Treatments for Schizophrenia and

Other Severe Mental Disorders

Chapter 15

Slides & Handouts by Karen Clay Rhines, Ph.D.

American Public University System

Comer, Abnormal
Psychology, 8e
DSM-5 Update

How Are Schizophrenia and Other

Severe Mental Disorders Treated?
For much of human history, people with
schizophrenia and other severe mental disorders
were considered beyond help
Though schizophrenia is still extremely difficult to
treat, the discovery of antipsychotic drugs has
enabled people with the disorder to think clearly
and profit from psychotherapies
Each of the models offers treatments for
schizophrenia, and all have been influential at
one time or another
Comer, Abnormal Psychology, 8e
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How Are Schizophrenia and Other

Severe Mental Disorders Treated?
It is important to keep in mind that throughout
much of the 20th century, the label
schizophrenia was assigned to most people
with psychosis
Clinical theorists now realize that many people
with psychotic symptoms are instead displaying
other disorders and were inaccurately diagnosed
As such, discussions of past and current approaches to
schizophrenia often apply to other severe mental
illnesses as well
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Institutional Care in the Past

For more than half of the 20th century, people
with schizophrenia were institutionalized in
public mental hospitals
Because patients failed to respond to
traditional therapies, the primary goals of the
hospitals were to restrain them and give them
food, shelter, and clothing

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Institutional Care in the Past

The move toward institutionalization began in
1793 with the practice of moral treatment
Hospitals were located in isolated areas to
protect patients from the stresses of daily life
and to offer them a healthful psychological
environment

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Institutional Care in the Past

States throughout the U.S. were required by
law to establish public mental institutions
(state hospitals) for patients who could not
afford private care
Unfortunately, problems with overcrowding,
understaffing, and poor patient outcomes led to
loss of individual care and the creation of back
wards human warehouses filled with
hopelessness
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Institutional Care in the Past

Many patients not only failed to improve
under these conditions but developed
additional symptoms, apparently as a result of
the institutionalization itself
The most common pattern of decline was called
the social breakdown syndrome, which involved:
Extreme withdrawal, anger, and physical aggressiveness
Loss of interest in personal appearance and functioning

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Institutional Care
Takes a Turn for the Better
In the 1950s, clinicians developed two
institutional approaches that brought some hope
to chronic patients:
Milieu therapy

Based on humanistic principles

Token economy programs

Based on behavioral principles

These approaches particularly helped improve

the personal care and self-image of patients,
problem areas that were worsened by
institutionalization
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Institutional Care
Takes a Turn for the Better
Milieu therapy

The premise is that institutions can help patients

make clinical progress by creating a social climate
(milieu) that promotes productive activity, selfrespect, and individual responsibility
Milieu-style programs have been set up in institutions
throughout the Western world with moderate success
Research has shown that patients with schizophrenia and
other severe mental disorders in milieu programs often
leave the hospital at higher rates than patients receiving
custodial care

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Institutional Care
Takes a Turn for the Better
The token economy

Based on operant conditioning principles, token

economies are used in institutions to change the behavior
of these individuals
Patients are rewarded when they behave in socially
acceptable ways and are not rewarded when they behave
unacceptably

Immediate rewards are tokens that can later be exchanged for

food, cigarettes, privileges, and other desirable objects
Acceptable behaviors likely to be targeted include care for oneself
and ones possessions, going to a work program, speaking
normally, following ward rules, and showing self-control

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Institutional Care
Takes a Turn for the Better
The token economy
Researchers have found that token economies help
reduce psychotic and related behavior
However, questions have been raised about such
programs:
Many research studies have been uncontrolled; instead of
patients being randomly assigned to groups, a whole ward
will participate in the program
Are such programs ethical and legal? Arent all humans
entitled to basic rights, some of which are compromised in a
strict token economy system?

