Paradigm Shift

Sandra Steingard, MD
122
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An important study, published in the prestigious British medical journal Lancet, was headlined on MIA this week. The study examined the effectiveness of cognitive behavioral therapy (CBT) to treat the symptoms of people labeled with a diagnosis of schizophrenia and related conditions who had elected to not take neuroleptic drugs. The study found that those who were in therapy had a modest improvement as compared to those who received “treatment as usual (TAU)”, meaning the other types of services available in their clinic. The study was conducted by a group who have been pioneers in this work for the past two decades.

In two different clinics, they compared two groups of 37 individuals who were experiencing psychotic symptoms and were not taking neuroleptic drugs. One group received TAU and the other group received CBT and TAU. Those in CBT were offered weekly sessions for up to 9 months and then received up to 4 additional sessions over the next 9 months.

The primary outcome measure was the Positive and Negative Symptoms Scale (PANSS), which was completed by a rater who did not know the treatment assignment. People were assessed at every three months through the first year and then at 15 and 18 months. This is considered a “single blind”- the person in the study knows if she has participated in CBT but the rater does not. They also collected data on the Psychotic Symptoms Rating Scale, a recovery rating scale, a scale of personal and social performance, and measures of depression and anxiety.

The baseline PANSS was about 70, which is considered to be moderately ill. In recent drug studies that I have reviewed, typical initial PANSS scores are about 90, so this group would not be considered to be as ill.

At 18 months, there were advantages for CBT. There was improvement in so-called positive symptoms (hearing voices, delusional ideas) but not for negative symptoms (apathy, withdrawal). The effects were considered small to moderate but on par with effect sizes in recent studies of neuroleptic drugs.

At 18 months, 7 of 17 (41%) in the CBT group and 3 of 17 (18%) in the TAU group experienced greater than 50% improvement in PANSS total score.  It is interesting that in the Wunderink Study, there was a 40% rate of recovery in the group who had intermittent drug treatment. Two individuals in each group experienced a 50% increase in PANSS scores during this time. (The numbers are lower at 18 months because not everyone was in the study for that duration; some had dropped out but others just enrolled later and were only followed for 9 months).

There were drop outs but it is notable that many people were willing to engage; about 50% of those referred ended up enrolling in the study. The average number of sessions was 13.2 with a range of 2-26. The authors also note that, overall, there was improvement in both groups although some people did not do well and there were people who fell out of treatment. About 20% of those in each group started on neuroleptic drugs during the study, but there were equal numbers in each group and this did not appear to impact outcome.

The main points they made were: this is not dangerous, this may help some people, this is an approach that should be offered. Many people choose to not take drugs and many stop them. With increasing evidence that these drugs contribute to worse outcomes, it seems imperative to offer alternatives. They acknowledge that this is a pilot study and they urge replication on a larger scale.

The accompanying editorial points out – as do the authors – that there was no placebo comparison group so we do not know if it was the specific effects of the CBT that had the greatest impact or the effect of having regular meetings with a caring, empathic person.

Not too long ago, I had a conversation with a senior researcher. I asked if he agreed – given the many problems associated with the neuroleptics – that we should be doing everything we can to identify those individuals who might get better without taking the drugs. His response was that this could never be studied. No IRB would ever approve a study.

A commentary published in Science Magazine, asked “Is It Time to Flush the Drugs?” This is not the question I would ask.

My questions are, “Is it OK to offer people alternatives?” or “Is it OK to wait before starting drugs?” or “Is it helpful to talk to people about their experiences?”

The accompanying editorial calls this study a “proof of concept” study. The concept is that cognitive therapy is an alternative to drugs. Yes, this is a small study. Yes, it should be repeated. My own thought is that the conditions and experiences that we label as psychotic are so highly variable, that there is unlikely to be one approach that will be helpful to everyone. I am drawn to the fundamental concepts encompassed by the Needs Adapted Approach.  Start with the problem as the individual defines it. Engagement is everything.  If someone does not talk to you it hardly matters what treatment you have to offer. That is where we start.

But at the next step, there are choices.

The paradigm is shifting.

122 COMMENTS

  1. CBT is just another technology….just what people don’t need. More technology.

    CBT is a process where by socially unacceptable truth is replaced with more socially acceptable lies. Lies it may be easier to live with…but still lies.

    Its brain washing….pure and simple. Brain washing usually entered into voluntarily but still brain washing.

    Buyer bewares.

    • I provide CBT to clients with anxiety problems, who have fears of particular objects or situations that are out of proportion to the actual danger posed by them. In CBT, I help my clients to face their fears so they can find out for themselves, through their own experience, how dangerous and intolerable (or not) feared situations really are.

      I do not use verbal persuasion to replace my client’s socially unacceptable thoughts with socially acceptable thoughts, nor do I personally know any other CBT practitioner who does this. The CBT I know is about helping clients live more meaningful lives by developing a more reality-based and useful perspective on matters of concern to them, and (critically) by acquiring new patterns of behavior that allow them to come to this perspective and pursue their own ideas of what living a fulfilling and meaningful life looks like.

      Because this is my notion of CBT, I am a bit perplexed by your description of this therapy. If I help an anxious client face her fears of, say, driving, and she learns through her own experience that driving is acceptably safe and tolerable and no longer fears and avoids driving as a result, have I brainwashed her? Have I replaced socially unacceptable truth with socially acceptable lies? Please help me understand. If you are referring to a different kind of CBT approach, understand that CBT is an umbrella term that includes many different theories and technologies, not all of which are created equally.

      Best,

      Brett

      • @Brett

        I have never heard of anyone being involuntarily detained because they fear driving. But then the U.S. is a car obsessed society so I suppose its not beyond the realms of possibility. But we will go with this trivial example as its the one you have chosen even though the article is about “psychosis”.

        That driving is acceptably safe is just an opinion of yours. It is a socially acceptable opinion, after all its a belief most people hold. However in 2012 34,080 people died on the road. 1.14 percent, if we looked at injuries we would get an even bigger number.

        It’s perfectly rational to be concerned about driving and perfectly rational to decide getting in a car is not worth the risk. It’s not the view of the majority of people….but thats not the point.

