Schizophrenia affects up to one in a hundred people at some point and can cause hallucinations, delusions, and loss of energy and motivation. Creative psychological interventions such as art therapy are widely used in combination with drugs. But the effectiveness of art therapy is unclear.

Professor Mike Crawford of Imperial College London, UK, and his team examined the benefits of group art therapy among 417 adults with a diagnosis of schizophrenia. The patients received group art therapy or non-art group activities each week for a year, or standard care.

The art therapy involved a range of art materials which the patients were encouraged to use “to express themselves freely.” Non-art group activities included board games, watching and discussing DVDs, and visiting local cafes.

This study differs from previous trials of art therapy by focusing on clinically important differences in outcomes. It also provides detailed information about attendance rates, and offers art therapy of a duration that is more like that in real-life clinical practice.

When patients were assessed after two years, overall functioning, social functioning, and mental health symptoms were similar between the groups. Levels of social functioning and satisfaction with care were also similar.

Patients offered a place in an art therapy group were more likely to attend sessions than those offered a place in an activity group. However, the levels of attendance at both types of group was low, with 39 percent of those referred to art therapy and 48 percent of those referred to activity groups not attending any sessions.

Writing in the British Medical Journal, the researchers state, “While we cannot rule out the possibility that group art therapy benefits a minority of people who are highly motivated to use this treatment, we did not find evidence that it leads to improved patient outcomes when offered to most people with schizophrenia.”

They conclude that art therapy, as delivered in this trial, “did not improve global functioning, mental health, or other health related outcomes.” They point out that “[T]hese findings challenge current national treatment guidelines that clinicians should consider referring all people with schizophrenia for arts therapies.” The authors suggest that art therapy should not be offered on a broad basis to all patients, but targeted at those most likely to make use of it, based on an assessment of the patient’s interest and motivation to attend sessions.

Currently, the UK’s National Institute for Health and Clinical Excellence recommends that doctors “consider offering arts therapies to all people with schizophrenia, particularly for the alleviation of negative symptoms.” This should be provided by a registered therapist who has experience working with people with schizophrenia.

The guidelines describe arts therapies as “complex interventions that combine psychotherapeutic techniques with activities aimed at promoting creative expression. The aesthetic form is used to ‘contain’ and give meaning to the service user’s experience, and the artistic medium is used as a bridge to verbal dialogue and insight-based psychological development.

“The aim is to enable the patient to experience him/herself differently and develop new ways of relating to others,” the guidelines add.

Professor Crawford and his team think that the lack of clinical improvement in their trial may be due to “the high degree to which people with established schizophrenia are impaired in their clinical and social functioning.” They explain that these impairments are known to increase over time, and the participants had been diagnosed for around 17 years.

It may be that to benefit from group art therapy, “patients need a greater capacity for reflective and flexible thinking,” so targeting interventions at an earlier stage of the illness may be more effective.

Commenting on the study, Dr. Tim Kendall of the UK’s National Collaborating Centre for Mental Health believes that, while art therapy is unlikely to be of clinical benefit for schizophrenia, it “still has great potential for success in the treatment of negative symptoms.”

In an online response to the study, psychiatric hospital art therapist Betsy A. Shapiro, of Alvarado Parkway Institute, La Mesa, California, says the once-weekly nature of the art therapy sessions in the study is a potential problem.

She writes, “I work with patients with schizophrenia and see them 3-5 times a week. Patients not only enjoy group art therapy, they excel in it. Working with a variety of materials keeps them focused, encourages their creativity and appears to increase self-esteem.”

She adds that patients can “show their auditory or visual hallucinations, and express feelings which are difficult for them to do verbally. It provides for safe release of strong emotions such as rage and has prevented them from hurting themselves, others or property.”

Overall, she concludes, “It would be a great disservice to patients if this study influenced a cut-back in art therapy services.”

References

http://www.bmj.com/content/344/bmj.e846

Group art therapy as an adjunctive treatment for people with schizophrenia: multi-centre pragmatic randomised trial. Crawford, M. J. et al. The British Medical Journal February 29, 2012 doi: 10.1136/bmj.e846

Though the book could have used a good editor and been more intuitively organized, it’s still a fairly compelling read, and offers some pointed comparisons between the Spiritist approach and the modern mainstream U.S. approach — the latter of which views mental illness as a physical disease to be medicated away despite the sometimes crippling side effects of medication.

Bragdon begins by introducing us to Gerry, an “attractive young woman” who experienced what seemed to be a psychotic break during a time of extreme stress. About four years ago, Gerry began exploring alternative forms of healing, including consulting with Bragdon, a spiritually-oriented psychologist. Now, Gerry is doing well, engaged, and intending to enter graduate school. The author writes that Gerry’s recovery was facilitated by empathy, encouragement, caring health professionals and family members, and “teachers who helped educate her about lifestyle choices.”

This approach, Bragdon tells us, mirrors the Spiritist methodology that is currently in practice in Brazil, where more than 12,000 Spiritist community centers and 50 Spiritist psychiatric hospitals freely offer “a highly effective… program of integrative care, treating the needs of the public side-by-side with conventional medical practitioners.” It’s a community-oriented, relationally-focused, holistic and welcoming model that treats the patient as a human being who has just as much insight into her illness as any professional. But it also involves some practices that the average U.S. citizen might find unfamiliar.

“According to Spiritists,” writes Bragdon, “optimal wellbeing is ours when we are 1) doing the mission that we agreed to do before coming into this life and 2) treating ourselves and others with compassion consistently.” She goes on to explain that a Spiritist “considers that a pervasive and long-lasting mental imbalance that threatens life may come because a person is rebalancing themselves after a life experience that was not compassionate or may come from having lost his/her purpose in life.”

That part may not sound unusual, save for the part about making agreements before we were born. But the Spiritist approach offers multiple techniques that a non-religious, States-bound consumer might find “out there.” These include the laying-on of hands, inspired speech and prayer, blessed water, peer support for the patient and the family (called “fraternal assistance” in the book), interactions with mediums and psychics, and a post-hospital program of study and philosophical and spiritual conversation. It also welcomes family members and loved ones to be involved.

Although it’s unlikely that the U.S. healthcare model is going to follow the Spiritist one anytime soon, and although the author doesn’t provide objective proof of the success of the treatment, what I found fascinating about Bragdon’s book is how the Spiritist approach reflects some of the insights the mainstream psychological community has come to about mental health. The differences are obvious, but the underpinnings between these two very disparate models is surprising. Some descriptions of the Spiritist approach that may sound more familiar:

“The inspired speech directs the patients to focus on the value of compassion and love, helping them recollect loving relationships they may have had or may long for, assisting them toward greater self-acceptance, compassion, and tolerance,” one description goes.

“Perhaps Spiritism has been so successful in its treatments because it facilitates individuals clarifying their life purpose and aligning with that purpose,” Bragdon posits.

“The treatment aims at working with the patients’ motivation and with their state of readiness or eagerness to change.”

Another passage describes spirits that cause negative thoughts. Taken together, these concepts of forgiveness, self-acceptance, compassion, life purpose, negative thoughts, and motivation are all vital aspects of established psychotherapy modalities such as Cognitive Behavioral Therapy, Buddhist Psychology, Acceptance and Commitment Therapy, and Motivational Interviewing.

Bragdon’s book may be of limited value unless one is interested in different cultural approaches to psychological treatment. For those who are intrigued, however, it draws a compelling Venn diagram of the similarities between seemingly separate schools of thought. The author’s description of several U.S.-based holistic mental health clinics certainly gives the reader hope that there are people in the States working to change the dominant “medication-not-meditation” paradigm — even as we’re slow to accept alternative healing methods.

