Hogarty Book review
Psychotherapy Research 14(4) 485–490, 2004 © 2004 Society for Psychotherapy Research BOOK REVIEWS Personal Therapy for Schizophrenia and Related Disorders: A Guide to Individualized Treatment. Gerard E. Hogarty. (2002). New York : Guilford Press. 338 pages, $39.00, ISBN: 1-57230782-X. Gerard Hogarty presents the latest developments in what he has termed “personal therapy” (PT) as applied to those individuals with a diagnosis of schizophrenia. Hogarty outlines three phases of treatment (basic, intermediate, and advanced) closely tied to phases and severity of the illness (e.g., prodromal, acute, stabilization, recovery, post-recovery). PT is a commendable attempt to arrive at a disorder-specific psychotherapy that is closely associated with a biopsychosocial model of the illnesses it proposes to treat: “PT is a treatment that acknowledges the biology of a brain disorder, the psychology of the person so affected, and the sociology of the environment that influences the course of the disorder, whether positively or negatively” (p. 2). Hogarty summarizes the research to date on PT, demonstrating that 26% of recipients were able to surpass premorbid levels of major role adjustment. PT was less effective with those who lived independently of the family and had to struggle with more pressing basic issues (e.g., stable housing arrangements). Hogarty emphasizes that the treatment components of the basic phase constitute a process rather than a rigid prescription. These components are based on the needs of the patient and must be blended with the patient’s own autoprotective strategies. The latter are health-promoting coping strategies that the patient uses to adapt to symptoms. Hogarty includes the following as treatment components of the basic phase: join with the patient to establish a treatment plan; provide a psychoeducational approach in regard to the nature of schizophrenia and its treatment; create a plan for the resumption of tasks and responsibilities; educate the patient in understanding the relationship between stress and the prodromes (i.e., early warning signs) of psychosis; help the patient to learn basic social skills, which include the subcomponents of role restructuring, conflict avoidance, and positive assertion. Hogarty defines the treatment components of the intermediate phase as follows: maintenance and enhancement of clinical stability (e.g., medication management); further personalization of psychoeducation; continuing recognition of responsibilities within the home environment; initial efforts to facilitate adaptation to disability; introduction of relaxation and social skills techniques that extend beyond the use of avoidance and prosocial statements; and, most importantly, the extension of internal coping techniques to the interface between highly individualized areas of distress and their management and containment. Treatment components of the advanced phase build on the previous phases and include psychoeducation, internal coping, progressive relaxation and imagery, criticism management and conflict resolution, and social and educational issues. PT, in this phase, attempts to assist the patient in seeing the effects of her or his subjective state and coping behaviors on the feeling states and behavior of others. Hogarty specifies various techniques to manage both valid and invalid criticism of varying degrees of intensity: “Few human experiences have been shown to have as serious an effect on the clinical stability and social adjustment of schizophrenia patients as critical and hostile comments” (p. 238). In the final chapter, Hogarty presents psychosocial treatment algorithms that are based on levels of functional disability and not so much on psychiatric history or symptomatology. Hogarty recommends various psychosocial interventions within the classifications of mild, moderate, or severe impairment according to the patient’s illness phase (i.e., acute, stabilized, post-recovery). In summary, Hogarty concludes: PT can be considered a core psychosocial treatment for achieving and maintaining stabilization, as well as an important aid to the enhancement of social and vocational functioning for patients who do not qualify for CET [cognitive-enhancement therapy]. ...Avoiding relapse and rehospitalization, let alone enhancing personal and social adjustment, should eventually convince even the skeptic that strategic psychosocial treatments, when combined with modern psychopharmacology and the necessary service delivery systems, will constitute the most cost-effective and humane approach to managing severe mental illness in the foreseeable future.” (pp. 275–276) I would like to summarize, on the basis of my psychology–psychoanalysis– neuroscience background (the neurobiology/neuroendocrinology of severe and chronic stress and the neuroscience research in the schizophrenias) and long-term psychotherapeutic treatment experience in various settings, including a state psychiatric hospital, what I see as the strengths and limitations of Hogarty’s model of etiopathogenesis and his treatment model of the schizophrenias. One significant strength, and corrective to more solely cognitively oriented models of treatment, is Hogarty’s emphasis on affective dysregulation and the attempt to help the patient in the early identification of prodromes as well as with associated internal and external coping strategies to achieve a sense of safety and affective equilibrium. However, I strongly disagree with Hogarty in his adherence to a linear and, at times, reductionistic model, which privileges the universality of a neurogenetic/ neurobiological cause (despite acknowledging the heterogeneity of the schizophrenic disorders, and in this case “one size fits all” appears acceptable to Hogarty) and understanding the affective dysregulation apart from such heavily researched factors known to result in emotional dysregulation as history of insecure and disorganized attachment patterns (Fonagy, Gergely, Jurist, & Target, 2002); various kinds of psychosocial trauma (Read & Ross, 2003), for example, physical and sexual abuse as well as neglect and peer rejection; and prenatal and postnatal stress (Levy, Grauer, Ben-Nathan, & deKloet, 1998). Secure attachment often leads to better affect regulation.
