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Researcher Courtenay Harding Finds Mental Health in the Wilds of Vermont

Is the often discouraging clinical view of schizophrenia misleading? Do doctors give too much weight to predispositions? Are many accepted treatments ineffective? Do people with schizophrenia recover over time?

In her rigorous longitudinal studies of people with schizophrenia, pioneering Boston psychologist Courtenay Harding says "yes" to all of the above. Her now famous "Vermont Study" and ten other long-term investigations of 2,415 subjects around the world confirm that one half to two thirds of those suffering from schizophrenia recover significantly over time.

Harding studied dozens of chronic patients who were ill for as long as 16 years and totally disabled for 10. They were released from a Vermont state hospital in the 1950s as part of deinstitutionalization. But instead of dumping the patients in the community, Dr. George Brooks, clinical director, used the new Thorazine drug as part of a comprehensive, flexible program of psychosocial rehabilitation to develop social and work skills, to regain confidence and cope with daily living. Initially, many of the former patients required governmental aid and community programs.

However, Courtenay Harding, PhD, found that by the 1980s 62% to 68% were significantly improved or completely recovered; 45% of Dr. Brooks' program graduates no longer had signs or symptoms of any mental illness. Sixty percent were productive; 40% working and 20% volunteering. After several decades a majority tapered off medication. The least effective treatments were by those doctors who espoused stabilization and maintenance, medications and entitlements.

What did those hardy and successful Vermonters say are the key elements for success? Symptom and medication management; case management and individualized treatment planning; rehabilitation and psychoeducation; a social life; productive work; self-sufficiency; integration into the community; and hope.

Says Dr. Harding, who directs the Institute for the Study of Human Resiliency, "We've forgotten a secret weapon is on our side--resilience. People facing life challenges such as serious illness, trauma, disability or disadvantage, can significantly improve through their ability to sustain grief and loss and to renew with hope and courage."

Psychiatrists Learn from Dr. Harding's Findings

Dr. Harding has witnessed a remarkable shift of attitude by psychiatrists in the last 16 years, "but they still have a long way to go." Harding states, "The National Institute of Mental Health has changed the way they speak about patients--now they say 'a person with schizophrenia.' The Surgeon General's report and the President's New Freedom Commission report are laced through with concepts of recovery. The DSM IV (the psychiatrist's manual) now has moved from saying 'recovery never happens' to it 'sometimes happens.'" But unfortunately, according to Harding, "The critical group that hasn't changed is the academic psychiatrists who train the young ones."

Dr. William McFarlane, who directs psychiatric research at Maine Medical Center, sees psychiatrists beginning to understand recovery, "first, because they see recovery occur before their eyes in startling relief as a result of the new medications; second, because the DSM IV implies that recovery can occur and, third, because a minority has been exposed to the recovery movement and understand the negative effect a grim prognosis can have to 'fulfill a prophesy.'" He agrees that academic psychiatry lags behind the times, "The picture here is not so pretty; medical school textbooks and training don't incorporate contemporary data or perspectives, including on long term-recovery. Here, major change is needed."

Lisa Dixon, a professor at the University of Maryland's School of Medicine, agrees about the tendency of psychiatrists to begin to understand that symptom remission does not equal recovery: "One can be recovered and still have some symptoms and one can be without 'symptoms' and not be recovered. Since psychiatrists tend to see people who are the most ill, we have a skewed view."

Harriet Lefley, a professor of Psychiatry at the University of Miami School of Medicine agrees that the pessimism is diminished, "but clinicians should never convey a discouraging prognosis; hope and belief in people's resilience have tremendously curative effects."

So what is Dr. Harding's message for clinicians? Don't suggest the worst outcomes to patients, including the need to take antipsychotics for the rest of their lives. That betrays hope and discourages self-healing. Show through words, actions and attitude that recovery is possible. Provide long-term options given that more than half can recover and others don't because of side effects or inadequate treatment.

She emphasizes that rehabilitation, "needs to begin on day one. [Don't] wait for stabilization because rehabilitation is complementary to medication for reducing symptoms."

It's time to base our beliefs about recovery and our treatment of schizophrenia on these facts rather than outdated beliefs and treatments.