Michael D. Rosberg, Ph.D.
For decades, the treatment of schizophrenia has largely followed a familiar pattern: periods of crisis intervention followed by extended cycles of disengagement, relapse, and rehospitalization. Advances in pharmacotherapy and psychosocial interventions have offered clear benefits, but the delivery of care too often remains fragmented and reactive. The result is preventable suffering and rising public costs for a population whose clinical needs are well understood but inconsistently addressed.
At ASC Treatment Group, we believe the problem is not the absence of effective treatments but the failure to consistently implement what we already know works. The clinical core of the problem is not technical. It is relational. Medication and psychotherapy work best when the person receiving them is an active participant in decisions about their own care, and the recovery that follows is durable to the extent that the person leaves treatment with a stronger sense of agency than they came in with. This essay focuses on the clinical practices that support that outcome.
What medication can and cannot do
Pharmacotherapy remains essential in reducing the positive symptoms of schizophrenia, including hallucinations, delusions, and disorganized thought. Second-generation antipsychotics have made this process more tolerable for many. But adherence remains a major challenge. Side effects, lack of insight, and disruptions in the systems through which medication is delivered all contribute to discontinuation and relapse.
At ASC, we have found that adherence improves substantially when individuals are actively involved in decisions about their care. Shared decision-making is not simply a compassionate idea. It is a clinically sound one. When clients work collaboratively with prescribing clinicians to select medications, adjust dosages, and manage side effects, engagement improves, and so does treatment retention. It is not unusual to see a client who previously cycled in and out of hospitals achieve stability once their voice is centered in the prescribing process (Deegan & Drake, 2006).
Two observations follow from this. First, what looks like nonadherence is often a reasonable response to a regimen the client had no real role in choosing. Second, the conversation between client and prescriber is itself part of the treatment. The medication does its work, but the relationship through which the medication is delivered determines whether the work continues.
Psychotherapy that matters for this population
Effective schizophrenia treatment requires more than medication. Evidence-based psychotherapies, including cognitive behavioral therapy for psychosis and motivational interviewing (Miller & Rollnick, 2013), help individuals manage internalized stigma, co-occurring substance use (Mueser et al., 2003), and the psychological toll of chronic illness. These interventions teach tangible skills, including reframing distorted thinking, managing triggers, and building coping strategies that hold up under stress.
They also do something the medication cannot do alone. They give the client a working model of their own experience. A person who can recognize the early signs of a relapse, name what is happening, and decide what to do next is functioning at a different level than a person who is simply taking the right pills. The clinical literature on motivational interviewing in particular is grounded in the same principle that runs through the prescribing relationship. Change is more durable when the person identifies the reasons for it themselves than when those reasons are imposed from outside.
Self-determination as the through-line
Perhaps the most underappreciated aspect of recovery is self-determination. Clinical success is rarely achieved through compliance alone. People need to experience agency in their treatment: to set goals, try new roles, and learn from their choices. ASC programs encourage this through peer mentorship, client advisory groups, and opportunities for leadership within the program community.
Clients who participate in designing their own schedules, managing responsibilities, or supporting others in recovery often show improvements in insight, adherence, and social functioning. The improvements are not surprising. The same psychological resources that allow a person to take ownership of their treatment are the resources that make recovery sustainable. When clinical care actively builds those resources rather than working around them, people begin to reimagine their identities, not simply as patients, but as capable contributors to shared spaces.
This is also where clinical practice and the design of the surrounding environment intersect, a topic developed more fully elsewhere in this collection. A program that asks clients to participate in their own recovery has to be designed in ways that make participation possible. The clinical and the environmental arguments are not separate. They are two sides of the same commitment to treating the person as the agent of their own care.
A call to implement what we know
Dr. Thomas Insel, former Director of the National Institute of Mental Health, has argued that the central problem in American mental health care is not the absence of effective treatments, but the failure to deliver them reliably to the people who need them (Insel, 2022). The challenge is no longer discovering what works. It is designing systems that deliver it consistently and respectfully.
At ASC Treatment Group, we accept that challenge. Our clinical model combines medication management, evidence-based psychotherapy, and a steady commitment to the client’s role as decision-maker in their own care. The results we have seen are consistent with what the literature predicts. Adherence improves, hospitalizations decline, and the recovery that emerges is one the person can sustain because it belongs to them rather than to the program.
If we are to improve schizophrenia care in this country, it will not be through innovation alone, but through implementation, with fidelity, with compassion, and with a clear understanding that the relationship through which treatment is delivered is as important as the treatment itself.
References
Deegan, P. E., & Drake, R. E. (2006). Shared decision making and medication management in the recovery process. Psychiatric Services, 57(11), 1636–1639. https://doi.org/10.1176/ps.2006.57.11.1636
Insel, T. R. (2022). Healing: Our path from mental illness to mental health. Penguin Press.
Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). Guilford Press.
Mueser, K. T., Noordsy, D. L., Drake, R. E., & Fox, L. (2003). Integrated treatment for dual disorders: A guide to effective practice. Guilford Press.