he has ever been in his life."
They said, "Then he must be taking his medication, no matter what he tells you, because he is incoherent and violent unless he takes his medication."
Six months later he went for another check-up. They called me before the check-up, so I told him that they would probably be more reasonable, but if not, to pretend to go along with them. They had him consult not only with his usual psychiatrist but obtained a second opinion from a psychiatrist, who had emigrated from Greece 2 weeks earlier and had trouble understanding the patient but approved the medication. They threatened him with a shot of Prolixin, and he agreed to a refill of Thorazine, which he pretended to take and threw away when he left the hospital. They reported to his sister that the medication was certainly helping him a great deal.
These days most psychoanalytic patients have had 4 or 5 treatments that haven't helped, or only partially helped before trying psychoanalysis, and you have to deal with the transference from earlier pseudotherapists as well as with the transference from parents.
If you are dealing with a hospitalized patient, you may have to go along with the medication routine until the patient is discharged. If you have sufficient respect from the staff, you may be able to withdraw the patient in hospital. One of the things I learned from my schizophrenia project was that the attendants and nurses get scared of their own feeling of helplessness without medication. It helps for you to be available. It also helps to let the staff know that it is all right to medicate to handle an emergency. This often decreases their feeling of helplessness so that they put up with more than you would have expected them to tolerate. Of course, Deikman and Whitaker (1979) demonstrated that you could take all patients off medications in an inpatient ward at the University of Colorado and the patients did better. Either Deikman or Whitaker was available to the staff by phone 24 hours a day if they were not in the hospital, and all situations were handled psychotherapeutically. They were accused of malpracticing for not medicating, but they had no suicides, suicide attempts or runaways. A well run better staffed comparison ward that had expert psychopharmacology had three suicides despite sending its more disturbed patients to a state hospital, unlike the psychotherapeutic ward. The patients from the psychotherapeutic ward did better afterwards. However, the experiment was discontinued and never repeated despite its success.
The one good thing about managed care is that patients are not kept in hospital long. While this has led to the demise of almost all of the few good hospital based treatment programs in the United States, it also means that patients will be out of the hospital in a short time and out of the control of hospital based psychiatrists with no training or knowledge of psychotherapy, unless the patients have the bad luck to be the victims of "Assertive Community Treatment" or outpatient commitment, as it is currently practiced.
The excuse for outpatient commitment is the supposed danger of violence, But the data are clear. Seriously mentally ill patients are not more dangerous than the general public unless they also have a substance abuse or alcohol problem. Far more dangerous are character disorders, especially psychopathic characters, again if combined with an alcohol or drug problem, according to John Monahan's large scale systematic research.
Everything I have said about depression and anti-psychotic medications also applies to so-called anti-anxiety medications. They all habituate within a year; within a year they are no better than placebos. As the British psychiatrist Isaac Marks said, if you cure an anxiety reaction with medication, you cure it for a year. If you cure it with a psychological treatment, you cure it.
Valium and Xanax are well known to be addictive. Even Consumer Reports had an article about the dangers, but patients aren't warned about it, and many have had serious problems. Because of the danger of addiction, Kernberg has warned that they are especially contra-indicated for borderline patients. A less publicized problem with all benzodiazepines is they interfere with the transcription of short term memory into long term memory, a serious side effect if the patient is going to have a normally complex life, that patients are rarely told about.
Physicians and nurses as patients frequently raise the issue of medication as a resistance. A physician with chronic depression had been treated with medication and psychotherapy for twenty years by a series of professionals in the Chicago area, some of whom called themselves psychoanalysts, before moving to Lansing. He and his wife were seeing the most recent in a series of attempts at marriage counseling. The marriage counselor insisted he needed individual psychotherapy and referred him to me. I told him my best guess was that he would have to be seen 3 times a week for at least 2 or 3 years. He said I was just trying to run a bill, that he worked for an HMO, and he knew that no one needed to be seen more than once per week, and no one needed more than 20 sessions. I said, "Let's see what we can do in 20 sessions once a week." As I always do when treating patients in a time-limited way, I reminded him at the beginning each of the last ten sessions "You only have 10 more sessions, How do you feel about that?" He began to get very angry at me for being such a son of a bitch that I would not see him more than 20 sessions. Then I said "Well, if you feel that strongly about it, we can continue after 20 sessions." In later sessions, he began to be furious at me for not being willing to see him more than once a week. "If you feel that strongly, I can make another hour available." In later sessions he began to be furious that I was not willing to see him more than twice per week. "If you feel that strongly, I can make a third hour available." Then he began to be furious that it was costing him so much.
