Factors Supporting Recovery

The saga of Nobel Prize winner John Forbes Nash Jr., whose 30-year battle with schizophrenia is the subject of the movie "A Beautiful Mind" (and of Sylvia Nasar's far more accurate biography of the same name), illustrates some of the factors psychiatric researchers and ex-patients say foster recovery.

"What the movie communicated is that recovery is possible, and in Nash's case the main elements we know to be effective were there," observed psychologist Xavier Amador, deputy executive director of research at the National Alliance for the Mentally Ill, an advocacy group.

These factors, which include medical and social support, decent housing and encouragement, do not guarantee improvement, nor does their absence make recovery impossible.

They include:

Age and onset. Studies have found that people who are older and whose symptoms appear suddenly do better. According to psychiatrist E. Fuller Torrey, 75 percent of people diagnosed with schizophrenia are 17 to 25. Nash was 30 when his illness struck abruptly; he was already a full professor at the Massachusetts Institute of Technology and had written the doctoral dissertation that would earn him a Nobel Prize in economics 45 years later. A person who had major problems in childhood, or who is diagnosed as a high school senior, may find recovery harder.

Managing Medication. Powerful antipsychotic drugs help some people enormously, while others get little or no relief from the vivid hallucinations, imaginary voices or persistent delusions that are the hallmarks of schizophrenia. In the movie, Nash says drugs helped him recover. But Nasar writes that Nash took no medication after 1970 "and indeed during most periods when he wasn't in the hospital during the 1960s." She speculates that this helped preserve his intellect and protect him from the disabling neurological side effects that are associated with long-term use of antipsychotics.

Psychologist Courtenay M. Harding, who has published several studies of patients discharged from the back wards of Vermont's state mental hospital, said that 50 percent of patients who fully recovered or significantly improved took no psychiatric medication at the time of the study, while another 25 percent used the drugs only when they felt they needed them. Learning how to manage the more disturbing side effects of drugs is vital, patients say. Psychiatrist Beth A. Baxter, 38, of Nashville, has taken Clozapine for seven years. The drug helped her return to practicing medicine full-time and to live independently -- but caused her to gain 100 pounds. (Substantial weight gain is a common side effect of many newer drugs.) "I joined a health program last year and I've lost 65 pounds so far, and I'm really proud of that," said Baxter.

Avoiding street drugs and alcohol. Nash did not have a substance abuse problem, but a lot of people with schizophrenia do. One study has estimated that 47 percent of people with schizophrenia have a co-existing drug or alcohol problem, which can worsen psychotic symptoms and seriously impede recovery.

Supportive relationships (and a decent place to live). Intense loneliness and social isolation are among the biggest problems for people with schizophrenia. The relationships Nash had with fellow mathematicians were essential to his eventual recovery, but the single most important factor in Nash's recovery was the bond with his remarkable wife, Alicia. She fed, housed and cared for him even after she divorced him, and never wavered in her devotion to him or her belief in his extraordinary talent. Most people who have recovered credit the steadfast encouragement of another person who they say believed in them: a therapist, teacher, counselor, nurse or, less often, a family member.

Productive work. For some patients this might involve starting in a sheltered program, then gradually moving to more challenging employment with people who are not mentally ill. "Clinics and day treatment centers can be like little ghettos" that expose patients only to the behaviors and problems of people with similar disorders, observed psychiatrist Daniel B. Fisher.

In Nash's case, the Princeton campus functioned as a therapeutic community. His bizarre behavior was mostly tolerated, and he was granted access to lecture halls and libraries and offered human contact without being forced to make it. As his schizophrenia receded, Nash participated in seminars and made friends with a few graduate students. Later he was given unrestricted access to a computer, which he taught himself to use, and began writing intricate programs.

Coping strategies. Learning about schizophrenia, recognizing the warning signs of relapse and developing practical coping strategies are crucial. Even after recovery "people still go through periods of severe distress, but then so does everyone," Fisher said. "It's a question of what happens in those states."

Cognitive therapy, a behavioral treatment that focuses on a rational evaluation of thoughts and practical ways to reduce symptoms, has proven to be beneficial. "We try to help people identify whether their symptoms make sense, so they can ask themselves: 'Does it seem likely that I'm the president?' " New York psychiatrist Francine Cournos said. "You can teach insight."

Amador notes that Nash essentially undertook a form of cognitive therapy on his own. "He rationally evaluated the advantages and disadvantages of responding to his delusions," Amador said.

Persistence. A reluctance to give up -- or to accept a prognosis of doom -- can be seen in Nash's story and was a factor mentioned by all eight ex-patients interviewed. It is also a trait researcher Courtenay Harding said was widespread among the Vermont patients who got better. Resilience appears to be related to basic personality traits and is largely untouched by mental
illness, Torrey said.

"I was told by one psychiatrist that I would spend the rest of my life in the hospital taking medication," recalled psychologist Patricia Deegan, 47, who was hospitalized for the first time as a 17-year-old high school senior.

Instead she managed to earn a doctorate in clinical psychology and helped found the National Empowerment Center in Lawrence, Mass., a resource center for recovering psychiatric patients. Recently she adopted a child as a single mother and has begun directing a program at Boston University. Deegan said she has not taken psychiatric medication or been hospitalized since 1994.

"For me," she said, "recovery was all about rejecting a life as an invalid and believing I could be something more."



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