Resources for Extraordinary Healing: Schizophrenia, Bipolar and Other Serious Mental Illnesses
CreateSpace Independent Publishing Platform, February, 2012
Paperback, 264 pages
$24.95

Managing Depression and Suicidality

It is common for clients with schizophrenia to feel grief and loss due to the myriad life changes that it triggers (Wittmann & Keshavan, 2007). In this sense, during treatment, it is essential for clinicians to help clients navigate through the grieving process. According to Tait, Birchwood, and Trower (as cited in Wittmann & Keshavan, 2007), depression has been found to lead to the abandonment of treatment by clients due to the isolating characteristics of the disorder. Abandonment of treatment poses serious drawbacks for clients.

Wittmann and Keshavan (2007) assert that the grieving process is a necessary component to coming to terms with a new diagnosis of schizophrenia. Due to the sense of loss experienced by individuals newly diagnosed with schizophrenia, it is essential for them to navigate and work through the grieving process (Wittmann & Keshavan, 2007). According to Lewis (as cited in Wittmann & Keshavan, 2007), by doing so, clients will learn to mourn the life and identity changes that have occurred, along with establishing the ability to integrate such change into their lives. It has been shown that counseling can be beneficial in such a situation.

Grief and mourning are a common component in clients diagnosed with schizophrenia (Wittmann & Keshavan, 2007). This is because the diagnosis of a serious, permanent mental disorder is a major life crisis for most. The disorder affects the mind in very serious ways (Wittmann & Keshavan, 2007). In some cases, clients might spiral into psychosis as a means of dissociating, or defending against facing, the losses their disorder has caused (Wittmann & Keshavan, 2007). Clinicians have a major hand in helping clients manage this crisis.

Numerous models exist to explain grief and mourning, and can also help professionals guide grieving individuals. Elizabeth Kubler-Ross (1969) proposed five stages of grief that individuals can experience while grieving. They include denial, anger, bargaining, depression, and acceptance. In contrast, Worden (2002) proposes four tasks, as opposed to stages of grief. These include accepting the reality that loss has occurred, feeling the pain and emotional responses to the loss that has occurred, readjusting to life after the loss, and finding ways to remember the lost individual. Although these models are meant to aid in grieving a person, individuals diagnosed with schizophrenia are, in fact, grieving the loss of the person they once were and will potentially no longer be. In this sense, these models offer a framework that can be used in counseling to help a client adjust to life after their loss of self.

A Safety Plan for the Newly Diagnosed

Clinicians should develop a safety plan for use in the event that a client presents with suicidal intent or depressive symptoms, as these are both common in newly diagnosed clients. One of the first issues to address is the onset of depressive symptoms or suicidal thoughts. A safety plan can involve listing symptoms characteristic of depression, including those characteristic to the client, as well as those that the client has not felt before, but could potentially feel in the future. This would help foster the client’s awareness of their own symptoms.

Along with such a list, clinicians can help clients determine the course of action to be taken if suicidal thoughts or feelings occur. Action plans can include emergency contact numbers, such as a suicide hotline and that of the primary therapist, the psychiatrist and other medical doctors, and family members or other individuals who serve as the client’s support system. One of these individuals could sit with the client and support them through the situation while attempting to contact appropriate clinicians. If the client has no close friends or relatives, suggest that they join an in-person or online support group.

Clients should be asked to keep a list of depressive or suicidal triggers. During sessions, the counselor and client could develop and implement ways for such triggers to be managed.

Clinicians should urge clients to remove from his or her home any items that could be used to self-harm. Making access difficult reduces the temptation to use them. This might be especially useful for clients who have already made attempts, and would also potentially increase the likelihood of them seeking some form of support or following an appropriate plan of action, rather than engaging in self-injurious behavior.

Clients can be encouraged to keep an up-to-date medication list with them at all times. This will help them if they need to seek out emergency services. During a crisis, it might be difficult for them to recall each of the medications they take, as their minds will be preoccupied.

Clinician should keep a current list of service providers to which clients can be referred. For example, if the client’s symptoms become more intense and overwhelming for them, and more in-depth treatment is required, the clinician should be able to make an appropriate referral or direct the client to an appropriate provider. This could further ensure the client’s safety, as he or she would receive the necessary services, especially if more in-depth treatment is required.

Conclusion

A diagnosis of schizophrenia presents serious implications for newly diagnosed individuals in particular. Those with schizophrenia have a vast series of challenges to face, including overcoming and grieving the loss of a sense of self, experiencing a loss of hope for the future, accepting the diagnosis, facing the fact that social, occupational, educational, familial, and romantic arenas might undergo marked change, and integrating new insights, coping strategies, and processes learned on their journey into their life.

Because the diagnosis of a serious mental illness can cause a major life crisis (Wittmann & Keshavan, 2007), clinician support is critical. This is especially true because depression and suicidal ideation are common in the newly diagnosed (Addington et al., 2004). Along with helping the client manage their diagnosis and helping to facilitate his or her grieving process, clinicians can help ensure client safety by establishing and agreeing upon a safety plan for use in the event that the client is experiencing depressive symptoms or suicidal ideations. Not only will this help clients to feel supported and cared for, but it will also potentially help save a life in the event of an emergency or crisis.

References

Addington, J., Williams, J., Young, J., & Addington, D. (2004). Suicidal behaviour in early psychosis. Acta Psychiatrica Scandinavica, 109(2), 116-120.

Kubler-Ross, E. (1969). On death and dying. New York: Scribner.

Wittmann, D. & Keshavan, M. (2007). Grief and mourning in schizophrenia. Psychiatry, 70(2), 154-166.

Worden, J.W. (2002). Grief counseling and grief therapy: A handbook for the mental health practitioner (3rd ed.). New York: Springer Publishing Company.

Before writing this book, Williams spent time as a hang glider pilot, winning one world championship and several national awards. Then, he tells us, he experienced a mental crisis that could have been labeled psychosis, but avoided getting diagnosed or “helped” by psychiatry. Instead, he says, he worked through his experiences on his own. This caused him to become interested in helping others, and he became a psychologist and researcher focused on the detailed exploration of the experiences of people who have undergone psychosis and then full recovery.

One of the key ideas Williams sets forth is that psychosis, in the presence of the right conditions, can be expected to most commonly result in a positive outcome: an outcome that is better than the state that existed before the psychosis. This assertion flies in the face of most of what our culture thinks it “knows” about psychosis, but the author documents the argument well.

Still, the perspective should not be confused with some romantic notion that psychosis is always a good thing — Williams is clear that it is hazardous under the best of conditions, and likely to lead to major ongoing life difficulties when the focus is just on attempts to suppress the process, as usually happens in developed countries today. What is critical to note, he tells us, is that these poor outcomes are typically due to poor handling of the experience, and not the nature of the experience itself.

Another major point Williams makes is that the core issues in madness are not a struggle with an “illness” experienced only by some, but rather a struggle with the existential issues that we all face, such as being caught between a fear of being separate and a fear of being overwhelmed or engulfed by connection. He outlines how the ability to regulate one’s approach to such dilemmas is lost in psychosis, usually in response to a number of stressful experiences—but also how the loss of one’s prior approach has the potential to lead to the emergence of new and healthier ways of being organized. He discusses these ideas first theoretically, then by clear descriptions of how these issues played out for the individuals he has researched, as they went through psychosis and then recovery.

The author argues that psychotic experiences typically occur as part of a process of experimentation at a deep level of the mind, a risky process of profound disorganization and then reorganization. He illustrates how the current mental-healthcare system interferes with rather than safely facilitates this process, and how recovery seems to only be possible when people manage to break away from the system to at least some degree. He then sketches out the possibility of a very different system of care that would recognize the meaningfulness and positive potential in psychotic breakdown.

