Personal Accounts: The Importance of Psychotherapy in Remission and Relapse

To live with schizophrenia is to live with uncertainty, to always have the threat of regression as a reality. After four years out of the hospital and feeling myself impervious, in 1996 I relapsed. I felt totally defeated, having all but forgotten that I had a chronic psychotic illness. It was nothing short of heartbreak.

I had been virtually unresponsive to all antipsychotic medication for 14 years after I was diagnosed with schizophrenia. Contrary to today's popular belief that people with schizophrenia do not benefit from psychotherapy, it was talk therapy that allowed me to make the progress I did during those years. I was able to tolerate agonizing symptoms while sitting with my therapist, I was able to learn some things about myself, and I even began to develop an observing ego. Had it not been for therapy, I would not have survived the constant relapses that occurred until we could find a medication that helped me.

In 1990 I discovered chlorprothixene (Taractan), a phenothiazine widely used in Europe but currently little known in this country. In the early 1960s, Taractan was very successfully used in the United States to treat otherwise nonresponsive patients and was central in allowing many patients to be deinstitutionalized. For some reason the drug fell into obscurity, and I learned about it from a European doctor. For me it hit the spot—what for me is that indefinable center, the core of my psychosis. I had never felt anything like it in my life. I was very stable and even managed to relax a little.

Then in early 1995, Taractan was pulled from the market. I was devastated and felt helpless. I wrote letters, made phone calls—all to no avail. The only choices left were the atypical neuroleptics. I switched over to risperidone, the new drug of choice at the time.

Risperidone worked relatively well, but I never felt really well. It didn't hit the spot. A year and a half later I was in the hospital suffering a complete breakdown. New is not always better, and now it seems there is little choice left. A 1986 booklet entitled Schizophrenia: Questions and Answers from the U.S. Department of Health and Human Services states that 40 percent of schizophrenic patients relapse within two years of leaving the hospital, even with continued medication compliance. A 1996 brochure, Understanding Schizophrenia, from the National Alliance for Research on Schizophrenia and Depression, cites five studies with a range of relapse from 7 percent to 33 percent with medication compliance. Although the chemistry of medications has changed between the time of these two statements, the reality of vulnerability has not.

The atypical medications, while touted for many as miracle drugs, may be more significant for their lack of side effects than for their efficacy for all patients. Since the fall of 1996, I have been on two other atypicals, clozapine and olanzapine, and was unable to tolerate the side effects they did have. I went back to risperidone and had brief, acute psychotic episodes while on only risperidone. I am now able to stabilize with the addition of a small amount of quetiapine.

However, the task lies before me to use psychotherapy to identify the psychological triggers of my psychosis and to find ways to contend with them. A New York Times article of January 20, 1998, describes people with schizophrenia as being "born with brain abnormalities that make them especially vulnerable to emotional stress. Overwhelming stress, often from dealings with other people, can lead to anxiety and depression, which may in turn spiral down into psychosis."

The key phrase here is "dealings with other people." One of the most profound difficulties people with schizophrenia can experience is interpersonal stress. When I had been having frequent psychotic episodes for some time, my therapist noticed that I would become confused and stressed when people asked me to do things for them that I found overwhelming. Although I couldn't see it, my therapist pointed out that my psychosis seemed to worsen so that I would not have to deal directly with the trigger—conflict with other people. It was only after I noticed this myself that I realized how right she had been. When I was able to address these interpersonal challenges head on, some of my psychosis abated.

Anxiety and depression are also very significant, and their specific nuances are central. For me, stress in the form of negative associations and disorientation can lead to psychosis. After months of experiencing excruciating episodes, I found that even passing bizarre or psychotic thoughts would send me into an apprehensive panic and then into a full-blown psychosis.

The challenge was to confront the panic in order to avoid the escalation. My therapist and I had to identify the triggers and learn strategies to keep me in the real world and away from the "crazy" thinking I was slipping into. Now I am learning to say, "Okay, this is the way my mind works—sometimes it goes a little off, but that's just who I am, and it is all right." At this point I need to get out of my head, physically get into a safe place, and think about something in the outside world that is concrete, known, and familiar. This strategy has alleviated some of the fears that lead to total loss of control.

On some recent occasions I have been able to stop myself in a slide into psychosis and avoid a close call. But I am still susceptible, and whether my psychosis lasts four hours or four days, it is always terrifying and devastating. This is where psychotherapy on an ongoing basis is crucial. I went through a long process with my therapist in order to be able to define what drives me into madness. Learning to accept the episodes as part of myself has been a challenge, but perhaps that is the only way to get through them. Psychotherapy is essential in helping one cope with such an adjustment in one's way of thinking.

Despite the emphasis on psychopharmacology in treating schizophrenia, psychotherapy must be available to monitor symptoms, progress, and signs of regression more thoroughly than many psychopharmacological practices allow. While psychopharmacology obviously has to be at the heart of treating schizophrenia, clinicians cannot overlook the need for continuing psychotherapy to develop coping strategies needed when regressions do occur. For many of us, relapse may be just a tomorrow away, and only with the cooperation of psychopharmacology and psychotherapy can we feel more confident that we can overcome these setbacks.

Ms. Ruocchio has published articles in the American Journal of Psychiatry, numerous other professional journals, and the New York Times. Her address is 54B Thayer Road, Apartment 2, Belmont, Massachusetts 02478. Jeffrey L. Geller, M.D., M.P.H., is editor of this column.