schizophrenia without drugs? There's good evidence for it.
researcher and psychiatrist Tim Calton examines studies
demonstrating how psychosis can be managed without medication. Such
non-drug approaches shoud no longer be ignored, he argues.
two hundred years ago medical psychiatry planted its standard within
the realm of the human experience of 'madness', quickly becoming
the dominant paradigm. Other ways of understanding and tending to
mental distress were suffocated or retreated to the margins. Psychiatry's
success in creating and disseminating knowledge about those forms
of life which get described as 'madness', 'psychosis', or 'schizophrenia',
quickly becomes apparent when surveying the first National Institute
for Clinical Excellence (NICE) guidelines for the treatment of people
diagnosed with schizophrenia.
document, a synopsis of so-called 'best practice' in the clinical
treatment of 'schizophrenia' within the NHS, clearly states that
antipsychotic drugs are necessary in the treatment of an acute episode
(National Institute for Clinical Excellence, 2002), a mandate not
extended to psychosocial interventions.
month we had
the updated guidelines
(National Institute for Clinical Excellence, 2009). They do appear
somewhat more balanced (stating that cognitive-behavioural psychotherapy
should be offered alongside medication), although important semantic
emphases remain (such as the fact that clinicians need only 'discuss'
alternative therapies, not necessarily offer them). The importance
granted medication, at the expense of other ways of understanding
and helping with mental distress, reflects the tendency for medical
psychiatry to see aspects of the vast and complex realm of human
experience as mere disease.
Although the NICE guidelines carry a powerful political imprimatur
they reflect the deep but extremely narrow tradition of biomedical
research into madness; research which would have us believe that
the only way to 'get better' and 'stay well' are to take antipsychotic
medication, for life if necessary.
question remains, however, as to whether it is possible to help
people experiencing 'psychosis' without recourse to antipsychotic
medication? Such a question might provoke a range of immediate and
urgent responses depending on your sociopolitical context, life
history and experience. One way of mediating this array of responses
would be to scrutinise 'the evidence' supporting the use of no or
minimal medication approaches to the treatment of 'psychosis'/'schizophrenia'.
is certainly a wealth of historical evidence supporting a non-medical
approach to madness ranging from Geel, the city in Belgium where
the 'mad' lived with local families, receiving support and care
that allowed them to function in the 'normal' social world despite
the emotional distress some experienced (Goldstein, 2003), to the
so-called Moral Treatment developed at the York Retreat by William
Tuke towards the end of the eighteenth century (Digby, 1985), which
advocated peace, respect, and dignity in all relationships, and
emphasised the importance of maintaining usual social activities,
work and exercise. These approaches, predicated as they were on
a gentle and humane engagement with the vagaries of human experience
at the limits, and invoking respect, dignity, collective responsibility,
and an emphasis on interpersonal relationships as guiding principles,
have much to tell contemporary biomedical psychiatry.
the modern era, non-medical attempts to understand and tend to 'psychosis'
have coalesced into a tradition counterposed to the biomedical orthodoxy.
The richest seam of evidence within this tradition is that relating
to Soteria House , the project developed by Loren Mosher and colleagues
in San Francisco during the early 1970s (www.moshersoteria.com).
Here, people diagnosed with schizophrenia could live in a suburban
house staffed with non-professionals who would spend time 'being'
with them in an attempt to try and secure shared meanings and understandings
of their subjective experience.
medication was marginalised, being considered a barrier to the project
of understanding the other, and was only ever taken from a position
of informed and voluntary choice. Arguably the most radical aspect
of the Soteria project was the emphasis given to building a case
across many different rhetorical levels, including the scientific/evidential.