        The point is that your job is persuade your client by what ever magic talking therapy device to hold the “socially acceptable” view.

        The only way to fail an assessment for CBT is to say you don’t want to do it. It’s brainwashing but it’s brainwashing that people go into voluntarily. Your clients have to want to do it…submit to the process…

        Brainwashing is a harsh word but it is an accurate word.

        As an aside I see that you presume to be the final arbiter of what counts as reality and what might count as a “useful” perspective as well…. all of which I am sure you will claim are perspectives you are careful not to impose on your clients….hmmmm

        • I did not know you were referring to CBT for psychosis in particular, since you did not specify this and CBT is a general approach for all manner of human suffering. You called CBT brainwashing and suggested it is a tool of social control. I highlighted what I thought was an example of CBT that was not these things. You called this a “trivial example.” The example I described is a common application of CBT for the most common type of mental health problem. Calling CBT for anxiety (i.e., helping anxious people face their fears) is an interesting example of “trivial.”

          Please re-read my post. Ask yourself is this is an accurate description of the type of CBT I described: “The point is that your job is persuade your client by what ever magic talking therapy device to hold the “socially acceptable” view.”

          try also:

          “…you presume to be the final arbiter of what counts as reality…”

          I described having patients learn what reality is from their own experience. Not my attempts at verbal persuasion. “Useful” is defined based on its function in the client’s life, not its consistency with my own beliefs about the nature of things. Are you sure you are not conflating the CBT I described worth a straw man CBT in which a bad therapist imposes his or her social political views on the patient? I’ll refrain from responding in kind with a snarky ad hominem attack.

          • @Brett

            I’ve read again and stand by my view.

            As to the claim that any therapist can eliminate all their personal bias from the encounter is a myth. Even an attempt at neutrality is to introduce a bias in itself.

            The idea of the object neutral observer is a conceit usually ascribed to psychiatrists but psychologists often make the same claim.

            I’m sure their is such a thing as a bad therapist…I also think that every therapist would agree with that statement. I doubt however if you surveyed every therapist you would find any who said that they were such an example.

  2. I am struck by the fact that the CBT group was given weekly sessions for only 9 months, but then over the remaining 9 months of the study, only another 4 optional CBT sessions was offered. That is no real test of a non-drug therapy. Certainly the drug group was encouraged to stay on the drugs for every day of the 18 months; why, with what is generally seen as a life-long affliction, would they essentially discontinue the CBT after 9 months (or for that matter, confine sessions to just once a week)? That reminds me of the Metro study of “ADHD” in which they discontinued the non-drug therapy well before the end of the study.

    This is, indeed, a proof of concept study. I just hope they grasp what the concept really is. There’s nothing magical about CBT – it’s no better than a lot of approaches, except it lends itself to clinical trials because it is manualized. This looks like an example of the street light effect, where they study something because it’s easy to study, not because it’s the most promising approach. CBT alone does not represent the many possible psychosocial approaches to the “patient’s” family, social environment and work and educational environs – all of which could greatly enhance the effectiveness of psychosocial approaches to “psychosis.”

    Open Dialogue is the best documented example of a real “full court press” psychosocial approach, and it puts the effectiveness shown in this study in the shade. It is easy to see why the Lancet study doesn’t appear to undertake something like Open Dialogue: 1) conventional psychiatry won’t touch the “unscientific” Open Dialogue, while CBT looks far more “scientific” to them, and 2) Mobilizing resources and training staff to implement Open Dialogue where it hasn’t previously existed is a daunting task.

    The study is helpful, but I hope people see how far reaching its “proof of concept” really is.

      • The stats I present are not complex – Effect sizes are essentially the mean of CBT minus the mean of TAU (divided by the standard deviation)
        Compare this to the inordinately complex stats performed by the authors of the paper!

        Anyway, looking at my post, you will see that if you compare the CBT and TAU groups at the end of the intervention (9 months) – they do not differ on total PANSS symptoms, positive PANSS symptoms or negative PANNS symptoms.

        In other words CBT has no impact on symptoms of psychosis – which is completely consistent with our recent meta analysis of 50 RCTs of CBT for psychosis in medicated patients (British Journal of Psychiatry) http://bjp.rcpsych.org/content/204/1/20

          • Steve – Treatment as Usual (TAU) in this study has no relationship to what we normally understand by TAU – take a look at the paper – many patients in TAU were simply ‘discharged’ – that is not TAU

  3. I did suffer from longterm withdrawal or rebound syndrome. CBT type psychotherapy got me out of trouble and this is better than largactil. Mindfulness from Buddhism has been around for 2,000 years. When I get an anxiety attack mindfulness works, I know this from practice and result. When I’m stressed my ‘head’ tells me lies. When I’m calm problems seem manageable.

  4. Oh blah blah blah blah! This study doesn’t matter because science doesn’t matter to psychiatry. This is just yet another we-need-more-research merry-go-round. The NIMH studies in the 60’s and 70’s ALREADY showed that non-drug alternatives were safe and effective. That was 50 years ago!

    And around and around and around and around we go.

    It’s time that people just took all this as evidence… for a criminal prosecution.

      • JeffreyC,

        I doubt skeptics in the psychiatric community will acknowledge CBT, Open Dialogue, or any psychosocial alternative to biomedical treatment for schizophrenia until clinical researchers conduct a study in which treatment-naive people diagnosed with schizophrenia are randomly assigned to either (a) “standard care,” representing the consensus best available biomedical approach emphasizing the disease model and “antipsychotic” drugs, or (b) a psychosocial alternative in which antipsychotics are used either very judiciously or not at all. If such a study, powered with a large sample size and conducted by reputable researchers funded by a large government grant, finds that (b) is unequivocally better than (a) both acutely and in long-term follow-up assessments, the psychiatric establishment may be convinced. This is a high bar, but I’m guessing this is what it would take.

        • No, they wouldn’t be convinced. There is already mountains of evidence against psychopharmacological treatments, on top of that fact that there has never been good evidence to support psychopharmacological treatments in the first place. They know the drug companies and their “science” is corrupt and they’ve had no excuse not to know this for decades.

          If such a huge double blind study were done and came to such a conclusion, they’d still say “more research is needed!”

