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The Treatment ofAcute Schizophrenia Without Drugs:An Investigation of Some Current AssumptionsBY WILLIAM T. CARPENTER, JR., M.D., THOMAS H. MCGLASHAN, M.D.,AND JOHN S. STRAUSS, M.D.

proaches to schizophrenia have been used for years fand have provided a rich source of information on phe- : ~nomenology and treatment effects. However, in the ab- ;i,sence of rigorous research methodology this informa- ; ~tion base is often dismissed as anecdotal, and the influ- :.;;jJence of psychoana lysi s and related psychological;approaches on the treatment of schizophrenic patients l:has waned. There are formidable intricacies involved;:in developing appropriate measures of change s p e c i f i - . ; ~cally relevant to the aims of psychotherapy, and until ' recently little attention has been paid to such assess- :ment problems (4-8). Thus. for example. it is possible)to demonstrate that drugs are more effective than psy-Jchotherapy in reducing a paranoid patient's bellig- jerency. but there is no way to assess the e f f e c t i v e n e s s ~ : 1of either mode of treatment on this palient's c a p a c i t y ~for in timacy .iPharmacological treatment of schizophrenia is ex-};traordinarily important in psychiatry. We bel ieve, how-!ever, that the treatment of schizophrenia has becomeso extensively drug oriented that a significant impediment has a,:isen to the exploration of alternative therapeutic approaches. The s ituation has reversed f r o m ; l ~the 1950s, when a commitment to psychological t r e a t - ' ~ment philosophies posed a serious resistance to phar-tmacological innovations. Klein (9) has noted that the Aautomatic and immediate administration of neurolep-'t ics to disturbed patients often precedes and precludeseven a diagnostic evaluation. This widespread and premature foreclosure on the optimal treatment of schizophrenia is reflected by the fact that millions of peopletake neuroleptics as the only important component oftheir treatment. "

LIMITATIONS IN KNOWLEDGE OFSCHIZOPHRENIAThis narrowing ofour clinical approach is e s p e c i a l l y ~alarming considering how little we know about schizoqphrenia. These limitations include the following:I. We know virtually nothing about the etiology 0

schizophrenia. Despite evidence for a genetic contribtion in some forms of schizophrenia, we know nothiabout the nature of this component, how it may contribute to vulnerability, or to what extent it accountfor the variance in manifest schizophrenia. At present

The authors examine the course of49 acuteschizophrenic patients in a program at the NationalInstitutes a/Health (NIH) emphasizing psychosocialtreatment and sharply limiting the use ofmedicationand contrast it with that oI73 similar patientsreceiving "usual" treatment in a separate study.Follow-up of the NIH group at one year and the othergroup at two years demonstrated a small hutsignificantly superior outcomefor the NIH cohort. Inaddition, the 22 NIH patients receiving medicationand the 27 dmg)i'ee patients had similar outcomes atone year. The authors discuss theleasibility qj'treating aClite schizophrenic patients with minimal lise( ~ f ' l 1 l e d i c a t i ( } l l .

Revised version of a paper presented at the 128th annual meeting ofthe American Psychiatr ic Associat ion, Anaheim, Calif ., May 5-9,1975.

FOR MANY understandable and good reasons, psychopharmacology is now preeminent in the treatment ofschizophrenic patients. Drug administration reducespsychotic symptoms, dulls the pain of anguishedpatients, renders hospitalized patients dischargeable,and maintains patients in the community. It provides arational and effective mode by which the physician caninduce desired change s in his pati ent well within thecontext of the medical model.Psychiatry's r ec eptivity to the use of psychopharmacology in the treatment of schizophrenicpatients has been enhanced by studies documentingthe effectiveness of drugs while failing to find any impressive evidence for the effectiveness of psychological therapies (1-3). However, these important studieshave shortcomings and are regarded by some as an unsatisfactory test of psychotherapeutic efficacy.On the other hand, we have little systematic information about psychotherapy (4). Psychotherapeutic ap-

