Psychiatry and Mental Healthiness – Part 1: Schizophrenia

For the context of this current series, Psychiatry and Mental Healthiness, please read my previous post Healthcare and the Human Experience.

I have a belief that the parts of mental illness that are currently considered “treatment resistant” will not be made better by some future medication. I could be wrong, but the history of psychopharmacology doesn’t support a positive outlook regarding a magic pill coming any time soon as the rate of efficacy of all medication classes hovers close to their historical peaks, and no novel treatments (except for one, clozapine, which is highly regulated because of serious side effects) have proven to be any more effective than their predecessors. If the “new” generation of psychiatric medications are better, it’s because they are safer or more convenient, but not because they are any more effective. Also at this point, they aren’t really new any more, since Prozac, the first SSRI came out in 1987, and the first wave of second-generation antipsychotics came out in the 1990’s. Either way, with no immediate help on the horizon coming from pharmaceuticals, we need better ideas and strategies to bring relief, resolution and ideally restore health for those who still suffer.

It’s my thought that the specific reason why certain parts of mental illness are unresponsive to the best currently available treatments is because as a field we’ve gotten too focused on illness and symptoms, and ignored the human needs that are required for true healthiness. In this series, Psychiatry and Mental Healthiness, I’ll expand upon this point and offer some direction, while staying grounded in truth based principles supported through research and our shared human experience.

Starting with the big picture, the aspects of mental healthiness that I see as having the most positive influence on “treatment” of Psychiatric illness are in the interconnected domains of relatedness (to ourselves and to others) and wellbeing (health, happiness, life satisfaction, personal growth).

Intrapersonal relatedness can be described as they way in which the different parts of our self, mind and body, connect and interact. The “me” part of our identity and experience. Our needs and feelings. What we perceive. Our thoughts and beliefs. They are all part of our inner world, and mindfulness is the means in which we can see the different parts and direct our mental energies where we choose. A measure of this would be a person’s Emotional Intelligence or EQ, an idea popularized by psychologist Daniel Goleman. Mindfulness and higher EQ have been linked to greater wellbeing, improved mental health, improved physical health, life satisfaction and predicts better social proficiency as well. The number of studies is large and diverse, here’s a snippet of some of the positive findings.

That brings us to interpersonal relatedness – how we connect and interact with others. The “we” part of our identity. What we can give to others through empathy, compassion and love. Also what we can receive from others, shaped by our earliest relationships in life, how we feel safe, secure, seen and soothed. It also includes how we see ourselves relative to other people. In other words, interpersonal relatedness is the measure of our capacity to meet the needs of others, and how other people meet our own needs. The equivalent measure would be our Social Intelligence. Developmental Psychology research has demonstrated that secure attachments in childhood predicts better prefrontal lobe functioning (the uniquely “human” part of the brain) as adults. The Grant Study, a remarkable 75-year longitudinal study of 268 physically and mentally healthy Harvard college sophomores from the classes of 1939–1944 has shown that “warm relationships” predict a whole range of positive outcomes, including happiness, earning potential, low levels of anxiety, how much you enjoy your vacations and your life satisfaction. In the words of the primary investigator, Psychiatrist George Valliant, “warmth of relationships throughout life have the greatest positive impact on life satisfaction”. He also summarizes the cumulative data by saying: “Happiness is love. Full stop.” Other psychosocial research demonstrates secure attachments as also positively predicting longevity, physical and mental health.

Building on relatedness, wellbeing has also shown to have positive effects on mental healthiness. A “broaden and build” theory of happiness and its relationship with wellbeing and life satisfaction suggests that these outcomes are interrelated – that happy people become more satisfied not simply because they feel better but because they develop resources for living well (Cohn et al, Emotion, 2009). These resources are internal (mindfulness, competency) and external (meaningful relationships, social support). I think of the “build” part as developing the differentiated parts of mind, and the “broaden” part as making connections between them. One of the last things that we do for my seminar is that we start with a blank wall in my conference room that has been covered with whiteboard paint. Then as a group, we start to illustrate what we’ve learned over the course of the past five weeks. As we do this, and as more and more components are put on the board, we can draw arrows showing the connections. Between personal growth and happiness. Between emotional intelligence and motivation. Between relationships and meaningfulness. Between authenticity and insight. On and on. These are natural connections that beautifully illustrate how the optimal state of our humanness is also very interdependent, highly connected, well balanced and integrated. Daniel Goleman says: “Empathy and social skills are social intelligence, the interpersonal part of emotional intelligence. That’s why they look alike.” Thomas Merton, a sainted Catholic monk/social activist/author of books on Buddhism said “Happiness is not a matter of intensity but of balance, order, rhythm and harmony.”