From time to time he would raise the issue of medication--anti-depressant medication. I would then give him a short review of the literature as I know it. He would always get furious at me for being so rigid. One day I realized what was going on. Patients figure out your weak spots. I'm pedantic. It makes good sense to give your patients any information relevant to something important to them when you think they might not know that information. But, having given it once, it is not necessary to keep repeating it. Rather we should be analyzing why they cannot make constructive use of it. I said to him, last session you raised the issue of medication, and as I always do I gave you a little lecture, and you got furious at me. And you should have, because I was stupid. I wonder if you bring up the subject of medication whenever there is something important to talk about that you would rather not talk about, and you know I'll go off on my tangent, instead of helping. You were angry and you should be angry, because I was stupid. Now, what was it we should have been talking about?"
And there was something. There always is.
But if we are not going to use medications, then we need to talk about what you do to handle the situations for which your colleagues run to medications. As one of my medical analytic colleagues said, correctly, I am predictable. Whenever someone brings up a difficult clinical problem, one of our colleagues will almost always say "Have you considered using medication?" and I will almost always say, "Is it possible to make another hour a week available?"
There is a chapter in my book with VandenBos "Psychotherapy of Schizophrenia" (Karon & VandenBos, 1981) entitled "Special Issues in Psychotherapy with Schizophrenia". It was originally titled "Special Issues in Psychotherapy." The editor objected that it had nothing to do with schizophrenia, and we objected that one or more of these issues are involved in every patient. We got nowhere trying to be reasonable, so we just added two words to the title and changed nothing else. It is still a good general consideration of "Special Issues in Psychotherapy." Included are discussions of treating economically poor patients, homicide, suicide, patients who won't eat, patients who can't sleep, prejudice, ethnicity, sexism, alcohol and other drugs, prisoners and other criminals. You can read it if we do not get to discuss the issue today.
There is no such thing as a spontaneous anxiety or an endogenous depression. If a patient is anxious, there is something to be scared of. If a patient is depressed, there is something to be depressed about. If it is not in consciousness, then it is unconscious. If it is not in the present, then it is in the past and something in the present symbolizes it. As Viggo Jensen put it, an endogenous depression is a very serious depression in someone whom you haven't talked to long enough to know why they are depressed.
I allow patients to call me. Rarely do patients abuse that privilege, but they can frequently weather a crisis, a panic, a suicidal impulse, a terrifying hallucination, even a psychotic break, if their therapist is a phone call away. Further, patients often get through difficult situations without calling you when they know they can reach you.
I have a phone by the side of the bed so that I do not even have to get out of bed to talk to patients. The less trouble for you, the easier it is to be kind. And you sleep much better if by dealing with a phone call, you can prevent a suicide or reverse a psychotic break.
There are very few patients who will abuse this. Usually, they are depressive patients who use the phone call to torture you. If it is not obvious, ask "why are you calling?" and keep asking until you get an answer. For most patients who need it, it is obvious why they are calling. If it is not obvious, then the patient needs to have interpreted in their next session, their wish to irritate you to prove that at least compared to all other people their parents were good, so they must seduce you into mistreating them.
The most important thing you do for a severely disturbed patient is not to run screaming from the room. That is already good therapy. It is essential that a therapist or analyst tolerate being confused. It is not our accurate empathy, but our attempt to understand (whether or not it is successful) that is helpful to the patient. That is usually what they are responding to when they feel we understand them.
In dealing with patients who say they are depressed, it is important to find out what they mean -- they may feel sad, lonely, frightened, ashamed, angry, guilty, or have no feelings at all. The defense mechanism of isolation is typical of severely depressed patients. They typically make no connection between their feelings and obvious experiences that would depress anyone. It is always important to ask what happened before they started feeling depressed and keep asking when they say "Nothing" or "Nothing important." The "unimportant" will turn out to make good sense of their symptoms.
It is up to the analyst to form a therapeutic alliance.
You must let the patient know that you want to help and you will help, and that patients with similar problems usually do get better with hard work and a competent analyst or therapist.
As you know, catatonic reactions do not require medication. The catatonic hears and understands everything that is going on. As Fromm-Reichmann described, the patient has a conscious fear of dying if they move. Animal research has shown hat it is the last stage of defense of an animal of almost any species when under attack by a predator which frequently leads to survival. All you have to do is tell the patient that you will not let anyone kill then and keep talking as sensibly as you can until they come out. Prouty has published procedures that get even the worst of patients communicating.
Hallucinations are simply waking dreams. Get associations if you can, and use them in the therapeutic process.
Delusions have four major bases. If you think the patient is delusional, ask him or her to tell you about it in as great detail as possible. Do not attack or humiliate the patient or call it delusional.
