Tag Archives: Open Dialogue

More on The Continuing Proof of the Efficacy of Anti-Psychotics

By Dr David Laing Dawson

The narratives from the proponents of Open Dialogue remind me of the narratives arising from the psychoanalysts working in private psychiatric hospitals in the United States in the 1950’s and 1960’s. Many case studies were available and even books written on the subject.

In the late 1960’s we were unlocking the doors of the mental hospital in Vancouver and applying therapeutic community principles. The principles and ideas of the therapeutic community can be found in the activities of the Open Dialogue program. And before that they can be found in the practices of small hospitals from the Moral Treatment Era of the 1850’s to 1890’s, and again, briefly, in some mental hospital reforms shortly after WW1 and before the Great Depression, albeit, in each case, within the language and pervasive philosophies of the time.

In the late 1960’s we had already discovered how wonderfully effective chlorpromazine could be in containing mania and reducing the psychotic symptoms of schizophrenia.

So in this context, knowing the evidence, the clear evidence of chlorpromazine being the first and only actually effective treatment for psychosis, and lithium for mania (beyond containment, sedation, shelter, kindness, protection, food, routine grounding activities, time and care) it behooved us to look closely at the claims of the psychotherapists who were writing such elegant and positive case studies from the American private hospitals.

So I read them.

They were interesting reading, detailing the relationship of therapist and psychotic patient, interpreting the content of the psychosis, and the painstaking time consuming process of building a relationship, working to help the patient view the world in a different manner, and always, through the pages of these reports, it was said great progress was being made. And they all ended with something like (this is the one I remember best) “Unfortunately, despite showing so much progress, patient X assaulted a nurse and had to be transferred to the State facility.” Curiously, as with many “studies” I read today, despite the obviously bad outcome, a paragraph is added at the end extolling the progress made (before the unfortunate outcome) and recommending we stay the course.

There are many interesting explanations for the continuing anti-medication (for mental illness) philosophies. (Note that almost nobody objects to taking medication for other kinds of suffering and illness). Marvin and I have written about a few – the preciousness of the sense of self, the wish that there be an immortal mind that can outlive a brain, the fear of being controlled, distrust of Big Pharma, professional jealousies, and turf wars. But writing the above reminds me of another reason this irrationality persists.

It was clearer to me then (1960’s/1970’s) than it is now, because we really wanted to find ways of helping without medication: It is much more ego gratifying to mental health workers of all stripes when our patients get better simply because of our presence, our words, our care, ourselves, than if we just happen to prescribe the right medication.

I remember well a patient, a professional, a few years ago, thanking me for helping him overcome a severe depression. “Nah,” I said, “I just managed to prescribe the right medication for you.” “No, no,” he said. “It was more than that.”

All right. There are a few moments when I can be attentive, thoughtful, kind, and even find the right words. But to try doing that alone while withholding medication for severe mental illness would be malpractice, cruel, egotistical, even sadistic.

 

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The Continuing Proof of the Efficacy of Anti-Psychotics

By Marvin Ross

Despite the protestation from the anti-psychiatry advocates, medication for schizophrenia works and another study has just been published to support that position. A new study based on a nationwide data of all patients hospitalized for schizophrenia in Finland from 1972 to 2014 found that the lowest risk of rehospitalization or death was lowest for those who remained on medication for the full length of time.

The risk of death was 174% to 214% higher among patients who never started taking antipsychotics or stopped using them within one year of their first hospitalization in comparison with patients who consistently took medications for up to 16.4 years.

It should be pointed out that this is real life data rather than a clinical trial involving a total of 8,738 people.

What is particularly significant for me in this study is that it is from Finland which is the home in one isolated part of that country (Lapland) to the alternative Open Dialogue espoused by the anti-psychiatry folks including journalist Robert Whitaker of Mad In America fame. Whitaker claims that 80% of those treated with Open Dialogue are cured without need for drugs.

I wrote about Open Dialogue very critically back in 2013 in Huffington Post and pointed out that there is very little research to demonstrate its efficacy. I actually asked a Finish psychiatrist, Kristian Wahlbeck who is a Research Professor at the National Institute for Health and Welfare, Mental Health and Substance Abuse Services, in Helsinki about Open Dialogue.

This was his answer:

“I am familiar with the Open Dialogue programme. It is an attractive approach, but regrettably there has been virtually no high-quality evaluation of the programme. Figures like “80 per cent do well without antipsychotics” are derived from studies which lack control group, blinding and independent assessment of outcomes.”

He went on to say that:

“most mental health professionals in Finland would agree with your view that Open Dialogue has not been proven to be better than standard treatment for schizophrenia. However, it is also a widespread view that the programme is attractive due to its client-centredness and empowerment of the service user, and that good studies are urgently needed to establish the effectiveness of the programme. Before it has been established to be effective, it should be seen as an experimental treatment that should not (yet?) be clinical practise.”

As for the claim that psychiatric hospital beds in Finland have been emptied, he said “in our official statistics, the use of hospital beds for schizophrenia do not differ between the area with the Open Dialogue approach and the rest of the country.”

My blogging associate, Dr David Laing Dawson also wrote about Open Dialogue in this forum with very skeptical view. He stated that the director of the program admitted that about 30% of the patients in Open Dialogue are prescribed medication so arguing that medication is not used is not correct.