Unusual as his ideas may seem, Williams convincingly demonstrates a very extensive knowledge of psychosis. In fact, his book may be among the best types of “preventive” measures — preventing one from entering the black hole of biomedical psychiatry, that is.

Rethinking Madness: Towards a Paradigm Shift In Our Understanding and Treatment of Psychosis
Sky’s Edge Publishing, April, 2012
Paperback, 398 pages
$24.95 

“Most three-year-olds are in bed by now, but most three-year-olds are not geniuses like my daughter,” begins January First: A Child’s Descent into Madness and Her Father’s Struggle to Save Her, a harrowing story of parents trying to discover what’s ailing their intelligent, precocious, yet violent and eccentric daughter. Jani’s high intelligence is how her father, author Michael Schofield, first tries to rationalize her increasingly bizarre behavior

The bizarre behavior ranges from her menagerie of imaginary friends, a devotion to the made-up world of Calilini, and a lack of interest in interacting with children her own age to sudden violent outbursts and attempts to physically assault her infant brother, Bodhi, whenever he starts to cry.

When Jani is found to have a high IQ during autism testing, but not genius-level, Michael and his wife Susan are dismayed. Could it be that something else is afoot?

We first see Jani’s terrifying dark side when Schofield describes a typical evening with the family. The infant, Bodhi, is sleeping, when Jani decides to turn up the television volume louder and louder. Her father asks her to turn it down, but she insists she can’t hear it. When the noise wakes up Bodhi, Michael and Susan take their well-rehearsed places with the urgency of two firefighters arriving on the scene of a five-alarm fire. Susan picks up the baby to protect him while Michael rushes to the kitchen to get him some formula to keep him quiet. But before he can feed the child, “Jani calmly walks around the coffee table that separates her from Susan and Bodhi. Susan starts to get up, recoiling, twisting to shield Bodhi. Jani reaches up and drives her fist into Susan’s stomach, just below Bodhi’s dangling legs.” Her father grabs her, immobilizing her as best he can, as she attempts to punch and kick him.

“If you tell me you won’t try to hurt Bodhi, I can let you go,” he tells her. “I have to hurt Bodhi,” she answers, in a voice, Schofield writes, “like she is being forced to hurt him.” “I have to,” she continues. “…I want to.”

This rather stunning scene illustrates what these parents are up against: a girl who is clearly bright and vivacious, but who is given to vivid hallucinations, desperate violence, and uncontrolled rages. Unfortunately, the realization that their daughter is not developing normally is only the beginning of the fight to help her. As Michael and Susan begin to try to understand what’s happening, they realize that psychiatrists and psychologists don’t necessarily have the tools to make their child “normal.” And, slowly, they realize that diagnosis and treatment won’t be simple or easy.

Parenting two young children is never easy on working parents, but with Jani always on the verge of erupting and attacking her brother, one parent can never be alone with both children. The tensions that are apparent between Susan and Michael from the beginning of the book understandably worsen as medications for Jani repeatedly prove to be less than effective. When Susan calls Michael as he’s walking the dog with Bodhi to tell him she’s admitted Jani to a psychiatric hospital, Michael becomes furious at Susan for overreacting. He feels that if he were just with Jani all the time, he could help her control her violent moods.

Indeed, the author often lets us know that he’s the only one who can deal with Jani on her level, attempting to meet her where she is mentally rather than trying to get her to follow the normal rules of society, as her mother tries to do. When Jani decides she’s done with whatever they’re doing she walks away without a care, ignoring the adults’ attempts to get her to follow their rules. At these times, her father jumps up to accompany her or distract her, while her mother attempts to get her to act in accordance with the generally accepted rules of the situation. This difference in their parenting styles becomes immediately apparent, and is an obvious deep source of friction that never seems to be resolved during the time period covered by the book.

Jani’s story is fascinating and troubling, but the story of her parents is nearly as troubling, with Michael’s frustrations apparent in the way he speaks of other adults in his world, especially his wife. Readers may be surprised that the couple is still together by the end of the book, considering the level of contempt Michael seems to feel for Susan. When Michael attempts suicide by swallowing an entire bottle of Lexapro, we understand the amount of energy he’s been expending thus far, and how much of himself he’s given up to keep his daughter from falling apart. One wonders whether, if the author could have accepted more help and weren’t as invested in the idea that he’s the only one who can console Jani, he might not have been driven to the brink of suicide.

By the same token, both parents’ devotion and persistence is what ultimately finds some measure of relief for Jani — though relief, according to the author’s blog (www.janisjourney.org), is temporary. “It’s not even good days and bad days,” he writes. “It is good moments and bad moments.”

The book drives home the murky reality that people with mental illness and their loved ones live in. For a diagnosis as serious as schizophrenia, and even for many less serious diagnoses, treatment is complicated and usually less than a hundred percent effective. The family’s story emphasizes how vital it is that loved ones advocate for their mentally ill family members, especially children. With Jani’s first institutionalization, her parents perceives the staff as uncaring and rude, and will not let her be re-admitted, opting instead to admit her in to UCLA. This proves to be a wise choice, but one that might not have been made had Michael and Susan not been aware and willing to demand better treatment for their daughter. Often, patients and their caregivers believe that healthcare providers know what’s best for them and choose to give up their power to the medical establishment. But this is not always the best choice.

Reading about Jani and her family’s struggles makes one feel empathy for the families of children with mental illness, but not hopeless. The book ends on a positive note, as Jani finds some measure of solace in a therapeutic horse-riding program and the family ultimately copes with her ambivalence towards her brother by renting two apartments in the same complex, so they can still be a family but both children can grow up without violence. Coping with a child’s mental illness takes ingenuity and courage, Schofield shows us. But it can be done.

January First: A Child’s Descent into Madness and Her Father’s Struggle to Save Her
Crown, August, 2012
Hardcover, 304 pages
$25.00 

As a mental health professional who works with individuals with various diagnoses, whenever I read a novel that portrays characters with mental illness there are certain things that I look for. First, I want to see if the author provides a realistic depiction of the symptoms that are presented. Also, I am interested in seeing what type of issues the author raises in regard to the diagnosis. On these accounts, Ms. Morgan does an excellent job. The way in which Caitlin’s parents are described never seems to be far off the mark from the reality of schizophrenia. The characters are not made to seem completely out of control like some schizophrenic stereotypes. Yet the author also does not sugarcoat the difficulties that the disorder can present in one’s life.

Caitlin, the story’s central character, is used to illustrate a multitude of complications that can arise when a person suffers from schizophrenia. We see the starts and stops with regard to treatment that are an unfortunate reality for schizophrenia patients and their families. There are the frequent hospital visits and the constant trying to make sense of her parents’ often-bizarre behavior. We see the strain that such an illness can put on a family, as Caitlin leaves to live with her uncle.

While Playing the Genetic Lottery does portray schizophrenia realistically, I did not find the overall story to be that enticing. Caitlin is a strong character, and her success through such a turbulent upbringing does provide the reader a sense of hope. However, many of the other characters that she deals with throughout the story seem somewhat stilted. There are only brief glimpses into some of the more interesting parts of their personalities.

Much of the plot revolves around a love story between Caitlin and Jason, who she meets while going to visit her brother at a behavioral health unit. I found it difficult to become involved in the romantic aspects of the story; however, this relationship was used with good effect to examine the issues that can arise for children of parents with schizophrenia. First, Caitlin questions whether she will develop a mental illness like her parents and brother have.  How would it affect her relationship with Jason if this happens? Also, if they did decide to commit to a long-term relationship, would the risk of having children with a mental illness be too great?

