Treating Schizophrenia without drugs? There's good evidence for it.
Reflections on my work in Therapeutic Communities and Networks - Drug Free recoveries from Diagnosed Schizophrenia
I have been working in Mental Health as a Social Work practitioner, Counsellor, Psychosocial Therapist and care Manager for over 30 years. I first worked with the London Borough of Harrow, London Borough Ealing and London Borough Brent, running Therapeutic Communities and applying ‘therapeutic community’ principles, within community settings and wider social networks. I have since worked in the Statutory Sectors (Health & Social Services), in the Voluntary Sector and worked as a Consultant.
David Cooper (Politics of Schizophrenia) took over the Therapeutic Community that I set up in Ealing in the 1980's. Since these earlier days of developing the techniques, I have since worked in the Voluntary Sector, organising small therapeutic networks and providing individual Counselling, Advocacy and Care Management support, to anyone with any form of psychological, social, or diagnosed ‘psychiatric’ problem.
With only few exceptions, everyone who was ‘voluntarily’ referred to us, with a diagnosis of Schizophrenia (and a significant number with Bi-Polar conditions), were identified to have had psychosocial experiences that fully accounted for the psychosis they experienced (or as demonstrated in their behaviour). Others people, with differing diagnoses who exhibited 'psychosis', usually had similar traumas.
My Practitioner Work and Operational Research, did not limit itself to the features of 'psychosis', It is just that these cases were usually seen as the most intractable conditions and ones for which it was often assumed there was no potential for therapeutic recovery, through any means, other than long term, symptom suppressing medication. All other forms of mental health conditions were worked with.
Other groups/conditions that we were able to positively work with and effect substantial recoveries, were; chronic Depressive Disorders, Obsessive Compulsive disorders, Eating Disorders, Reactive Depression and Suicidal Tendencies, Autistic Spectrum disorder, 'Suppressed Intellectual Functioning' and 'Challenging Behaviour' (institutionalised) of people with Learning Difficulties, Acquired Brain Damage & Dementia.
From my previous 'anecdotal' experience, gained in my work with Learning Disability services, I had already successfully worked in the 'recovery' of people with diagnosed, protracted psychiatric disorders and autistic features. The contradictions that I was experiencing, between the conventional expectations and the actual & further potential for recovery, seriously challenged the conventional psychiatric edicts.
The approach we took was very 'ordinary', largely accepting the person's experiences as both 'real' for them and having genuine validity; in terms of the 'therapeutic' conversations we had with them. As a consequence, RD Lang became, and remained, an inspiration for identifying psychosocial causation and developing psychosocial therapeutic techniques. To understand the therapeutic process you have to do it.
These identified psychosocial features included very obvious early developmental, adolescent transitional and adult 'trauma’. In addition, there were sometimes due to drug, alcohol and other toxic impacts; including the use of prescribed psychotropic drugs. Often (but not always) it appeared to be a combination of influences which triggered the first and subsequent 'psychotic' episode. Psychiatric practice itself the rest.
The developmental 'social trauma' experiences, along with some toxic effects, proved adequate to account for much psychosis the person was experiencing. The fear of the experiences, coupled with the condition, the ‘induced’ belief that there was no ‘cure’ and an insistence that they would have to rely upon psychiatric expertise and heavy-duty medication; engrained the ‘problem’ and thoroughly disempowering the person.
My job, along with the therapeutic team and the wider 'community', was to accept, trust and seek to identify the validity of all these personal experiences, appreciate the various contributions of 'cause' and come to a rational understanding (or a 'theory'), from which we could work. This all felt very natural and presented no problems to us, until we engaged with the conventions of 'psychiatry'. We did not let this stop us though.
All these Person Centric, Outcome Focused recovery regimes were applicable to all psycho-social conditions I/we encountered. They are applicable to 'challenging behaviour' as they are to 'psychosis'. They are as applicable to engaging the psycho-social impact of Autism, Learning Disabilities, Dementia, and Trauma of physical & sensory disablement, as they are the features of Serious Mental Health problems.
At the end of the day, the 'Recovery' and 'Enablement' Regimes, based upon the principles I/we established, are empowering to the individual and provide a significant measure of 'Real & Informed Choice'. The underlying Ethic is to return the person to the 'Normal' range of psychological and social 'Inclusive Identification', Social Opportunities, Dignity and Reasoned Expectations, by validating their 'Differences'.
Most importantly, the Therapeutic, Recovery and Enabling processes involved, can start at the very beginning of the assessment process and proceed throughout the whole of the Care Management and Case Recording process. If there is a proper 'Person Centred' commitment from the beginning and the person's perspective is fully taken into account, interpreted in their best interests, outcomes will be in their best interests and will be the least restrictive, least disabling, least dependency creating and 'Least Risky' Outcome Options & most easy to Manage.
Therapeutic Communities & Networks
We worked on that basis of getting the person to understand how their psychosis evolved out of their basic creative (imaginative) character. We demonstrated how this was possibly 'compromised', by poor developmental and social learning; poor social acceptance of individuality and self-determination (self-actualisation), intolerance of ‘difference’ and fundamental misunderstanding of differing ‘learning’ & ‘expression’ styles.
