Recovery From Schizophrenia: Psychiatry And Political Economy

TREATMENT 283individual’s goals should be to do well and to feel good—the medication is a tooltowards that end, The patient, however, may identify the medicine withthe illness and see it as a stigmatizing and controlling force (which it often is, ofcourse). To get around this problem one may do a number of things—help theperson identify certain goals and the extent to which medication can assist inreaching them; discuss his or her reaction to the illness, to the medication, tocontrol and to stigma as separate but related issues; and delegate to the patientauthority over his or her own medications at the earliest workable opportunity sothat he or she can set the dosage to achieve the desired benefit.The person with schizophrenia does not respond well to ambiguity in therapyor to a neutral and distant therapist. Communication should be straight-forward,expectations clear-cut and the therapist should not hesitate to act as a role modelfor the patient. Psychotic experiences may be discussed frankly, not to uncoverdynamic origins, but to alleviate the person’s fears and perplexity about them andto identify stresses that provoke their appearance. The emphasis in therapy,though, needs to be on problems in daily living—work, personal and familyrelationships, finances and accommodation—and a major goal of treatment shouldbe the reduction of stress in these areas.Paradoxically, the therapist for people with psychosis will find that he or she isencouraging many clients that they can overcome their disability and accomplishmore, while he or she must persuade the others that they suffer from an illnessand should accept restrictions and limit their horizons. As argued in Chapter 8,this phenomenon is exacerbated by the stigma of mental illness. To consideroneself both mentally ill and capable creates cognitive dissonance; people tendeither to accept the label of mental illness and adopt the associated stereotype ofincompetence or they reject the notion that they are ill or disabled. The solutionis to proceed slowly, to avoid pushing the person who accepts the diagnosis to dotoo much too soon and to avoid vigorously attacking the denial of the personwho rejects the illness label.Herein lies one of the potential advantages of group therapy for people withpsychosis. Cognitive-dissonance research demonstrates that people are more likelyto change their attitudes if they can be encouraged to express in public an opiniondifferent from their usual belief. By bringing together in a therapy group peoplewith psychosis who variously accept or reject the illness label and who have avariety of levels of functioning, one may hope that the less competent patientswill accept the possibility of becoming more capable and that those who denytheir illness will change their opinion. A group focus on practicalaccomplishments and the development of social skills is indicated. A review of theresearch on the effectiveness of group psychotherapy for outpatients withpsychosis has suggested, in fact, that such treatment is particularly valuable inboosting both the clients’ levels of social functioning and their morale. 36