I will not spoil the novel’s outcome, but I will say that the author provides a well-educated examination of the questions at hand. Those uninitiated with mental illness and its treatment may actually learn a great deal through the story of Caitlin and her family. Whether Ms. Morgan writes from research or personal experience, I do not know. Yet she seems to cover a variety of topics, from the epidemiology of schizophrenia to the different modalities of therapy that are currently used. The problem with this, however, is that the dialogue between characters sometimes feels like a recitation of a psychology textbook rather than an actual conversation. I understand that the author wanted to make sure she provided accurate information; however, there were several points where this took me out of the story.

For someone who is unfamiliar with schizophrenia or mental illness in general, I can see this being a good introduction. The author even provides discussion questions at the end of the book that make it a good choice perhaps for an introduction to psychology class or a book club. However, for someone who has extensive history dealing with schizophrenia either through personal or professional experience, I would not recommend this book. The story, on its own, did not have enough emotional impact to keep me interested in the characters.

At the same time, I commend Ms. Morgan for writing a novel that examines such complicated issues. As this is her first novel, I look forward to seeing how she may expand on similar themes in future works. I believe it is important for us to use literature as a means of educating others about mental illness and fighting against the stigma in our society. While Playing the Genetic Lottery may not be a perfect novel, it does offer a glimpse into a part of the world that is all too often ignored.

Playing the Genetic Lottery
By Terri Morgan
Silverdarts Press: March 15, 2012
Paperback, 388 pages
$14.99

Normally, specific parts of the brain are tuned into each another at certain frequencies, say the researchers. This rhythmic activity produces brain waves and allows information to be processed in order for us to react.

The team used the analogy of an orchestra to explain how this works. They say that brain activity can be compared to the performance of an orchestra in which string, brass, woodwind and percussion sections are joined together in rhythms dictated by the conductor. In a similar way, specific structures in the brain tune in to one another at certain frequencies. Their rhythmic activity creates brain waves, and the tuning of these brain waves normally allows information to be processed that guides our behavior. But cannabis causes disturbances in systems involved in concentration and memory, the team found.

The primary psychoactive ingredient of cannabis, known as THC, activates cannabinoid receptors, which are found in many brain areas. In the research, the team measured the electrical activity from hundreds of neurons in rats when given a drug similar to THC which also stimulates cannabinoid receptors.

This showed that the effects on individual brain regions were subtle, but brain waves across the hippocampus and prefrontal cortex were completely disrupted. These two brain areas are vital for memory and decision-making, so the rats were no longer able to accurately navigate a maze. Both areas are also involved in schizophrenia.

Findings are published in the Journal of Neuroscience. The authors write that these results show a possible mechanism behind the cognitive impairment caused by cannabis that was described by Dr Frederick T. Melges and his team back in 1970. Dr. Melges called the effect “temporal disintegration,” and described it as “difficulty in retaining, coordinating and serially indexing those memories, perceptions and expectations that are relevant to the goal one is pursuing.”

More recent studies suggest that THC given intravenously to healthy volunteers can induce several psychotic symptoms of schizophrenia, so the authors believe that THC studies be used to model broader aspects of the disease, not just cognitive dysfunction.

Dr. Jones commented, “Marijuana abuse is common among sufferers of schizophrenia and recent studies have shown that the psychoactive ingredient of marijuana can induce some symptoms of schizophrenia in healthy volunteers. These findings are therefore important for our understanding of psychiatric diseases, which may arise as a consequence of ‘disorchestrated brains’ and could be treated by re-tuning brain activity.”

Co-author Michal Kucewicz added, “These results are an important step forward in our understanding of how rhythmic activity in the brain underlies thought processes in health and disease.”

The researchers conclude, “These tools will continue to shed light on the neural mechanisms of working memory and decision making in health and disease.”

A 2012 review of current knowledge shows that the endocannabinoid system in the brain has a major role in schizophrenia. “Data reported so far clearly indicate the presence of a dysregulation in the endocannabinoid system in animal models of psychosis as well as in schizophrenic patients,” the review says.

Its authors, led by Professor Daniela Parolaro of the University of Insubria, Italy, add that animal models suggest that adolescence is “a highly vulnerable age for the consequences of cannabis exposure on different domains (such as cognition and social behavior) that are altered in psychotic disorders.”

They suggest that drugs which target the cannabinoid system are “a new therapeutic possibility for psychotic disorders.” However, they warn that drug studies so far have not had straightforward results, with different types of drug showing different effects.

But despite all these limitations, cannabidiol, a compound found in cannabis that activates cannabinoid receptors, has shown fairly consistent antipsychotic properties in animal tests. Recent studies indicate that cannabidiol may be as effective as antipsychotics in treating schizophrenia.

The benefit of cannabidiol appears similar to that gained from atypical antipsychotic drugs, and so far it is considered a safe and well-tolerated compound. Future studies will need to compare its antipsychotic effects against standard drugs for schizophrenic patients.

References

Kucewicz, M. T. et al. Dysfunctional Prefrontal Cortical Network Activity and Interactions following Cannabinoid Receptor Activation. Journal of Neuroscience, published online October 25, 2011.

Zamberletti, E., Rubino, T. and Parolaro, D. The endocannabinoid system and schizophrenia: integration of evidence. Current Pharmaceutical Design, published online June 7, 2012.

That’s because postpartum psychosis (PPP) is a “psychiatric emergency,” said Margaret Spinelli, M.D., associate professor of psychiatry at Columbia University Medical Center. Think of it as a heart attack, Twomey said. “You might survive it without immediate aid, but why risk it?”

PPP is a temporary but serious illness characterized by delusional thinking. Twomey, a survivor of PPP, described it as “a different reality superimposed onto this reality.” For instance, it’s like watching a TV show and believing that it’s perfectly normal for the actors to be speaking to you, she said.

PPP has a rapid onset, usually starting in the first days or weeks after the baby’s birth, said Katherine Stone, an advocate for women who suffer pregnancy- or childbirth-related mental illnesses and founder and editor of the award-winning blog Postpartum Progress.

This illness requires immediate medical attention because there is a risk of suicide or infanticide, Stone said. In other words, “postpartum psychosis has the potential to lead a mother to take actions that she would never otherwise take that could harm herself or others,” she said.

Still, it’s common for people to dismiss this risk. We know that our loved ones are good people who’d never hurt their kids (as are we), Twomey said. However, this has nothing to do with a woman’s character or ability to be a good mom, Stone said. (It’s also not her fault!) Again, PPP is an illness — and one with unpredictable actions, Dr. Spinelli said.

Fortunately, PPP is fully treatable. Below, experts discuss the warning signs, risk factors and how families and friends can help.

Warning Signs of Postpartum Psychosis

“Since women with postpartum psychosis often experience a lack of insight, it’s usually the people around her who will be the ones to recognize something is wrong,” Stone said. In fact, Twomey called family members “the first line of defense.”

That’s why it’s key for families to step in and call the doctor immediately or go to the emergency room. You might be thinking, “But what if I’m wrong?” What if she isn’t struggling with PPP? As Stone said, “I’d rather have it turn out that you were wrong, than have a person ignore the symptoms and have that lead to a tragedy.”

These are the most common signs of PPP.

• Hallucinations: seeing or hearing things that aren’t there
• Delusions: bizarre beliefs that only make sense to the individual. Delusions often have religious undertones. For instance, she might believe “…that her child is a savior or has been sent to save the world, or is possessed or going to come to some harm from nefarious forces if she doesn’t take action,” Stone said.
• Confusion
• Paranoia
• Mania (high energy)
• Depressed mood or irritability
• Inability to sleep

(In some cases, a woman might be rational enough to seek help. Twomey wanted women to know that “no matter what you experience, [PPP] is recognizable, diagnosable and treatable.”)