The initial psychosis is usually precipitated by some (often recent) traumatic events in their lives. This can be (as described) a toxic effect, sometimes resulting from, or aggravated by, the use of alcohol and/or drugs. Sometimes the trigger was due to the use of antidepressant and psychotropic drugs, in the early treatment of serious depressive, or psychotic reaction to traumas (sometimes 'suppressed' in memory).
The impact of physical, psychological, emotional and social trauma can affect people differently. The differences are not manifestations of 'weaknesses' just 'different' in response to circumstances; according the the personality, learning style, previous 'adjustment' experiences and the previously established 'social expectations' of the person. These 'social expectations' were to prove crucial in later therapeutic work.
Deconstruction and Reconstruction:
We effectively 'deconstructed' their negative psychiatric experiences and 'reconstructed' their personal and social experiences. The deconstruction of the 'negative' psychiatric experience was relatively easy, as classical psychiatry is poorly founded and its theory and rationales easily shown to be flawed. Most 'clients' already knew this and many had rejected these assertions for some time.
This reconstruction of their 'understanding' of the nature and cause of their 'psychotic' experiences was a little more difficult, as it was necessary to wait for the person to be 'ready' to seek an explanations. To do this they had to acknowledge that the problem existed. To feel safe to do this they had to appreciate that although classical psychiatry had got the cause wrong, the problem still existed for the person.
The process of 'validating' their experiences (including the psychosis) as understood reactions to circumstances and 'creative' responses to previously poorly understood experiences, was usually enough to gain the confidence of the person. We were then able to proceed with the reconstruction phase of their recovery, which we always did within the person's own 'frame of reference', wherever possible.
This was enough to get them to take a new perspective on their condition and open up the possibilities of gaining insight into it. It is true that insight is difficult to achieve while within a ‘psychotic’, or ‘fright’ state, however, they were able to become skilled in anticipation and avoiding switching into such a state, once they more fully understood how this happened and what variables and influences contributed to this.
General Results of the Operational Research:
At the end of therapeutic recovery period (initially between 6 &18 months) and for as long as we were maintaining contact with the person (anywhere between 2 - 25 years), these recoveries were progressively without the support of psychotropic medication, or the complete absence of it. Some 'clients' recovered and went on their own way and we can only hope they maintained their wellbeing, not following up on them.
With the majority of people, we were able to maintain some follow up, sometimes formally, but mostly informally. These clearly persistent recoveries were often with the abstinence from other drugs and often with the abstinence from alcohol also. These abstinences did seem to improve the rate and persistence of the person's recovery, although they were not a 'required condition' of our recovery process.
All 'clients' demonstrated either complete absence of symptoms, or substantial moderation of symptoms, to a degree that they were able to monitor and adjust their established regimes to compensate for the recurrence of any residual psychotic features. In the 'Therapeutic Community' environment the recovery was quicker, but follow up generally briefer.
In the current 'Therapeutic Networking' ('Community Care' environments) approach, the process is somewhat 'relatively' slower, (relative to the but clearly well sustained and monitored over approximately 2-4 years. The number of participatory 'clients' is smaller (ranging between 5-12), but success rates seem similar.
During the 3 years of the first study, 6 years of my second study and the last 15 years of therapeutic networking, I have follow up a few people for as long 4 - 5 years and one as longer than 25 years. All had maintained their recoveries and returned to productive lifestyles, 'within the terms they had subsequently chosen'; mostly adjusting for the improved opportunities for 'managing' stress, rather than avoiding work/life stress.
Criteria for the Recovery Regimes:
We turned no one away and did not 'filter' for those who would be most responsive to the 'recovery regime'. We accepted everybody referred, including people with homicidal backgrounds, alcohol and drug problems and on Home Office Supervision Orders. The selection was mostly a process of 'self selecting' and the only early withdrawers were people with alcohol problems and no significant psychotic features.
In no case was there an obligation for the person to be part of a 'follow up' monitoring scheme. The follow up, with ourselves, was informal and entirely under control of the person. This fully respected the choice and dignity of the person and was in keeping with the ethics of the Recovery Regime. It was not felt necessary for formal follow up to be part of the Operational Research methodology.
Reactions of Clinical Psychiatry
I was never accredited with ‘cure’ by any psychiatric institution, or psychiatrist, although the individuals were often astonished by how free they were of their symptoms and how empowered they had become, resulting from their therapy. Most came off all their medication, although some chose to maintain a reduced level. Others felt secure enough to return to medication in times of crisis, which may have precipitated a psychotic state.
The best we were able to get from psychiatry was an acknowledgment of a ‘misdiagnosis’. That was satisfying enough, as there were few exceptions to ‘substantial recovery’ (in as much as anyone is completely sane). I have found the same intractable behaviour from psychiatry since the earliest days, even with clear evidence presented to them. It is as if psychiatry itself is a collective delusional state, with one willing to speak out about the inconsistencies.