          People need to wake up to the fact that psychiatry is a criminal enterprise. Performing widespread malpractice for the sake of medicaid and insurance company reimbursements because nobodies going to pay them 160k a year to talk to people about their problems.

          Harm for the sake of profit. It’s that simple. A case can be made that no reasonable and intelligent person would have chosen their side of the fence based on the evidence unless they had such a conflict of interest. When thinking about all the children whose lives have been ruined by these days, such as myself, there’s no way they should not be facing criminal charges. They never had any good science to begin with and for 50-60 years studies have been coming out and discrediting their nonsense and yet they kept going… and still keep going.

          • For crying out loud, the research discrediting their nonsense is already many times more significant than the dubious drug company and drug company front studies that they use to support it! They’re just like creationist in the fact that they make up their opinion, claim it’s the truth and then no amount of science can convince them otherwise. It’s like when Kent Hovind said he’d accept “the theory of evolution” when a scientist showed a monkey giving birth to a human baby! The fact that most of the studies discrediting their nonsense have been replicated, and the fact that most of this evidence was conducted by people on that side of the fence trying to find SUPPORT for drug treatments… in any other field of science, this would have been considered conclusive decades ago!

            Neuroleptics especially have been shown to damage the brains of all animals that they were ever tested on! And now when human studies show that same damage, they say it’s caused by the illness!!! They hold up those “early and late grey matter” brain scans IN THEIR DEFENSE — IT’S THE SCIENCE THEY HANG THEIR HAT ON!

        • I disagree.

          I don’t think it will matter how many good and reputable studies we do, biopsychiatry will not turn loose of its stand about the need for the toxic drugs. There are far too many things tied up in this for many psychiatrists to admit that other things work better than the drugs.

          Their lifestyles, bank accounts, large houses in gated communities, prestige as “real” doctors, and egos are too tied to the present belief system about treatment. There’s a quote from Terence McKenna that kind of sums things up. “The eyes are useless when the mind is blind.” Too many psychiatrists are “blind” in their minds and refuse to entertain anything other then their approach to things.

        • But that’s what Loren Mosher did back in the early 70s, and they didn’t want to believe it and fired him as head of schizophrenia research and defunded the program! These people aren’t interested in science, they want to be RIGHT so they can keep making MONEY. Anything that challenges their religious worldview will be thoroughly trashed and anyone supporting these views will be personally attacked or ignored. That’s how they work. They’ll never be convinced by evidence, because they aren’t interested in evidence. Our only hope will be that new practitioners will be educated as the older “key opinion leaders” die off, while patients continue to demand more options. Psychiatry will be dragged kicking and screaming from their dogma, regardless of the facts.

          —- Steve

    • JeffreyC,
      Mine ears have never seen a more accurate comment than yours on Feb. 9 2014 at 7:12 PM

      But I wonder how do we arrive to a criminal prosecution

      When psychiatrists themselves have always been
      Inquisitor, Judge, Jury,Torturer,and Executioner to multitudes ?

  5. Since apparently, if I read this right, the research subjects were people who refused drugs and were not receiving them, I’m not sure what important conclusions could be drawn from this research. These are very atypical people. CBT vs. drugs would be much more meaningful.

    Whatever conclusions can be made from this study, I don’t see it as that revelatory. I wish it was.

  6. Thanks for posting this Sandra. I think eventually alternative models for handling first time psychosis will at least be acknowledged, if not promoted. However, as a therapist myself, I wonder about the real world application of CBT as a primary model of care. Would insurance companies pay for ongoing therapy to work through psychosis? The vast majority of people I work with are poor and have Medicare or no insurance. If they receive benefits they can see a provider once every couple months, a case manager infrequently and maybe some group therapy once in a while. Weekly one on one CBT visits seems luxurious.

    Sadly, we have moved to the ten minute drug based model of care because its easier, simpler and (I assume) cheaper for insurance companies. The only way I see this model changing is to present evidence that alternative systems such as CBT/Open dialogue can provide cost savings to insurance companies.

    • Dear Johnathan , Recovery (30 yrs) for me was due to Basic Psychotherapy (it wasn’t just beneficial). I can substantiate the Recovery. This has saved the Irish welfare state about 1.5 million euros or £1 million in sterling.
      In 2012 I caught my GP covertly claiming for me as a Severely Mentally Ill person by way of SMI Register (I’m a subcontractor in the building industry). He took me off it very quickly and fiddled around with diagnosis when I challenged him. I pushed for full acknowledgement and it escalated. Its now with the Ombudsman.

  7. Sandra,

    A non-drug (or less drug) approach has proven to be successful for years:

    “We identified 3 controlled trials involving a total of 223 participants diagnosed with first- or second-episode schizophrenia spectrum disorders. There were few major significant differences between the experimental and control groups in any of the trials across a range of outcome measures at 2-year follow-up, though there were some benefits in specific areas.”

    More here:

    http://www.moshersoteria.com/articles/review-of-the-soteria-paradigm/

    Whether it’s the safe environment provided by non-professionals who worked within the Soteria Project; or Open Dialogue, CBT; or a holistic approach that utilizes orthomolecular medicine:

    http://www.earthhouse.org/index.html

    IMO, it matters not.

    There are *plenty* of ways that work.
    We haven’t begun to scratch the surface.

    Duane

  8. I wonder how many individuals have the ability to access CBT.

    My county’s public mental health system serves over 40,000 annually and the menu is limited to meds, beds (the hospital), crisis intervention, limited individual therapy, the day programs, and the sheltered workshop. Specific treatment modalities are rarely mentioned, off the menu alternatives are never mentioned and getting any treatment at all is challenging.

  9. Reminded.

    The Partnership Model
    “…professionals and non-professionals work together to provide services. The recipients of services are told that they, too, are partners in the service. However, the distinction between those who give help and those who receive it remains clearly defined. I consider services based on this model to be alternatives in name only. The overwhelming majority of alternative services […] fit into the partnership model.”

    […]

    “‘Alternatives’ based on the partnership model continue many of the same abuses.”

    The Supportive Model
    “…membership is open to all people who want to use the service for mutual support. Nonpatients and ex-patients are seen as equals, since everyone has problems at some time or other, and are capable of helping one another. Professionals are excluded from this model […] because they use a different model of helping, which separates those who give from those who receive help.”

