Psychologist

Spring, 1999 Volume 34 Number 1 The Psychologist A publication of the Society for General Psychology Division One of the American Psychological Association Officers of the Society President Kurt Salzinger Its Official Hofstra University The name of the Division is now The Society for Hempstead, NY 11550-1090 General Psychology: Division One of the Ameri- [email protected] can Psychological Association. PastPresident Frank Farley PresidentElect Lewis P. Lipsitt SecretaryTreasurer Lee H. Matthews 5 Platt Street Kenner, LA 70065-1018 [email protected] Inside this issue you will find a hopefully contro- versial article on the treatment of schizophrenia Members-at-Large C. Alan Boneau written by Bert Karon. Old friend and Division James Butcher mainstay Greg Kimble was interviewed on the Morton Ann Gernsbach occasion of a number of things including his Nora Newcomb receiving two awards, one by APA and one by the Michael Wertheimer Society. His responses are included within. An Wendy Williams invited address at the last APA convention by Representative to APA Council current Society President Kurt Salzinger is Gregory A. Kimble added as an extra treat. Then there are a number of business items including info about candidates Editor: The General Psychologist for the upcoming Society elections and the min- C. Alan Boneau 6518 Ridge Drive utes of the last Society Executive Committee Bethesda, MD 20816 meeting. Enjoy. [email protected] Historian Donald Dewsbury Editor: Review of General Psychology Peter Salovey Department of Psychology Yale University New Haven, CT 06520-8205 [email protected] 1999 Program Chair Donald N. Bersoff Villanova Law School Villanova, PA 19085 [email protected] THE TRAGEDY OF SCHIZOPHRENIA Bertram P. Karon, Ph.D. Michigan State University schizophrenia was found to be highly variable, seeming The real tragedy of schizo- more like the vicissitudes of life than the course of a phrenia is not the severity of the disease or several diseases. This and the other four studies which followed schizophrenics for more than 25 symptoms and the suffering that results years, from Switzerland, Germany, and the United States, were summarized in 1987 by Harding, Zubin, and for patients and families, but that we Strauss (1987), who noted that 30% fully recovered in the know treatments that work and are not long run, and that 60% to 70% became self-sufficient. This was not due to any modern treatment. Moreover, re- using them. Families and patients are settling for diagnosing the patients using DSM-III diagnoses, which treatments that aim at making the patient a lifelong are essentially the same as DSM-IV, in place of earlier cripple who is not too disturbing. Even when medications diagnostic criteria, made no difference in predicting the are maintained, two-thirds of patients will be re-hospital- long-term outcomes in Hardings study. ized within two years. Psycho-educational programs, Harding (1988) pointed out that, even though profession- which potentially could be helpful, usually give false als who have encouraged patients to take their medica- information which make worse the burdens of both pa- tion have been well meaning, in this study all of the tients and their families. patients who fully recovered were among the 50% who Eugen Bleuler described schizophrenia as consisting of: had stopped taking their medication. This could mean autism (that is, impaired relations with other people); either that the healthier patients feel freer to stop, despite thought disorder (that is, the inability to think logically their doctors advice, or that the medication, helpful in the when you want to); and seemingly no affect or inappropri- short run, prevents full recovery. ate affect; and the more dramatic symptoms which might More recently, Harding (1995) has summarized five more or might not be present: hallucinations, delusions, and/or studies, for a total of ten, with somewhat more variability, catatonic stupor. DSM-IV simply spells this out in a way that permits reliable diagnosis, but with scientific short- Author Notes: I would like to express my gratitude to my wife, comings. Mary Karon, who has made my work possible. I also want to The most important research on schizophrenia in the last thank Michael Teixeira, Ph.D., Leighton C. Whitaker, PhD, Gary R. VandenBos, PhD, and Anmarie Widener, M.A., M.S.W., all of twenty years are the long term follow up studies. whom have influenced the content of this article. Kraepelin (1907), Eugen Bleuler (1911), and Manfred Rosalie G. Weiss Lecture, American Psychological Foundation, Bleuler (1971; 1978) taught that schizophrenia was a American Psychological Association, San Francisco, CA, Au- chronic disorder, that it might have remissions, but that gust 16, 1998. An earlier version was delivered as the first Mruk the outlook was poor in the long run. But as Manfred Memorial Lecture on Schizophrenia at Michigan State Univer- Bleuler pointed out, they were misled because they fol- sity, May 1, 1998. lowed only hospitalized and re-hospitalized patients. Requests for reprints should be sent to Bertram P. Karon, PhD, When Ciompi (1980) published 40 year follow-up data for Psychology Research Building, Michigan State University, East patients in Switzerland, from 1900 on, the course of Lansing, MI 48824-1117. 