its original nature, its drug-altered character, and thoughts about its
Nathaniel S. Lehrman, M.D.
Clinical Director (retired), Kingsboro Psychiatric Center, Brooklyn NY
Schizophrenia has long been the loosely defined term for the most severe
type of mental disability without clear, anatomically-demonstrable brain
pathology. Although a huge research industry has engaged for almost a century
in a still-fruitless search for specific biological causes, this Gordian knot
was cut by Richard Jenkins (1952), director of research for the Veterans
Administration, when he proposed that schizophrenia was really a
psychosocially-produced neuropsychological disorganization (the acute phase)
followed by faulty reorganization, the chronic phase.
At that time, when psychopharmacology was just beginning in American psychiatry,
3.38 per thousand Americans were mentally disabled, with most of them diagnosed
with what might be called "pre-drug" chronic schizophrenia. In 2004, fifty
years later, with medication having eclipsed counseling within the
doctor-patient relationship as the heart of psychiatric treatment, the number of
mentally disabled Americans has increased six times, to 19.69 per thousand,
again with most diagnosed as chronic schizophrenia - but this is the "drug-era"
kind. This startling development, in association with other data, suggests the
existence of a new cause of chronic schizophrenia: medication.
In support of that hypothesis, Whitaker points out that "MRI studies have shown
the ... link between [psychotropic] drug usage and chronic illness. In the
mid-1990ıs, several research teams reported that the drugs cause atrophy of the
cerebral cortex and enlargement of the basal ganglia. Then, in 1998, researchers
at the University of Pennsylvania reported that the drug-induced enlargement of
the basal ganglia was associated with greater severity of both negative and
positive symptoms.ı In other words, they found that over the long term, the
drugs cause changes in the brain associated with a worsening of the very
symptoms the drugs are supposed to alleviate. The MRI research, in fact, had
painted a very convincing picture of a disease process: an outside agent causes
an observable change in the size of brain structures, and as this occurs, the
patient deterioriates." These patients represent the new iatrogenic
2. The nature of pre-drug-era schizophrenia:
the acute emotional experience
"Pre-drug schizophrenia" has two meanings: schizophrenia before the current
drug era, and a first episode schizophrenia patient today who has not yet been
given medication. Jenkinsı notion of schizophrenia as disorganization followed
by reorganization (applicable to both meanings) is close to Whitehornıs concept
(undated; Liddell, 1956, 75 ff) of "the acute emotional experience." This he
defines as "an unpleasant, confusing, disorienting, biological condition,
characterized subjectively as an excited, tense feeling with considerable
tendency to act, but with some uncertainty as to what to do, and characterized
objectively by motor restlessness or activity, not smoothly patterned, with
indications of excess effort, as shown in the facial and respiratory
musculature, tremor of voice and of skeleto-muscular action, together with
sudden changes in visceral activity." It is "disruptive of the smooth,
habitual, integrative modes of behavior." This is the physiology of what we call
the acute schizophrenic episode.
As "an internal crisis, in which habit is interrupted and the more raw or
primitive facilities for biological adjustments are summoned up," the acute
emotional experience (and the acute schizophrenic episode) includes "the
neural capacities of the organism for forming new associations between reaction
and situation, and for reorganizing behavior... a capacity which might lie
latent and unused if not activated by an emotional experience." Viewed over a
larger time span, such experiences have not infrequently been followed by
significant improvement in the adjustment to life - a "better level of
This growth-evoking function is, however, "not always successfully achieved" in
real life. With "rigid conditions,... acute emotional experiences [can be
produced] whose resolution is blocked by inhibitory training, thus reducing the
[potentially positive effect of the disorganization, and] transforming it into
conditions of disability and distress, chronic or recurrent." This is chronic
schizophrenia, in which the "neural capacity for forming new associations" can
cause patients to insist that one plus one add up to eleven.