    The Separatist Model
    “…ex-patients provide support for one another and run the service. All nonpatients and professionals ae excluded because they interfere with consciousness raising and because they usually have mentalist attitudes.”

    Open Dialogue is a Partnership Model and is thus not a true alternative. Soteria, as defined above, is a hybrid Supportive/Partnership Model and is also thus not a true alternative.

    As Chamberlin underlines: “Totally nonprofessional (ie. Separatist) alternatives for people in crisis are truly separated from the mental health system.”

    In “On Our Own” Chamberlin consistently and convincingly argues that orthodox models of care for the mentally distressed and distressing are harmful. Alternatives that spring up are most often, under closer examination, alternative in name only.

    • I find your thoughts interesting and somewhat challenging.

      I think all social movements need a separatist edge (radical feminists, black consciousness, LGBT, working class unions and other groups all have separatist groups).

      However they also integrate and influence the mainstream.

      I think Open Dialogue can be thought of in two ways:

      1 the way the mental health system in Western Lapland is organised with funding from the state, managerial systems, administrates and workers who carry out the job.

      2 a way or organizing meetings with family and social groups where a member is suffering extreme mental distress with the intent of relieving the suffering of the person who is mentally distressed. The skills needed are:
      a) to be able to shut up and listen
      b) to be able to ask tactful questions and use other conversational methods to enable participants to talk about and reflect on their experiences of the distressed person and of each other
      c) the ability to observe and think about how people in the group are getting on and tactfully tell the group what you have noticed. If you are lucky they listen and slightly change how they are treating the distressed person and each other in such a way that reduces the distress by helping people understand each other and get on better.

      Anyone can use this method if they so wish whether they be professionals, non-professionals or ex-patients. Many people use elements of this method already.

      Soteria can also be thought of in two ways
      1 a research project of the NIMH with funding, admin, managers, buildings and staff
      1 People who are very distressed living with some quite nice people. The quite nice people get to talk over how living together is going with someone who is quite nice once a week so that any difficulties are ironed out. Generally this helps distressed people calm down and feel better.

      Anyone can use this method if they so wish whether they be professionals, non-professionals or ex-patients.

      We definitely need more separatist consciousness raising amongst ex-patients (or Survivors of the disgusting and damaging state funded cult of Psychiatry as they used to be known)

  10. A Separatist Model environment may be the best place to give and get a real hearing of real alternative lived experience based, smorgasbord healing of the* first do no harm* kind ,while at the same time having the best chance of recognizing and birthing ongoing honest alternatives that can maintain integrity and help a growing number to leave behind the morphing all engulfing, mindless and heartless, posturing criminal ruthless, PsychopathiclyPsychiatricElectricDSMpharmaStranglehold.

  11. I think, neither CBT nor drug therapy are totally bad. They are just variants of treatment available for participants of mental health system. What is of primary importance for me is non-coercion and humanistic attitude towards these participants by mental health practitioners and academicians. Otherwise, they would not be participants of mental health system anymore; they will become victims of the violence initiated by this system – or, to be more precise, by the powerful social groups who define what is “normal” and “abnormal” according to the discourses they propagate, and regularly resort to violence to suppress forms of experience, interpretation and behavior which contradict the picture of the world they want to draw. Therefore, mental health system which initiate violence becomes the repressive tool of the current social order, hiding under the deceitful interpretations provided by the dominant culture – interpretations which describe as pathology everything (and everyone) that do not submit to them.

    The core humanistic, non-violent mental health theory and practice is its genuine attention to, and respect for, humans and humane existence in all its diversity and complexity. Unlike medical model, humanistic approach is based of a non-condemnatory acceptance of “abnormal” and “deviant” perspective, with providing necessary support in the process of the person’s inner integration inside its own psyche and outer integration in society and culture. For the mental health professional who embrace such approach, the aim of therapy (and therapist) is to assist the person in reclaiming his or her wholeness, by productive synthesis of all parts of personality, whether they are considered “normal” by the dominant discourses or not.

    So, such attitude strongly differs from the tendency of medicalization of deviance and coercive conformism, which is characteristic for the mainstream mental health system. This system is not interested in the integration of “normal” and “deviant” parts of psyche, society and culture; to the contrary, it is interested in suppression (if not outright elimination) of the forms of the human existence – experiences, interpretations, behaviors – that differ from what is considered to be “the objective reality” by the powerful and authoritative sociocultural forces and groups. But the concept of “the objective reality” is just a philosophical assumption, historically formed and refined in the Western culture as a result of principal body-soul dualism of the dominant theological tradition of Christianity. Later it was transferred from theology to philosophy, and gained power – I suppose, not only because of philosophical argumentation, but mostly as a result of social pressure to accept one parts of nature and deny the others. It is one of many interpretative models, exalted by particular power-relations in the rigid and hierarchical social structure and expressed with the language which is typical for the dominant, institutionalized culture. In the past, when the cultural authority was organized religion, it was the language of theology, denouncing the anomalous forms of human existence as “sin” and “devilry”. Today, the ideology of scientism, with its absolutisation of biophysical aspects of nature, re-defined “sin” and “devilry” as “delusion” and “hallucination”. It fact, what we have here is just the anomalous behaviors, interpretations and experiences, something which is ignored or denied by the social institutes of power. It would be quite accurate to use the term “consensus reality”, which precisely catches the problem of authoritarian approach to any anomalous, out-of-consensus phenomena; their non-dismissive interpretations by experiencers, researchers and supporters; and social activities based on such interpretations.

    Humanistic therapist should always be acutely aware of the impossibility to strictly separate “real” from “unreal”. What we have for sure is the field of experience, in its wholeness and diversity. People always tried to separate it in this or that form, projecting semiotic classifications of discourses preferred by them onto this phenomenal field, and pretending that such separation is “really true”. However, as humanistic therapist should understand and remember, all such separations are conceptual, the implications of this or that arbitrary discourse, which produce the constructive sociocultural reality-tunnels of groups and persons. However, the existential experiential reality-as-whole still remains itself in full, in all its irreducible complexity; and particular persons and groups would still either experience it as a whole or – more often – create their own alternative reality-tunnel.

