Treating Refractory Schizophrenia

Refractory schizophrenia occurs in about 30% of cases. When medication doesn’t work, traditional therapy can still be effective.

I’ve recently had a few new people come in for therapy with diagnoses on the schizophrenia spectrum. Not only that, but they’ve tried a few different medications with no significant reduction of symptoms. Refractory is just a fancy way of saying treatment resistant.

As a therapist, when I hear that my new clients have treatment resistant schizophrenia, my first thought is this- Can therapy help someone who isn’t helped by medications? After all, schizophrenia is a pretty major mental illness.

It’s not like depression or anxiety where the cause could be either biological or psychological, and the origin of the symptoms shapes treatment. Instead, schizophrenia is understood as a primarily biological disorder with clear ties to dysfunction in major brain systems.

With schizophrenia, medication works to relieve symptoms in approximately 70% of cases. That’s a much lower number than I expected. That means 30% of people who experience schizophrenia get little to no help from medications. There’s a lot we don’t know about schizophrenia though, so we could see that number decrease as we learn more about the brain and how it works in mental illness. In fact, I just read an article today about scientists searching for brain cues related to major mental illness. They discovered tons of tiny factors that all play into the etiology and course of major mental illness.

But that’s a bit of a tangent. My goal was to learn if there were any therapy interventions that were designed to work for people with refractory (treatment resistant) schizophrenia spectrum disorders.

I was actually surprised to find that this has been studied by a few different researchers. I found two different treatment protocols based on CBT that were demonstrated to be effective with refractory schizophrenia. They seemed similar, with slight differences. I figured it would be easy to combine these approaches and create a protocol of my own that will hopefully be effective in my three new clients.

I’ll post the full protocol in a separate post. For now, here are the two studies I used to develop this method of treatment for refractory schizophrenia.

 

Cognitive–behavioural therapy for refractory psychotic symptoms of schizophrenia resistant to atypical antipsychotic medication. Lucia R. Valmaggia, Mark Van Der Gaag, Nicholas Tarrier, Marieke Pijnenborg, Cees J. Slooff. The British Journal of Psychiatry Apr 2005, 186 (4) 324-330; DOI: 10.1192/bjp.186.4.324
The omnipotence of voices. A cognitive approach to auditory hallucinations.. P Chadwick, M Birchwood. The British Journal of Psychiatry Feb 1994, 164 (2) 190-201; DOI: 10.1192/bjp.164.2.190

Therapy 101: How to Find a Therapist

In the Therapy 101 series, we’re covering the basics of what you should know before going to see a therapist. This post looks at finding a new therapist and the nine factors to consider when deciding to commit.

Finding a therapist can feel like online dating. It usually begins with a search- therapists near me, counselors near me, therapy for depression, best counseling group. You scroll through bright, happy websites full of professional photos of well-lit, smiling people. They all say pretty much the same thing. You’re stuck and I can help you. They have lots of buzzwords. Change. Transform. Holistic. Wellness. Some list a fee or insurance networks they accept. Many don’t. It can seem like there’s no real difference between them. But there is, and it’s not something you can see from a website. It’s their personality.

After all the effort you’ve put into finding a therapist, it’s tempting to pick the first one who calls you back. But it’s worth it to find someone who really gets you. Studies of the effectiveness of therapy show that it’s the relationship you have with your therapist that’s the biggest predictor of change in your life. It’s not the methods- results show that the therapy method doesn’t matter so much even though they seem so different.

Treat the first session like a date- it’ll probably be a bit awkward and you don’t really know each other but you’re trying to see if it’s a good fit and trying to make a positive first impression while being authentic about your experiences and struggles.

Many therapists offer a free initial consultation so you’re not dropping a hundred dollars on someone you don’t want to see again. But many don’t offer a free first session or do a free consultation on the phone only, so you may have to make a bit of an investment in finding the right person.

Here are nine signs you’ve found a good therapist:

*note: many of these signs reference California legal and ethical standards for therapists with a state license and may not apply in other states.

  1. They’re above board from the start. Your therapist should go over things like fees, cancellation policies, confidentiality, mandated reported requirements, and other boilerplate details with you. If they don’t mention any of these things, that’s a sign they’re uncomfortable talking about difficult topics, but it also indicates that they either don’t know the law or are purposely ignoring it. Not a good trait in a therapist.
  2. They can explain the process of therapy to you. Every therapist does therapy a bit differently, but the time you spend in therapy generally has a beginning, middle, and end. If the professional therapist can’t tell you what to expect in therapy, watch out! They might not know what they are doing or they might want to bring you in with no defined end so you’re in therapy for years (and paying every week!).
  3. They listen to you. After the required details are taken care of, the therapist should ask you why you’re coming to therapy. Depending on the therapist’s methods and the nature of your problems, they might ask about your childhood, your relationships, your sleep habits, or even your current thoughts and feelings. No matter how they direct the conversation, you should expect to spend a good amount of time talking about yourself and your experience. Stay away from the therapist who hears “I’m depressed” and doesn’t ask more- it shows they don’t really care about your side or how your personal history has shaped the current issue.
  4. You feel heard. Some therapists listen but you’re not quite sure they’ve really understood what you were saying. It’s a good sign when your therapist reflects back what they heard you say and asks if they’ve got it right. That shows they’re actually trying to get your perspective accurately and are willing to ask for clarification.
  5. They ask about your end goals. There are a few ways they might ask about this. Phrases like “if the problem was gone, what would be different” and “how would you like things to be with your spouse” are indicators that your therapist is looking for specific, measurable goals so they know when you’re heading for the end phase of therapy.
  6. You feel comfortable in the room. Therapy takes a while. You should be comfortable on the furniture, feel safe parking your car or taking transit to the office. This may seem like a small thing, but if you don’t feel like you can relax in the room, it’ll be easier for you to skip sessions later when it’s hard to get out the door.
  7. You like the look of your therapist. It can seem shallow to judge someone by their appearance, but it’s actually pretty important. If you feel attracted to them, you might not be completely honest about the weird parts of your past. If they seem too young, too old, or too close to your own age, you might not feel able to trust their judgment. Some people need to see an older therapist who reminds them of their grandparent. Couples may prefer to see a married therapist. Teens often like therapists who are either younger adults or older adults- not someone parent aged. A person who has experienced sexual assault may want to see someone completely different in race and gender from their attacker.
  8. The therapy style seems like a match. If you’re more analytical, look for a therapist who can explain your anxiety in a more technical way. If you’re a creative type, steer clear of the technical therapist and look for someone who will do process art, dance therapy, or music therapy with you. A good therapist can be both- they’ll mirror the way you talk and match their style to your personality and way of thinking.
  9. You’re comfortable with the fee. Most people aren’t comfortable talking about money, especially when it comes to admitting that something is too expensive. If you really feel like this is someone you could work well with, ask about sliding scale fees or suggest a fee you feel comfortable with as long as it’s similar to the current fee structure. It’s no fun for anyone to have a mass of unpaid bills collecting.

If they’ve got all these factors, you’ve found a match! Just remember, first sessions are often like first dates, and if you can afford it, give a maybe therapist a few sessions to get to know you before making a final decision. Of course, a red flag therapist shouldn’t get a second session- get out of there right away if you feel uncomfortable or if they’re clearly doing illegal or unethical things.