In classical music, one common format is to take a theme and then write a series of variations. Bach, Mozart, Beethoven, Brahms, and Rachmaninoff, for example, all wrote pieces entailing variations on themes written by someone else. That format makes it possible to look at an idea from a variety of alternative perspectives. I will try to do something analogous using as theme the article in this issue by Turner et al. (1), which will be viewed from three perspectives or “variations”: 1) the patients and problems being treated, 2) the treatment approaches, and 3) the need to consider them together.
The article, titled “Psychological Interventions for Psychosis,” presents a meta-analysis of a group of treatments for psychotic patients. The core idea, of course, is to determine the best way to treat a person afflicted by psychosis, focusing in this study on psychological methods. Forty-eight outcome studies comparing psychological treatments were included and then grouped into six categories for treatment comparison. Results showed that cognitive-behavioral therapy (CBT) was significantly more effective for reducing positive symptoms, and social skills training for reducing negative symptoms. In direct comparisons between two treatment methods, CBT was more effective than befriending for overall symptoms and more effective than supportive counseling for positive symptoms.
Several years ago, I was reviewing treatment programs in the psychiatric hospital of a neighboring state. While visiting various parts of the hospital, I went onto one of the wards. When I looked out at the ward from the nursing station window, only one patient was visible. She was sitting on a bench, a somewhat heavy middle-aged woman in a Mother Hubbard dress. I couldn’t tell if she seemed lonely or if her thoughts were just off somewhere else. I asked the nurse if that was the only patient on the unit. The nurse said, “No, but she’s a schizophrenic and is too difficult, so we don’t let her off the ward. The other patients are all outside in the yard.” I went up to the woman and told her that I was a doctor reviewing the treatment program at the hospital and asked if it was all right if I talked with her. “Yes,” she said, so I began asking her things like how long she’d been in the hospital. “A long time.” “How is it for you here?” “OK.” And we continued on: “Are there a lot of other patients here?” “How’s the food?” things like that. After a bit, I asked her if I could sit down on the bench and we could talk further. She said that was fine, so I did, and we continued. After a while, I asked her why she was here on the ward while everyone else was outside. She said, “They don’t trust me.” I asked her why, and she said she didn’t know. I then asked her what she would like to do if she had the chance. She said, “Be a secretary.” “Have you ever done that?” “I took a course in high school.” “What kind of subjects were in it?” “Oh, typing and things like that.” Do you like to type? “Yah, but I’m not sure I could do it anymore.” And we continued on for another 15 minutes or so, after which I said I had to go but hoped she would be able to do some typing. I thanked her for talking with me and returned to the nursing station.
Now what has this exchange to do with the Turner et al. article? At first when I recalled the experience I asked myself the same question. Then I thought, it’s the wide range of characteristics that are important in real people with psychosis, people with schizophrenia, even those “too difficult,” the sickest of the sick. By comparing treatment types, one of the issues the Turner et al. article raises is the implicit question of whether different patients have different needs requiring different treatments. In the experience I described, my conversation with even this very sick patient was totally “normal.” This “schizophrenic” who was so sick she couldn’t even be allowed to partake in the activities of other very sick patients, had a totally normal conversation with me. What about all her thought disorder, her abnormal affect, her psychotic symptoms? I don’t mean to imply that she didn’t have any of these or even that she wasn’t difficult. What struck me as being so weird was that at least some of the time, this perhaps very disturbed woman did not seem disturbed at all. How is that possible? What does that tell us about “schizophrenia” or perhaps mental illness more generally, and about treatment needs?
How does that experience connect with the Turner et al. article? Well, for one thing, it recalls to us that patient needs are not as simple as they are often depicted. That statement may seem naive, but it is often neglected in considering treatment, especially in research and in our theories. Psychosis, even “schizophrenia,” is not like a severe pneumonia or a broken leg. With those problems, you can’t just go off and play a game of football or whatever. There, when you’re really sick, you’re really sick. But this woman, as sick as she might have been, was also capable of acting in a totally normal way. And having seen hundreds of “very sick” people with severe mental illnesses, I am impressed by how much this variability is more often the rule than otherwise. How is that possible, if you have defective genes, brain problems, abnormal neurotransmitters, or even a very troubled childhood? That woman emphasizes that the reality of mental health/illness is actually very complex (2, 3). Let’s say this woman was fine as long as we were only talking about certain things, or when there weren’t a lot of people around. Then we are instantly into issues of context and meaning; all these things and more are also relevant not only to understanding the problem of the disorder but also to considering treatment and the diversity of treatments that may be required.
The Turner et al. article highlights the fact that there are many possible psychological treatments for psychosis. That in turn raises the question of what would happen if we considered more than just these. Most often, treatment proposals and studies identify one treatment in question and focus primarily on it. By looking at many treatments, this meta-analysis begins to highlight the very diversity of the treatment possibilities that exist. But in focusing on the plethora of treatments available, the Turner et al. article opens up the possibility of also thinking about the treatments not discussed. Medications of course are mentioned, but what about other possibilities? The woman described above stated that she would like to work as a secretary. That could be a wild fantasy, of course, or not. Recent advances in what used to be limited to rehabilitation approaches involve far more “radical” programs, such as Housing First (4), in which the person with the problem does not have to agree to any of the traditional treatments before being helped with housing. Helping a person find a work placement, or perhaps helping the woman on the bench with advancing her secretarial skills, would also be relevant, whether or not she is “too difficult.” Peer support programs are another approach to focusing on the person’s health as well as on the deficits. These programs connect the patient with a person who has had similar experiences and can therefore provide a specific kind of human contact as someone who really “knows what it’s like” and hopes for improvement and for a better life (5).
The Turner et al. report is a meta-analysis of psychological interventions for psychosis; the variations on its theme of patient and treatment diversity imply also the need to go further and suggest how we might bring some order into these complex linked worlds. The article represents an important piece in such an effort by attending to the consideration of diverse treatment forms. Its imperfections are not primarily a fault of the authors, who have made a herculean effort to engage the problems of diversity and the complexity of the topic. Such an effort is essential for our field, necessary shortcomings notwithstanding. Studies of pure forms of patients and pure forms of treatments have their utility as well, but to accept that such studies are sufficient to deal with the real world underestimates the major complexities of that world (6, 7).
It is worth noting that many experienced clinicians spend their professional lives trying to deal the best they can with diverse treatments and even more diverse patients. And of course patients themselves are almost always confronted with the complexity of their problems and optimal ways of dealing with them. Rather than ignoring these problems, anything we can do to provide even a little more order to this complex world is crucial, even with the limitations that our methods and concepts involve.