    Of course, such experiential defiance perceived as an insult by authorities, which have an unpleasant tendency to confuse discursive and phenomenal, presenting (and perceiving) their preferred interpretation of existence as existence itself. For them, their interpretation is “real”; therefore ones who deviate from what is “allowed to exist” must be somehow deficient. Being in control of language, authoritarian groups are free to attach any symbolic labels to the “deviant” experiencers, stigmatizing them this or that way: they were “puppets of Satan” in the religious past; they are “mentally ill” in the scientistic present. Being in position of power, authoritarian groups are free to initiate violence against the “deviant” experiencers, condemning them to torture; their control of language let them to disguise such violence under the rhetoric of “helping them” and “doing it for their own good”. So, anomalous experience is suppressed under the conceptual disguise of either theology or medicine; but what we have here is, in fact, is extremely cruel, oppressive and deceptive form of pedagogy.

    Dichotomy between “objective” and “subjective” is pedagogic in nature; it is put into our minds in childhood, during the process of our socialization, which results in semiotization of experience according to interpersonal connections and resulting social needs (which are the integral part of a larger social structure, and are largely determined by the dominant discourses). So-called “madness”, therefore, is not a form of pathology, as proponents of medical model insist. It is either refusal or inability to conform to the phenomenal and discursive demands of the social authorities; a non-compliance which, being voluntary or involuntary, let one to prefer one’s own existential nature to the pedagogic pressure; to prefer one’s existential-phenomenal integrity to the interpretative models provided by the discourse imposed by the pedagogues.

    Therefore, practitioners of coercive psychiatry are in fact guardians of social power-relations, maintaining the powerful ones’ interpretation of experience from the anomalous experiences and experiencers, as well as from the alternative interpretations and interpreters.

    Well, all what I said is quite critical. Yet, the main difference of the phenomenal reality from the authoritarian rhetoric is its diversity and complexity. It is not simplistic black-and-white picture; there is no “absolute good” and “absolute evil” there. Any phenomenon has different sides of it, if being perceived from different perspectives. Mental health system is no exception. There is not only authoritarian cruelty there; there are some positive roots of genuine support for the people in mental and spiritual distress.

    These roots are seen in the work of people who came to the system with honest humanistic intention, with a real goal of helping people – and had enough integrity, sincerity and volition to resist indoctrination by the deceptive theories and involvement into violent practices. Ones who saw that the horrible reality of the system has little to do with the propaganda of “beneficial treatment” under which it hidden itself. Ones who were persistent enough in their honest desire to really help people in distress and courageous enough to raise their voice against the situation where the institutions which were apparently created to help ones in distress in fact produce such distress, in terrifying quantities and qualities.

    Psychiatry – as well as psychotherapy, counseling, social work, education, spiritual guidance and so forth – can really help many people suffering from the mental, social, spiritual problems. But to do that, they should not initiate violence against the very people whom they are going to help. By initiating violence, they betray not only these people, who put their trust and hope in them but were subjected to torture – they betray themselves, throwing away the identity of the helping professional and embracing the one of the repressive inquisitor, and yet hiding under the language of “treatment”.

    And to maintain awareness and understanding of their duty of the helping professionals, and to prevent themselves from degradation to the role of professionals of repression, they should always perceive – and treat – people as people, not as dehumanized biological robots. These are persons with whom they are dealing with, not clusters of symptoms on which one could stamp a medically-sounding label.

    As for humanistic theory practice, it can – and should – be diverse, allowing people to choose the form of it which they prefer. It may be CBT, too; it may be something somatic in nature, operating under integrative biopsychosocial conceptual network, such as exercise, nutrition, or drugs – yes, even drugs. They are not totally bad; they may be used a voluntary choice by mental health system participants who chose them being honestly informed about their side-effects and potential dangers. This is their body, their mind, their consciousness; they are free to transform it, to seek a support in such transformation from the people with necessary knowledge and skills, and to refuse to participate if don’t want to.

    And they should be treated and respected as persons whether they choose.

    This is my view. Dr. Steingard, I would be glad if you respond. Of course, I would be glad to see a response by anyone else, too!

  12. Are psychiatrists not required to toe the line as written in the guidelines of their guild and does not their refusal , risk a lowering of their cash flow ? Does not their refusal to remove themselves from an enterprise that shamelessly, barbarically even, tortures children speak volumes ? Why not the courage to throw the entire enterprise overboard ? Why pretend there are not endless amounts of human beings whose lives would be greatly improved if psychiatry did not exist ? Furthermore why pretend there are not numerous modalities in existence to actually non coercively help the human being ? Trying to reform psychiatry would at best be like putting lipstick on a pig.

  13. Dr Steingard,
    if we take it that 50 RCTs exmaining CBT for ‘schizophrenia’ have been conducted over 20+ years, we might assume that they have managed to capture a reasonable degree of heteroegenity (acute, chronic etc) – see our meta analysis published Jan 1 2014 http://bjp.rcpsych.org/content/204/1/20

    If you accept that premise….then we have ‘no evidence’ from RCTs that benefits comes from CBT – in fact the trials show that 94% and 97% of the CBT and control groups overlap on positive and negative symptoms respectively at the end of treatment – in other words, we with regard to positive and negative symptoms – at best we have 6% & 3% who ‘may’ benefit – this does not seem – to me – to be sufficiently large to warrant investing public money and hope in such an intervention.
    If someone can show it works for a predefined subgroup, that is great, but it has never been achieved – and these RCT participants are the ones most likley to benefit (having been screened into demanding studies that last months)

    Re Cognitive remediation, I dont know the package you mention and havnt seen their papers, but am familiar with the general literature – and it indicates a benefit in the order of just under half a standard deviation improvement in cognitive performance.