"Fundamental patterns of emotional reaction and temperamental types seem to have
undergone little change in mammalian evolution," according to Lashley (undated;
Liddell, 1956, p. 83). Since "the major changes [seen in humans] are rather
the result of development of intelligent foresight and the inhibition of action
in anticipation of more remote prospects," the stages of emotional breakdown
seen in animals under stress are relevent for humans.
According to Liddell (1956, p. 81 ff.), the first of these levels in a sheep
subjected to continuing stress was "a stage of prophylactic caution, in which
its movements are markedly restircted and deliberate. It has become a
perfectionist. It seems as if it feared to do the wrong thing."
Next comes a "a stage of oscillating emotional behavior" in which the sheep "is
thrown first into a stage of rigid immobility" and then "responds explosively
with vehement movements often resembling aggressive behavior." This can be
compared to the rapid mood and behavior changes of both acute schizophrenia and
the acute emotional experience.
Then, although the sheepıs behavior "may appear to have stabilized, its
deportment has subtly altered and now appears peculiarı or unfamiliar.ı" This
is the chronic, or defectively reorganized, stage.
In every case of schizophrenia I have seen, and in most cases discussed in the
literature, its causes can be traced to the patientıs recent and remote
experiences, and, usually, to his increasingly unsuccessful efforts to deal with
3. The pre-drug treatment of acute schizophrenia
The central role of trust, and careful physical examination
The first task in treating the acutely disturbed pre-drug schizophrenia
patient has always been to calm him. He needs a stable, supportive and
sensitive social environment within which those caring for him - his
psychiatrist or other primary care-taker especially - have the immediate
obligation to win his trust. In general medicine, the physician-patient
relationship is responsible for about half of the overall therapeutic impact of
any treatment; in psychiatry, which lacks specific therapeutic modalities such
as antibiotics, the impact of that relationship is even greater. (White, 1991)
Medical and nutritional status must also be carefully evaluated immediately,
since difficulties or deficiencies in either area can alone produce psychiatric
The role of medication
Medication can help the acutely disturbed schizophrenia patient but only if
it is administered respectfully - with the patientıs informed consent rather
than as a chemical sledge-hammer - and only for a short time. That consent
requires his being told what the drug is, how it will help HIM (by reducing his
anguish, for example), and what its side-effects will be. Only if a patient is
dangerously out of control, and skilled efforts to win his consent for needed
medication are unsuccessful, should he ever be given medication without that
consent. But even then, efforts to win it should never stop. Once trust is
won, consent and cooperation concerning medication, and all other aspects of
treatment, will almost always follow. Patientsı attitudes toward taking
prescribed medication are a good barometer of the state of the doctor-patient
The initial, detailed history
The creation of a detailed history, especially of the events leading to the
current crisis, is more than just an accumulation of data. It is in itself
an important part of the calming process. The mere effort to fashion such a
history reassures the patient that his current plight is comprehensible and
therefore perhaps even correctible, rather than mysterious and irreversible.
Since assembling a history also requires contact with the patientıs
"significant others," the process can strengthen the patientıs relationships
with both them and his caretakers.
Psychotherapy, insight and change
Formulating a history will gradually evolve into psychotherapy. A patientıs
maladaptive attitudes, beliefs and behavior can slowly become recognized, and
therefore available for bilateral examination and possible change. (Lehrman,
1982) "The neural capacities of the organism for forming new associations
between reaction and situation, and for reorganizing behavior" come into play in
accomplishing such changes, and can result in the patientıs being better off
after his acute episode than before it.
Exercise: physical and mental
Acute psychotic episodes are often accompanied or followed by physical and
mental inactivity, which can easily deteriorate into chronic indolence. Physical
and mental activities should therefore be started as soon as possible after
treatment begins, and continue as long as it does. Key reasons for my own
recovery when I was hospitalized in 1963 for paranoid schizophrenia were my
running a mile a day in the hospital gym, playing my violin, and starting an
intellectually challenging historical research project. The importance of
intellectual challenge in recovering from schizophrenia cannot be overestimated;
a once-disorganized mind requires special exercises to recover after being
fractured just as a limb does.
