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Summer 2009 | Vol 12 No 4

Myth busters

Revisiting myths about schizophrenia with implications for treatment

Revisiting myths about schizophrenia with implications for treatment
In 1994, Dr. Courtenay Harding and colleagues published a paper entitled “Empirical correction of seven myths about schizophrenia with implications for treatment” in Acta Psychiatrica Scandinavica. It presented evidence to challenge myths about schizophrenia that persist across mental health disciplines and that stand in the way of effective treatment and recovery. Fifteen years later, CrossCurrents summarizes these myths so you can reflect on what has changed – and what hasn’t.

Myth: Once a schizophrenic always a schizophrenic.

Fact: This myth reflects the “clinician’s illusion,” in which clinicians may repeatedly see the few most severely ill in their caseloads as “typical,” when in fact, these individuals represent a small proportion of the actual spectrum. Recent studies have investigated the assumption of downward course and have found wide heterogeneity in the very long-term outcome. These studies have consistently found that half to two-thirds of individuals significantly improved or recovered, including some chronic cases.

Myth: A schizophrenic is a schizophrenic is a schizophrenic.

Fact: There is a lot of variation within the diagnostic category. There is a tendency in the field to lump everyone with the same diagnosis together for treatment and research. In reality, every group of individuals has substantial heterogeneity. In addition to the major impact of gender, there are considerable differences in age, developmental tasks, education levels, job histories, symptom presentation, coping skills, personal strengths and weaknesses, meaning systems, response to stress in general and to stress of particular situations. Schizophrenia is itself heterogeneous, which Swiss psychiatrist Eugene Bleuler recognized in renaming dementia praecox (meaning a premature deterioration of the brain) as “the group of schizophrenias.” This heterogeneity requires a comprehensive, biopsychosocial assessment of each client’s unique status, the place in his or her own course trajectory and ecological niche. Individual differences require individualized treatment planning, appreciation of developmental achievements and goals and recognition of the “person behind the disorder.”

Myth: Rehabilitation can be provided only after stabilization.

Fact: Rehabilitation should begin on day 1. “Real treatment” in today’s managed care climate consists of assessment, diagnosis and medication. Anything else, such as rehabilitation, often must wait until stabilization and is often considered an ancillary service. However, stabilization usually leads merely to “maintenance,” not rehabilitation. “Real treatment” has been only modestly successful in reducing symptoms, and in helping the client by increasing the levels of functioning in self-care, work, interpersonal relationships and community reintegration. The burgeoning field of psychiatric rehabilitation combines with medical treatment to significantly improve the client’s level of functioning.

Myth: Why bother with psychotherapy for schizophrenia?

Fact: Supportive psychotherapy is crucial for integrating the experience and enhancing continued adult development. Research findings about the ineffectiveness of psychotherapy in curing schizophrenia have led to widespread discouragement in this area and to a relative lack of innovation and research. However, instead of abandoning psychotherapy altogether, the challenge is for clinicians to use psychotherapy appropriately for maximum benefit. Surveys and personal accounts of consumers have indicated that they value psychotherapy and find it beneficial. Moreover, several different types of psychosocial interventions have demonstrated a positive impact on the lives of people with schizophrenia, including family interventions, tailored group therapies and very specific, targeted cognitive remediation.

Myth: People with schizophrenia must be on medication all their lives.

Fact: Only a small percentage may need medication indefinitely. Long-term studies have shown that a surprising number of people (25%–50%) were completely off medication, experienced no further signs and symptoms of schizophrenia and were functioning well. Over time, most people with schizophrenia altered their dosages and schedules.

Myth: People with schizophrenia cannot do anything except low-level jobs.

Fact: People with schizophrenia can and do perform at every level of work. The idea that individuals with schizophrenia are unable to work or can only achieve a low level of functioning has had longstanding credence, with only 10–30 per cent of people with schizophrenia working full-time. The early vocational approach consisted primarily of sheltered workshops designed for people with developmentally disabilities, with little thought about whether these workshops were appropriate for people with serious mental illness. There has also been little appreciation of the power of stigma and the low priority for vocational rehabilitation. Studies have found that symptoms and levels of functioning, such as work, were only loosely related to one another, and that some people can work well despite ongoing and persistent positive symptoms.

Myth: Families are the cause of schizophrenia.

Fact: Families can provide critical information and provide environments to lower a relative’s vulnerability. The myth that families cause schizophrenia flourished before the most recent biological revolution in psychiatry. Proponents of this myth targeted the family’s severe dysfunctions as the cause of schizophrenia. Although many researchers have since discarded this myth, it has survived even in the current biological era. Family researchers have demonstrated that the emotional and interactional climate of families can help precipitate relapses, as well as that enhanced family communication can lower vulnerability to relapse, but they have failed to show that family factors are necessary and sufficient causes of schizophrenia. It is now recognized that schizophrenia is vulnerable to environmental stresses and triggers, but that stressors, such as family environment, are not sufficient. The optimal roles of families in treatment and the appropriate relationships between clinicians and families are now well-established, if not widely realized.

Source: Harding, C.M. & Zahniser, J.H. (1994). Empirical correction of seven myths about schizophrenia with implications for treatment. Acta Psychiatrica Scandinavica, 90 (suppl. 384), 140–146