    So, cognitive remediation currently offers more hope than CBT – but addresses cognition rather than symptoms (which may, indeed be the problem for CBT – it is being sold to sufferers as a quasi-neuroleptic)

  14. This is a fascinating discussion between Dr. Steingard and Dr. Keith Laws. From my quick skimming of the original post and then the comments, my understanding is that Dr. Laws maintains that 20 years of research consistently shows that CBT helps at best 5 – 7 percent , which, from a public policy point of view (money) , is not justified for the many. Before she spends her own money on training, Dr. Steingard wants to know if Cognitive Enhancement Therapy shows more promising results, which apparently it does, but it works on cognition, not symptom reduction. What I take away from this is that individuals are not statistics. My son has tested out many interventions, none of which have the Good Housekeeping Seal of Approval (except for the drugs, of course, which produce more or less the same effect in everybody)). By ignoring Randomized Control Trials, I think he’s done rather well. Had he been deterred from trying because the stats weren’t in his favor, he might not be where he is today. Most of the interventions he tried hold no scientific interest in any case. Cognitive Behavioral Therapy is a hot ticket item these days and we are hearing lots about it. CBT is one therapy he hasn’t tried, but it may very well work for the 5 to 7 %. In any case, this is an academic debate, and individuals needing help should hold a different standard by which to judge the product. Again, thanks for a good discussion.

    • Dear Rossa
      people may choose to follow paths that are ‘unevidenced’ – that is their choice – but in the UK NHS, we cannot afford to direct taxpayers money towards interventions that are shown to be of little or no use (at the expense of pursuing possibly more helpful alternatives).

      By the way, please note that I said “at best we have 6% & 3% who ‘may’ benefit” – and put ‘may in quotes – it is also possible that they ‘change’ after CBT not because they benefit but because their condition is worsened by CBT. And that is important to know – CBT for psychosis therapists have avoided documenting possible ‘harm’ of CBT therapy. Very few studies examine this but where they do, harm has been documented e.g. http://www.ncbi.nlm.nih.gov/pubmed/22759932
      We would not stand for this in drug studies – why should we in psychological interventions?

      Please also note that Dr Steingard nor anyone else here (on my quick look) mentions the fact that serious adverse events (SAE) were documented in 10% of participants in this specific trial with unmedicated individuals – including e.g. 2 deaths, one attempted suicide and one serious case of threatening another – this was in 74 people at start of study and only 51 remaining at the end (how ‘tolerable’ is this)
      – compare with 50 trials of CBT in medicated individuals covering nearly 3000 people – not one death ever reported

      • Interesting Keith. Here in the States, almost no public money is put towards individual therapy such as CBT on a long term basis. Frankly, if you are poor with only public insurance (Medicare/Medicaid) you will receive free antipsychotic medication and very occasional visits with a prescriber and a case manage. No individual therapy. Even if efficacy was shown, I doubt public insurance would cover regular CBT.

        You mention deaths and an attempted suicide for unmedicated individuals. I assume you are implying that unmedicated individuals have a higher risk of death. That is a fairly big assumption. Other studies have shown otherwise. Here’s one. http://bjp.rcpsych.org/content/188/3/223.abstract

        On the other hand there is demonstrate lee proof that antipsychotics lead to enormous health risks such as diabetes, heart disease, obesity and early death.

        Though CBT may not be the answer, it certainly does not cause an immense amount of long term health complications. If the first rule is “Do no harm”, then I would suggest the UK NHS needs to go back to the drawing board.

        • I know Jonathan, the culture is different. Bear in mind in the UK, CBT is to be “offered to all people with schizophrenia” according to national guidelines (regardless of issues of heterogeneity)

          Re adverse events, again I should note that 10% in that study is undoubtedly an underestimate because the researchers lost contact with so many participants for whom the experience was presumably not tolerable! And one-third chose to become medicated duting the trial. My point is that these adverse events have not happened in trials of 1000s where paticipants were medicated.

          Also note that TAU does not mean TAU in this trial – many of the controls were simply ‘discharged’, with no care – just followed up by the researchers

          Nobody (including me) would argue that medication has no problems, but it has to be weighed against the risks of no medication – and this trial in some resepcts highlights that dilemma

          • NICE guidlines do indeed say everyone who has a diagnosis of schizophrenia should be offered CBT and also family interventions.

            I however know very few people who get this.

            In fact the time staff in Community Psychiatric Health Teams spend with people with long term mental health conditions in the England has been cut down considerably since the last government came in and started cutting all government services. Now depot injections and seeing a nurse for twenty minutes once a fortnight and no other care for people who are very distressed is, in my experience, common.

            There is then the problem that CBT therapists may not have much experience of dealing with people who are very distressed.

            Finally, as far as I know, and my personal experience tallies with this, it is the relationship with the therapist and the client, as expressed by the client that is important. The model used is not very important at all.

          • I note Keith Laws does not look at the evidence of increased relapse rates when people come off drugs.

            Had the people who were on the no drug option just come off drugs? if so there would be a considerable risk of, “Adverse events.” I’ve seen the effect of sudden withdrawal of major tranquilizers and it is not pretty in some people. Mind you, the effect of the drugs is pretty horrible in some people too.

            A friend has developed akathesia and is taking a sleeping pill to enable him to sleep because of this. He was attacked by a friend, raped and his house was broken into – then he developed anxiety and what the services call, “Ideas of Reference,” ie he thought the TV was talking about him, when the news had bad news he imagined he had caused it. He knew it was rubbish but the services upped his drugs and did not talk about what he had gone through at all. This is typical of UK treatment of people diagnosed with bipolar and schizophrenia. CBT – rubbish (I’d write something more angry and slightly offensive but I’d get censored) how about just being nice to people who are distressed and acting odd and showing some interest in their life?

            humbug, humbug, bah. TAU discharged with no care; well in my experience it’s no care while seeing services except nasty live long tranquilizers are added

          • John Hogget (on February 12, 2014 at 1:02 pm) offers the following observation,

            I note Keith Laws does not look at the evidence of increased relapse rates when people come off drugs.

            Had the people who were on the no drug option just come off drugs? if so there would be a considerable risk of, “Adverse events.” I’ve seen the effect of sudden withdrawal of major tranquilizers and it is not pretty in some people. Mind you, the effect of the drugs is pretty horrible in some people too.

            John’s point there reminds me of an exceedingly brief exchange, that I had, with Keith Laws, via Twitter, a bit over a year ago…

            It began as I’d noticed, that, in one of his tweets, Keith was enthusiastically recommending a certain meta analysis to another twitterer — a published Irish psychiatrist (Niall Crumlish).

