Friday, January 27, 2023

Comments by Steffen Moritz, PhD

Showing 29 of 29 comments.

  • Hello,
    Based on the above discussion in Mad in America in May, MCT is open source now: This took a while, sorry for the delay.
    This means that you can edit/alter the MCT as you like. I agree that some phrases/terms appear stigmatizing (clearly, this was never our intention!). So, we are fine if existing slides are deleted, new ones are edited etc. All the best and thanks for all the input. You can register at no cost regardless whether you are a clinician, patient or a relative.
    I learnt a lot, yours, Steffen

  • Dear phoenix,
    Thanks for your kind and funny emails, I hope we stay in contact. No need to apologize!
    By the way, my favorite Austrian words are “Pfiat Di Lackerl” (especailly in Kärnten) or “Fluchtachterl” (last 1/8l wine before you leave the bar) and “Stiegenhaus” (staircase).
    “Phoenix”: funny, we have just developed an imagery rescripting self-help manual for people with depressive symptoms called “Like a Phoenix from the Ashes”:
    @knaps: As I said. If you and others like to view me as an Anankin Skywalker on his way becoming Darth Vader, that’s OK. Time wlll tell whether my colleagues and I will succeed to change the system for the better or become part of it.
    All the best, yours, Steffen

  • Hey phoenix,
    Thanks for your 2 latest posts but I must admit that I a bit disappointed that you did not read mine to the end. It took me quite some time to think about how to respond and I might deserve to be heard, too. Ok, there is clearly some redundancy in my blog but you won’t find out until you read it to the end. MCT is about attenuating overconfidence and delaying momentous decisions – this is nothing that at least I have learnt in kindergarten and I continue to think MCT is a new approach (especially as we have created a lot of seeing-is-believing hands-on exercises, see especially module 4, where people are demonstrated that jumping to conclusions and overconfidence foster incorrect decisions in an entertaining and non-insulting way). For both people with and without mental problems but especially for the latter because they are easily taken away by emotions (not all, but many!) it is often a good idea to hear each other out and perhaps sleep over something before we jump to our guns/to conclusions.
    respect because I am doctor/patient-doctor relationship?: This is not my attitude at all. I come from a working class family and I do not think I am superior to a non-doctor. No joke: I had a little speech impediment when I was awarded professorship because I tried to come across very intellectual and started fuzzy sentences I was not able to finish 😉 We should respect everybody regardless of education, gender etc. My former boss and head of the clinic was always making fun about himself for his bad marks in school. In Hamburg, my hometown, we have a saying that fits quite well: the boy is no good for business, he has to go to university ;-)) All I wanted to express is that saying that someone is creating kindergarten stuff, is living in a do-gooder-bubble or has developed a dehumanizing approach (many other *expressions* [again, the content is debatable] that would have insulted you or others perhaps too) as some bloggers put it is neither polite in Vienna nor in Valdiwostok and is undeserved in this harsh tone in my opinion!
    I would be happy to hear from you sometime but perhaps not today!

    Yours, Steffen

  • [sorry, was written in a hurry, please excuse grammar and errors]

    Hey guys,
    Welcome back to the forum or… well…perhaps I should say Coliseum 😉 The blog has taken a very different turn since I left and I am not so sure if anyone is still here. I guess, you might be around, Phoenix, and there might be still some bullets left for me in your gun, “Slaying_the_Dragon_of_Psychiatry”.
    For lack of space my responses will be mainly directed to you, Phoenix, as you have written by far the most. Still, I would like to thank all of you for your comments and replies. While I do not agree with all of what has been written, I respect the different opinions expressed and is has urged me to make some significant changes pertaining to the MCT. Most importantly, we will create a developer version of MCT which will allow clinicians to re-write text on the slides. Some translations need to be improved and I also agree that some formulations can be viewed as stigmatizing although this was never intended. I would now prefer to speak of individuals with psychotic symptoms rather than equating people with their diagnoses. However, please look at the additional module on dealing with stigma where we make very clear that psychological problems are ubiquitious and that even psychotic symptoms are known to many many people.
    I have read the manymanymany replies (thanks) during my vacation but felt unable to answer, mainly because it takes a lot of time to enter text in a mobile phone plus it has a German auto-correction function (do not know how to disable it). It would have made my grammar even worse. I remember from one German forum that a member even doubted I was a professor because I did not set commas properly ;-)). So, please excuse my absence,
    I am still on vacation but home now and can type from my computer. I will make my reply as short as possible. I must say that I was not very happy about the language, especially by you, Phoenix: “do-gooder-bubble”, “kindergarten level”, ” being the kind and jolly good person as you prefer to come across”, “You believe in different sets of people which are determined by their genetics, their temper, and their childhood upbringing” – you are quite eloquent and you have complained about abusive language and patronizing behavior. Why not be nice yourself to a person who you do not know
    Try walking in my shoes. You are anonymous; many of you have fancy nicknames while I am here with my full name, email etc. I do not expect a lot of respect and it is good to be critical but you might have found some expressions insulting, too, if you were me.