At the t ime this work was doneDr. Carpenterwas Acting Chief, Psy-"chiatric Assessment Section and Dr. McGlashan was Chief, ClinicalResearch Unit, Psychiatric Assessment Section, Adult PsychiatryBranch, National InstituteofMental Health, Bethesda,Md. Dr. Car penter is now Director, Schizophrenia Research, New York StatePsychiatric Insti tute, 722 West 168th St., New York, N.Y. 10032.Dr. McGlashan is Staff Psychiatrist, Chestnut Lodge, Rockville,Md. Dr. Strauss is Director, Clinical Psychiatry Research, University of Rochester School of Medicine, Rochester, N.Y.

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factor can be said to be a necessary and sufficientof schizophrenia, or even necessary but inDifficult diagnostic issues and patient heteroity limit the interpretation of data from any studyschizophrenic patients.The assessment techniques that measure courseoutcome in schizophrenia have serious short ngs, especially as applied in studies comparingeffects.of the paucity of etiological knowledgeschizophrenia is important since psychiatrists ofassume tha t a r e a ~ o n e d u n d e r s t a n d i n g of its causes exist, lacking only in detail . In fact, no other disin the history of psychiatry has had a richer panof global claims to its cause and cure. Recognition

our ignorance is important because, as commonsuggests and Soskis (10) has demonstrated,logical assumptions influence a physician's choicetreatment modality.e second point-the problem of diagnostic shortwidely acknowledged but rarely adin study designs evaluating treatment modaliThus a group of pat ients who are called schizoenic but who lack descriptive (let alone etiological)ogeneity are often studied for treatment response,the study results are generalized as though schizoenia were a single illness (II).e third point-inadequacies in the assessment ofand outcome-is the least well recognized butaps the m o ~ t crucial. There are many dimensionsa patient's fate, and the effect of treatment on acourse cannot be adequately determined unthis complexity is taken into account. The capacto relate socially is not the same as the capac ity tod a job, and neither of these factors can be predict

by assess ing the patient's symptom picture or theessity for hospitalization. However, all too fret ly the effect of treatment on outcome is deterby measuring uni tary dimensions such as theof hospital stay.(12) reviewed the literature on maintece drug therapy in schizophrenia and found that on

of 31 studies measured the effectiveness of drugy on dimensions other than symptom relapse ortalization. While these measures/arcr vitally imthey fall drastically short of a comprehensiveof the patient's functioning,.fhis point wasusing 2-year f o l l o w - J . l p ' ) ~ s s e s s m e n t s of 85zophrenic patients we evaluated as part of the Inn a l Pilot Study of Schizophrenia (IPSS) (13).were only modest associations between 4 oute variables, i.e., time in hospital, social function,function, and symptoms (14). Furthermore, theciation between any I of these measures at 2-year

and the other measures at 5-year follow-upminimal, and in some cases negligible (I5). Fo r exle, assessing hospital status during a 2-year followves minimal information abollt social or workat 5-year follow-up. Schwartz and asso-

CARPENTER, MCGLASHAN, AND STRAUSS

ciates (16) also found discordance between 4 outcomemeasures, i.e., mental status, social and role functioning, rehospitalization, and satisfaction with treatment.Studies assessing the relationship between treatmentand outcome are severely limited unless they arebased on multiple outcome dimensions.The paucity of long-range follow-up studies also re

stricts our understanding of the effects of pharmacological t reatment . Most reports focus on changes in thepatient during hospital stay or brief follow-up periods,and few studies go beyond 2 years . Engelhardt (17)has called at ten tion to the diminishing differences(from clinical assessment) between drug- and placebotreated patients as their course is followed over a longer period of t ime. This does not lessen the importanceof the short-term effects of drugs, but it does suggestthat we know very little about their comparative longterm advantages.