“PPP can wax and wane,” Twomey said. So even if a postpartum woman seems reasonable at times, don’t let that dissuade you from getting help. It’s a myth that women with PPP are either completely delusional or totally normal. As Twomey said, “a woman can seem perfectly normal one moment and psychotic the next.”²

Risk Factors of Postpartum Psychosis

Women with bipolar disorder or schizophrenia (or who have a family history of these illnesses) are most at risk, Stone said. Some women might not even know that they have either disorder. For instance, some moms might’ve never received a diagnosis of bipolar disorder, Stone said. In fact, according to Spinelli, PPP “usually signals a first episode of bipolar disorder.”

If you fit these risk factors, consider writing a letter to yourself explaining that you might have PPP, listing some of the symptoms and including the individuals you trust, Twomey said. If you do experience PPP, you’ll have given yourself important and sound information, she said.

Not having these risk factors doesn’t put you in the clear. Twomey emphasized that every expectant mom is potentially vulnerable.

How Family & Friends Can Help

• “Be informed before it happens,” Twomey said. This way you “can be an advocate, be aware of the warning signs, appreciate the dangers and treat her with compassion, love and understanding,” she said.
• Don’t ignore the signs. “I think family members sometimes want to explain away the symptoms of postpartum psychosis rather than admit a new mom has it and likely needs to be hospitalized,” Stone said. You might worry that she’ll be “locked up forever,” she said. But getting your loved one help is the best thing you can do for them — and their baby. Women with PPP are often hospitalized so they can get proper treatment. (This usually consists of close monitoring and taking antipsychotic medication.) But after they’re stabilized, women can return home. “Please don’t ignore the symptoms because of fear or lack of understanding!” Stone said.
• Don’t confuse your loved one with their illness. Twomey often hears husbands say that this isn’t the woman they married. Women with PPP can act completely out of character, even becoming verbally abusive, Twomey said. This might lead some families to alienate their loved one or view her as the enemy, she said. But it’s vital to understand that this isn’t your loved one, she said. PPP is causing this kind of odd behavior, Stone said. “…It would be unfair to blame her or stigmatize her for that behavior,” she said.
• Support your loved one. Give her your full support both while she’s in the hospital and after she comes home, Stone said. This includes helping her care for the baby and making sure she gets enough sleep, Spinelli said. Also, make sure your loved one is getting the best treatment, and go with her to doctor’s appointments, Twomey added. Stone recommended reading the valuable guides from the UK organization Action Postpartum Psychosis.

PPP is a serious illness that requires urgent treatment. If your loved one is experiencing any of the warning signs, don’t hesitate to get her help — and always be on her side, Twomey said.

Further Reading

Check out Postpartum Support International, a non-profit organization that’s filled with valuable information and resources. Also, Twomey wrote a helpful post on the three important bricks of PPP.

1. Statistic from Postpartum Support International
2. Check out Stone’s site, Postpartum Progress, for more on symptoms “in plain mama English.”

When Truth Lies, a novel, follows this young man’s quest for all things young people can’t wait to experience: newfound independence, dates, and sex. All turn problematic for Kevin when he exhibits signs of schizophrenia.

Author Terry Garahan writes this story based upon his experience as a social worker who worked with mentally ill patients. Now he’s a professor at Ithaca College. He created the character of Kevin to give readers insights into this complex disease: what patients really experience, and the challenges that they and their families face.

The story begins when some frat boys talk Kevin into “borrowing” a keg for one of their parties. Kevin brings the beer cooler over with every intention of returning it to the school where he works. However, he’s caught and charged with grand larceny. The judge gives Kevin a choice: jail or the Army (Vietnam is in full swing). He opts for the Army, believing he’s on a mission to end the war. However, when Kevin enters boot camp, fear paralyzes him.

He had been moved from stockade to stockade in the military system, put on buses, and shackled to the front seat. He was passed like a baton, on and on, to the next place north. Death hunted him at every step, each cell and locked room a place of filth and squalor. Each guard, a fallen angel, each meal filled with dead flesh scorched by a flame.

Finally he ends up in a mental hospital. However, he escapes and joins a group of hippies. They load up the “Cool Bus” and head to Woodstock for a three-day concert, where they drop acid. Kevin becomes even more strung out, thinking he has lost pieces of himself. “I lost me,” he cries. “I’m not here. I’m not sure I ever was. I’m not sure I ever will be.” A medic is found in the crowd who just happens to have a supply of antipsychotic medication. Kevin is temporarily calmed, and the scene closes with Jimi Hendrix playing the Star-Spangled Banner.

Frankly, I’m not sure why Garahan decided to write a fictional account when he had real-life experiences with schizophrenic patients. Was he afraid of exposing past clients (couldn’t he disguise their identities the way Oliver Sacks does)? Or did fiction just seem easier? He could use composites to turn several characters into one in this made-up account. It’s a little confusing as he’s putting this forward as an honest book about schizophrenia, and yet the story seems overly dramatic, set within clichéd sixties moments and dated hospital scenes and treatments.

For these reasons, I don’t find this story very convincing. When Kevin ends up at yet another mental hospital, the psychiatrist sends him to the canteen every day to fetch his lunch. Of course, Kevin has been hiding his medication inside his cheek and mixing it into the doctor’s food. Lo and behold, the doctor develops a “unexplained” lethargy. Not only does this seems highly unrealistic, but it’s silly.

There are a number of really good memoirs about schizophrenia. Among them are Angelhead by Greg Bottoms and Memory Palace by Mira Bartok. I happen to love a small, self-published book by Brooke Katz, I Think I Scared Her, who gives a detailed account of her own childhood schizophrenic onset, hearing voices. She didn’t tell her parents for years because she didn’t want to upset them. These stories, to me, give clearer and more honest pictures of this illness. I think Garahan missed an opportunity to share his unique insights and observations to really enlighten and inform readers

To his credit, however, he does deal with tough subjects that many other writers would have skirted, such as sex and its complications for the mentally ill. In addition, he creates scenes of life on the streets, which patients, family, and friends may find only too familiar.

As a work of fiction, When Truth Lies transports readers into a world that may be largely unfamiliar. Because Garahan avoids all medical jargon, this tale engages readers in Kevin’s life and keeps us wondering, will he turn out all right?

When Truth Lies: A Journey With Schizophrenia
By Terry Garahan
Louis Publishing Group: 2011
Paperback, 249 pages
$11.99

Nonadherence has critical consequences, including worsening of symptoms and hospitalization. “Rates of relapse for those [patients] taking vs. not taking medications are about 44 percent and 20 percent respectively,” Velligan said.

What Predicts Nonadherence

When it comes to adhering to treatment, people with schizophrenia aren’t all that different from individuals with other chronic conditions, including diabetes and high blood pressure, Velligan said. Not taking medication seems to be a problem for conditions that require long-term treatment.

The major difference, however, is that individuals with schizophrenia can have poor insight into their illness, which makes them more likely to skip treatment. In fact, poor insight may be the biggest predictor of nonadherence. “Individuals don’t think they are ill, or don’t understand that when acute symptoms subside medication is still necessary,” Velligan said.

The very nature of schizophrenia can complicate adherence. For instance, consistency is key for following treatment. But people with schizophrenia have a hard time sticking to routines. “There is no regular pattern of behavior that can make adherence easy,” Velligan said.

They also struggle with cognitive impairments. Patients may intend to take their medication but simply forget. “In these cases sometimes as many as half the doses are missed, making the medication less effective,” Velligan said.

But the negative consequences of stopping medication aren’t obvious to patients. If a patient misses a pill, there are no immediate repercussions, she said. “Symptoms may not get worse for days, weeks or even months [which makes it] very difficult for the person to make the connection between poor adherence and rehospitalization,” she said.

Some patients skip doses or stop taking medication because of side effects. For instance, weight gain and movement side effects are especially bothersome to patients, Velligan said.

Also, patients with substance abuse problems are less likely to adhere to treatment, she said.