    From the dozens of sentences that have been written since my last post I will first address the below ones because I thought about these the most:
    “Could you see yourself becoming mentally ill? Severely depressed maybe, suicidal? Or, god behold, straight out manic, jumping out of your bathtube in excitement and running through the rain to the bar full of happiness but stark naked. You seem to be quite a reasonable person thus mania would probably free all your deep cravings to finally just let it all hang out for one day.”

    I have picked the quote (A related quote from phoenix starts ” I also sincerely hope that Steffen and others without lived experience…”) because I have heard this many times before. Many individuals with mental problems seem to think that their clinicians are perhaps ignorant and cold but (or perhaps because of this) super-resilient and never experienced *severe* mental problems themselves. This is not true. Freud was one of the first to disclose mental problems in his “Psychopthologie des Alltageslebens” (Psychopathology of everyday life) where he reported experiences of auditory hallucinations. Marsha Linehan, the founder of dialectical behavioral therapy (DBT), an accepted and evidence based treatment for personality disorders, was diagnosed among other labels with schizophrenia in her early life:
    Being a psychologist/psychiatrist or patient is not mutually exclusive at all and I have struggled with mental health problems myself. Not happy to talk about this but this seems to best way to gain some creditability.
    When I was 18-20 I met FULL criteria for anorexia (my mother had it too). I somehow made it without treatment. So according to the bio-bio-bio model that some of you suppose I am clinging to I would be more vulnerable than phoenix and others as I got a mental illness a lot earlier and with far less stressors (father died when I was four, that’s almost all – just a difficult and sensitive child, I guess etc.). For some, I might look now like Anakin Skywalker turning into Darth Vader. I still consider myself vulnerable in a sense of being unstable under stress and sensitive. This is also a point I want to bring across in the MCT. Cognitive biases are normal and must not be understand solely as weaknesses. Biases (e.g. inflated responsibility and perfectionism in OCD) can also be virtues. It all depends. Biases are not biological flaws and can sometimes be induced by context. For example, if you experinentally induce a dilemma or severe doubt most people will react subsequently with compensatory overcertainty (a student of mine just completed a thesis on this).

    I have been in psychological treatment later for tinnitus (I am a great fan of Heavy Metal and have a Judas Priest tattoo; did not carry ear plugs during an extremely loud “Annihilator” concert because in former times this was considered against the rules of RocknRoll – this was when the tinnitus started ;-)) and I never regretted it and I am not ashamed. The therapist and I are not talking much about the tinnitus any more (I have accepted it and I sometimes do not hear the noise for days although it is there) but with other problems, some of which can be labeled mental health issues. We all struggle!
    I was never the brightest kid in the yard (I like the German equivalent better which goes like “no the brightest candle on the cake”, not sure if that exists in the English language, too) but I think I am a good psychologist because I have made my own experiences with mental problems and tried to amalgamate personal experience and the urge to help myself and others with psychological methods. This has led to several self-help manuals that my unit provides at no cost in many languages for, just to name a few, auto-aggressive behavior ( – click on English page) and obsessive thoughts ( These have been validated by independent groups. I am not self-complacent and think I am healer or so. What might have worked for me, might not work for others, so everything needs to be evaluated and thrown in the dustbin if results are not good. For MCT meta-analyses show that it has an impact on people’s symptoms and I am disappointed that this is not really acknowledged by anyone here.

    The other quote I would like to pick is this:
    “Steffen, you cannot trust whatsoever positive feedback your patients give you. As a mental illness patient you get trained to give the right answer and you are pressured into the feeling of being intrinsically inferior. Everything you do, the way you feel and think, is permanently critizised allthough you are simultaneously told its not really your fault. Your subjective experience is downplayed and given little value”

    I understand your point, Phoenix, but why not ask how we measured acceptance? Why making such bold conclusions? I know many patients hide their opinions for fear of rejection or other negative consequences so we ask all patients in Hamburg to “vote” and throw their score sheets in a box with no name on it but just a symbol (this symbol allows us to analyze personal developments even though we do not know who the person is). If a patient refuses, which happens sometimes but not often this is totally OK. Most of the time, patients like that we ask them for their judgments and to assess how we did ad how we can improve!

