Ann-Louise S. Silver, M.D.
September 22-25, 2003 ISPS Meeting in Melbourne “Reconciliation, Reform and Recovery: Creating a future for psychological interventions in psychosis.” Debate on the question “Can biological and psychological interventions be integrated in the treatment of psychosis?”
I oppose “educating” patients that their brains are broken, that schizophrenia is a brain disease, and that they must stay on costly and anesthetizing meds for the rest of their lives. These authoritarian unsubstantiated statements impede trust and diminish hope. Our whole diagnostic manual is built merely on personal impressions, not hard data. All diagnostic groups slide into each other with debatable overlaps. (Boyle, Kendell & Jablensky) All the brain changes in schizophrenia are the same as those in chronic and severe anxiety and PTSD. Psychotherapy is a biologic treatment, helping restore a normal cognitive/emotional balance. Meds that block dopamine pathways block limbic system connections with the cortex, impeding salience, defined by Kapur as “a process whereby events and thoughts come to grab attention, drive action and influence goal-directed behavior…” (p. 14) This loss of verve, sense of wonder at a natural scene, or pleasure in a new insight or interpersonal connection, is intolerable for at least 75% of patients, who discontinue their meds within two years. (Psychiatry24x7.com which is sponsored by Janssen) As Courtenay Harding found in her famous Vermont follow-up study, 1/3 of hospitalized patients had recovered years later and were fully integrated into their community. They had all discontinued their medications. (Bleuler noticed the same pattern.) And as the World Health Organization found in its huge study comparing outcomes for schizophrenia in the developing and industrialized countries in the 1970s up to 65% recovered in the developing countries, where meds were less available. (Leff) Even with our second generation meds, we have nothing like these recovery rates. With meds, we make our patients more functional, that is manageable. But while psychosis produces a deep alienation, medication produces a loneliness for one’s self, and an oppressive dullness. I recommend that all medication enthusiasts take Zyprexa, 2.5 mg. per day for a month. They might prescribe less.
In 1916, Ernest Bullard, who founded Chestnut Lodge, wrote on the Wisconsin county farm hospitals. “Thirty percent of patients work all day; 20% work one-half day or more, and 23% do some work.” (vol 3, p. 833) We have nothing like these employment statistics. Our patients are too drugged to care.
I worked at Chestnut Lodge from 1976 until it closed in 2001, working in both the non-medication and medication eras. In the non-medication era my schizophrenic patients did far better than do those in the more modern era. They chose careers, pursued them, and married. One patient, who had been called the sickest schizophrenic patient admitted to the adolescent division, is raising three children and works as a registered nurse. In the later era, none chose a career, although many held various jobs, and none married or even had lasting relationships. Earlier, the therapeutic relationships were as intense as adoptions. Later, a polite distance persisted. I feel I could have been replaced. Attachment, as Fonagy and others have demonstrated, is crucial for emotional development.
The Lodge Wednesday Conferences had been intense and intimate as we discussed transference and countertransference. Once meds came in discussions derailed into whether to add this med or change that. Visiting guests including Parisian analyst Joyce McDougall, found them boring. She asked “Where’s the analysis?” When a patient became upset on the unit, the nurses called the administrator for more meds, rather than calling the therapist for insight. Usually, the therapist never even learned of the upset. Patients moved quickly to outpatientcy, combining behavior modification, individual and group therapy; we were no longer a community.
One would think that the costs of mental health care would have declined as hospitals downsized or closed. Amazingly, in the U.S., the costs in 1990 were $32.5 billion and in 1995 had doubled to $65 billion. (Rice & Miller) Patients now live in the community, in so-called supportive living facilities, which are often horrific. And they have landed in our jails and prisons, in numbers Fuller Torrey showed are in the same proportions as when Dorothea Dix roused the nation. (ref) And
Lehman and Steinwachs have found that on average, schizophrenic patients have only eight mental health appointments per year. (2003) Prescribing meds has become our rationalization for abandoning our most needy patients.
Meanwhile, all the case reports of success through psychotherapy are discounted as anecdotal. Pharmaceutical enthusiasts hail “evidence-based” studies. Gottdiener and Haslam have published a meta-analysis validating the role of psychotherapy. And Emmanuel Stip has reviewed four meta-analyses of medication research studies and finds the research lacking: studying patients over too short a time interval, comparing newer anti-psychotics with very heavy doses of Haldol, withdrawing research subjects abruptly from their meds, thus causing a rebound psychosis, which is then misidentified as re-emergence of the disease. Some senior researchers have lent their names to papers for which they have not seen the raw data. Editorials and articles in the New England Journal of Medicine and the JAMA decry the intrusion of the pharmaceutical industry into the workings of medical schools and research institutions, where research findings not promoting the product are never published, and grants to those schools or clinics are withdrawn and researchers lose their jobs. (Choudhry et al; Angell, May 18 & June 22, 2000; Bodenheimer) David Healy’s experience is telling. (Healy) Data linking SSRIs with suicide and homicide are center stage. Data about anti-psychotics andobesity, diabetes, pancreatitis, and tardive dyskinesia are next. We are on the cusp of exposes of the pharmaceutical industry similar to those of the tobacco and oil industries.