ISSUES CONCERNING DRUG TREATMENTIt is often assumed that noxious side effects of neuroleptic treatment of schizophrenia are limited to unpleasant autonomic alterat ions, extrapyramidal effects, rare allergies, and infrequent tardive dyski- Inesias. Recent evidence (18-20) has more careful lydocumented the relationship between drug treatmentand the inducement or reinforcement of defect or negative symptoms (e.g., anhedonia, social isolation, postpsychotic depression, and amotivational syndromes).

Nevertheless, relatively scant attention has been paidto this problem or to possible later effects of long-termdrug use on affect modulation, communication, perception, or other central nervous system functions. Inaddit ion, little notice has been given to the so-calledsecondary side effects, such as the impact on a child'sdevelopment should his mother be on long-term heavymedication. This results in a situation not entirely dissimilar to that of past enthusiasm for lobotomies, whenattention focused on the positive attributes of the procedure to such a degree that the short- and long-termhazards were overlooked.Two recent review art icles have suggested that theunequivocal acceptance of neuroleptic therapy inschizophrenia is being reexamined. Tn a review ofmaintenance drug therapy Davis (2l) pointed out thatthere is a subgroup of schizophrenic patients whoshould not be treated with neurolept ics. Cri teria foridentifying this subgroup are not yet established. Furthermore, Davis believes that most patients on chronicmaintenance therapy deserve a trial of withdrawalfrom drugs; this has the potential of enhancing the clinical course as well as reducing the risk of neurologicalcomplications. Davis is joined in this argument by Gardos and Cole (22), who have stated that "every chronic schizophrenic outpatient maintained on antipsychotic medication should have the benefit of an adequatetrial without drugs" (p. 35). Based on their review,these authors predicted that as many as 50% of all med-

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TREATMENT OF ACUTE SCHIZOPHRENIA WITHOUT DRUGS

icated chronic schizophrenic outpatients would do aswell clinically without medication.The ascendancy of drug treatment in schizophreniahas been accompanied by an emphasis on short-termcrisis management, rapid discharge from the hospital,and community-oriented services. These trends springfrom a recognition of the negative effects of chronicinstitutionalization and from frustration with lengthy

psychotherapeutic procedures. These trends may havegone to extremes; the wisdom of early discharge andreturn to the community, for example, is beginning tobe questioned (23, 24).

Together, these factors have led to the following 5prevalent and understandable, but erroneous, assumptions:

l. The schizophrenic patient must be treated withdrugs and fai lure to do so is unethical.2. Such patients must be maintained on drugs aftersymptomatic recovery.3. Relapse must be prevented s ince the psychoticstate is, in i tself. pathogenic and actively nurtures adeteriorating course.4. No major treatment emphasis besides drugs is essential for schizophrenics.5. There are relatively few hazards in using medication.Although we regard these 5 assumptions as unwarran ted, we do not subscribe to opposite conclusions.Answers to these problems must be derived from careful scientific study. Our argument is that current treatment attitudes far outdistance their informationalbase. The polemics often introduced into discussionsof treatment do not reflect scientific fact. However, issues at the interface of pharmacotherapy and psychotherapy were intelligently discussed in a recent reportby the Group for the Advancement of Psychiatry (25).It seems apparent that ou r profession should encourage the continued evaluation of reasoned and innovative treatment approaches for schizophrenia.

THE STUDY

In this paper we describe a hospi ta l program foracute schizophrenic patients that emphasizes psychosocial treatment and sharply limits t he use of medication. The course of patients so treated is examined andcontrasted with that of similar patients treated in otherhospital facilities: This is not a comparative outcomestudy using controlled therapeutic protocols. Rather,we use available data to address one central question:does withholding medication in the context of psychosocial treatment bias aga inst a favorable outcome inacute schizophrenia? .