    I would like to end with the final words poor Barbara Graham uttered before her execution: “Good people are always so sure they’re right.” This is directed to both many of my colleagues but also a lot of people in the antipsychiatric movement. You seem to know it all! Why not discuss and see if we can learn from each other, why shouting (or writing?) the opponents down. Psychologists in psychiatric institutions are sometimes seen as the naive “Uncle Toms” of psychiatry who stand in the way of an epic battle between good and evil. This is wrong in my opinion. Psychotherapy can help a lot of people, even with severe mental problems. However, funding is poor and we need more financial support but perhaps more importantly more encouragement. Of course I would be happy for donations for the MCT but I am equally happy for donations to other psychotherapeutic treatments or organizations like MIA who try to bring together patients, relatives and clinicians.

    Yours, Steffen

  • re: Slaying_the_Dragon_of_Psychiatry: “Text book knowledge in psychiatry = canonized fiction and delusion.”

    What I wanted to say is that even the (obviously at least in your opinion) “Necronomicon” (H. P. Lovecraft) of modern psychiatry acknowledges that mental health and mental illness are not dichotomous. Most problems exist on a dimension and some symptoms that decades ago had been regarded as clear signs of mental illness like voice hearing (prevalence 15-20% in the general population) or false beliefs are very common in the population. The line between need/no need for (voluntary) treatment is thin but often visible in my opinion: At some point quantity *can* lead to a new quality and that is when symptoms result in harm to oneself (e.g., suicidal thoughts, severe rumination) or other people (e.g. violent acts against relatives etc.).
    I would like to add that psychiatry/clinical psychology is less and less fixated on contents – suffering is a far more important criterion. Believing the CIA is behind you is not more or less “mad” or “sane” than believing that Jesus sits next to God or that he was born by a virgin. However, we usually treat the former because such beliefs (often – not always) come with a lot of fear and despair. Yet, also deep religious beliefs which according to public opinion are somehow “OK” *can* lead to psychiatric problems (I remember the mother of a class mate who was deeply religious and was unsure about a stomach operation; after a lot of prayers she finally chose to undergo the surgery but it failed and her somatic condition worsened which she viewed as a sign of divine punishment and was deeply depressed for some time).
    Yours, Steffen

  • To all of you
    It has been wonderful to exchange views with you in the last days, although it sometimes felt like in the last minutes of the movie “Last man standing”. Again, sorry for the English. I will be on vacation for the next two weeks and while my wife’s “security system” is not perfect (I will be able to respond emails) she will definitely not let me access the computer. Happy to talk to you after May 7th.
    I just would like to assure you that there are a lot of good, warm-hearted and dedicated people working in psychiatry and we need your support and encouragement to grow and to “hold the fort”. A lot of you have experienced bad things in “my institution” but don’t generalize and please do not blame the researchers/clinicians like me who talk to you and are open to change (again, the MCT was developed in close exchange with “you” – there is so much wisdom in many patients and their relatives and we can only improve tratments if the “experts by profession” and the “experts by experience” collaborate). No need to feel compassionate with me or others but sometimes it feels like a two-front war as a psychologist – you have *some* (not all, not even most!) biological researchers and the ”big industry” against you and then you have the antipsychiatric movement that at times (again not all!) treats you like the lackey of a post-nazi organization (already said that before). As I said, in my hospital and many others “we are proud to serve” so to speak and if a patient does not want medication that is fine and in many cases medication is not even offered because guidelines endorse psychotherapy.
    I have re-read this twice and I regrret that I may sound like a false priest (e.g., Robert Mitchum in The Night of the Hunter, my favorite Scene: Sorry for that…
    Alle Gute für Euch, Gruß, Euer Steffen
    (translate with of you want)

  • Hello Gerard,
    Thanks. Under a certain amount of stress we all fall apart mentally. CBT – if practiced correctly – does not treat people with mental problems like a broken radio but as humans with vulnerabilities (that we all have!) and certain experiences that impact our psychological well-being. The blame is not necessarily put on the individual. But it is a big difference what developers of CBT had in mind and what is actually done by some therapists (I think it is a minority). This is also a problem with the MCT – we provide the training at no cost via the internet. Every therapist can download and I had comments of patients complaining that they had to go through a 3 hour module with their therapist!!! It is like with IKEA furniture. People just do read the manuals (where we make clear that each session should not be longer than 45-60 minutes, that humor and empathy is important and that it is not a lecture), that is why we started to provide workshops to raise compliance of therapists with the rationale of MCT, yours, Steffen