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Institutional Care
Takes a Turn for the Better
The token economy
Questions have been raised about such programs:
Are such programs truly effective? For example,
patients may change overt behaviors but not
underlying psychotic beliefs
Transitioning from a token economy system to
community living may be difficult for patients

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Institutional Care
Takes a Turn for the Better
Token economy programs are no longer as
popular as they once were but they are still
used in many mental hospitals, usually along
with medication
This approach has also been applied to other
clinical problems

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Antipsychotic Drugs
While milieu therapy and token economies
helped improve treatment outcomes, it was
the discovery of antipsychotic drugs in the
1950s that revolutionized treatment for those
suffering from schizophrenia

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Antipsychotic Drugs
The discovery of antipsychotic medications dates back
to the 1940s, when researchers developed
antihistamine drugs for allergies
It was discovered that one group of antihistamines,
phenothiazines, could be used to calm patients about
to undergo surgery

Psychiatrists tested one of the drugs, chlorpromazine, on 6

patients with psychosis and observed a sharp reduction in
their symptoms
In 1954, chlorpromazine (under the trade name Thorazine)
was approved for sale in the U.S. as an antipsychotic drug

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Antipsychotic Drugs
Since the discovery of the phenothiazines, other
kinds of antipsychotic drugs have been developed
Those developed throughout the 1960s, 1970s, and
1980s are now referred to as conventional
antipsychotic drugs

These drugs are also known as neuroleptic drugs, because

they often produce undesired movement effects similar to
symptoms of neurological diseases

Drugs developed in recent years are known as

atypical or second-generation antipsychotics

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How Effective Are

Antipsychotic Drugs?
Research has shown that antipsychotic drugs
reduce symptoms in at least 65% of patients
diagnosed with schizophrenia
In direct comparisons, drugs appear to be more
effective than any other approach used alone

In most cases, the drugs produce the maximum

level of improvement within the first six months
of treatment

Symptoms may return if patients stop taking the drugs

too soon

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How Effective Are

Antipsychotic Drugs?
Antipsychotic drugs, particularly the
conventional ones, reduce the positive
symptoms of schizophrenia more completely,
or at least more quickly, than the negative
symptoms
Correspondingly, people who display largely
positive symptoms generally have better rates of
recovery than those with primarily negative
symptoms

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How Effective Are

Antipsychotic Drugs?
Although the use of such drugs is now widely
accepted, patients often dislike the powerful
effects of the drugs, and some refuse to take
them

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The Unwanted Effects of

Conventional Antipsychotic Drugs
In addition to reducing psychotic symptoms,
conventional antipsychotic drugs sometimes
produce disturbing movement problems
These are called extrapyramidal effects because
they appear to be caused by the drugs impact on
the extrapyramidal areas of the brain

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The Unwanted Effects of

Conventional Antipsychotic Drugs
The most common of these effects are
Parkinsonian symptoms, reactions that closely
resemble features of the neurological disorder
Parkinsons disease, including:
Muscle tremor and rigidity
Movements of the face, neck, tongue, and back
Great restlessness, agitation, and discomfort in
the limbs

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The Unwanted Effects of

Conventional Antipsychotic Drugs
The Parkinsonian and related symptoms seem to
be the result of medication-induced reductions of
dopamine activity in the basal ganglia and
substantia nigra, parts of the brain that
coordinate movement and posture
In most cases, the symptoms can be reversed if
an anti-Parkinsonian drug is taken along with the
antipsychotic
Sometimes the dosage must be decreased or the
medication must be halted altogether

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The Unwanted Effects of

Conventional Antipsychotic Drugs
In as many as 1% of patients, particularly elderly ones,
conventional antipsychotic drugs produce neuroleptic
malignant syndrome a severe, potentially fatal
reaction

Symptoms include muscle rigidity, fever, altered

consciousness, and improper functioning of the autonomic
nervous system

As soon as the syndrome is recognized, drug use is

discontinued and each symptom is treated medically

Individuals may also be given dopamine-enhancing drugs

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The Unwanted Effects of

Conventional Antipsychotic Drugs
A more difficult side effect of conventional
antipsychotic drugs appears up to 1 year after
starting the medication
This reaction, called tardive dyskinesia, involves
writhing or tic-like involuntary movements, usually of
the mouth, lips, tongue, legs, or body
It affects more than 10% of those taking the drugs and
patients over 50 years of age seem to be at greater risk
Tardive dyskinesia can be difficult, sometimes impossible, to
eliminate