The service system itself can make adherence difficult. “Sometimes patients are given appointments with an outpatient doctor after hospital discharge that will occur after their prescription from the hospital will run out,” Velligan said.

Strategies That Improve Treatment Adherence

Cognitive-behavioral therapy (CBT) is effective in enhancing treatment adherence. CBT doesn’t challenge a patient’s resistance to medication; instead it explores why the person doesn’t want to take medication and helps them reevaluate their negative beliefs toward medication.

Also, CBT helps patients identify their recovery goals, and links them to treatment adherence, according to Velligan. For instance, many people with schizophrenia take their medication because of relationships, whether it’s a relationship with their spouse or family member. For these individuals, one goal may address relationship quality.

CBT incorporates motivational interviewing techniques and helps patients see a clear link between poor adherence and relapse. (This full-text article provides more information on CBT for schizophrenia.)

Visual reminders, such as signs, checklists and pill containers, facilitate adherence. Velligan and her colleagues have even used electronic pill containers to prompt patients and provide a slew of important information: “to tell patients when to take medication, remind the person of the dose and reason for medication, tell the person if they are taking the wrong medication or taking it at the wrong time, and download adherence data to a secure server so that a caregiver or caseworker can keep track of adherence are becoming more widely available.”

Another option is injectable medication. Several studies have shown that long-term injectable antipsychotics increase adherence and decrease relapse risk. (Learn more here and here.) “If a person does not show up for an injection, the treatment team knows there is an issue and can intervene in a timely way,” Velligan said. Other research has suggested that it’s also important to discuss the benefits of adherence with patients receiving injectable medication.

How Loved Ones Can Help with Adherence

When someone with schizophrenia stops taking medication or skips other treatments, it can be frustrating and difficult for loved ones. You may naturally feel powerless. However, you have more influence than you realize, Velligan said. Here are several ways you can help.

• Make your support contingent on adherence. It’s common for loved ones to support the person financially and provide them with a place to live, Velligan said.
• Help them find effective treatment. Get your loved one involved in therapy and working with an experienced psychiatrist, Velligan said.
• Set up reminders for medication. Use pill containers, checklists and signs to make remembering to take medication much easier, she said.
• Try injectable medication. “With an injection, the person does not have to face the decision every day about taking medication, and remind themselves every day that they have an illness,” Velligan said.

Further Reading

Velligan, D.I., Weiden, P.J., Sajatovic, M., Scott, J., Carpenter D., Ross, R., Docherty, J.P. (2009). The expert consensus guideline series: Adherence problems in patients with serious and persistent mental illness. The Journal of Clinical Psychiatry, 70, 1-46.

Throughout the book, Kaye fluctuates between the past and present to tell her story. She begins her narrative with some insight into the possible early warning signs of Ben’s illness:

It all started, or so I thought, with marijuana. Or did the trouble really begin when Ben dropped out of high school, with plans to travel cross-country, search for his father, and knock on doors to ask for work if he needed money?

Maybe I should have recognized schizophrenia when Ben was fifteen, the night he broke down in sobs after a huge fight with me and said, “What’s wrong with me, Mom? Please, please, find me someone to talk to. I don’t know what’s happening. I used to be so happy.”

The consistent theme throughout Kaye’s book is that “there must be a reasonable explanation” for her son’s maladaptive behavior. She carries the reader along and we, in turn, can feel her pain to find the answers to her son’s issues and problems. She begins some of her chapters with excerpts from Ben’s writings, which provide the reader some insight into his perspective on his struggles:

I am most of my voices

Many different selves

I don’t need to give in to what I fear

Just give in to the fact that I’m afraid.  

~ Ben, c. 2001

As a helpful resource, Kaye includes ‘chapter guideposts’ which clarify some of the various issues and terms related to loving someone with schizophrenia. She also offers tips and resources to assist in the management of the disorder. One guidepost she provides in chapter 19 is entitled “some reasons for medication noncompliance” For example, the individual may have a “lack of insight into the illness (biological — the brain is impaired),” “they don’t like the side effects (weight gain, sexual performances, sedated feeling)”  and “fear of becoming medication dependent.” Kaye also offers suggestions for what loved ones can do about this problem, including watching for the return of symptomatic behavior and increasing supervision of medication.

Ben was diagnosed with ADHD in high school. Kaye notes that during the following years, “he was to pass through the hands of four psychiatrists, several therapists, and several diagnoses and prescriptions.” He was also subject to five psychiatric hospitalizations in 2003 alone, then two more at a later date. Those eventually led to his current recovery. Kaye described the weight of Ben’s illness on her life: the “family feels isolated, stigmatized, and often very alone.”

It is remarkable that Kaye remained optimistic about her son’s recovery even as she trudged through all the years of hardship and anguish. Her dedication to her son is reflected in a statement made in her introduction: “Ben has never lost us; the love of his family has been part of his recovery.“ Currently, Ben is in recovery as he adheres to a medication regimen and lives in a group home. Kaye is hopeful that her son “can one day attend college, hold a job and eventually live on his own.”

It is unfortunate that Kaye and her family had to go through so much before Ben received the correct diagnosis of schizophrenia. From this psychotherapist’s perspective, it seemed obvious from early in the book that Ben was struggling with more than just typical ADHD-related issues. Therefore, I found myself feeling frustrated by the various mental health professionals that Kaye consulted and why they could not see what was the core diagnosis underlying his maladaptive and tormented behavior. On the other hand, the book also reminds me that schizophrenia does not make up a person’s complete identity. These individuals are more than just their voices and symptoms; they are human beings that require love, compassion, dignity and respect. 

Overall, Ben Behind His Voices is a book I would recommend for those individuals diagnosed with schizophrenia as well as those who love them. Kaye shares her own personal pain and frustration in understanding the illness as well as provides suggestions to readers on how to best cope with it. It also offers hope to those families who may be on the verge of giving up on their loved one and further reminds mental health professionals to remain compassionate in their treatment of persons afflicted with this tragic disorder.

Ben Behind His Voices: One Family’s Journey from the Chaos of Schizophrenia to Hope
By Randye Kaye
Rowan & Littlefield Publishers: August 16, 2011
Hardcover, 320 pages
$26.95

Dr. Uy Hoang of Oxford University, UK, and colleagues looked at hospital and death records from 1999 to 2006. By 2006, the mortality rate for patients with schizophrenia or bipolar disorder was about double the average for the population. What’s more, this mortality gap has widened over time, they report on the website of the British Medical Journal.

For schizophrenics, the risk was raised by 60 percent in 1999, but more than twofold by 2006. For people with bipolar disorder, it was 30 percent higher in 1999 and ninety percent higher by 2006.

About three-quarters of all deaths were classed as natural causes. Circulatory disease and respiratory disease were the main components of this increase.

The authors say, “There is a need for better understanding of the reasons for the persistent and increasing gap in mortality between discharged psychiatric patients and the general population, and for continued action to target risk factors for both natural and unnatural causes of death.” They conclude: “Optimizing the general health of people with schizophrenia warrants urgent attention.”

Commenting on the findings, Dr. Brian Miller of Georgia Health Sciences University points out that the well-documented link between schizophrenia and bipolar disorder and increased early death from natural causes “is an important public health problem.”

He calls for better integration of mental and physical health services after hospital discharge, “because integrated primary medical care is associated with improved outcomes.”

Over the past ten years, the raised rate of coronary heart disease, stroke, and cancer among people with severe mental illness has been the focus of much research. This raised rate is not clearly linked to medication, smoking, or social deprivation.

The reasons are “are little understood and likely to be complex,” say Dr. Hoang and colleagues, but “are likely to be influenced by adverse lifestyle and social factors associated with the presence of mental illness such as alcohol and illicit drug use, and exposure to poor housing.”