            Though I’m just a ‘liberal arts’ guy trained in the basic dynamics of hypnotherapy (and, so I consider myself rather unqualified to compete intellectually, in discussions of science, with such scientists), I found the official conclusions of that meta analysis to be questionable.

            So I sent Keith the following message (and never received any reply):

            …I checked out the study you were recommending.

            In doing so, something popped out, as problematic, about the researchers’ conclusions…

            (At least, that was/is my impression.)

            So, I sent you both two tweets.

            Here’s the first tweet I sent you,

            “Note prominently p. 5: “Antipsychotics were mostly withdrawn abruptly, [only] 11 studies included gradual withdrawal” @Keith_Laws @niallc74″

            Here’s the second tweet I sent you,

            “Naturally, abrupt withdrawal leads to seeming ‘relapse,’ as abrupt withdrawal symptoms are the result. @BeyondLabeling @Keith_Laws @niallc74”

            You replied,

            “@BeyondLabeling @niallc74 Sorry , not understanding what you are saying?”

            Keith, the researchers’ “Interpretation” of their meta-analysis study is, that, “Maintenance treatment with antipsychotic drugs benefits patients with schizophrenia. The advantages of these drugs must be weighed against their side-effects. Future studies should focus on outcomes of social participation and clarify the long-term morbidity and mortality of these drugs.”

            I am pointing out, to you (and to @niallc74): Their study regards 65 trials, only 11 of which studied *gradual* withdrawal from those drugs.

            I.e., the vast majority of the trials they studied were looking at effects of *abrupt* withdrawal from the drugs.

            And, everyone who knows anything at all, about these drugs, knows, that: abrupt withdrawal leads to severely disabling effects, almost always.

            Indeed, those effects tend to look like ‘relapse’ of the original ‘symptomology’ – or worse.

            So, of course, they’re going to be looking at a lot of seeming ‘relapse’ of so-called symptomology, in this particular meta-analysis.

            It’s really a whole lot of severe *withdrawal* effects, that’s being recorded, in most of those studies, and the researchers’ “interpretation” of their meta-analysis is failing to emphasize that very important point.

            Therefore, it’s my opinion that the researchers’ interpretation is sorely lacking.

            If, perhaps, you have time, here’s an interesting paper on the ‘meta-analysis’ process…

            Clinical judgment in psychiatry.
            Requiem or reveille? (by GIOVANNI A. FAVA)

            http://informahealthcare.com/doi/pdf/10.3109/08039488.2012.701665

            Kind Regards,

            J.

            http://www.twitlonger.com/show/jk3i8u

      • John
        you say “There is then the problem that CBT therapists may not have much experience of dealing with people who are very distressed”

        According to many influential CBT for psychosis advocates, CBT does not need to be delivered by people with highly specialist training e.g. as here advocated by authors who are members of the NICE committee or have been members http://www.rima.org/web/medline_pdf/BrJPsychiatry_40.pdf
        In this study they were trained for 10 days to deliver CBT for psychosis

        • John
          in reply to “I note Keith Laws does not look at the evidence of increased relapse rates when people come off drugs.”

          I gather from your comment that you have not yet read the paper being discussed here. It is freely available on link in my blog http://keithsneuroblog.blogspot.co.uk/

          The individuals tested in this study were either never medicated in their life or drug free for a minimum of 6 months

          So the adverse events are not a reaction to drug withdrawal

          • Beyondlabelling
            I cant recall a 140 character discussion on Twitter after 12 months, nor do I see if you replied to me when I said I didnt understand your point?

            The reason I ask is because if you read that whole paper to which you refer, you will see that Leucht et al directly examined abruptness of withdrawal in the results and say
            “Abrupt or gradual withdrawal of prestudy
            antipsychotic drugs did not change relapse risk” – so perhaps you didnt read it fully

          • Keith,

            A long time has passed, so I don’t blame you for not remembering the exchange.

            RE: “nor do I see if you replied to me when I said I didnt understand your point?”

            To refresh your memory, here’s the link to my tweet reply (1:46 PM – 11 Oct 2012):

            http://twitter.com/BeyondLabeling/status/256495979291877377

            If you follow that link, you can read that tweet and see that it ends with a link to my TwitLonger message to you.

            You must have missed that tweet.

            Not a big deal.

            Respectfully,

            Jonah

            P.S. — And, Keith, that quoted line, which you offer from Leucht is, I believe, highly disputable. It should be questioned.

            It’s a completely counterintuitive conclusion (not that that makes it wrong); but, in fact, because it is so counterintuitive, I certainly did read the entirety of that paper… and found that there’s plenty of reason to question it, based on comments within the body of that paper itself.

            For example, see the last paragraph of page 6 of that Leucht PDF:

            “Viguera and co-workers’ primary meta analysis showed that abrupt or gradual withdrawal of treatment did not alter the effect, but in an individual patient analysis of three trials, investigators reported significantly higher relapse rates after abrupt withdrawal than after gradual reduction…”

            Also, most prescribers know nothing about tapering (i.e., truly gradual reductions); hence, I suspect, in most instances, what is reported as “gradual reduction” from neuroleptics reflects a rather swift rate of reduction — rather abrupt, after all (not truly gradual).

    • hi

      This blog is very stimulating.

      There’s no such thing as a chemical imbalance in the brain. The reason people don’t recover is because tranquillisers are not medicine and problems remain unsolved.

      I was heavily  diagnosed and long term  recovery was  as a result of psychotherapy.   This is because psychotherapy provides  solutions.

      CBT for me  is the same as the other therapies only that the terms and explanations are easy to understand. But I think the therapist would need to have insight to be able to apply it. I found elements of it helpful but that was all I needed.

      I think its more or  less accepted now that  the psychiatric drugging and disease model  approach causes the chronic disability.

      CBT is not magic, its hard work like all big changes, we all want to go to heaven but no one wants to die.