1 - 12 2 leading to the conservative recommendation that profes- most frequently used, patients benefited. Today they have sionals tell patients and families: largely been abandoned, the patients have stopped get- ting better, and psychotherapies have been succeeded by You have a serious illness but results from 10 worldwide physical treatments that claim to be more scientific, which studies show that you have a 50-50 or better chance of significant improvement and perhaps recovery. It may do not require understanding the patients, and which take a long time, but we will be here to help you maximize have economic advantages for everyone except the pa- the return to functioning. tients. And the myth of incurability has been re-created. Comprehensive surveys of outcome studies in the United Nonetheless, DSM-IV (American Psychiatric Associa- States show 28% favorable outcome before 1925; 49% tion, 1994, p. 282) states that Complete remission (i.e., a from 1956-1986 when psychotherapy was most likely to be return to full premorbid functioning) is probably not offered; and 36% from 1986 to 1994 (Hegarty, et al., 1994). common in this disorder. a statement not only denying the existence of patients who have recovered with appro- In the 1930s, Harry Stack Sullivan and Frieda Fromm- priate treatment, but contradicting the findings of every Reichmann consistently helped schizophrenics. The long term follow up study. Professionals regularly tell treatment was arduous, but patients improved (Fromm- patients and their families that the patients will never get Reichmann, 1950; Sullivan, 1953). The well-known novel, better, robbing them of hope. I Never Promised You a Rose Garden (Greenberg, 1964), described that early treatment. The author, who had been Patients are told they must never have children. But as a patient of Fromm-Reichmann, used an assumed name. Manfred Bleuler first reported (1978), the data are that It was only after later novels under her own name became 80% of children of schizophrenics raised by their schizo- popular that she finally attached her name to this book, phrenic parent never become schizophrenic. And the which not only describes such treatment, but demon- 20% rate of schizophrenia can be lowered by preventive strates the kind of recovery that allowed the patient to counseling. write so well. At the end of the eighteenth century, before modern To understand schizophrenic persons is to grasp painful psychotherapy or modern medication, Phillipe Pinel facts about the human condition that we would rather not (Bockoven, 1972) and the other practitioners of moral know. The sociological data about schizophrenia remind treatment innovated treatments that worked, contradict- us of unpleasant realities. For example, a disproportion- ing the earlier myth of incurability. In France, England, ately greater incidence and prevalence of schizophrenic Scotland, and the United States, moral treatment pro- disorders is associated with low socioeconomic status duced startling results: 60 to 80% of patients were dis- (Hollingshead & Redlich, 1958), which cannot be ac- charged. counted for by downward drift. While this is disputed, Its elements were simple: first, no cruelty, no humilia- current data are still consistent (Cohen, 1993). This sug- tion, use physical force only to prevent the patient harm- gests, and psychotherapeutic experience makes vivid, the ing him or herself or someone else, but not for physical and psychological pain, humiliation, and physi- punishment nor, to use modern jargon, negative rein- cal danger associated with being very poor in our society forcement. Second, get as accurate a case history as create realities which those of us who are not very poor do possible (you might learn something about this patient not like to perceive or remember. Similarly, schizophrenic or even about such patients in general). Third, encour- disorders are more common among those who are the age work and social relations. Finally, most powerful victims of prejudice and discrimination (Karon, 1975). and seemingly unscientific do your best to understand Thus, the psychotherapist, to be effective, will often be the patient as an individual human being. But from the confronted with the ugliness of the economic, racial, eth- records of hospitals that continued in existence, not only nic, and religious discrimination which have contributed were the results better than those previous, they were to these disorders. The fact that the long-term prognosis better than the middle and end of the nineteenth century for schizophrenics is better in nonliterate cultures (Sarto- and the beginning of the twentieth century when moral rius, Jablensky, & Shapiro, 1978) reminds us of the relative treatment was abandoned, and the discharge rates lack of kindness in our civilization.

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