Even where there was a clear ‘organic’ character to the psychosis, which had led to the diagnosis of schizophrenia, there were clear benefits from the psychosocial therapy and clear causal understanding of ‘cause and effect’. Explanation of a condition, with improved ‘expectation’ of personal control over the condition, helped the person manage their symptoms better. This was mostly because the felt ‘safer’ with them and felt more ‘empowered’.
Psychosocial Therapeutic Skills
The socio-therapeutic techniques we used were the ‘natural’, social skills of open minded, young, optimistic therapists, with a sound grounding, understanding and critical perspective on psychology and sociology. They also had varying developmental and social experiences, including serious trauma and derivations, which they were willing to acknowledge.
The staff group were expected to engage in the same ‘psychosocial’ experiment as their clients. This mainly involved working from some very basic social rules and evolving an agreed set of rules and guidelines that fitted the group’s tasks and objectives.
Rather than ‘fragmenting’ the techniques into ‘cognitive’, ‘social’, ‘conscious’, ‘unconscious’, ‘rational’ and ‘intuitive’, etc.; we worked holistically, valuing our collective understanding of these various ‘understood’ and interacting components. Staff picked their own particular counselling & therapeutic styles and techniques, seeking training in the areas of their individual interests.
When working in the staff group, and the therapeutic community, they subjugated their individual styles to the more holistic approach. During individual counselling and small group therapies, the preferred styles of individual therapists came into their own. No style was ‘too precious’ just useful for dealing with a particular problem, or fitting a particular individual.
It is no wonder that it works so well and I still find it incredible that intelligent professionals are unable to appreciate that these techniques do work, very efficiently, over relative short periods of time and produce dramatically improved outcomes (especially when compared with long term, high level, psychotropic medications and periodic ‘intrusive’ interventions).
Of course, there are some psychotic conditions, which appear intractable and persistent. Some of these are evidentially organic in character. As I say, some improve non- the-less. Others, especially some extreme cases of paranoid schizophrenia, seem to be very resistant. Even this is simply explained. Most diagnostician seek to identify a single condition to explain all features. This is one of the biggest mistakes in psychiatry and psychology.
Cognitive Errors (of Psychiatry)
Too often, we assume all symptoms that are observed to be the result of a single ‘diagnosed’ condition. Only rarely to we see a proper appraisal of all the challenging features of a person’s psychosocial dynamic. If you have a diagnosed schizophrenia, all subsequent behaviours, altered states, and confounding expressions, are due to that single ‘condition’.
This often includes the anger expressed at restrictions and impositions (including those that we feel we can justify). It can include the frustration at not being listened to, or properly understood (sometimes because of ‘our’ limited thinking). There is also the depression and anxieties that arise out of having what we are told is an intractable and debilitating condition
Most importantly, there are the symptoms of all those other conditions we may develop quite independently. Some of these are other ‘reactive’ condition, which are designed to give us respite from distress, like grieving, low mood, anger and anxiety. Of course, these are soon turned into intractable condition, for being identified as ‘abnormal’. It seems we must never rests from stresses (unless we wish to be identified as ‘weak’).
Well, some of these other psychosocial conditions include features that are sociopathic and psychopathic in character. We understand these as personality features, rather than psychiatric conditions. Non-the-less, it is these ‘independent’ features when coupled with a ‘psychosis’ that produces the convenient, unified condition of ‘paranoid schizophrenia’.
Basically; reasonably socially integrated people experience psychosis because of developmental, social and toxic trauma. Fear, poor social reaction and psychiatric determinism entrench these features into the ‘diagnosed’ condition. Likewise, people who have a diminished, or corrupted, psychosocial relationships / cognitive styles (for whatever reason) can also develop psychosis and have this ‘condition’ become entrenched.
Outmoded Quasi-scientific Thinking
The whole system of psychiatric classification needs complete revision. It is essentially bankrupt. With the help of social-psychological developments (including a better ‘cognitive’ and ‘behavioural’ understanding of the effective therapeutic styles of intervention), psychiatry has made some advances in the treatments of neuroses and depressions, but is in the stone-age in respect of psychosis.
Delays in this revision are largely due to the psychiatry’s dependence, for income and credibility, on legal status of its diagnosis and the protection of society from risk (acknowledged) and inconvenience (disguised). Small wonder we see few changes and almost total resistance to acknowledging psychosocial causes (like work and social stress) and psychosocial ‘cures’.
The human, social and economic costs of this ‘distorted’ psychiatric perspectives, are accelerating and practices remain inconsistent with the established principles and laws of Human Rights. The principles of ‘least restrictive’, ‘dignity’ and relating to ‘mental capacity’, are seriously compromised by current psychiatric thinking and impacts on the entitlements of those with ADHD, Dementia and Autism, as well as the ‘Psychoses’.
Not only is there now sound evidence to challenge existing psychiatric thinking, there is also now sound logic and challenging theory which completely undermines the whole basis of classification and ‘normalistic’ understanding of traditional psychiatry. Classical Psychiatry is now unable to defend its position, except in the most extreme cases of proven organic conditions. It must otherwise rely upon maintaining ‘fear’ to keep its control over our minds and behaviour.