Continuity of care
Placing the psychiatrist-patient relationship at the heart of treatment
means that the patient should continue being treated by the same doctor and
treatment team wherever he may be: in hospital, clinic, group home or whatever.
This differs immensely from the current care pattern, in which a patientıs
caretakers change each time his location does. (Lehrman, 2003)
4. The pre-drug treatment of chronic schizophrenia
In 1982, I described my own succesful, albeit incomplete, psychotherapeutic
treatment of over a hundred unselected chronic patients in a state hospital
aftercare clinic. An energetic, determinedly-optimistic psychiatrist-patient
relationship was central to that treatment, including the firm insistence that
the patient could indeed improve or recover, but only thru his own useful
and/or satisfying activities, which I would assist and guide.
Treatment began with an initial visit of an hour or more, during which the
patientıs history began to be obtained, and discussion of his immediate
post-hospital goals started. Then his "significant others" were met with for
historical information, and for me to understand - and perhaps correct -
conflicts among them. As the patientıs maladaptive problems began to be
recognized, we would agree on specific changes he was to attempt to make by the
time of our next visit. While the basic treatment plan involved our meeting
every two weeks, the patient had my home phone number and could call, and, if
necessary meet with me, before then.
A central aspect of treatment was reduction of medication - to zero, if
possible. This process, which requires careful monitoring by the psychiatrist,
could begin only when the patientıs life was relatively calm and after a firm
therapeutic relationship had been established. Dosage reduction was a joint
endeavor for patient, doctor and, often, the "other(s)." After reviewing the
emotional distortions produced by the medications, and especially their blunting
effects, a dosage reduction of between 10% and 20% would be agreed on, with the
patient and the "other(s)" being warned that the reduction would almost always
be accompanied by some recrudescence of symptoms, but that the reactivation
would certainly diminish and probably disapper within a few days. If the
patient could withstand that reactivation, he would remain at the lower dosage.
If he found the reactivated symptoms too difficult to handle, he could choose,
on his own, to return to the original higher dosage. After a month or two of
stability at the lower dosage, further reduction would then be attempted.
Skills in individual, couples, and family therapy, and knowledge about drugs and
how gradually to reduce dosage, are among those required for proper care of
mentally disabled schizophrenia patients. Having those skills within one
professional, preferably the psychiatrist, is, in general, far more efficient
and effective than dividing them among several different caretakers.
5. The current drug-based treatment of chronic schizophrenia:
the increasingly bleak picture created by the extrusion of the psychiatrist
Although the idea that chronic mental patients can indeed recover has
recently been resurrected, especially by some of those providing maintenance
services (e.g. drop-in centers), the organization of public care around drug
treatment seriously reduces the likelihood that recovery will ever occur.
A strong, positive, trusting doctor-patient relationship is psychiatryıs most
important therapeutic tool. Todayıs primary focus on medication may neutralize
that relationshipıs positive effect, if not actually making it anti-therapeutic,
because of its total transformation of the psychiatristıs role in patient care.
This is particularly troublesome in the public sector.
The psychiatrist, instead of having intimate knowledge of the patient and his
problems, and helping him solve them, is now limited to focusing on symptoms,
and to prescribing medications for them. Examining the medicationsı
effectiveness in reducing symptoms has replaced working together on the
patientıs functioning and problems as the main subject of psychiatrist-patient
Patients often resent the drugsı unpleasant side-effects. These include the
emotional blunting which impedes patientsı efforts to regain control of their
lives. They therefore often want to reduce or stop the medications. But
psychiatrists, wrongly comparing psychiatric drugs to insulin for diabetics,
insist they are needed for the rest of the patientıs life. The conflict thus
created can reduce, or even reverse, any positive therapeutic impact the
doctor-patient relationship might have. This reversal of therapeutic impact is
shown by a recent study of the long-term effects of "atypical" anti-psychotic
drugs. Despite the study psychiatristsı hope that the patients would continue
the drugs for the full 18 months of the study, 74% discontinued them before it
ended. (Lieberman, 2005) The psychiatrist can thus become the patientıs
adversary rather than his advocate.
