Editor’s Note: Over the next several months, Mad in America is publishing a serialized version of Peter Gøtzsche’s book, Mental Health Survival Kit and Withdrawal from Psychiatric Drugs. In this blog, he discusses psychotherapy. Each Monday, a new section of the book is published, and all chapters are archived here.
I know psychiatrists in several countries that don’t use psychiatric drugs or electroshock. They handle even the most severely disturbed patients with empathy, psychotherapy and patience.1
The aim of psychological treatments is to change a brain that is not functioning well back towards a more normal state. Psychiatric drugs also change the brain, but they create an artificial third state—an unknown territory—that is neither normal nor the malfunctioning state the patient came from.2
This is problematic because you cannot go from the chemically induced third state back to normal unless you taper off the drugs, and even then, it will not always be possible, as the patient might have developed irreversible brain damage.
A human approach to emotional pain is very important, and treatment outcomes depend more on therapeutic alliances than on whether psychotherapy or pharmacotherapy is used.3 Furthermore, the more in agreement physicians and patients are about what is important when being cured from depression, the better the outcomes for positive affect, anxiety and social relationships.4
Most of the problems patients face are caused by maladaptive emotion regulation, and psychiatric drugs make matters worse, as their effects constitute maladaptive emotion regulation.5 In contrast, psychotherapy aims at teaching patients to handle their feelings, thoughts and behaviour in better ways. This is called adaptive emotion regulation. It may permanently change patients for the better and make them stronger when facing life’s challenges.
In accordance with this, meta-analyses have found that the effectiveness of psychotherapy compared with depression pills depends on the length of the trial, and psychotherapy has an enduring effect that clearly outperforms pharmacotherapy in the long run.6,7
There are substantial issues to consider when reading reports about trials that have compared psychotherapy with drugs. The trials are not effectively blinded, neither for psychotherapy nor for drugs, and the prevailing belief in the biomedical model would be expected to influence the psychiatrists’ behaviour during the trial and to bias their outcome assessments in favour of drugs over psychotherapy. Trials that show that the effects of a drug and psychotherapy combined are better than either treatment alone should also be interpreted cautiously, and short-term results are misleading. We should only take long-term results into consideration, e.g. results obtained after a year or more.
I will not advocate combination therapy. Doing effective psychotherapy can be difficult when the patients’ brains are numbed by psychoactive substances, which may render them unable to think clearly or to evaluate themselves. As noted earlier, the lack of insight into feelings, thoughts and behaviours is called medication spellbinding.8,9 The main biasing effect of medication spellbinding is that the patients underestimate the harms of psychiatric drugs.
I shall not go into detail about psychotherapy. There are many competing schools and methods, and it is not so important which method you use. It is far more important that you are a good listener and meet your fellow human being where that person is, as Danish philosopher Søren Kierkegaard advised us to do two centuries ago. As there are many trials with cognitive behavioural therapy, this tends to be the preferred method, but if used too indiscriminately, it can degenerate into a sort of cook-book approach that pays too little attention to the concrete patient’s special circumstances, wishes and history.
When we wanted to study the effect of psychotherapy on suicide risk, my oldest daughter and I focused on cognitive behavioural therapy for the simple reason that most of the trials had used this method. As noted earlier, we found that psychotherapy halves the risk of a new suicide attempt in people acutely admitted after a suicide attempt.10 This is a very important result that is not limited to cognitive behavioural therapy. Emotion regulation psychotherapy and dialectical behaviour psychotherapy are also effective for people who harm themselves.11
Psychotherapy seems to be useful for the whole range of psychiatric disorders, also psychoses.1,12 A comparison between Lappland and Stockholm illustrates the difference between an empathic approach and immediately enforcing drugs upon patients with a first-episode psychosis.13,14 The Open Dialogue Family and Network Approach in Lappland aims at treating psychotic patients in their homes, and the treatment involves the patient’s social network and starts within 24 hours after contact.13 The patients were closely comparable to those in Stockholm, but in Stockholm, 93% were treated with neuroleptics against only 33% in Lappland, and five years later, ongoing use was 75% versus 17%. After five years, 62% in Stockholm versus 19% in Lappland were on disability allowance or sick leave, and the use of hospital beds had also been much higher in Stockholm, 110 versus only 31 days, on average. It was not a randomised comparison, but the results are so strikingly different that it would irresponsible to dismiss them. There are many other results supporting the non-drug approach,1 and the Open Dialogue model is now gaining momentum in several countries.
Psychotherapy does not work for everyone. We need to accept that some people cannot be helped no matter what we do, which is true also in other areas of healthcare. Some therapists are not so competent or do not work well with some patients; it may therefore be necessary to try more than one therapist.
Like all interventions, psychotherapy can also be harmful. Child soldiers in Uganda who were forced to commit the most horrible atrocities have survived the psychological trauma remarkably well by avoidant coping.15 If a therapist had insisted on confronting these people with their encapsulated trauma, it could have backfired quite badly. In somatic medicine, a healing wound should most often be left alone, and human beings have a remarkable capacity for self-healing, both physically and psychologically. Obviously, if the healing goes badly, e.g. because a broken bone was not appropriately put together, or a trauma continues preventing the patient from living a full life, it may be necessary to open the wound.
Physical and emotional pain have similarities. Just like we need physical pain in order to avoid dangers, we need emotional pain to guide us in life.16 Acute conditions like psychoses and depression are often related to trauma and tend to self-heal if we are a little patient. Through the process of healing—whether assisted by psychotherapy or not—we learn something important that can be useful if we get in trouble again. Such experiences can also boost our self-confidence, whereas pills may prevent us from learning anything because they numb our feelings and sometimes also our thoughts. Pills can also provide a false sense of security and deprive the patient of real therapy and other healing human interactions—doctors may think they need not engage themselves as much when a patient is taking drugs.16
Being treated humanely is difficult in today’s psychiatry. If you panic and go to a psychiatric emergency ward, you will probably be told you need a drug, and if you decline and say you just need rest to collect yourself, you might be told that the ward is not a hotel.1
To read the footnotes for this chapter and others, click here.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.