  • …oops, I only read half your post, sorry. I work in Germany in a psychiatric hospital and we strictly adhere to treatment guidelines but the hospital has a troubled past. We looked at old medical records and found that until the 1970s many patients received “insulin coma therapy”. It is sad and almost unbelievable because safer treatments were already available.
    But: Psychiatrists have become more and more critical about medication and are aware of their side-effects. We had some “sputnik shocks” – just to name a few: the meta-analysis by Leucht showing that antipsychotics only have medium effect size, data by Andreasen (then Editor of American Journal of Psychiatry) that antipsychotics can harm brain metabolism, Kirsch’s meta-analysis on antidpressants etc. Please read Moncrieff’s blog, she has done great work.
    If a patient chooses not to take drugs this is usually tolerated and for some disorders like OCD and depression they are often the only treatment. Medication are only given in rare incidences against the will of a patient if his or her life is in danger (acute suicidality). No one is drugged anymore to silence him/her – I can say that at least for my hospital.
    In Germany psychotherapy is the first-line treatment. I will be part of the expert group working on the renewal of the German treatment guidelines for OCD (this diagnosis exists; OCD symptoms are extremely common, see, but when they rise to a certain degree they can become a huge and disabling problem that needs treatment) and I am pretty sure that the old text will be essentially confirmed stating that cognitive behavioral therapy with response prevention should be sought first. Antidepressants might be considered but only when psychotherapy is not effective. Antipsychotics agents should not be given at all if OCD is mono-symptomatic.

  • Dear Igor,
    Thanks for your comment; I will discuss the recommendations with my team. The MCT is a low-threshold approach necessitating little therapeutic skills so it can also be administered by nurses, psychological students etc. with little training. Why? Too complicated training approaches (or those that require expensive and long curricula) often do not make it into the psychiatric “DNA”/infrastructure. They die in beauty (expression? – again, I am not drunk, stupid or anything – English is just not my native tongue). The modules are quite structured and I agree there is a lot of text but trainers are advised not to read the text but to use these as notes and to find their own language. Humor and empathy is key. It is like a discovery. There have been quite a lot of studies from my group and others on effectiveness (delusions, positve symptoms) but also acceptance/appraisal and around 80-85% of participants say they like the training and have fun (we always make an anonymous poll at the end where patients assess us and give marks on how they liked the particular module and the performance of the trainer, just like in a regular hotel) because we try to explain (well we struggle) how positive symptoms come about and that the cognitive apparatus from people with psychosis is not that different from “normal” people. It is about escalations of regular biases that under stress and with some past trouble can create the storms of psychosis (again, not all psychotic symptoms need to be treated, in some cases a reality distortion can be functional). However, I am not a fan of “Kumpel Psychiatrie” (the term buddy psychiatry comes perhaps closest) that claims that all people are psychotic, psychiatry is psychotic etc.
    Russia: We have a Russian translation, not sure how good it is.
    Thanks, Igor, really appreciate your tone. I have learnt a lot by patients and some of the contents of MCT where directly inspired by what patients said or suggested for improvement.

    Yours, Steffen

  • Dear Lawrence,
    Thanks a lot.
    “We all have beliefs not based in reality.” – This is what I have already written, we all have distortions. Bad example – I know but look at my picture – I am balding but I often like to think it’s a whirl 😉 Biases/distortions are not “sick” per se and sometimes even promote mental health (large literature on unrealistic optimism etc.). However, *escalations* of certain biases (e.g., overconfidence, jumping to conclusions) can *under stress* trigger severe symptoms that may cause subjective suffering (e.g., anxiety, feelings of persecution). This is well replicated.
    It is now text book knowledge in psychiatry that most symptoms are dimensional. The healthy are not as healthy and the “psychotic” is not as non-comprehensible as our older colleagues thought. This is why Jaspers’ fourth delusion criterion was skipped!

    “some are “psychotic” and thus need “treatment/help”, while others are not”
    People do not need help because they are psychotic. I would never say that. They only need help if they suffer (many) or in the rare cases that they bring suffering to others. Seeing the ghost or hearing the voice of a beloved one who has passed away is a form of reality distortion which may even bring comfort to some.
    Ambiguity is hard to tolerate but: it all depends.

