New IRIS Guidelines for Early Intervention in Psychosis


The ‘Initiative to Reduce the Impact of Schizophrenia” (IRIS) has updated its 1998 guidelines for early intervention in psychosis to state that not all people need antipsychotics and in fact could recover without them, and to suggest other approaches such as  spiritual work, hearing voices work, unusual beliefs work and systemic practice.

IRIS Guidelines →

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Kermit Cole
Kermit Cole, MFT, founding editor of Mad in America, works in Santa Fe, New Mexico as a couples and family therapist. Inspired by Open Dialogue, he works as part of a team and consults with couples and families that have members identified as patients. His work in residential treatment — largely with severely traumatized and/or "psychotic" clients — led to an appreciation of the power and beauty of systemic philosophy and practice, as the alternative to the prevailing focus on individual pathology. A former film-maker, he has undergraduate and master's degrees in psychology from Harvard University, as well as an MFT degree from the Council for Relationships in Philadelphia. He is a doctoral candidate with the Taos Institute and the Free University of Brussels. You can reach him at [email protected].


  1. It did mention that some people do fine without antipsychotics, but it was rather tepid support. The general thrust is that we should get people on antipsychotics if we can, though they do support low dosages. Trauma goes almost unmentioned. The part on CBT is probably the best, but isn’t really coherently connected to the rest – if hearing voices is a common phenomenon, and people we diagnose as “schizophrenic” are just at the far end of that spectrum, why are we treating people who hear voices as diseased individuals instead of having the primary goal be to help them make sense of their experience? Shouldn’t drugs be an ADJUNCT to these efforts, rather than the primary form of care? These guidelines don’t appear to challenge the medical paradigm, though they do expand on it significantly. I’d say it’s an improvement, but a very minor one.

    —- Steve

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  2. It all sounds so great on paper. My experience in real life was totally different. Nobody inquired what happened prior to my son’s breakdown or what brought it on. Doctors are only too keen to pathologise and diagnose. They did their best to keep me out of the picture. They loughed when my son reported the terrible side-effects of the antipsychotic medication and refused to lower the dose. There was no therapy of any kind offered to him. Nobody talked to his brothers and sisters who stopped him from killing himself. They had to cope the best they could with the trauma of it all and three of them experienced a break-down themselves a few months later. And yes, the antipsychotic meds did nothing for my son because they stopped him from thinking and dealing rationally with what had happened to him. Once off the meds he started putting two and two together and understanding what had happened to him.

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  3. The biggest problem I see is they are hanging on to the almost military-medical model of Early Intervention: the stakes in “tackling” psychosis early in life are supposedly just as great as in cancer and diabetes (where delay in treatment can clearly kill you, or at least cost your eyesight and your right leg). And “structural brain abnormalities” show up early in psychosis, which we must curtail. (I would love to see their evidence for this one; they seem to have ignored the growing body of conventional research that shows the MEDS leading to brain shrinkage and other structural abnormalities.) Without much better evidence for these claims they should be regarded as scare propaganda pure and simple.

    I’m glad to see them advocate respecting the “informed choice to decline medications” — but can informed choice really be based on scare propaganda? In other parts of the document they group non-pill-taking with non-attendance, substance misuse and other obvious signs of “trouble.”

    All in all, this is probably better than the last version, but seems tailored to let the treatment team do whatever it feels best and still be able to quote this document in support. Person-centered, evidence-rich, cost-effective, strengths-based … who is against any of that lovely hyphenated BS?

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  4. Given the role Patrick McGorry has played in these guidelines nothing should be suprising. For those that do not know who this guy is, just be thankful your governments are not following his lead. The Australian Government worships the ground he walks on, is spending BILLIONS of dollars to set up these early intervention services to treat those supposedly “at risk” of psychosis, before it even begins and this does include with antipsychotics. MOST other proponents in the early intervention field in the rest of the world are very cautious of the idea that you can predict psychosis, but not Patrick McGorry. He claims that if you have ever had a time when you could not think of the exact word you wanted to say, even if you could get your meaning and message across that you are at ultra high risk of psychosis and should be forced to take antipsychotics for life. He places child abuse victims in CBT, so they can learn that their beliefs about being abused were just figments of there imagation, and all they need to do is the think exactly how the therapist thinks and all will be perfectly fine. CBT is based on the premise that everything is caused by faulty thinking. That the therapist is an expert at knowing everything a person should be thinking and that the person needs to think exactly as the therapist tells them. It is so beyond belief as to be stupid. It is used extensively to help people to understand the chemical imbalance in the brain they have and why they need to take these medications for life. A person’s thinking is related to their experiences, if you want a person to think differently you need to give them different experiences. If you want a child who has been raped to believe that not all men will hurt them, you need to give them positive and safe experiences with men. It is not going to happen by telling them that they are wrong to think as they do. Thinking is not wrong, it is simply what it is.

    CBT is very acceptable, it is as close to the diseased brain model you can get. Just say the person has diseased thinking and it is all OK. Other therapies require you to look at what is going on for someone, but they don’t wnat to do that, much easier to just tell them they are defective. When CBT works the therapist has not done true CBT. CBT done by manuals as it should be, has excessively high drop out rates, as most people experience it as traumatic and abusive.

    Like others I also have a problem with this idea that we can somewhere prevent a non existant condition from taking hold. Even if you could prevent psychosis, one would first have to know what psychosis is. Since they do not know what psychosis is, that is simply not possible. We also know that ALL research that shows changes in the brain has been done on those on medications. NO research ANYWHERE in the world has ever shown any changes or differences in those that were not medicated. But like everything they see schizophrenia as something that is resembling medication side effects. They need them medicated early as otherwise none will ever get schizophrenia as the symptoms are based on those on medications!!

    And of course we see the ties these people have to drug companies. The evidence is that first generation antipsychotics are slightly more tolerable, but they continue to argue that the new ones, that are still on patent have less side effects. Again there is NO evidence of this. All the evidence is the absolute opposite. Drug them up and get paid big bucks from drug companies is all that they care about. How they can seriously believe that these drugs can help anyone is beyond me.

    Of course what they fail to recognise is that any benefits are based purely on them using lower doses of medications. The higher the dosages the more disabled the person becomes. And they claim this is due to early intervention, it is in fact due to the fact that they are not even psychotic yet!! How much does it take to sedate someone that is not even in full psychosis??

    They did initially claim that with early intervention the people would be discharged from services and just recieve medications from GP’s for life, after about 18 months in the service. They are now finding they need a minimum of 5 years and of course that a whole range of other services must also be provided. We already know that if you never give them antipsychotics to begin with people will be free from services in the 18 months, but they are not willing to look at what is happening with Open Diaglouge in Western Lapland, Finland. Soteria did not require 5 years and of course no medications were required.

    WHY are they not able to see past their own eyes??

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