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Book Review   |    
Return From Madness: Psychotherapy With People Taking the New Antipsychotic Medications and Emerging From Severe, Lifelong, and Disabling Schizophrenia
Christopher Kennedy, M.D.
Psychiatric Services 1998; doi:
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by Kathleen Degen, M.D., and Ellen Nasper, Ph.D.; Northvale, New Jersey, Jason Aronson, 1996, 242 pages, $40

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Should the use of psychotherapy be revisited as an important component of treatment for many of our patients who have schizophrenia? In Return From Madness Kathleen Degen and Ellen Nasper present the idea that many patients who respond well to clozapine or other atypical antipsychotic drugs need psychotherapy and can significantly benefit from it. The authors present their rationale through both theory and case example. They describe the type of therapy they use and give advice to clinicians who might do the same.

The authors are a psychiatrist and a psychologist at the Greater Bridgeport (Conn.) Community Mental Health Center, which has a sizable clozapine treatment program. As their clozapine program developed, they noted a group of significantly recovered patients who were much less able to take advantage of further rehabilitation than would be expected based on the extent of their symptom resolution. Many were having difficulties managing intense feelings, painful memories, and identity crises. From late adolescence, the time when their schizophrenic symptoms began taking control, they developed a sense of identity as a mentally ill person. The patterns of behavior they had formed to cope with mental illness now inhibited their potential. Despite their renewed social and vocational abilities, they were confronted with their previously discarded hopes and aspirations and the fact that they could not recover lost time. The authors developed a relationship-based psychotherapy group designed to assist these patients "to mourn their lost years and help them reconcile to an identity that did not exclude their experience as a mental patient."

The message in this book is greatly enriched by case examples that highlight the paradoxical pain and difficulties sometimes brought about by emergence from a life of psychosis. Patients' reactions, the adverse consequences, and their use of the therapy group are quite instructive. As a bonus, the authors have included appendixes with protocols for prescribing clozapine and managing reduced white blood cell counts, as well as a sample patient education sheet about clozapine. The book is indexed, and a reference section is provided.

Although Return From Madness effectively uses case examples to argue its points, it lacks scientific validation for the authors' assertions. After asking the question "Would clozapine alone, slowly and over time, have helped [patients] attain a healthy sense of self and an expanded capacity to work and relate to other people?" the authors state, "We find it impossible to believe that people who had improved significantly but were muddling along without a sense of purpose or direction for months would suddenly get their lives together in the ways we have described without psychotherapy." Despite the lack of proof, one is left with the impression that they are correct.

This book has appeal primarily for clinicians who work closely with patients with schizophrenia, especially clinicians who prescribe antipsychotics, program services, or provide therapy. It is easy to read and has simple enough explanations of technical terms that it is accessible to clinicians at all levels of training and even to the lay population. On the other hand, the discussions of basic psychiatric concepts combined with a tinge of sermonizing toward clinicians, plus the sometimes repetitive nature of the arguments, may dilute the focus of the book for some readers.

However, the good in this book outweighs any weaknesses. Clinicians will find that the insights and sensitivities gained from reading Return From Madness can help them more effectively understand, interact with, and plan treatment for people with schizophrenia, especially those who are lucky enough to have significant symptom resolution.

Dr. Kennedy is assistant professor of psychiatry at the University of Massachusetts Medical Center in Worcester and chief of psychiatry at Worcester State Hospital.

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