Limiting the psychiatristıs role to monitoring medication has led to the
reassigning to other mental health workers of the provision of individual
contact and understanding which patients need, and which psychiatrists once gave
them. This task, previously reassigned from psychiatrists to other
professionals - social workers, psychologists and nurses - is now being
transferred to non-professionals, so that whatever individualized care the
patient now receives is provided increasingly by poorly-trained mental health
aides. (U.S.P.R.A., 2005) Not only are these aides unfamiliar with the
subtleties of managing interpersonal relationships, with the family dynamics so
important in mental health care, and with techniques to help patients understand
their pasts and change their futures, but their primary, and often only, task is
defined as ensuring that the patient takes his medication.
6. Two new over-medicating and under-counseling programs
The over-medicating and under-counseling characterizing two new programs for
the mentally disabled exemplify what is happening nationally. The Texas
Medication Algorithm Project, which the Presidentıs New Freedom Commission on
Mental Health describes as a model program, recommends the placing of large
numbers of mentally disabled patients on the newest and most expensive drugs. (Lenzer,
2004) That state, apparently in response to the mounting costs, dissolved its
existing mental health department, transferred mental health centers to the
state health department, and directed them to focus on "disease management" - "a
managed care concept that [supposedly] helps to care more effectively for people
with chronic diseases like major mental illness." (Tennison, 2004)
Medication is the first item on all levels of the systemıs benefit package. At
its lowest level, the package offers "five hours of medication management per
year," which, according to the chief operating officer (C.O.O.) of a local
public mental health center, includes "20 minutes with a psychiatrist every 90
days." While claiming that "mental illness is finally being treated as a brain
disease," the C.O.O. maintains that "the emphasis is on treating the whole
person," and that "the clients will [therefore] be more involved in their own
treatment, giving them a better opportunity for recovery."
Despite this "recovery" rhetoric, the brain disease concept of mental illness,
and the "disease management" model of its treatment, both represent the same
self-fulfilling prophecy - that mental illness is necessarily chronic and
irreversible. Defining the new system's primary role as providing permanent,
long-term care ignores how current treatment methods (and drugs in particular)
create chronicity, and ignores or abandons those efforts toward full
recovery which are most likely to succeed: those made before chronicity, drug
dependence and indolence have developed.
In New York State, the primary purpose of its new "Personalized Recovery
Oriented Services" (PROS) is to get Medicaid (i.e. 50% federal) funding for
existing "rehabilitation programs," such as day hospitals and drop-in clubs,
which are too often little more than baby sitting or make-work operations. (Jaros,
2004) Its complicated reporting system evokes memory of Pinheiro's 1990 comment
about the difference in psychiatric care then from 15 years earlier: "if you
now lose a patient, that is bad. But if you lose a patient's records, you must
be prepared to leave town." (Pinheiro, 1989)
Like the Texas program, New York's has different "service components" "to assist
individuals in managing their illness and restoring the skills and supports
necessary for living successfully in the community," and to assist "in attaining
specific goals such as a higher level of education, secure housing and
employment." Despite its recovery rhetoric, however, it is also based on the
indefinite continuation of drug treatment, which in itself reduces the capacity
to attain such higher goals.
On a wider basis, a nationwide Certified Psychiatric Rehabilitation Practitioner
(C.P.R.P.) program has been set up to train staff relating directly to patients
in these and similar programs. (U.S.P.R.A., 2005) Admission to the
certification examination requires a minimum of high school or equivalent;
psychosocial rehabilitation (P.S.R.) experience of 6 months to 2 years,
depending on education level; and additional approved training in P.S.R. (60
hours for most applicants). Whether called C.P.R.P.'s or case managers, these
are relatively untrained people who, in being given primary responsibility for
chronic patients, will serve primarily as state-paid baby-sitters whose first
task is to ensure that patients take their medications.
