To the Editor:
This letter concerns the article "Psychosocial Treatments of Schizophrenia," published in April 1993. 1 The information presented gives a brief but good overview of how treatment for the mentally ill has progressed in the past 40 years. The explanation of how consumers benefit greatly from taking prescribed medications while being involved in group or individual therapy is well written.
Two types of therapies not discussed or elaborated upon are direct case management and the clubhouse model of psychosocial rehabilitation. A social worker assisting a mentally ill person in his or her own home environment greatly increases the client's success in staying healthy and productive. A case manager may teach or improve average daily living skills in the home while monitoring care needs. Economically speaking, it is more cost effective for a consumer to Uve in the community rather than in and out of hospitals.
The clubhouse model incorporates a program of daily support for its "members" who have a mental illness. Both other members and staff interact and encourage to assure that the member feels he or she belongs and can contribute to the program. Members must only take prescribed medications and see their doctor to stay in the program. With members and staff working closely together, it is a therapeutic alliance that does not end when the member goes home. Clubhouse does not use group therapy. Therapy takes place while working in an entire program ranging from clerical work, preparing meals, to possible employment and support of themselves in outside jobs. Examples of clubhouse include Fountain House in New York City and Independence Center in St. Louis, Missouri.
From my experience, it is often more insightful and beneficial to and for clients to assist and observe them in the home or working alongside them. This does not mean personal and group therapy or hospitalization are rarely needed. Using only one type of prevention often leaves gaps in a person's long-term recovery. An example of this is vocational rehabilitation. It is a beneficial program, but cannot give the total support that someone may need to succeed. Medication monitoring, case management, therapy, and home environment all contribute to success or failure.
1. Schwartz BJ, Cecil A, Iqbal N. Psychosocial treatments of schizophrenia. Psychiatric Annals. 1993; 216-221.
David Lysakowskl, MSW, LSW
The Authors Respond:
We would like to thank Mr. Lysakowski for calling attention to the benefits of intensive case management and of the clubhouse model in working with patients with schizophrenia. We agree that such programs can help in the management of many patients.
Our article on psychosocial treatments was not intended to fully cover the whole range of possibilities. We chose to review only those interventions that have been studied and are supported in the literature by research data.
Clearly, treatment of patients with schizophrenia and other chronic psychiatric illnesses ought not be limited to one modality. Interventions directed at multiple systems and areas of functioning can enhance the likelihood of successful outcomes for these patients. Fortunately, studies of intensive case management are in progress and we hope that clinicians' intuitive feelings about psychosocial clubs and ICM will be borne out by research findings.
Alec Cecil, EdD
Bruce J. Schwartz, MD
Naveed Iqbal, MD
Department of Psychiatry
Monteflore Medical Center
The University Hospital for the
Albert Einstein College of Medicine
Bronx, New York
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