    • I personally came out of the cave of psychiatry by testing many different things on myself, sometimes or often against official orders, walking many wrong roads, correcting the path when I realised it was a wrong path, etc. Hard to test this kind of thinking with RCT. I eventually found a system (low-carb diet, exercise, basic psychology on habits etc, some Eastern practices such as zen) that works very well for me. I could have chosen drugs such as neuroleptics or SSRI, but eventually I considered them not useful. I found the techniques that actually worked largely through my personal self-experiment, study, etc. Some other person may have another set of techniques or drugs that work for them. I also understand I had enough money, education, time, etc, to think and experiment like this.

      • Hermes, I think this is one of the sanest approaches to managing mental health, whether it is sanctioned by “Science” or not. The problem we encounter when relying entirely on double blind studies is the sheer complexity of experience that can not be reduced to simplistic controlled studies.

        How can one possibly do a double blind study that tests the efficacy of a low-carb diet, specific exercise, basic lifestyle psychology and zen meditation vs. antipsychotics? There are too many variables. There is bio-individuality. Length of chronicity of illness. Age. Community support. If the person has been on drugs or not before starting the study. And on and on.

        I think its deeply important for someone who is going through severe emotional distress to experiment with a number of ways of helping themselves. As long as those ways aren’t potentially harmful, it can be incredibly fruitful to explore ways of managing mental health that don’t involve extremely powerful drugs that are destructive to health long term. Capital S Science might not back you up…but the proof is in your own level of well being.

  15. In any case, I actually prefer to be in the TAU (treatment as usual) group in the sense of this study, which is stopping drugs & psychiatrists and not getting therapy of any kind either. Nice to hear it’s more effective in some senses compared to CBT. 😉

    • Factchecker
      I have read the new study published today http://ajp.psychiatryonline.org/article.aspx?articleID=1831621 and it does not contradict anything we say in our latest meta analysis.

      Just saying this does not make it so – if you feel it does, then by all means please be specific in this forum

      The paper you mention has one ‘accidental death’ – it alters nothing – even if its 1 death (accidental) in 50 trials of medicated individuals (2500-3000 individuals) vs 2 deaths in one trial of (74 individuals reduced to <40 at trial end) unmedicated indviduals

      Nobody denies deaths in antipsychotic trials – its an irelevant argument to what I am saying

      Perhaps even tell us who you are if you are going to accuse me of smears

  16. Dear Keith,

    I’d like to relate my own full and longterm recovery to you as a result of basic psychotherapy. I can substantiate what I say.

    In 1983 when I stopped the Modecate depot injection  I became disturbed and had to go into hospital. A psychologist in there told me everyone one could get better without drugs.

    In the next 6 months I eventually  recognised withdrawal syndrome and I began a slow taper.

    What works for normal anxiety works for extreme anxiety:

    It is very difficult to stop fearful thinking when the worst thing seems likely to happen. But its  possible to do this very  gradually and  eventually the anxiety stops.

    When the anxiety stops the opposite to anxiety  happens: things don’t seem larger than life and the worst thing doesn’t seem likely to happen and  problems can be worked out along reasonable  lines.

    My experience is that the non drug approach works brilliantly  for ‘Schizophrenia’.

  17. Dear Fiachra
    I wouldnt doubt your experience for a minute – I am pleased that you found it helpful. Many would say similarly of medication.

    I am only asking that people are allowed to assess the evidence for every intervention whether its psychological or drug based. Especially non-scientists ie the vast majority of people needing these drug and talk therapies – we have a duty as scientists to make clear to the public…what are the pros and cons

    The problem is that drugs are painted as bad and psych interventions are painted as good – it is of course not that simple. If you are radically changing someone’s thinking with drugs or talk – we need to be aware of the chances of benefit and of course, the chances of harm.

    We are all aware of the negative consequences of antipstchotics (and maybe the evidence on the potential benefits) – by contrast, we know next to nothing about the harm of CBT (and where evidence exists, it suggests it may be harmful in psychosis – I gave one referenced example above)

    Re the benefits of CBT for psychosis, these are sadly -at best – minimal (according to the evidence from large groups of individuals in trials – at least in terms of reducing symptoms
    themselves)

    Finally, we might also ask why CBT for psychosis researchers do not routinely examine potential harm in their RCTs – we wouldnt allow drug companies such leeway…would we?

  18. Dear Keith
    Thanks for replying. I did see coverage your study in the general media.
    My psychiatric treatment was very unsuccessful and expensive. I did have a number of suicide attempts and a number of near misses relating to the depot medication. I think that for any talking treatment to work the therapist has to know what they’re doing. My own psychotherapy was ‘holistic’ and outside of the NHS and by way of my own choice.
    I do definitely believe that a ‘dodgy’ psychotherapist could skrew the head.

  19. The underlying assumption behind all the “cures” is that the “mentally ill” person is a machine that was either poorly made or has a broken part. That the behavior of our psychotic might be the an act of intelligence is simply too far fetched. So we have to do something to make this person functional. What shall we do? Over the years highly trained individuals have tried all sorts of crazy things like lobotomies, electro convulsive shock, all sorts of drugs with varying usually not satisfactory results. Since drugs bring in so much money they have to be keep in the process. The things that do work are person intensive and therefor usually too expensive. And keep in mind that some persons just want to be they way they are, e.g. the great German poet Holderlin. The mysteries of the human being are far subtler than the psychiatrists and their “science”. I am glad alternatives are being tried. R.D.Laing and others recommended these years ago–but they were not profitable for psychiatrists. So . . .always looking for the money maker the pharmaceuticals made one of those deals with the devil along with the psychiatrists. The whole field of mental health is now so corrupt I do not know what can be done. I simply feel compassion for those that find themselves confined somewhere within loveless walls.

    • Dear AgniYoga
      Suitable treatment might be promoted as being more expensive but it doesn’t have to be. The best advice and support can be from the independent self help groups, these groups are everywhere.

      A Soteria communal house, might cost less than a ‘psychiatric’ communal house.

      The idea behind the ‘Chemical Imbalance’ the ‘Bio Research’ and the ‘medication’ is that it keeps the Doctor in his job, in Authority, and at a Medical Rate of pay.

  20. Yes, I agree with you; and these groups are often more helpful than the “professionals”. I was alluding to states finding it easier on budgets to simply hand out medications and skip talk therapy. The idea that these medications really help is not based on science. However, they keep some people in a docile trance.