METHOD

Our program was established on an II-bed clinicalresearch unit in the National Institutes of Health16 Am J Psychiatry 134:1, January 1977

(NIH) Clinical Center designed to investigate the reltionship between diagnostic and psychobiological varables. We selected pat ients with flagrant psychotbreaks but with reasonably adequate social and worfunction prior to the onset of their psychotic episodeWhile this was general ly not their first psychotic epsode, most of the patients could be considered acute osubacute schizophrenics. Informed consent was obta ined f rom all pat ient s after the nature of the treament/research program was fully explained.At admission the patients were removed from amedication for 3 weeks. Toward the end of this 3-weeperiod a battery of psychobiological, clinical assessment, and psychophysiological research procedurewas undertaken. The patients had a maximum hospitaization of 4V2 months; the average stay was slightlless than 4 months (117 days). If the patients werplaced on drugs after initial tes ting, they repeated th3-week drug-free period to permit research retestinprior to discharge. After discharge testing the patientwere hospitalized as necessary for 2 weeks to permreinstitution of medicat ion and reintegration into thcommunity. Init ial fol low-up evaluat ions were conducted 1 year after admission.Therapeutic Environment

The therapeutic philosophy was that self-undestanding and social adaptation are fundamental to thprocess of recovering from psychotic episodesPatients were seen in psychoanalytically oriented psychotherapy 2-3 t imes a week. All patients participatein group psychotherapy once a week and most patientalso had family therapy once weekly. Self-understand.ing was emphasized in these sessions; psychotic m a n i -festations were regarded as reflections of intrapsychicconflict and repetitions of past experience. The treating psychiatrists ranged in experience from t h i r d - y e a r residency to second-year postresidency. Senior p s y ~ choanalysts experienced in the treatment of s c h i z o - phrenic patients provided weekly supervision. 1Social adaptation was the principal focus in the g e n ~eral therapeutic milieu with the nursing staff, occupa-tional therapist, recreational therapist, and others. Thestaff helped patients both control and understand theirbehavior. Special emphasis was placed on clarifyingbehavioral communications, helping the patient asseshis effect on others, and exploring alternative e x p r e s ~sions of impulses and ideas. This aspect of the thera:peutic work was carried out in the informal c o n t a ~ t that the nursing staff had with pat ients as part of o r d i ~nary ward life. It was also pursued on a group basis fot,45 minutes a day at rounds where all staff and patientmet to discuss issues relevant to patient care and war''The young psychiatrists treating the patients were not advocates'.i1f:any particular psychotherapeutic approach but were i n t e r e s t e d _ ~learning about the therapeutic potential of the doctor-patient relationship. Most of the supervisors had worked at Chestnut Lodge..some point in their profess ional l ives and had been int luenced Ilthe work of such people as Su ll ivan (26) and Fromm-Reichmann (27).


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This process was no doubt facilitated by the unit'sl size and ample staff. The average staffing patternuded 3 psychiatrists (with bo th clinical and reresponsibilities), 1 social worker, 1half-time acties worker, and 13 nurses and nursing assistantsided among 3 shifts, 7 days a week).mention should be made of our milieu apbecause the question inevitably arises as toseriously ill, drug-free schizophrenic patientsbe managed from day-to-day, let alone be treatedtherapeutic community. Jones (28) originally emsized patient responsibility, democracy, and overof roles within staff and between staff and patientstherapeut ic milieu. The utility of such an apch with schizophrenic patients has come undertion because these patients are often fragmentedregressed, with a poorly developed social capacitya strong tendency toward severe withdrawal (29).k ing this into account , we evolved a therapeut icty organized around a clearly defined medicalel. Hierarchical s taff role definitions were preed, and the psychiatr ist in charge of the unit had

responsibil ity for the t reatment program. Allrs of the community were responsible for sharformation and ideas relevant to the clinical operaAttendance at' ward meetings and therapeutic sess was required. This organizat ion pr.ovided theexternal ego boundaries necessary for regressedents, yet maximized the immense resources of theto enhance effective social intercourse, elimiisolation, and press patients to quickly resume inal responsibility. The use of medication wascribed only during the research drying-out periotherwise, the patient's doctor could elect to use, although emphasis was always on psychosocial