“There is an urgent need for more research to understand the contribution of the six leading global risk factors for mortality identified by WHO, namely, hypertension, smoking, raised glucose concentration, physical inactivity, overweight and obesity, and high cholesterol concentration, to excess mortality in people with severe mental illness, including schizophrenia and bipolar disorder,” they warn.

Late diagnosis and inadequate treatment of physical illnesses may also be contributing to the problem for people with schizophrenia, add the experts.

The finding that mortality for people with schizophrenia has widened recently is reflected in the findings of a systematic review by Dr. Sukanta Saha and colleagues based at the Queensland Center for Mental Health Research in Australia in 2007.

The team reviewed 37 studies based in 25 countries and found that most of the major causes of death were elevated in people with schizophrenia, and this has “worsened in recent decades.” It seems to affect men and women equally.

Risks increased during the three decades examined in the study. This finding is consistent with earlier studies, suggesting that “people with schizophrenia have not fully benefited from the improvements in health outcomes available to the general population,” say the researchers.

They point out that several of the newer, second-generation antipsychotic drugs can trigger metabolic syndrome, which is associated with a two- to threefold increase in death from cardiovascular disease and a twofold increase in deaths from all causes combined.

“Adverse health outcomes associated with weight gain and/or metabolic syndrome (e.g. heart attack or cancer) may take decades to fully emerge,” they warn. “In light of the rising risks already identified by this review, the prospect of further increases in mortality for schizophrenia is alarming.”

They conclude, “It is sobering to reflect on this paradox of schizophrenia treatment. As we become better at detecting and treating the core symptoms of schizophrenia, patients have worsening mortality rates.

“Given the potential for an even greater disease burden as a result of the introduction of second-generation antipsychotic medications, research aimed at optimizing the physical health of people with schizophrenia needs to be undertaken with a sense of urgency.”

References

Hoang, U., Stewart, R. and Goldacre, M. J. Mortality after hospital discharge for people with schizophrenia or bipolar disorder: retrospective study of linked English hospital episode statistics, 1999-2006. The British Medical Journal, 2011;343:d542.

www.bmj.com/cgi/doi/10.1136/bmj.d5422

Miller, B. J. Editorial: Hospital admission for schizophrenia and bipolar disorder. The British Medical Journal, 2011;343:d5652.

www.bmj.com/cgi/doi/10.1136/bmj.d5652

Saha, S., Chant, D. and McGrath, J. A systematic review of mortality in schizophrenia: is the differential mortality gap worsening over time? Archives of General Psychiatry October 2007, Vol. 64, pp. 1123-31.

David Stringer has a well-written account  of how a family member can feel about their mentally ill, substance-abusing sibling and son.  In his first-person memoir the reader can’t help but empathize with David and his family but also feel strong emotions for David’s brother John who is riddled with problems. We can all see that John has made some very poor choices that affect everyone around him but David lets us know that he is a genuinely good-hearted person.  John’s affliction with schizophrenia and his substance abuse are similar, as far as I can tell, to the “chicken and egg” question.  Which came first, his schizophreni — leaving him wide open for self-medication — or drugs as a “party favor” and then his schizophrenia giving him an excuse?

On page 81 the author puts it well when he speaks of “disengagement-through the use of drugs…drug use was common, and drug abuse is sometimes a mask for schizophrenia.”  That makes me wonder how often this happens, and for how long, in other families.  It’s made clear to the reader that John had always been a gregarious, fun-loving guy, perhaps to the point of being a “party guy.”  I have to wonder whether his personality led to his drug abuse or if it was the mental illness that led him to have this type of personality.  Either way this was a tough road for John but then it also brought his family into this “hell” with him. 

On pg. 112 the author succinctly states how their mother, who feared losing John forever, would send him money even though she knew where it would probably go. But her fear overcame common sense and she felt she did what she had to in order to help him stay alive.

I found this book to be what I would consider an account of how James Frey’s family must have felt like in “A Million Little Pieces.” It made me realize that while this man was obviously hurting that there was a whole family going through this with him.  I believe this book will bring a lot of insight to other families who are going through this same sort of hell and feel alone and as if they’ve done something wrong.  The book doesn’t pull any punches and goes straight to the situation as it is.  Where John’s friend, Reingold, says “life is fragile, puny and temporary” on page 69 I believe he sums up the reasons why we should “know” the ones we love while we still can.

The concept of not “knowing” a loved one until after something terrible happens is one that I believe goes on too often. Really getting to know someone, especially someone with obvious problems, is very difficult and we all have our own problems to deal with but as the author pointed out, it can be well worth the effort it takes!

I found it interesting that the author states that “John reminded me of Dean in Kerouac’s “On the Road” because that’s one of my favorite books and I had already been making the same comparison.  There are definite parallels, one of which is that John wanted to see and do all that he could in the time given to him.  Though this can be a good trait, it can also be a curse, especially for a man already battling his own demons.  I’ve dealt with this feeling of unrest and the wonder of what I’m missing “out there” to the point of having lived in four different states and at least seven different cities in the past twenty years, never settling down and meeting several “John Stringers” during this time.  Though I don’t think that these people had the same problems as John, they were clearly fighting their own demons, both internally and externally, and that also brings one back to the “knowing” people.

I think this book would be very helpful to anyone dealing with similar circumstances, whether in their own family or the family of friends and loved ones.  People in this line of work, helping the mentally ill or the addicted, would get a great deal of insight as to the impact the people they are trying to help have on their families.

The author also does a good job of explaining and trying to remove the stigma put on homeless people who are probably just not equipped or don’t have the family who’s equipped to help them realize and fight the problems that have forced them into this lifestyle.  Too often these people are treated as sub-human, animals or invisible rather than normal human beings with afflictions we are lucky enough to have escaped.

I found the book to be entertaining, easy to read and well-written.  If the author’s plan was to help the general public understand at least a little of the life of the “John Stringers” in our lives he did a great job, But as far as I’m concerned he also wrote something that would help the caretakers of such afflicted people to really understand the impact of these poor souls on their families and loved ones. This, I believe, is a great learning tool.  I’m left thinking of what the author states on page 298, “John has helped me see more people as my brothers.”  That can’t be a bad thing!

We children of schizophrenics are the great secret-keepers, the ones who don’t want you to think anything is wrong (p. 5).

Author Mira Bartok has encapsulated in this statement her life as the daughter of mentally ill musical prodigy Norma Herr.  The Memory Palace describes Ms. Bartok’s journey from scared child to haunted college student to free adult and finally back again to scared child, sitting at her mother’s bedside as she succumbs to the effects of a lifetime of poor (mostly homeless) living.  It is a moving, evocative story, relating Norma’s schizophrenic mind to Mira’s later experience with traumatic brain injury, and how this helped them to reconcile after 30 years of estrangement.  A difficult read at times due to the subject matter, The Memory Palace is nonetheless a valuable addition to the narrative of mental illness in our society and in our families.

The book begins at the end, so to speak, as Ms. Bartok’s mother is fading away in a Cleveland hospital.  She happens to find some keys among her possessions, one of which is to a storage unit containing vast stacks of old photos, diaries, and mementos that serve to open the floodgates of the author’s memory.  She then decides to create a “memory palace” to sort and categorize these intense experiences based on a method created by Matteo Ricci, a Jesuit priest with incredible mnemonic abilities.  Each subsequent chapter is opened with a painting that Ms. Bartok has created to symbolize a specific room in her palace, accompanied by selections from her mother’s letters and diaries that allow the reader to experience her descent firsthand.

From here, we return to the author’s childhood years.  She and her sister suffered at the hands of her steadily declining mother after her father essentially disappeared.  The family lived with her grandparents, who weren’t much better in terms of providing any sort of parental support.  There are many vivid and graphic examples of the type of abuse Ms. Bartok endured, among them the following excerpt of a bedtime conversation with her mother:

“‘I have to tell you something important,’ she says.

