“…A lot of points Luc Ciompi makes (Schizophrenia Bulletin, 2015, volume 31) resonates with my views also, as I feel, emotional dysregulation (intense agitation-stress experience) may be the origin of atypical thinking and behavior and may well underlie the development of psychosis and schizophrenia (a la Freud’s psychotic defense in the presence of overwhelming existential anxiety).
For many. especially with a history of persistent psychosis with compromised functioning of long-standing nature, medication does have some ameliorating effect on stress agitation level, making the persons more amenable to therapeutic prompts by restoring some degree of homeostasis balance in some ways so as to make the persons think more adaptively in terms of “here and now” existence, and correspondingly increasing their capacity to respond to “therapeutic prompts” and participate more readily in positive redirection strategies, enhancing overall functioning. But “atypical behavioral symptoms” characterized by hallucinations or delusions may have become “behavioral habits” over time and not responsive to medication treatment for many of these people. I have made this case in several of my previous postings.
(I am not proposing that people who for some reasons others develop habits of engaging in hallucinations and delusions as part of transitory or life -long experiences are necessarily have schizophrenia or psychosis, which depends on significant impairment in adaptive functioning and sense of caring for oneself.
But unfortunately medication practice for persons with schizophrenia is targeted to eliminate or reduce the so-called “behavior habits,” and often results in over-medication, or unnecessary medication with resulting side effect issues in the pursuit of something that it cannot achieve .Calming effect of any medication practice may for some reduce the discomforting effect of hallucinations and delusions, making for some more tolerable with these symptoms, but there is no evidence that medication eliminates them. Elimination or reduction of “behavioral habits” may need to be addressed within the framework of psycho social intervention and in the context of social and cultural practice or determination to the extent they cause personal distress or perceived social distress associated with the history, and potential for “at risk behaviors.”.
Efforts to reduce agitation arousal stress experience must include research in more targeted medication practice such as reducing the presumably involved chemical transmitter, dopamine on the mesolimbic system ( supposedly responsible for emotional regulation), but not reducing the frontal lobe functioning (supposedly involved involved in planning and thinking).This has not happened yet, causing positive and negative effects of psychotropic medication. As I understand, anti-psychotic medication has a generalized effect on reducing dopamine everywhere in the brain. May be future medication research will be more promising. There is also corresponding need for exploration of different ways of providing therapy and therapeutic and milieu supports to maximize individuals own capacity to think, feel, and behave in ways that reduce personal as well as social distress.
By the way, I am not proposing that everyone will need or benefit from a biological based medication approach, but some do and some may not need at all, or some may need occasionally, and the therapeutic benefits that the medication brings about can as well be achieved potentially by psycho-social intervention and presence of personal traits, and It will be a judgment call on a case by case basis.
From the psycho-social intervention perspective, one may also need to view how the traditional “talk therapy” or variant of it focusing on “deficit focused” approach and revisiting one’s personal history and past “negative life experiences” is helpful or not for people with long-term persistent psychosis and schizophrenia. There is also a corresponding need for acknowledging the “intact areas” of one’s functioning and resiliency, how best to promote stimulation of these areas to enhance sense of well being and functioning, no matter how “disabled” the persons appear to be. Focusing on their “long standing habits described as symptoms, (hallucinations or delusions as the case may be, or other forms of “maladapive behavior symptoms), and focusing on their presumed historical origins, whatever they may be, in conjunction with a corresponding focus on the “expressed deficits” the persons currently display- reflecting the “judgment” of the “care givers” or “the helping professionals,” may not be the most productive ways to practice for this clinical population. As they may generate “negative relationships between therapists and clients, as well as may induce covert or overt “agitation and stress arousal symptoms” countering any therapeutic benefits one desires to achieve. It may also may reinforce the continued identification with the “illness persona” that the persons have come to believe in, which may unwittingly counter the need for increased identification with positive self-image necessary for recovery. There is a positive benefit of emphasizing being in the present “here and now existence,” learning relaxation-mindfulness and other coping strategies, as well as learning to engage in a variety of mind stimulation strategies, and developing a sense of connection to others through existential discussion perspectives, and in the use of positive redirectional activities- thus helping them make the best of one’s present life circumstances.
Beside people with long-standing history of schizophrenia may have compromised ability to respond to auditory based conversational mode optimally and may have impaired capacity to internalize verbally mediated information processed in therapy, and in their ability to translate changes in their personal life outside the therapy session without therapeutic prompts built in the setting. I have commented in this before here and in our publications.
This point I am making may not be case with highly intelligent and educated people who for some reasons develop transient psychotic episodes and have the intact capacity for internalization and self-reflection, and retain the ability to change their thinking, and life styles with or without support or having profited from therapeutic support in the past to recover their functioning.
Working in state inpatient facilities, community mental health centers, and nursing homes, I found that many people diagnosed or treated with schizophrenia have different developmental histories: learning disability, substance abuse, mental retardation, as well as childhood trauma and or negative life experiences. Any strategies that involve greater emotional stability by medication and or psychotherapy process will enhance each person’s capacity to maximize his or her thinking as to how best to manage the present reality of living experience in collaboration with support of “significant-others involvement” and the mental health community at large.
It is also worthwhile to read another article published in the same issue in Schizophrenia Bulletin,2015, volume 31) First Person Account, “A Carer’s Perspective: The View From Australia” by Paul Kauffman.
It describes the kind of people with schizophrenia that I have mostly encountered in my clinical work over a 40 some years, which does not include, I must confess, outpatient therapy clients with mostly intact cognitive functioning associated with a high level of education, and suffering from what appears to be “transient psychotic experiences.” and have the demonstrated capacity to profit from traditional psychotherapy modalities. So my comments are limited to the group that I have worked with. Nevertheless, my sense is that this group may constitute the largest percentage worldwide, who are identified as people with schizophrenia. This article describes what the advocacy role, (family) can achieve to enhance quality of life and functioning, to significantly impact “improvements,” within, however, some “persistent disability framework.,” which unfortunately many people with longstanding history of psychosis and schizophrenia continue to exhibit in spite of years of psychiatric services. Considering that many persons with schizophrenia may not have this kind of family support or advocacy, my sense is that the quality of life for many of them may be much more compromised than what is described for this person.
So much more work needs to be done in practice innovations and research in this area of mental health service for this population. It is in a way this is an exciting field for patient, patient advocates, and mental health professionals that there are all kinds of possibilities to move forward in different directions to improve the quality of life and care for people with psychosis and schizophrenia of varied manifestations.
But one needs to be open, not judgmental, and not be dogmatic in trying to impose one’s specific professional training or identification with a model that one has been exposed to in training. Given the individual and cultural variability and circumstances in people with psychosis and schizophrenia, one has to be “creative and innovative” in clinical practice, whether from medication practice or psychotherapy practice perspective.
It is exciting to participate in an “open dialogue” and information and opinion sharing process …”