With psychiatric treatment programs based on drugs continuing to multiply, and
with the expectation that the mental health screening program of the Presidentıs
New Freedom Commission will find six million more "mentally ill" among this
countryıs 52 million school children and five million adult school staffs,
(Waters, 2003; Lenzer, 2004; Whitehead, 2005) we cannot be optimistic about the
treatment of mental illness in general, and schizophrenia in particular, until
and unless the psychopharmacological epidemic of mental disability is brought to
an end, and mentally disabled patients are actively encouraged to return to
productive activities, and reduce medications, rather than wasting their days in
unstructured drop-in clubs.
The nature of schizophrenia has changed markedly over the past half-century
because the drugs used to treat it aggravate the disability it causes. Through
the years, schizophrenia was a psychosocially-produced neuropsychological
disorganization, with little or no visible brain pathology, which was followed
by reorganization - on the same, a lower, or a higher level. Today, the
significant brain changes produced by the drugs in these patients often make
schizophrenia a very different disorder, from which return to normal living is
even harder. An ever-increasing class of permanent psychiatric cripples is thus
The doctor-patient relationship is the most important therapeutic tool in the
treatment of disabling mental disorder. Todayıs focus on drugs tends to make
that relationship oppositional. Effective treatment requires the continuation
throughout the patientıs illness of the same trusted therapeutic relationships
wherever the patient is located; reliance on activities which are truly
mind-building (useful and satisfying) rather than basket-weaving or its
equivalent; and, as much as possible, the gradual reduction of medication.
Jaros, R. (2004) PROS Update: Highlights of OMH Draft PROS Regulations, May;
source: NYAPRS <www.nyaprs.org;.
Jenkins, R.L., (1952). The schizophrenic sequence: Withdrawal, disorganization,
psychotic reorganization. American Journal of Orthopsychiatry, 22, 738
Lehrman, N.S. (1982) Effective psychotherapy of chronic schizophrenia.
American Journal of Psychoanalysis, 41, 121 - 132.
Lehrman, N.S. (2003) The rational organization of care for disabling
psychosis: "if I were commissioner." Ethical Human Sciences and Services 5,
45 - 53.
Lenzer, J. (2004) Bush plans to screen whole U.S. population for mental illness.
Sweeping initiative links diagnoses to treatment with specific drugs. BMJ
328: 1458 (19 June)
Liddell, H.S. (1956) Emotional hazards in animals and man. Springfield,
IL: Charles C Thomas. p. 81.
Lieberman, J.A., Stroup, T.S., McEvoy, J.P. et al (2005). Effectiveness
of antipsychotic drugs in patients with chronic schizophrenia, New England
Journal of Medicine 353, (no. 12) 1209 - 1223, September 22.
Pinheiro, M.V. (1989) Viewpoint: U.S.A., 13 years later. Psychiatry, 52,
469 - 474.
Tennissen, M. (2004) Mental health care undergoing changes. Port Arthur
(TX) News, September 4. <http://www.panews.com/articles/2004/09/04/news/01news.prt>
United State Psychiatric Rehabilitation Association (2005)
http://www.uspra.org; see: Psychiatric Rehabilitation
Certification Program, "the emerging gold standard in psychiatric
Waters, R. (2005) Medicating Aliah. Mother Jones, May-June.
Whitaker, R. (2005). Anatomy of an epidemic: psychiatric drugs and the
astonishing rise of mental illness in America. Ethical Human Psychology and
Psychiatry, 7, 23 - 35.
White, K. L. (1991) Healing the schism: epidemiology, medicine and the publicıs
health. New York: Springer Verlag.
Whitehead, J.W. (2005) Rutherford Institute interviews: A lone wolf talks on
the drug l eviathan; An interview with Allen Jones, 10/13/05. http://www.rutherford.org/oldspeak/articles/interview/oldspeak-jones.htm