Since Freud, psychiatry and medicine has held with the assumtion that talk therapies can not work for “the psychoses”. Of course, that notion was never founded upon anything other than some beardy bloke’s prejudices, and reinforced by the beardy, patrician prejudices of the massed beardy-blokes who had put each other in charge of things at the time.
Psychiatry went down the route of a whole bunch of “therapies” that now seem horrific, damaging and ineffective- eventually ending up with promoting the “better living through chemicals” philosophy – as in they have a better life funded by all of us taking their chemicals.
Meanwhile, the likes of Melanie Klein had been showing this assumption to be utter beardy-bloke-bunkum for some time, but since she had the temerity to be not only a woman but a divorcee too, she could not possibly be taken too seriously by the beard-growers. Nonetheless, Kleinian therapy has been a solid school of psychoanalysis since, and practitioners have been merrily working away with people and their psychoses all the while the beard-growers said it couldn’t possibly work.
Institutions are always slow moving and the institutions of medicine – of which psychiatry is a branch- were just not smart enough to figure out how to change and just not smart enough how to acknowledge that just because they didn’t know how to do it then that did not mean someone else might.
Well, now they’re getting a bit smarter, or at least some are, and getting curious enough to find support to fund studies to show how that which the beard-growing institutions held to be impossible is, er, very possible.
In the UK the likes of Tony Morrison and Paul Chadwick, Richard Bentall have been conducting research in this area for a decade or more – around psychosis and CBT [ a concentrated form of “talk therapy”], even showing that for some patients talk therapy can be at least as effective as drugs.
US NIMH’s RAiSE Early Treatment Program
Now, here’s news from a recent NYT article this week reporting on a latest study – and a large one- looking at broader approches- medicines and therapies combined – and telling the institutions of psychiatry what most humans already know.
As one of the doctors quoted in the article says, it takes a long time for new ideas to find their way into clinical practice – he says the average is seventeen years- this one’s taken about a hundred years and counting, so progress is very welcome.
This large scale government funded study showed that patients who received lower doses of medication and greater emphasis on one on one talk therapy and family support did better.
The NIMH funded study showed how treatment focused on helping a person make sense of their life and learning new skills that they can use in their lives – including for some patients, rudimentary ways to live with the voices- and enabling them to play a bigger role in their own lives is more effective than using all those resources to remove choice and to coerce people to take more pills.
Under reported, is how talk therapy takes time – clinicians have to spend more time interacting with patients – more than ten minutes a month talking about meds- so they get to see their patients as human beings rather than unwitting objects of their expertise, clinicians get to understand the complexities of their patients lives, the clinicians get to be more human and the patient gets to be both listened to and have a greater say.
- RAISE – at NIMH
- Comprehensive Versus Usual Community Care for First-Episode Psychosis: 2-Year Outcomes From the NIMH RAISE Early Treatment Program http://ajp.psychiatryonline.org/doi/abs/10.1176/appi.ajp.2015.15050632?journalCode=ajp
- in The News – NYT Article http://www.nytimes.com/2015/10/20/health/talk-therapy-found-to-ease-schizophrenia.html?_r=0
New York Time article:
“As for medications, I have had every side effect out there, from chills and shakes to lockjaw and lactation,” said a participant in the trial, Maggie, 20, who asked that her last name be omitted. She did well in the trial and is now attending nursing school.
Doctors praised the study results.
“I’m very favorably impressed they were able to pull this study off so successfully, and it clearly shows the importance of early intervention,” said Dr. William T. Carpenter, a professor of psychiatry at the University of Maryland, who was not involved in the study.
Dr. Mary E. Olson, an assistant professor of psychiatry at the University of Massachusetts Medical School, who has worked to promote approaches to psychosis that are less reliant on drugs, said the combined treatment had a lot in common with Open Dialogue, a Finnish program developed in the 1980s. “These are zeitgeist ideas, and I think it’s thrilling that this trial got such good results,” Dr. Olson said.