You never know that something is delusional just because it is improbable. If you investigate a delusion from the patient's point of view, he or she will discover its inconsistencies or even that it is delusional. Then your interpretations solve a problem for the patient.
The most source of delusions is transference -- the reexperiencing in the world at large of unbearable childhood feelings and experiences.
The second source is the denial of, projection of, and reaction formation against the fear of being homosexual, based on the misinterpretation of the longing to be close to someone of the same sex as homosexuality, which Freud (1911) so aptly described in the case of Schreber. The secondary sources describe everything except what is important and therapeutically useful in Freud's description, namely the schizophrenic' withdrawal from everyone and the consequent loneliness underlying this longing to be close to someone of the same sex. It is useful to tell the patient, "you are not a homosexual but you are lonely, and we all need friends of both sexes."
The third source of delusions is strange beliefs actually taught in their family.
The fourth source is the attempt to make sense out of a world where one's real-life experiences are different from what other people have experienced. The patient is trying to make the best sense ho or she can out of his world.
I often say of a delusion "That is a brilliant explanation." "Then, you think it's true," "No, but that's because I know some things about the human mind you don't know yet, and I'll be glad to tell you about them if you're interested. But given what you do know, that's a brilliant explanation."
A patient termed an incurable schizophrenic by his outpatient psychiatrist, who had treated him with medication and psychotherapy, and by a consensus of the inpatient psychiatric staff, who had treated him with increased and combined medications, was brought to my office after his wife, on my advice, refused to permit electro-convulsive therapy and had withdrawn him from the hospital, despite the staff's objections. The psychiatric staff told her she was killing him. He was not eating, he was not sleeping, and he was continuously hallucinating.
He was from a middle-class family and had considered himself lucky to have such good parents. However, even before his first psychotic break, he could not remember his childhood before the second year of high school; he did not think this was abnormal.
I immediately stopped all medications and started real treatment -- 7 days the first week, 6 the second, and so on, until a regular 3-day-a-week schedule. His wife and friends of the family took turns being with him for the first 2 months. Since not eating can kill you in 30 days, the treatment started with that symptom doing what I recommend in my book. The second session was at 7:00 a.m. at an all night restaurant. He said, "I can't go in there. They'll think I'm crazy." "No,? I responded, "They'll think you're drunk." "I'll throw up. " "Do you think you're the first drunk who threw up here tonight?"
I discussed food, the fear of poisoning, and its possible origins while I ate. The patient reported nausea while watching me eat. By the third restaurant session, he took some coffee for himself. Then coffee and toast at the next session. Finally, he ate breakfast, but he objected, "I'm paying for therapy and all I do is watch you eat. I've got a right to be listened to." At that point we returned to the office for more traditional treatment.
Six months later he was working at an intellectually demanding job. A year later I could say to him: "Anyone can go crazy under enough stress, but under the stresses of ordinary life, you will never be psychotic again." He said, "This is better than I have ever been, better than what I used to call normality, but if you think this is good enough for me, you're crazy.'
The treatment process eventually became more traditional. We moved to a couch and I sat behind him when it seemed more useful. This patient saw me for 14 years. He kept raising new issues. In his third year, he startled me by saying "I have a book to write and I can't. Is that something that you can help me with?" Somewhat dubiously, I said, "People do go into analysis for writer's block." We spend most of a year on it, and he wrote that book. He has written several since. Others in his field have told me that his professional reputation is based on that first book now considered a classic in his field. Obviously it was well worth a year's analytic work. He knew that, even if I did not.
In his prepsychotic period, he had never eaten a meal without nausea. During treatment, after a trip to France, he recounted with tears in his eyes, "I can't tell you what French cooking is like. There is nothing like it in the United States.?
He went through psychosomatic problems and then marital problems. "I could leave her. There are bright, attractive, interesting women out there, but it would devastate her. When I needed her, she saved my life. The doctors said, "Shock him." My family said, "Shock him." People in your department said, "Shock him, but she had the courage to defy them and see that I got real treatment. And I just can't do that to her."
He described his need for the last two years of treatment; "I have a teen age son. When he was a kid, he had a psychotic father. That was a hell of a thing to do to a kid. And I need help in undoing the harm I did him."
He is now internationally renowned in his field. He is an outstanding scholar and teacher, as well as a good husband and father. His therapy did not make him a bright man nor a kind man, but it did keep his brightness and kindness from being destroyed. It did allow him to feel safe, perceive and think realistically and creatively, and use his intelligence and kindness to make his own and other people's lives more interesting.
All that we have to offer our patients is understanding, but that is far more powerful than any medication.
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