Rethinking schizophrenia:
its original nature, its drug-altered character, and thoughts about its treatment
 Nathaniel S. Lehrman, M.D.
Clinical Director (retired), Kingsboro Psychiatric Center, Brooklyn NY
October, 2005
1.  Introduction

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.  (Whitaker, 2005)

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 Œassociated 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 chronic schizophrenics.

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 functioning."  

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 Œpeculiarı or Œunfamiliar.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 them.  

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 symptoms.

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 relationship.

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 meetings.

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 being created.

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 <;.

Jenkins, R.L., (1952). The schizophrenic sequence: Withdrawal, disorganization, psychotic reorganization.  American Journal of Orthopsychiatry,  22,  738 - 742.

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.  <>   

United State Psychiatric Rehabilitation Association (2005); see:  Psychiatric Rehabilitation Certification Program, "the emerging gold standard in psychiatric rehabilitation."

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.