Further descr ip tions of this clinical prohave been reported elsewhere (30, 31).Two Patient Cohortsthis report we compare the first 49 diagnosedophrenic patients admitted to the NIH researchwith 73 patients seen as par t of the IPSS (13). Thepat ients received the "usual" hospital care ine Georges County, Maryland (metropolitan

D.C.), about 1970. 2 Two of us (W.T.C.J.S.S.) made index diagnoses in both groups folthe descriptions and categories ofDSM-IJ (32).ype diagnoses in the NIH patients were catatonic,oid, acute schizophrenin-eaction, and schizo-afschizophrenia. The 73 IPSS' patients given4 subtype diagnoses were included in the study.

used for diagnosis was a 12-point system for iden-

patients and the hospital facilities have been described else(30). Usual treatment involved the ubiquitous lise of neuromedication, Sllpport from the nursing staff, and contact witht s and social workers at least weekly during hospitalPsychiatrists in these facilities Were more experienced thanH clinical associates, but nursing staff-to-patient ratios wereorable.

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/CARPENTER, MCGLASHAN, AND STRAUSS

tifying schizophrenic patients (33), the presence ofSchneider's first-rank symptoms (34), and a profileanalysis of variance across 27 psychopathological dimensions (35) comparing NIH and IPSS patients.Prognostic and outcome variables were assessed usingschedules developed by Strauss and Carpenter (36).Premorbid, diagnostic, and outcome data were collected using semist ructu red interviews developed forwork in the IPSS (13, 36) (i.e. , Present State Examinat ion, Psychiatr ic History, and Social Descriptionschedules).Before reporting the results, we should again emphasize that neither the NIH program nor the IPSS wasdesigned for treatment evaluation. In these 2 separateprojects, similar clinical data were collected withoutany preconceived plan to compare patients. Thiscauses certain methodological problems, and we usethese data illustratively rather than definitively. Onemust keep in mind that "usual community care" wasjust that, and patients were not on controlled therapeutic protocols. NIH patients, on discharge, entered a variety of treatment settings (or none at all) but rarely received intensive psychotherapy. In fact, treatment during the follow-up period was similar for the NIH andIPSS groups. The question we address with these datais whether treating acute and subacute schizophrenicpatients without drugs results in untoward outcome.

RESULTSThe study (NIH) patients and comparative (IPSS)patients were similar in impor tant respects. Table Iprovides descriptive information for each sample.

There were no statistically significant differences between any of the variables. Sign and symptom characteristics of all patients were determined within 10 days .after admission. The profile analysis of variance across27 psychopathological dimensions (e.g., anxiety, audi-

TABLE 1Descriptive Data on the NIH and IPSS Schizophrenic Patients

NIH Group IPSS GroupItem (N=49) (N=73)Mean age (years) 23.77.8 28.98.3SexFemale 29 52Male 20 21Marital statusEver married 15 43Never married 34 30

Socioeconomic c1ass*I 5 2II J2 5

II I 15 24IV 12 28V 4 J4VI I 0 According to Hol lingshead and Redlich (37),

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e. This process was no doubt facilitated by the unit's. all size and ample staff. The average staffing patterneluded 3 psychia tr is ts (with both clinical and rearch responsibilities), 1 social worker, 1 half-time ac-vities worker, and 13 nurses and nursing assistantsivided among 3 shifts, 7 days a week) .. Brief mention should be made of our mil ieu approach because the quest ion inevitably arises as towhether seriously ill, drug-free schizophrenic patientscan be managed from day-to-day, let alone be treatedin a therapeutic community. Jones (28) originally emphasized patient responsibility, democracy, and overlap of roles within staff and between staff and patientsin a therapeut ic mil ieu. The utility of such an approach with schizophrenic pat ients has come underquestion because these patients are often fragmented-and regressed, with a poorly developed social capacityand a strong tendency toward severewithdrawal (29).