But the worst effect of this wild meds enthusiasm is that young psychiatrists now often ask the team’s social worker, “Why are you bothering to talk to this patient? I’m already giving him medications.” In losing interest in the patient’s life story, we have abandoned ourcharges, and our Hippocratic Oath, to do no harm. A whole body of knowledge on therapeutic skills is being ignored. The psychiatrist’s job is to mediate between the alienated person and the community. In over-emphasizing medicating troublesome individuals, psychiatry has become an instrument of the state, and no longer the ally of its most needy citizens. The recent hunger strike by Mind Freedom in California is no surprise, and no rare aberration. The growing Recovery Movement demonstrates that patients would sooner have psychotherapy from each other than submit to medical management. As Harold Searles predicted in 1975, “If the psychoanalytic movement itself takes refuge in what I regard essentially as a phenothiazine-and-genetics flight from this problem, then the long dark night of the soul will have been ushered in…” (Searles, p 227)
Quoting recently deceased Sally Cameron a London nurse: “A psychotherapist acts not so much as a skilled mechanic working on a machine, but as a caring and skilled gardener offering a nourishing environment in which living things are helped to do their own growing. A therapist therefore acts not as controller but as facilitator, and this involves having the courage to take the lead from the patient, no matter how chaotic and seemingly senseless that may be.”
Angell, M. ( May 18, 2000) “Editorial: Is academic medicine for sale?” New
Eng. J. of Medicine. 342, 20: 1516-1518.
-------. ( June 22, 2000) “Editorial: The pharmaceutical industry: To whom is it accountable?” New Eng. J. of Medicine. 342, 25: 1902-1904.
Bentall, R. (ed.) (1990) Reconstructing Schizophrenia. London. Routledge.
-------. (2003) Madness Explained: Psychosis and Human Nature. London. Penguin.
Bodenheimer, T. (May18, 2000) “Uneasy alliance: Clinical investigators and the pharmaceutical industry.” New Eng. J. of Medicine. 342, 20: 1539-1544.
Boyle, M. (2002) Schizophrenia: A Scientific Delusion? London. Routledge.
Bullard, E. (1916) In: Hurd, H. (ed.) “The care of the insane in Wisconsin: The Wisconsin system of county care of the chronic insane.” vol. III. pp. 824-839. The Institutional Care of the Insane in the United States and Canada. Baltimore, MD. Johns Hopkins.
Cameron, S. (1998) “Whose reality is it anyway?” Chapter 10 in Barker, P. & Davidson, B. Psychiatric Nursing: Ethical Strife. London. Arnold.
Choudhry, N., Stelfox, H, & Detsky, A. ( February 6, 2002) “Relationships between authors of clinical practice guidelines and the pharmaceutical industry.” J. Amer. Med. Assn. 287, 5:612-617.
Fisher, S. & Greenberg, R. (1997) From Placebo to Panacea: Putting Psychiatric Drugs to the Test. New York. Wiley.
Fonagy, P., Target, M, Gergely, G. & Jurist, E. (eds.) (2001) Affect Regulation, Mentalization, and the Development of the Self. New York. Other Press.
Gottdiener W, & Haslam N (2002) “The benefits of individual psychotherapyfor people diagnosed with schizophrenia: A meta-analytic review.” Ethical Human Sci. Serv. 4:163-87.
Harding, C. (1987) “The Vermont Longitudinal Study of Persons with SevereMental Illness.” Am. J. Psychiatry. 144:727-734.
-------. (1987) “Chronicity in schizophrenia: Fact, partial fact, or artifact?” Hosp. and Community Psychiatry. 38:477-485.
-------. (1994) “Empirical correction of seven myths about schizophrenia with implications for treatment.” Acta Psychiatrica Scandinavica. 384 supplement: 140-146.
Healy, D. (2003) “One side of the background to an academic freedom dispute.” Academy for the Study of the Psychoanalytic Arts.
Hedges, L. (ed.) (2000) Terrifying Transferences: Aftershocks of Childhood Trauma. Northvale, NJ. Aronson.
Hornstein, G. ToRedeem One Person Is to Redeem the World: The Life of Frieda Fromm-Reichmann. New York: The Free Press, 2000.
Kapur, S. (Fall, 2002) Narsad Research Newsletter Vol. 14, Issue 3, p. 12.
-------. (2003) “Psychosis as a state of aberrant salience: A framework linking biology, phenomenology, and pharmacology in schizophrenia.” Am. J. Psychiatry. 160: 13-23.
Karon, B. P., & VandenBos, G. R. (1981). Psychotherapy of Schizophrenia: The Treatment of Choice. Northvale, NJ: Jason Aronson.
Kendell, R. & Jablensky, A. (2003) “Distinguishing between the validity and utility of psychiatric diagnoses.” Am. J. Psychiatry. 160: 4-12.
Leff, J. Sartorius, N., Jablensky, A., Korten, A. & Ernberg, G. (1992) “The International Pilot Study of Pschizophrenia: five-year follow-up findings.” Psychological Medicine. 22: 131-145.
Lehman, A. & Steinwachs, D. (2003) “Lessons from the Patient Outcomes Research Team (PORT) Project.” J. Amer. Acad. of Psan. and Dynamic Psychiatry. 31:141-154.
Read, J. Mosher, L. & Bentall, R. (2004 – in press) Models of Madness: Psychological, Social and Biological Approaches to Schizophrenia. London, Brunner/Routledge.
Read, J., Perry B, et al. (2001) “The contribution of early traumatic events to schizophrenia in some patients.” Psychiatry. 64:319-45.
Rice, D. & Miller, L. (1996) “The economics burden of schizophrenia: Conceptual and methodology issues and cost estimates.” in. Moscarelli, M., Rupp, A. & Sartorius, N. (eds.) Handbook of Mental Health Economics and Health Policy. Vol. I: Schizophrenia. Pp. 321-334. New York. Wiley.
Searles, H. (1975) “Countertransference and theoretical model.” Chapter 14 in Gunderson, J. & Mosher, L. (eds.) Psychotherapy of Schizophrenia. New York. Jason Aronson. pp. 223-8.
Stip, E. (2002) “Happy birthday neuroleptics! 50 years later: la folie du doute.” Eur. Psychiatry. 17:115-9.
Whitaker, R. (2002) Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill. Cambridge, MA. Perseus.