In the new study, doctors used the medications as part of a package of treatments and worked to keep the doses as low as possible — in some cases 50 percent lower — minimizing their bad effects. The sprawling research team, led by Dr. John M. Kane, chairman of the psychiatry department at Hofstra North Shore-LIJ School of Medicine, randomly assigned 34 community care clinics in 21 states to provide either treatment as usual, or the combined package.
The team trained staff members at the selected clinics to deliver that package, and it included three elements in addition to the medication. First, help with work or school such as assistance in deciding which classes or opportunities are most appropriate, given a person’s symptoms. Second, education for family members to increase their understanding of the disorder. And finally, one-on-one talk therapy in which the person with the diagnosis learns tools to build social relationships, reduce substance use and help manage the symptoms, which include mood problems as well as hallucinations and delusions.
For example, some patients can learn to defuse the voices in their head — depending on the severity of the episode — by ignoring them or talking back. The team recruited 404 people with first-episode psychosis, mostly diagnosed in their late teens or 20s. About half got the combined approach and half received treatment as usual. Clinicians monitored both groups using standardized checklists that rate symptom severity and quality of life, like whether a person is working, and how well he or she is getting along with family members.
The group that started on the combined treatment scored, on average, more poorly on both measures at the beginning of the trial. Over two years, both groups showed steady improvement. But by the end, those who had been in the combined program had more symptom relief, and were functioning better as well. They had also been on drug doses that were 20 percent to 50 percent lower, Dr. Kane said.
“One way to think about it is, if you look at the people who did the best — those we caught earliest after their first episode — their improvement by the end was easily noticeable by friends and family,” Dr. Kane said. The gains for those in typical treatment were apparent to doctors, but much less obvious.
Dr. Kenneth Duckworth, medical director for the National Alliance on Mental Illness, an advocacy group, called the findings “a game-changer for the field” in the way it combines multiple, individualized therapies, suited to the stage of the psychosis.
The study, begun in 2009, almost collapsed under the weight of its ambition. The original proposal called for two parallel trials, each including hundreds of first-episode patients. But recruiting was so slow for one of the trials that it was abandoned, said Dr. Heinssen.
“It’s been a long haul,” Dr. Heinssen added, “but it’s worth noting that it usually takes about 17 years for a new discovery to make it into clinical practice; or that’s the number people throw around. But this process only took seven years.”
Abstract of Study Report
The original study report is published in The Journal of American Psychiatry- extract below, including link to original.
Comprehensive Versus Usual Community Care for First-Episode Psychosis: 2-Year Outcomes From the NIMH RAISE Early Treatment Program
The primary aim of this study was to compare the impact of NAVIGATE, a comprehensive, multidisciplinary, team-based treatment approach for first-episode psychosis designed for implementation in the U.S. health care system, with community care on quality of life.
Thirty-four clinics in 21 states were randomly assigned to NAVIGATE or community care. Diagnosis, duration of untreated psychosis, and clinical outcomes were assessed via live, two-way video by remote, centralized raters masked to study design and treatment. Participants (mean age, 23) with schizophrenia and related disorders and ≤6 months of antipsychotic treatment (N=404) were enrolled and followed for ≥2 years. The primary outcome was the total score of the Heinrichs-Carpenter Quality of Life Scale, a measure that includes sense of purpose, motivation, emotional and social interactions, role functioning, and engagement in regular activities.
The 223 recipients of NAVIGATE remained in treatment longer, experienced greater improvement in quality of life and psychopathology, and experienced greater involvement in work and school compared with 181 participants in community care. The median duration of untreated psychosis was 74 weeks. NAVIGATE participants with duration of untreated psychosis of <74 weeks had greater improvement in quality of life and psychopathology compared with those with longer duration of untreated psychosis and those in community care. Rates of hospitalization were relatively low compared with other first-episode psychosis clinical trials and did not differ between groups.