'. Taking this into account, we evolved a therapeuticcommunity organizec! around a clearly defined medicalmodel. Hierarchical staff role definit ions were preserved, and the psychiatr ist in charge of the unit had_final responsibil ity for the t reatment program. All:members of the community were responsible for sharing information and ideas relevant to the clinical operation. Attendance at'wardmeetings and therapeutic ses-'sions was required. This organization pr.ovided thefirm external ego boundaries necessary for regressedpatients, ye t maximized the immense resources of thegroup to enhance effective social intercourse, eliminate isolation, and press patients to quickly resume in-'dividual responsibility. The use of medicat ion wasproscribed only dur ing the research drying-out peri'ods; otherwise, the patient's doctor could elect to usedrugs, although emphasis was always on psychosocialtreatment. Further descriptions of this clinical program have been reported elsewhere (30,31).In this r eport we compare the first 49 diagnosedischizophrenic patients admitted to the NIH researchunit with 73 patients seen as part of the IPSS (13). TheIPSS pat ients received the "usual" hospital care inPrince Georges County, Maryland (metropol itan'Washington, D.C.) , about 1970. 2 Two of us (W.T.C.and J .S.S.) made index diagnoses in both groups fol. lowing the descriptions and categories of DSM-II (32).'Subtype diagnoses in the NIH patients were catatonic,paranoid, acute schizophrenic reaction, and schizo-af-fective schizophrenia. The 73 IPSS pa tien ts giventhese 4 subtype diagnoses were included in the study.used for diagnosis was a 12-point system for iden-

patients and the hospital facilities have been described elsewhere (30). Usual treatment involved the ubiquitous use of neuroJeptic medication, support from the nursing staff , and contact withpsychiatrists and social workers at least weekly during hospitalIzation. Psychiatrists in these facilities were more experienced thanthe NIH clinical associates, but nursing staff-to-patient ratios wereless favorable.


tifying schizophrenic patients (33), the presence ofSchneider's first-rank symptoms (34), and a profileanalysis of variance across 27 psychopathological dimensions (35) comparing NIH and IPSS pat ient s.Prognostic and outcome variables were assessed usingschedules developed by Strauss and Carpenter (36) .Premorbid, diagnostic, and outcome data were collected using semistructured interviews developed forwork in the Ipss (13, 36) (i.e., Present State Examination, Psychiatr ic History, and Social Descriptionschedules).Before reporting the results, we should again emphasize that neither the NIH program nor the IPSS wasdesigned for treatment evaluation. In these 2 separateprojects, similar clinical data were collected withoutany preconceived plan to compar e patien ts. Thi scauses certain methodological problems, and we usethese data illustratively rather than definitively. Onemust keep in mind that "usual community care" wasjust that, and patients were not on controlled therapeutic protocols. NTH patients, on discharge, entered a variety of treatment settings (or none at all) bu t rarely received intensive psychotherapy. Tn fact, treatment during the follow-up per iod was similar for the NIH andIPSS groups. The question we address with these datais whether treating acute and subacute schizophrenicpatients without drugs results in untoward outcome.

RESULTSThe s tudy (NIH) pat ients and comparative (lPSS)patients were similar in important respects. Table Iprovides descriptive information for each sample .

There were no statistically significant differences be.tween any of the variables. Sign and symptom characteristics of all patients were determined within 10 daysafter admission. The profile analysis of variance across27 psychopathological dimensions (e.g., anxiety, audi-

TABLE 1Descriptive Data on the NIH and IPSS Schizophrenic Patients

NIH Group IPSS GroupItem (N=49) (N=73)Mean age (years) 23.77.8 28.9::':8.3SexFemale 29 52Male 20 21Marital statusEver married 15 43Never married 34 30

Socioeconomic c1ass*I 5 2II 12 5

II I 15 24IV 12 28V 4 14VI 1 0 According (0 Hollingshead and Redlich (37).