‘What?’

‘Don’t drink milk before going to bed.’

‘Why not?’

‘Because rats like milk.’

‘What?’

‘A rat will eat your face off if it smells milk. And Myra?’

‘What?’

‘You girls are my most precious possessions.’” (p. 54)

In order to cope with the instability and tension, Ms. Bartok escaped into the worlds of writing and art, activities that later became her career.  Her mother, in the meantime, became increasingly uncontrollable and even violent.  After Ms. Bartok and her sister left for college, Ms. Herr would call them incessantly, show up unannounced, and threaten them and their friends.  Once she attacked them for suggesting that she needed treatment, they jointly decided to break off all contact with her and change their names.  Myra Herr is now Mira Bartok.

Over the next seventeen years, during which time the only contact mother and daughter had was through a P.O. box, the author achieved a level of professional and personal success, albeit not without some difficulty.  She spent time travelling abroad in Europe, the Middle East, and Scandinavia, exhibiting at art shows and publishing articles and books under her new name.  In what she eventually recognizes as a repetition of living with her mother, Ms. Bartok marries William, who we gradually learn is seriously mentally ill as well.  It takes her some time to realize she can, and indeed needs, to break free, but she does and goes on to meet and marry Doug.  They are still married, and he allows her to have a healthy and stable life.

Back in America, Ms. Bartok was in a horrible car accident at age 40, which resulted in a traumatic brain injury.  She lost much of her ability and memory, and while she was able to improve, everyday life remains difficult.  Through the process of experiencing the world shifting in and out of focus, needing to expend a lot of energy to simply make it through the day, along with a need to reconnect to her now-unreliable memories, the author makes the decision to reach out to her mother:

I’ve already lost her once, and have, at least for a time, lost myself.  I don’t want to lose her again. But I decide I can only see her if she is in some kind of supervised setting.  Otherwise, she’ll try to come home with me.  I contact the social worker and we begin the long process of finding my mother a permanent home.  Which, in the end, turns out to be a quiet dark room in a hospice ward. (p. 267)

She discovers that her mother is terminally ill and flies to see her.  Eventually, her sister joins them, and they begin the process of understanding and ultimately reconciliation.

The first reaction inspired by The Memory Palace is to the effects of the deinstitutionalization of the mentally ill, instigated by President Kennedy.  In 1974, the plan was to “…replace our backward state hospital system with newer and better narcoleptic drugs and free comprehensive community care (p. 107).”  The only real effect on Ms. Bartok, however, was that each time she and her sister were forced to commit their mother to the hospital, she was released after a shorter and shorter stay. 

“The miracle drugs… don’t help at all.  As for the comprehensive community care, we’re still waiting for it to arrive,” writes the author.  Her family received no social assistance, and even during the violent episodes when police were called, they just sent Ms. Herr to the emergency room, had her drugged up, and released her to start the cycle over again.  Ms. Bartok writes compellingly on why this should not have been allowed to happen—and is clearly very angry at lack of effort from society and public policy to successfully treat schizophrenics.

It would have been nice to see this level of detail when reading about the author’s brain injury and the results thereof.  She does provide a medical explanation, but this reader wanted to learn more about its specific effects, which are detailed in the author’s Q and A at the back of the book (but not within the text, other than a broad overview).  It would have helped tie Ms. Bartok’s mental decline with that of her mother’s, although even as is, this connection is movingly presented:

…although my condition has improved it’s clear that there are many problems that will never go away.  Weeks blur into months and years.  I’ve lost the order of things.  To the outside world, however, I show a different face that the one I show with Doug at home.  Children of the mentally ill learn early on how not to be a bother, especially if they grew up with neglect. (p. 266)

The original paintings that begin each chapter are beautiful and evocative, and the journal entries provide first-person view of the perspective of a schizophrenic mind.  There are some timeline jumps within chapters that can be jarring, but overall the book is organized and laid out well, in such a way as to evoke the most understanding of the main narrative.

It is difficult to say whether Ms. Bartok and her sister did enough with the situation and acted correctly in their relationship with their mother, but that’s not the point of the book.  The Memory Palace serves as a window of understanding into the complicated, judgmental, and often misunderstood world of mental illness, allowing those of us who have been lucky enough to not grow up under the thumb of schizophrenia the opportunity to expand our view.  Well-written and emotionally wrenching, this book is testament to the achievement of Ms. Bartok in overcoming her childhood, the tragedy of her mother, and finally her traumatic brain injury.

The Memory Palace: A Memoir
By Mira Bartok
Free Press: January 11, 2011
Hardcover, 320 pages
$16.50

In my current position as a rehabilitation counselor at a psychiatric center (as well as in my previous employment), I have worked with numerous people who have been diagnosed with schizophrenia. I have witnessed how devastating the illness can be not only for those who are diagnosed, but for their family members as well. Schizophrenia is a commonly misunderstood diagnosis. The term “schizophrenic” is used all too often in horror movies and news stories alike with the intent of scaring people. In reality, the scary thing is not people who suffer from this illness, but how many people never get the help they need because of the stigma associated with the diagnosis. With this book, Margaret Hawkins helps to shed some light on this reality.

In After Schizophrenia, Margaret Hawkins tells us the story of her sister, Barbara, who suffered from schizophrenia for years without receiving any type of treatment. Hawkins begins by giving the reader some background about her sister. According to the author, Barbara was a “stunning and self-aware young woman” through high school and college. She was very successful both socially and academically. There were subtle signs that something might be wrong while Barbara was in college; however, she was able to complete her degree. She met a man with whom she fell in love and soon after completing college, Barbara got married and moved with her husband to Iraq. For the most part, it seemed as if all was going well.

However, as Barbara’s letters home began to change, the author realized that something did not seem right. Her sister slowly began to sound like a different person, and it was not clear what was happening. Eventually, Barbara’s marriage fell apart and she moved back with her parents. Like so many people who have been diagnosed with schizophrenia, Barbara’s symptoms started to take shape in her early adulthood and escalated rather quickly. Unfortunately, as is also too often the case, neither Barbara nor her family really understood the types of treatment that were available at the time or how to go about getting help.

As the title suggests, After Schizophrenia’s second half focuses on how Barbara was able to get treatment and become “reawakened” after about 30 years of experiencing symptoms. For anyone who has either suffered from schizophrenia or knows someone who has, this part of the book may be especially moving. While reading about the author’s first coherent conversations with her sister after years of attempts, I was reminded of many of my own interactions with clients after they had begun to participate in their own treatment. I imagine anyone with similar experiences will also have similar feelings reading about Margaret Hawkins and her sister’s journey.

One thing that should be pointed out is that the title of this book might be misleading to some people. The author does not suggest within the book that her sister is somehow completely “cured” of schizophrenia by the book’s end. Rather, the title is meant to convey that through obtaining treatment, Barbara was able to overcome some of the more debilitating symptoms that came along with her diagnosis. In the final chapters, the reader sees the slow return of the “stunning,” “self-aware” woman we are introduced to in the beginning of the book.

As someone who works with people diagnosed with schizophrenia on a daily basis, I know that the saga of Barbara and her mental illness is one that is very similar to that of many others. I hope that through books such as this, Margaret Hawkins and other authors will help bring schizophrenia out of the shadows of misunderstanding. I am a supporter of any work that helps bring to light the fact that with the proper treatment, people with schizophrenia and other similar diagnoses can live fulfilling, meaningful lives. This book certainly manages that feat in addition to being an emotionally powerful family chronicle. If you or someone you know is currently suffering from schizophrenia, After Schizophrenia will definitely be an inspiration.

After Schizophrenia
By Margaret Hawkins
Conari Press: October 1, 2011
Paperback, 256 pages
$16.95