At the time my article appeared in Huffington Post, someone on Mad In America agreed with me that there was insufficient evidence on the efficacy of Open Dialogue and said that a US study was set to begin in, I think, Boston. I did find a completed study on Open Dialogue done by Dr Christopher Gordon. His study involved 16 patients and he states at the outset that

“Since this was not a randomized clinical trial and there was no control group, we cannot say that these outcomes were better than standard care, but we can assert that they were solidly in line with what is hoped for and expected in standard care.”

In the paper that is in a legitimate psychiatric publication, he states that of the 16, two dropped out and a further 3 had disappeared at the end of the study so no data is available for them. This is a study of 11 people who completed the one year term.

He then points out that:

“Of note, four individuals had six short-term psychiatric hospitalizations (two involuntary).”

and that:

“three of the six individuals who were not on antipsychotics at program entry started antipsychotics. Of the eight already on antipsychotics, four had no change in their medication, and four elected to stop during the year. Both groups of four had similar outcomes and continued to be followed in treatment. Shared decision making and toleration of uncertainty contributed to these choices.

Hardly the success he suggests if the goal was to help them get well without medication.

But, coming up at the end of May in Toronto we have a conference with Robert Whitaker and others on Shifting the Narrative on Mental Health from the psychiatric disease model to the relational/recovery model, and on the challenges that are stacked against that eventuality.

Now I would say that the challenges against that shift are science but they define it as “The challenges and resistances to progressive change are of an ideological, macro-economic nature guaranteeing a protracted and difficult struggle for recovery advocates.”

A Psychiatrist Critiques Open Dialogue

By Dr David Laing Dawson

We humans are a strange and contradictory species. While most of us are willing to take any number of potions and pills to limit the effect of the common cold, to boost our energy levels, to ward off aging, sore joints, and failing libidos, and a great many of us are willing to consume dangerous liquids, pills, and injectables to ameliorate the anxiety of knowing we are vulnerable, mortal and inconsequential life forms, and some of us decide to undergo toxic chemotherapy for a ten percent better chance of survival, there are others of us (perhaps not different people) who would deny (proven effective) antipsychotic drugs to someone suffering the devastating and dangerous symptoms of psychosis, of schizophrenia.

Even if some form of two year intensive counseling/therapy/group therapy worked as well as four weeks of Olanzapine, what on earth would be the justification for withholding the Olanzapine?

To be fair we have been here before. We have all, including psychiatrists, wanted to see, to understand, mental illness, both in mild form and severe form, as adaptations and temporary aberrations of the workings of the mind. And, by extension, amenable to persuasion, love, kindness, respect, and a healthy life style. In the Moral Treatment era of the mid to late 1800’s that healthy life style was based in Christian principals of routine, work, duty, etiquette, and prayer in a pastoral setting. For someone with a psychotic illness this undoubtedly would be preferable to the imprisonment that came before, to the massive overcrowded mental hospitals that grew and grew after the industrial revolution, and even, for many, preferable to the mental health systems of 2015. But it did not treat or cure psychosis.

Through the 40’s, 50’s and 60’s many notable psychoanalysts tried treating schizophrenia with their own particular form of “open dialogue”. I read many of their books and case histories. And while they are fascinating explorations of the human condition and equally interesting attempts to find meaning within madness, it did not work, at least not as a treatment to alleviate suffering and disability.

And then in the sixties and early seventies we experimented with therapeutic communities. When I listen to the staff of Open Dialogue in Finland talking about their program I can imagine my colleagues and I saying the same things about our experience in Therapeutic Communities of the 1960’s. It was humbling, as close to a level playing field as possible, a marvelous learning experience for staff, a laboratory of interpersonal and group dynamics, an open, respectful environment for patients, but it was not an effective treatment for psychotic illness, at least not without the addition of anti psychotic medication.

Harry Stack Sullivan, a psychiatrist working before the introduction of chlorpromazine wrote that “schizophrenics are not schizophrenic with me.” And what he meant, I think, was that, with a little skill, plus respect, patience, a non-judgmental attitude, knowing when to talk and when to listen, knowing what to avoid and what to ignore, one can have an enlightening and pleasant conversation (dialogue) with someone suffering from Schizophrenia. But that conversation is not a lasting treatment or cure.

It is also notable, I think, that the psychiatrist and director of Open Dialogue in Finland, in interview, acknowledged that she prescribes neuroleptic medication for “about 30 percent” of their patients. Now, from what I know of human nature and our tendency to round our figures up or down depending on the social moment, maybe that is 35 to 40%. And given the way they work as a 24 hour on call mobile immediate response team, with no filters for severity or urgency, even if only 30% receive neuroleptic medication, it sounds about right. In truth then, Open Dialogue in Finland is NOT not using neuroleptic medication to treat people with severe psychotic illness.

I have no doubt that they have created relationships and a social environment for their patients in which less medication is necessary to help them survive and function. I think it is the same thing our ancestors did in the moral treatment era, and again, what we did in some therapeutic communities of the 1960’s.

Open Dialogue also reminded me of some other experiments with around-the-clock, immediate response teams preventing hospitalization and achieving better results than hospitalization. When I explored some of these in the 1970’s and 1980’s wondering if they could be reproduced outside of their funded clinical trials I found young idealistic doctors and nurses quite willing at that time in their lives to be on call 24/7 without extra pay, with limited personal life during the course of the experiment. We could approximate these programs in real life but we could not replicate them.

We have ample reason to not trust big pharma and their incessant push to expand their customer base, but let us also be aware of both history, and the realities that surround us, of the many people with psychotic illness now back on the streets, in the hostels and jails, of the need for better mental health care systems, and the need for better cost effective treatment, and of the many people for whom our current medications have been both sanity and life-saving.