Am J Psychiatry 134:1, January 1977 17


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tory hallucinations, restricted affect) revealed clinicalsimilar ity in both pattern and severity of symptoms.This method and the psychopathological dimensionshave been previously described (35, 38). The NIH andIPSS cohorts were also similar (i.e. , not significantlydifferent statistically) in their respective mean prognostic scores (38.36.5 and 37.95.2) . The prognosticscale consisted of IS i tems measuring factors found byprevious workers to have prognostic significance (36).Evaluation of outcome was based on assessment ofwork function, social function, t ime spent in a hospitalduring the year,3 and symptoms dur ing the month preceding follow-up evaluat ion. Mean outcome scoresdemonstrated a small but significant superiority for theNIH patients (l2.73.2 versus 1I.I4.0 for the IPSSpatients, p


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ients receiVIng higher dosages of medication or, se patients relapsing while receiving neurolepticsemore severely ill. An alternative, albeit unlikely,othesis should at least be enter ta ined to explainese findings: it is possible that treatment with phenoiazine medication actually increases the risk of rese. There is no question that, once patients areced on neuroleptics, they are less vulnerable to re-if maintained on neuroleptics. But what if thesetients had never been treated with drugs to begin? Virtually all of the outpatient maintenance studbegin with fully medicated patients (many of whomve recently been discharged from the hospital) whothen divided into drug and placebo groups. Thesedies usually do not include a group of patients whove been free of drugs from the moment of theireakdown and hospitalization. In es sence, we havee reliable data on the frequency of relapse duringnatural course of the schizophrenic process. Thekoven and Solomon study (41) relates to this quesin that one cannot simply say that before neurolep-

s were available relapse rates were higher.n any case, in an illness with so many paradoxes,raise the possibility that antipsychotic medicationymake some schizophrenic patients more vulnerIe to future relapse than would be the case in the natIcourse of their illness. Thus, as with tardive dyskiwe may have a situation where neuroleptics inase the risk for subsequent illness but must bentained to prevent this r isk from becoming manit. Insofar as the psychotic break contains potentialhelping the patient alter pathological conflicts withhimself and establish a more adaptive equilibriumh his environment, our present-day practice of imdiate and massive pharmacological interventionbe exacting a price in terms of producing "recov-d" patients with greater rigidity of character strucwho are less able to cope with subsequent lifehere are methodological shor tcomings in ourdy, since a comparative investigation of treatmentnot the goal of the research programs. Two criticalblems are the differences in timing of the follow-upluations and the failure to control treatment in eipatient group. Earlier in this paper we cited evisuggesting that the first p roblem probablysed outcome against the psychosocially treatedents. Regarding the second problem, we haveed this report on observations of "usual" treat

nt in different settings. Since few patients in eitherreceived intensive psychosocial therapy afterharge, the advantages and/or disadvantages of psytreatment may be obscured by similarities intreatment.interesting questions remain from the observaon the NIH patients. What determined who re"ed medication, and why did pat ients removedphenothiazines for research pro toco ls fail to re? With regard to the first question, our analysisaled that symptom and prognostic s tatuses were