Subjected to a randomised controlled trial in comparison to 'treatment
as usual' (TAU - hospitalisation and medication), with follow-up
assessments at six weeks and two years, it proved at least as effective
as TAU with some specific advantages in terms of significantly greater
improvements in global psychopathology and composite outcome, significantly
more participants living independently, and significantly fewer
readmissions (Bola, 2003). A Swiss iteration of Soteria reported
similar results and suggested these could be achieved at no greater
fiscal cost than TAU (Ciompi, 1992), whilst a recent systematic
review of all the evidence pertaining to Soteria confirmed both
claims (Calton, 2008).
evidence supporting the use of non-medical approaches to helping
people diagnosed with 'psychosis' / 'schizophrenia' has emerged
from Scandinavia and the USA (Calton, 2009). In the former, so-called
'Need Adapted' treatment, an approach which places great emphasis
on interpersonal relationships and striving after meaning, whilst
decentring medication, treating it as merely one of a plurality
of interventions, is associated with people spending less time in
hospital, experiencing fewer 'psychotic' symptoms, being more likely
to hold down a job, and taking much less antipsychotic medication.
In the latter, evidence from an innovative series of research projects
conducted in the 1970s suggests not only that people diagnosed with
'schizophrenia' can recover without the use of antipsychotic medication
when exposed to a nurturing and tolerant therapeutic environment,
but also that antipsychotic medication may not be the treatment
of choice, at least for certain people, if the goal is long-term
conclude then, it seems appropriate, given the evidence, to claim
that the human experience of 'psychosis' can be helped without recourse
to the use of antipsychotic medication. The research cited above
does not appear to have been considered in the current NICE guidelines
(presumably because of the small number of studies undertaken using
minimal or no medication approaches), though may well be incorporated
into the next iteration. This should happen because the lack of
any meaningful idea of choice with regard to treatment for people
diagnosed with 'psychosis' / 'schizophrenia' in the UK is abundantly
apparent; a state of affairs that may not be sustainable given recent
pronouncements on patient choice (DoH, 2008).
must remember, honour and reiterate these alternative traditions
of thought and practice if we are to overcome the extant biomedical
Calton is a psychiatrist and winner of the 2005 Royal College of
Psychiatrists Research Prize and Bronze Medal. He is a research
fellow at the Institute of Mental Health in Nottingham and special
lecturer in the department of health psychology at the University
* National Institute for Clinical Excellence: Schizophrenia: Core
Interventions in the Treatment and Management of Schizophrenia in
Primary and Secondary Care. London , NICE, 2002
National Institute for Clinical Excellence: Schizophrenia: Updated
Guidelines for Core Interventions in the Treatment and Management
of Schizophrenia in Primary and Secondary Care. London , NICE, 2009
Goldstein JL, Godemont, M.M.L.: The legend and lessons of Geel ,
Belgium : A 1500-year-old legend, a 21st-century model. Community
Mental Health Journal 2003; 39(5):441-450
Digby A: Madness, Morality and Medicine: A Study of the York Retreat,
1796-1914. Cambridge , Cambridge University Press, 1985
Bola JR, Mosher, L.R.: Treatment of Acute Psychosis Without Neuroleptics:
Two-Year Outcomes From the Soteria Project. Journal of Nervous and
Mental Disease 2003; 191(4):219-29
Ciompi L, Dauwalder, H.P., Maier, C. et al: The pilot project "Soteria
Bern": clinical experiences and results. British Journal of
Psychiatry 1992; 161:145-53
Calton T, Ferriter, M., Huband, N., Spandler, H.: A Systematic Review
of the Soteria Paradigm for the Treatment of People Diagnosed with
Schizophrenia. Schizophrenia Bulletin 2008; 34(1):181-192
Calton, T., Spandler, H.: Minimal Medication Approaches to the Treatment
of People Diagnosed with Schizophrenia. Advances in Psychiatric
Treatment 2009 (in press)
Department of Health: High Quality Care for All. London , DoH, 2008
18, 2008: Underground recovery - Clinical psychologist Rufus
May explains why, when using a non-drug approach to help
a doctor who heard voices, he had no choice but to work in secret.
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