As a psychotherapist with about 25 years experience working with individuals with a severe mental illness and as an editor of a newsletter devoted to the psychological therapy of this population, I find Hogarty’s relatively pessimistic view of a psychotherapy that is informed by contemporary psychoanalytic relational and interpersonal perspectives to be unwarranted and perhaps uninformed about recent developments in psychoanalysis. [The newsletter is titled ISPS-US. The international web site for this newsletter is http://www.ISPS.org.] Current psychoanalysis is integrating research data from a diversity of fields, including, for example, infant research, affective neuroscience, cognitive psychotherapy, developmental psychobiology.
Hogarty understands the schizophrenias as primarily neurological disorders with a primary neurogenetic/ neurobiological cause, which is neurocognitively expressed in such processes as, for example, working memory, attentional control, and stimulus discrimination. There are many researchers who question the scientific validity of separating affect from cognition and many who view the schizophrenias as primarily an affective disorder with secondary neurocognitive dysfunction (Ciompi, 1997). There are also researchers who view the neuroplasticity of the brain to be the nonspecific etiopathogenesis of the schizophrenias as well as many who point to the rather large overlap of neuroscience findings in the schizophrenias as well as in chronic and profound stress (Cotter & Pariante, 2002). In fact, Heinrichs (2001), in his meta-analysis of the neuroscience research in schizophrenia, demonstrated that patients with a schizophrenic disorder are more reliably differentiated from normal controls by neurocognitive processing (in particular, P50 evoked potentials) than by their neurobiology. In brief, my greatest disagreement with the model proposed in Hogarty’s volume is that all patients with a diagnosis of schizophrenia are given a form of psychoeducation in which they are told they have a brain disease without any clinical substantiation of this and without any attention given to the distinction between causation and correlation (e.g., whether the neuroimaging findings are direct manifestations of the primary neurogenetic/neurobiological disorder or the result of the symptoms/condition, such as profound stress). (For example, ventriculomegaly, one of the more robust neuroscience findings in schizophrenia research is nonspecific; it is observed in affective disorders, posttraumatic stress disorder, and chronic and severe stress, as well as in the normal aging brain.) Otherwise, I believe that Hogarty’s approach as outlined in this volume offers the clinician a humane and sophisticated psychosocial treatment approach with a clinically underserved population, which is a significant advance over current psychosocial interventions that ignore or minimize the affective components of this group of mental illnesses. References Ciompi, L. (1997). The concept of affect logic: An integrative psycho-socio-biological approach to understanding and treatment of schizophrenia. Psychiatry: Interpersonal and Biological Processes, 60, 158–170. Cotter, D., & Pariante, C. M. (2002). Stress and the progress of the developmental hypothesis of schizophrenia. British Journal of Psychiatry, 181, 363–365. Fonagy, P., Gergely, G., Jurist, E. L., & Target, M. (2002). Affect regulation, mentalization, and the development of the self. New York : Other Press. Heinrichs, R. W. (2001). In search of madness: Schizophrenia and neuroscience. New York : Oxford University Press. Levy, A., Grauer, E., Ben-Nathan, D., & de Kloet, E. R. (1998). New frontiers in stress research: Modulation of brain function. Switzerland : Harwood Academic. Read, J., & Ross, C. A. (2003). Psychological trauma and psychosis: Diagnosed schizophrenics must be offered psychological therapies. Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry , 31, 247–268. Brian Koehler doi:10.1093/ptr/kph040 Received November 30, 2003 Accepted December 7, 2003 Brian Koehler, Ph.D. |