Now transitioning from healthiness to illness, there is a natural corollary as to what defines healthiness – that the absence of these healthy qualities and experiences increases the risk of unhealthiness and illness. I reviewed the historical limits of medication earlier. Interestingly, short term psychotherapies also have efficacy rates comparable to medication for certain diagnoses, with combination treatments involving therapy and meds generally being best. But these efficacy rates also usually leave around 25% of all patients with less than acceptable outcomes. Like medications that are indicated for specific psychiatric disorders, these short term therapies are also tailored to aim at resolution of symptoms of specific diagnoses. Cognitive Behavioral Therapy (CBT) is the most studied psychotherapy form, and has consistently demonstrated outcomes comparable to medication treatment alone for depression, anxiety disorders, alcoholism and other substance use. The exception to this “as good as medication” trend with CBT, is that when CBT is applied to Schizophrenia, focusing on the false belief of “defeatedness,” the results show it to be more helpful than medication for the treatment of half of the symptoms of this chronic mental disorder, the group of symptoms classified as negative symptoms. Negative symptoms include apathy, social withdrawal, and decreased emotional expressiveness. This has real world significance because medications have very minimal benefit regarding this group of symptoms. In related work, UCLA’s Schizophrenia Clinic has adapted a social skills curriculum used for Autism, to help teach patients with Schizophrenia how to read emotions, intentions, have empathy, and make connections. This too has also demonstrated measurable and meaningful improvements in negative symptoms. Why is this significant to the concept of mental healthiness? Because essentially what is happening is that forming relationships (social intelligence, meaningfulness), developing a self belief of competency (emotional intelligence, mindfulness), and fostering personal growth is causing an “untreatable” part of Schizophrenia to improve. Research on the effects of loneliness by Social Neuroscience founder John Cacioppo has demonstrated real detrimental mental and physical effects, similar to what we see as Schizophrenia’s negative symptoms, in otherwise “normal” but chronically lonely people. They even demonstrate higher risks of dementia, also a previous finding thought to be part of the degenerative disease process of Schizophrenia. Makes you wonder if negative symptoms are really a core part of the illness, or a product of having a highly stigmatized illness, a belief system of defeatedness (for patients and treatment providers), and the experience of social isolation. Taken together, this is a great example of how focusing on being mentally healthy can be a “treatment” for mental illness. In the specific example of Schizophrenia, these examples show that a health-focused and humanistic approach can meaningfully help the parts of the illness that medication or symptom focused approaches can’t.

In my practice I’ve had a few surprising experiences that have really changed my perspective on what is possible and expected for the long term outcomes for people diagnosed with Schizophrenia, completely consistent with these empirical findings. The common thread is that the most meaningful intervention in regards to these patients’ stability and wellbeing, is not their medication (which they all do take). It is their social connectedness and their lack of self identification with the diagnosis. I say that this had been surprising because it is not what I was taught to expect during my residency training. I was taught that Schizophrenia is a chronic, debilitating, brain-wasting, life-robbing diagnosis. And that we should work with patients and families to prepare them for this bleak prognosis, and the sooner that they accept this, the better it will be for all – specifically for setting realistic and lower expectations. The best we could hope for was some level of autonomy and a lifetime of medication compliance. I wish I could say that it was my own optimism and this knowledge of Social Neuroscience and the CBT that they only do in Europe that made me believe otherwise. But it wasn’t, because I didn’t learn that stuff until later. I learned this from the example of important people in my patients’ lives. Because when I attempted to prepare a patient and family for this bad prognosis for their son who took a leave from college after his first psychotic episode, his parents took a “let’s see” attitude and encouraged him to take the steps he could to work his way back to college. And he did. They didn’t and still don’t see him as a “Schizophrenic” but just as their son. He’s doing great right now. You wouldn’t know that he had Schizophrenia, because when we last Skyped, he was excited about the end of college and this innovative project he was working on with some new friends. And I wouldn’t believe it myself seeing him today, if it wasn’t for the fact that I saw him at his worst a few years ago, then improve significantly on medication, come off his medication and quickly deteriorate into psychosis, then improve again when he resumed.

I also learned from a husband who was very insistent that we did not describe his wife by the diagnosis given to her by a Psychiatrist a long time ago. Her husband also worked hard to have a conservatorship removed, not maintained, to restore her dignity, autonomy and personhood. She was paranoid, disorganized, and emotionally flat when I saw her for the first time years ago. When we meet now, we talk about her grandchildren for whom she is the primary caretaker three days a week, and what she’s reading in her book club. She laughs, connects, feels at ease. In the last two minutes, I make sure she has her refills which she keeps track of better than I do. I never mention the “S” word. It’s not important, she is healthy and she is well.

So here’s my prescription for what’s best for Schizophrenia, which is supported by research, experience, and a broader lens looking at healthiness and not just illness: 1) the right medicine – the most tolerable, least restrictive, at the lowest effective dose possible, 2) fostering meaningful relationships, and 3) maintaining an individual’s humanness.

In the next entry in this series, I’ll talk about what research says about the positive or negative impact of our primary relationships upon mental illness, with a focus on Bipolar Disorder and how this prescription works there too.

– Thank you to the individuals and their families for giving me permission to share their stories above.

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