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The Unwanted Effects of

Conventional Antipsychotic Drugs
Since learning of the unwanted side effects of
conventional antipsychotic drugs, clinicians
have become more cautious in their
prescription practices
They try to prescribe the lowest effective dose
They gradually reduce or stop medication weeks
or months after the patient begins functioning
normally

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Newer Antipsychotic Drugs

In recent years, new antipsychotic drugs have
been developed
Examples: Clozaril, Risperdal, Zyprexa, Seroquel,
Geodon, and Abilify

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Newer Antipsychotic Drugs

These new drugs are called atypical because
their biological operation differs from that of
conventional antipsychotics
They appear more effective than conventional
antipsychotic drugs, especially for negative
symptoms
They cause few extrapyramidal side effects and
seem less likely to case tardive dyskinesia

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Newer Antipsychotic Drugs

They do, however, have serious problems as
well:
They carry a risk of agranulocytosis, a lifethreatening drop in white blood cells
They also may cause weight gain, dizziness, and
significant elevations in blood sugar

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Psychotherapy
Before the discovery of antipsychotic drugs,
psychotherapy was not an option for people
with schizophrenia
Most were too far removed from reality to profit
from psychotherapy

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Psychotherapy
Today, psychotherapy is successful in many
more cases of schizophrenia
By helping to relieve their thought and perceptual
disturbances, antipsychotic drugs allow people
with schizophrenia to learn about their disorder,
participate in therapy, think more clearly, and
make changes in their behavior

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Psychotherapy
The most helpful forms of psychotherapy
include cognitive-behavioral therapy and two
broader sociocultural therapies: family
therapy and social therapy
These approaches are often combined

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Psychotherapy
Cognitive-behavioral therapy
An increasing number of clinicians employ techniques
that seek to change how individuals view and react to
their hallucinatory experiences, including:
Provide education and evidence of the biological causes of
hallucinations
Help clients learn about the comings and goings of their
own hallucinations and delusions
Challenge clients inaccurate ideas about the power of their
hallucinations

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Psychotherapy
Cognitive-behavioral therapy
An increasing number of clinicians employ
techniques that seek to change how individuals
view and react to their hallucinatory experiences,
including:
Teach clients to reattribute and more accurately
interpret their hallucinations
Teach techniques for coping with their unpleasant
sensations

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Psychotherapy
Cognitive-behavioral therapy
New-wave cognitive-behavioral therapies also
help clients to accept their streams of problematic
thoughts
These techniques help patients gain a greater
sense of control, become more functional, and
move forward in life
Studies indicate that these various techniques are
often very helpful

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Psychotherapy
Family therapy
Over 50% of persons recovering from
schizophrenia and other severe disorder live with
family members
This creates significant family stress
Those who live with relatives who display high levels of
expressed emotion are at greater risk for relapse than
those who live with more positive or supportive
families

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Psychotherapy
Family therapy
Family therapy attempts to address such issues,
create more realistic expectations, and provide
psychoeducation about the disorder
Families may also turn to family support groups
and family psychoeducation programs
Although research has yet to determine the usefulness
of these groups, the approach has become popular

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Psychotherapy
Social Therapy
Many clinicians believe that the treatment of people
with schizophrenia should include techniques that
address social and personal difficulties in the clients
lives
These include: practical advice, problem solving, decision
making, social skills training, medication management,
employment counseling, financial assistance, and housing

Research finds that this approach reduces

rehospitalization

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The Community Approach

The community approach is the broadest approach for
the treatment of schizophrenia and other severe
mental disorders
In 1963, Congress passed the Community Mental Health
Act, which said that patients should be able to receive care
within their own communities, rather than being
transported to institutions far from home
This Act led to massive deinstitutionalization of patients
Unfortunately, community care was (and is) inadequate for their
care
The result is a revolving door syndrome