similar for patients who did and did not receive drugs;this suggests that variables other than clinical status(perhaps, for example, staff anxiety or treatment attitudes of the patient's psychiatrist) contributed to medication use. Consonant with this , we found that thepatient's date of admission was a powerful predictor ofwhether or not drugs were used. The first 10 patientsand 8 of the last I I pat ients admitted to the programreceived drugs. We viewed this as a problem in thetreatment program transit ion in that about 6 monthswere required to establish the program initially. Similarly, toward the end of the program the treatment philosophy of the unit could not be fully maintained because patients and staff anticipated a change in treatment orientation. In any case, simply knowing the dateof admission and identifying patient's doctors were sufficient to predict who would receive medication.We can only speculate why patients did not relapsewhen drug therapy was discontinued. It is clear, however, that relapse in chronic schizophrenic patients following medication withdrawal should not be generalized to an acute schizophrenic population. In addition, increased symptoms after drug reduction duringan active psychotic period should not be confused withthe reappearance of psychotic symptoms (relapse) in arecovered patient. We suggest that the 17 patients whodid not relapse after phenothiazine discontinuationwere no longer symptomatically psychotic. Medication may have been therapeutic earlier, but it was nolonger needed. The further improvement in thesepatients during drug withdrawal may be related to a lifting of the negative elfects of phenothiazines, with general activation ofalfect, motivation, movement, abilityto experience pleasure, and social involvement.During the 3 years of this program we systematicallysought ou r patients' impressions regarding many aspects of the program. This was done at discharge andfollow-up. These data suggest that patients found theNIH therapeutic program significantly different fromprograms they had participated in in other hospitals.Generally, patients reported experiencing more anguish with our treatment approach, whereas they felt agreater sense of frustration and of being "frozen in thepsychosis" in set tings emphasizing drug treatment.Many of the patients found their social experiences inthe NIH ward both grati fying and informative , andthey reported that their l ives had been enhanced as aresult of their therapeutic experience. A few patientsmade negative assessments; they felt their psychosiswas destructive and their attempts to understand itwere of no value. These reports highlight the importance of a continued search for subgroups of schizophrenic patients who are responsive to different therapeutic approaches.In conclusion, our clinical observations in a biologically oriented clinical research project employing psychosocial treatment techniques argue for the feasibilityof treating acute schizophrenic patients with minimaluse of medication. The experience can be gratifyingfor patients and staff. Patients in such a program have

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not fared poorly compared with patients treated inmore conventional settings. We found it possible touse a research strategy for investigating drug-freeschizophrenic patients while maintaining a responsibletherapeutic approach to these-patients within theframework of a medical model.

REFERENCESI. May PRA: Treatment of Schizophrenia: A Comp,irative Studyof Five Treatment Methods. New York. Science House. 196R2. Hogarty GE, Goldberg S, Schooler N: Drug and sociotherapy inthe aftercare of schizophrenic patients. III. Adjustment of non

relapsed patients. Arch Gen Psychiatry 31 :609-618, 19743. Grinspoon L. Ewa lt JR, Shader RI: Schizophrenia. Pharmacotherapy and Psychotherapy. Baltimore. Williams & WilkinsCo. 19724. Feinsilver DB. Gunderson JG: Psychotherapy for schizophrenics-is it indicated? A review of the relevant iiterature. Schizo-.phrenia Bull 6:11-23. 19725. Rubins JL . Rucker MS: On evaluating the effectiveness of psychoanalytic therapy for the acute schizophrenics. Am J Psychoanal 34:241-256, 19746. Waskow IE. Parloff MB (eds) : Psychotherapy Change Measures . Nat ional Ins ti tu te of Mental Health. Washington. DC.US Government Printing Office, /975

7. Kernberg 0, Burstein E. Coyne L. e t a l: Psychotherapy and psychoanalysis-the final report of the Menninger Foundation'spsychotherapy research project. Bull Menninger Clin 36: 1-275.19728. Strupp HH, Bergin AE: Some empirical and conceptual basesfor coordinated research in psychotherapy: a critical review ofissues. trends. and evidence. ln t J Psychiatry 7:18-90. 19699. Klein DF: Who should not be treated with neuroleptics but often are. in Rational Psychopharmacotherapy and the Right toTreatment. Edi ted by Ayd FJ J r. Baltimore, Ayd Medical Communications, 1975. pp 29-3610. Soskis DA: Aetiological models of schizophrenia: relationshipsto diagnosis and treatment. Br J Psychiatry 120:367-373. 1972

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