  • “When my wife first started hearing the ‘voices’ she thought they were external, too. She called them aliens. But I redirected her by gently insisting they HAD to be internal and thus part of her ‘system’. It took her a few years to fully embrace the other girls, alters if you prefer, but now she recognizes them as part of her internal mental system.”
    Thanks for sharing. This is wonderful. In the MCT+, in one of the modules we convey techniques of compassionate mind (our approach is eclectic, we combine a lot of techniques from different therapeutic “schools” because there is no one route to recovery) and try to gently connect the “voices” to prior experiences with personal demons etc. In many voice hearers the voices are quite congruent with/or exaggerations of what significant others once said to them. In fact, we published three papers were we found that depressed patients and those with OCD to some degree also have vivid and acoustic ruminations and obsessive thoughts. Voice-like thoughts are quite common

  • I do not agree. Psychosis is not a myth, neither is OCD. We can debate about diagnostic labels (e.g., schizophrenia etc.) and pathologization human experiences as well as treatments but there *are* people that need help and more importantly want help and we have been able to show in a lot of well controlled empirical studies that we are able to provide this help with MCT. This has been confirmed with meta-analyses.

  • Hey Steve,
    Thanks, that is why we encourage trainers to skip exercises, delete slides or insert new ones. for exmaple, some do not like the part where we explain what cognitive biases have to do with psychosis as they – like you – reject the label. That’s fine – this is not carved in Stone. MCT is not a cook book. Most trainers show this slide and then discuss with patients. Most agree, others don’t. that’s fine too. The idea is to exchange view and to validate different opinions. Agree to disagree is also Ok.
    “I figure that the only one who knows what’s really going on is the client” – I do not agree but I think that the ‘”customer is always right” (I like the German equivalent better: the customer is king). So, if a patient wants to work on self-esteem rather than on voice-hearing we should consider this preference.

  • Thanks, Sa.
    We aim to provide therapists some degrees of freedom. If they do not like a particular exercise: no problem. They can just skip it because we have more material than can done in 45 minutes. We also provide a template to create new exercises. It is important that we have open and fair discussions (it is OK if patients disagree with some contents) and to share experiences.

  • Your German is very good.
    checklists: not good at all. Proper assessment needs time as symptoms are often fluctuating. Especially in the first minutes many patients are extremely tense and seem more severely ill than they are. We had a case where a patient was to referred to my unit for suspected mental retardation. It turned out the poor guy had above average IQ but was so intimidated by all the staff suddenly surrounding his bed and asking him short questions and requesting even shorter answers. Also, sometimes patients do not answer honestly in such contexts for understandable reasons, they underreport symptoms for fear to be wrongly classified (e.g., an OCD patient with full insight who has the obsessive thought to stab his children might not report this because he worries that an antisocial personality is suspected, or a voice hearer does not speak about the voice for fear to be „punished“ with more medication) or else they over-report because they want to be taken seriously and get the possible treatment. So, it needs time to build a good relationship and to come to reliable assessments… I always tell our students (and future doctors) to assess and treat a patient as if it was a relative.

  • Sorry, humor is not a great German virtue, I fear. Like you, I am also quite skeptical about biological models of mental illness (-> Neurocognitive deficits in schizophrenia. Are we making mountains out of molehills?; and some years ago we investigated the question how neuroleptics actually work, which led to the effect by defect hypothesis:
    Yet, some patients seem to benefit from medication. Unfortunately, at least for psychosis, psychological programs are yet not sufficiently effective to provide full recovery. We still have a long way to go; funding of psychological research is a serious issue.
    Yours, Steffen

  • Hey all,
    First of all, I am new to this great forum. Hello everybody. Second, please excuse my writing. I am from Germany and – to quote Marc Anthony – “my English is not very good-looking” 😉 Third, I am on vacation starting Saturday. So, I won’t be able to reply posts following Friday (until May 7th) but you can reach me via email ([email protected])
    Kind regards, Steffen

  • Dear Slaying_the_Dragon_of_Psychiatry,
    Puh, please excuse but this not so warm welcome reminds me of an old advertisement:
    I would like to exchange views with you but please familiarize yourself with our program first and don’t be such offensive. I am happy to learn from you and the program was actually developed in exchange with patients.
    Yours, Steffen

  • Hello Gerard,
    Thanks a lot. Early behavior therapy was indeed a bit like that. However, evidence-based CBT (so if it is conducted properly by a therapist) will address trauma, here is just one quick example that I found:
    Our program also targets deeper emotional problems and self-esteem, especially the individualized format:
    yours, Steffen

  • Dear Mr McCrea,
    Good point. Cognitive biases are not confined to people with psychosis. We always stress this in our papers and talks. Virtually everyone has such distortions and some of these (e.g., Pollyanna effect (bias of “normal people” to remember pleasant items more accurately than unpleasant ones, unrealistic optimism and others) even seem to promote mental health.
    Jumping to conclusions and overconfidence is indeed a problem in medicine and also at times in psychology. Some of my colleagues do not take sufficient time to collect and weigh information properly. Our approach is “normalizing” – people with psychosis are not treated as aliens with weird thoughts and malfunctioning minds.