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What Are the Features of

Effective Community Care?
People recovering from schizophrenia and other
severe disorders need medication,
psychotherapy, help in handling daily pressures
and responsibilities, guidance in making
decisions, training in social skills, residential
supervision, and vocational counseling
This combination of services sometimes is called
assertive community treatment

Other key features are

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What Are the Features of

Effective Community Care?
Coordinated services

Community mental health centers provide medications,

psychotherapy, and inpatient emergency care
Coordination of services is especially important for mentally ill
chemical abusers (MICAs)

Short-term hospitalization

If treatment on an outpatient basis is unsuccessful, patients may

be transferred to short-term hospital programs
After being hospitalized for up to a few weeks, patients are
released to aftercare programs for follow-up in the community

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What Are the Features of

Effective Community Care?
Partial hospitalization

If patient needs fall between full hospitalization and

outpatient care, day center programs may be effective
These programs provide daily supervised activities
and programs to improve social skills
Another kind of institution that has become popular is
the semihospital, or residential crisis center houses
or other structures in the community that provide 24hour nursing care for those with severe mental
disorders

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What Are the Features of

Effective Community Care?
Supervised residences
Halfway houses (or group homes) provide shelter and
supervision for those patients who are unable to live
alone or with their families, but who do not require
hospitalization
Staff are usually paraprofessionals
Houses are run with a milieu therapy philosophy
These programs help those with schizophrenia adjust
to community life and avoid rehospitalization

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What Are the Features of

Effective Community Care?
Occupational training and support

Paid employment provides income, independence,

self-respect, and the stimulation of working with
others
Many people recovering from schizophrenia and other
severe mental disorders receive occupational training
in a sheltered workshop a supervised workplace for
employees who are not ready for competitive or
complicated jobs
An alternative work opportunity for individuals with severe
disorders is supported employment

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How Has Community

Treatment Failed?
There is no doubt that effective community programs can
help people with schizophrenia and other severe mental
disorders recover
However, fewer than half of all people who need them
receive appropriate community mental health services

In any given year, 40% to 60% of all people with schizophrenia

and other severe mental disorders receive no treatment at all
Two factors are primarily responsible:
Poor coordination of services
Shortage of services

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How Has Community

Treatment Failed?
Poor coordination of services

Mental health agencies in a community often fail to

communicate with one another
To combat this problem, a growing number of
community therapists have become case managers for
their clients
Case managers offer therapy and advice, teach problemsolving and social skills, and ensure compliance with
medications
Case managers also try to coordinate available community
services for their clients, guide them through the system and
protect their legal rights

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How Has Community

Treatment Failed?
Shortage of services
The number of community programs available to
people with severe mental disorders falls woefully
short
The centers that do exist generally fail to provide
adequate services for people with severe
disorders
While there are various reasons for these
shortages, the primary one is economic

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What Are the Consequences of

Inadequate Community Treatment?
When community treatment fails, many
people suffering from schizophrenia and other
severe mental disorders receive no treatment
at all
Many return to their families and receive
medication and perhaps emotional and financial
support, but little else in the way of treatment

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What Are the Consequences of Inadequate

Community Treatment?
Around 8% of patients enter an alternative care
facility (such as a nursing home), where they
receive custodial care and medication
As many as 18% are placed in privately run
residences where supervision is provided by
untrained individuals
Another 34% of patients are placed in singleroom occupancy hotels, generally in rundown
environments, where they survive on
government disability payments
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What Are the Consequences of Inadequate

Community Treatment?
Finally, a great number of people suffering
from schizophrenia become homeless
Approximately one-third of the homeless people
in America have a severe mental disorder,
commonly schizophrenia

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The Promise of
Community Treatment
Despite these very serious problems, proper
community care has shown great potential for
assisting in recovery from schizophrenia and
other severe disorders
In addition, a number of national interest groups,
including the National Alliance on Mental Illness
(NAMI), have formed to push for better
community treatment

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The Promise of
Community Treatment
Today, community care is a major feature of
treatment for people recovering from severe
mental disorders in countries around the
world
Both in the U.S. and abroad, varied and wellcoordinated community treatment is seen as
an important part of the solution to the
problem of schizophrenia
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