“He Is Psychotic and Always Will Be”

This chapter continues an examination of the superintendency of William Alanson White but offers a more granular discussion of how ideas about racial difference shaped the clinical encounter in the era of dynamic psychiatry. Specifically, it looks at how Saint Elizabeths’ staff applied particular somatic “therapies”—including seclusion, restraint, and hydrotherapy—to black female, white female, black male, and white male patients. It also argues that the clinical staff’s limited psychotherapeutic engagement with African American patients was further undermined by two things. One was the psychiatrists’ assumptions about the inaccessibility of the black psyche—either because of the absolute cultural foreignness or natural duplicity of African Americans. The other was their tendency to prioritize black patients’ rehabilitation as laborers. Finally, the chapter looks at the quotidian ways that patients exerted their agency in the clinical encounter by resisting medical surveillance and institutional management.

ECT: Examining a controversial therapy in the armamentarium of psychiatry

Historically, treatments for severe psychoses and affective disorders were nonexistent, and patients with mental disorders were transferred to asylums for public safety. This deficiency in treatment inspired the inception of somatic therapies, of which electroconvulsive therapy (ECT) was the most efficacious. This paper will outline the birth of ECT, the controversies leading to its decline, and the subsequent resurgence back into practice.

Somatic Treatments for Psychotic Disorders

A variety of somatic therapies can be used to treat individuals suffering from psychosis. Most commonly, providers will prescribe antipsychotics, which generally block dopamine receptors and are particularly useful at reducing positive symptoms. Second-generation antipsychotics have fewer movement side effects than older agents do, but they are more expensive and have more metabolic side effects. Long-acting injectable (LAI) antipsychotics can be useful for improving outcomes, especially in non-adherent patients, and clozapine is the gold standard for treatment-refractory psychosis. Other agents may be useful for adjunct therapy, or in early psychosis, such as antidepressants, mood stabilizers, and benzodiazepines. In this chapter, we will also review other somatic therapies such as electroconvulsive therapy (ECT) and other neuromodulation approaches.

Psychosocial Treatment for Psychotic Disorders: Systems of Care and Empirically Supported Psychosocial Interventions

In this chapter, we discuss psychosocial interventions, including psychotherapies and other services useful for helping individuals with psychotic disorders. We explain the basics components of the systems of care through which these services are frequently offered, focusing on outpatient treatments. Psychosocial rehabilitation is highlighted, as it helps patients move towards recovery, which is an important model for psychosocial care. A number of evidence-based psychotherapies are explored, notably cognitive-behavioral therapy (CBT), family therapy, and cognitive remediation. Many of these treatments can be given individually or in groups, and although underutilized, can improve outcome when combined with somatic therapies. Other services have been shown to be useful in recovery, such as case management, assertive community treatment, and housing, and these are explored in this chapter as well. Finally, we review the role of hospitalization and involuntary treatment in the care of patients with psychotic disorders.