Science notices that “For decades, antipsychotic drugs have been the main line of defense, but they have serious side effects and lots of patients end up not taking them. Recently, a number of clinical trials have suggested that psychological approaches, including old-fashioned “talk” psychotherapy and a method called cognitive behavioral therapy, can be moderately effective in many cases. These techniques engage with the human being behind the symptoms and are attracting increasing attention from the medical profession.”
Balter, M., Talking Back to Madness. Science. March 14, 2014. 343(6176): 1190-1193. DOI: 10.1126/science.343.6176.1190
From the article:
“Most schizophrenia experts subscribe to the stress-vulnerability model of the disorder, in which some individuals have a greater predisposition—either because of genes, childhood trauma, or environmental factors—to psychosis than others. In vulnerable people, psychotic episodes are often set off by some sort of stressful event, usually in the late teens or early adulthood.
“But past psychological approaches, such as psychoanalysis, have shown limited success in treating the disease. Sigmund Freud, the founder of psychoanalysis, eventually gave up on using it to treat psychotic patients, although a number of later post-Freudian psychiatrists continued to use it with sporadic success. When antipsychotic drugs arrived in the 1950s, with their clear ability to dampen the worst psychotic symptoms, psychotherapy became increasingly marginalized.”
“Drugs have serious side effects, however, and at least 50% of patients either refuse or fail to take them, according to recent studies. Moreover, the search for genes behind schizophrenia and other mental illnesses, which might lead to new drug therapies, has failed to produce any smoking guns and has led only to the discovery of a large number of genetic variants, each conferring a very small additional risk. “We’re trying to fix something, but we don’t know what’s broken,” says Brian Koehler, a psychologist at New York University in New York City who also sees schizophrenia patients in private practice.
“Now, psychological treatments are gaining ground again. Most advocates of psychotherapies insist they are not claiming that schizophrenia is purely a psychological malady caused by a dysfunctional family background. “We’re looking for a much more nuanced form of psychiatry that doesn’t reject biology, but that is able to situate the biology within the realm of lived human experience, which is socially and culturally determined,” says psychiatrist Pat Bracken, director of mental health at Bantry General Hospital in Ireland.
“In 2012, another team confirmed that CBT could be effective for so-called negative symptoms of schizophrenia, such as emotional distance, apathy, and social withdrawal, which are usually much harder to treat.
“And the most recent CBT trial, published last month in The Lancet
, concludes that CBT might serve as a substitute for antipsychotic drugs in some cases, rather than just an adjunct to them as in most clinical studies (see Science
). In this study, 74 schizophrenia spectrum patients who were being treated in Manchester and Newcastle, and who had declined to take drugs, were randomized by computer into two groups, one receiving TAU and the other TAU plus CBT.
“After 18 months, the CBT group showed moderately better scores on various tests for psychotic symptoms; indeed, CBT performed about as well as antipsychotic drugs do when compared with placebos, meaning that CBT could substitute for drugs in some situations—especially those in which patients are refusing to take them anyway.
“Clinical psychologist Anthony Morrison of the University of Manchester, who led the study, stresses that a drug-free approach might be appropriate only for patients who are relatively high-functioning and have not shown any risk to themselves or others. Nevertheless, the results are “utterly convincing,” says Max Birchwood, a psychologist at the University of Warwick in Coventry, U.K.
“Arenella, who treats Terry and some of her other patients with a combination of psychodynamic and CBT approaches, says that in the end it doesn’t matter whether talk therapies work because of the theory behind them or just because someone is taking the patient and their symptoms seriously. “It may be a placebo effect, but I will go for all the placebo effect I can get,” she says. “I’ll take it.”
“In the end, the spread of talk therapies for psychosis could be limited by a scarcity of resources, and of therapists willing to try them. Treating such clients is very stressful and seldom financially rewarding. “A lot of people don’t want to take these patients,” Arenella says. “Working with them is scary. People get violent, people get hurt, computers get thrown to the ground, ceiling tiles get pulled out.” And Martindale says that “contact with madness is very disturbing; it conjures up all sorts of feelings.”
“Government agencies and insurance companies can help by covering such treatments, even though they are more expensive in the long run than drugs, say Arenella and others. They are worth trying, Bracken says. “I have a lot of patients whom I would say recovered from psychosis. I see people who move on with their lives, get their quality of life back, are able to live independently.” Indeed, the popular notion that a schizophrenia diagnosis is a life sentence of mental illness is not borne out by the statistics: In one typical study, published in the American Journal of Psychiatry in 2004, researchers found that nearly 50% of first-episode schizophrenia or schizoaffective disorder patients were symptom-free after 5 years.
“But many people don’t get there no matter what we do,” Bracken says, “until that spark in them finally says, ‘I want my life back.’ “