Interview with psychologist Lloyd Ross on treating schizophrophrenia

These positions sound very sectarian...

Eeyore,
How so - and what are your views on these issues?

If you want some data on the link between "things going wrong in life" and schizophrenia, here's some:

"In a very different tone than that of “schizophrenia is a destructive, inherited brain disease,” Anjnakina et al. state at the top of their article “The relationship between childhood adversity and psychotic disorder is well documented.” Indeed, this is true. There is not enough room here to begin to do the vast amount of literature justice, but I will provide just a few key resources. Read et al.17 concluded in 2005 that child abuse is a causal factor in “schizophrenia.” Read et al.18, after identifying similarities in the brains of traumatized children and adults who were diagnosed with schizophrenia, demonstrated the neurodevelopmental pathways through which childhood adversity may cause psychosis. In 2004, Janssen et al.19 established a strong dose-response relationship between childhood abuse and psychosis after following 4045 individuals from the general population for two years. Bentall et al.15 also found a dose-response relationship between childhood abuse and psychosis (meaning that the greater number of adverse experiences and/or the higher the severity, the greater the risk), wherein those who had a high-severity of childhood abuse were 48.4 times more likely to develop psychosis as an adult. When specificity and dose-response relationships are demonstrated, a causal relationship is strongly probable. In fact, Bentall et al.15 stated that “experiencing multiple childhood traumas appears to give approximately the same risk of developing psychosis as smoking does for developing lung cancer.” And, lastly, in the same month as the Sekar study was released (January 2016), so too was a nationwide cohort study out of Denmark and Sweden20 which found that experiencing the death of a first-degree relative before 18 years of age, especially from suicide or accident, resulted in a 39% increased risk of being diagnosed with schizophrenia."

Citations -

15. Bentall, R., Wickham, S., Shevlin, M., & Varese, F. (2012). Do specific early-life adversities lead to specific symptoms of psychosis? A study. Schizophrenia Bulletin, 38, 734-740.

16. Cohen, P., Brown, J., & Smaile, E. (2001). Child abuse and neglect and the development of mental disorders in the general population. Development and Psychopathology, 13, 981-999.

17. Read, J., van Os, J., Morrison, A. P., & Ross, C. A. (2005). Childhood trauma, psychosis, and schizophrenia: A literature review with theoretical and clinical implications. Acta Psychiatrica Scandinavica, 112, 330-350.

18. Read, J., Fosse, R., Moskowitz, A., & Perry, B. (2014). The traumagenic neurodevelopmental model of psychosis revisited. Neuropsychiatry, 4(1), 65-79.

19. Janssen, I., Krabbendam, L., Bak, M., Hanssen, M., Vollebergh, W., de Graaf, R., & van Os, J. (2004). Childhood abuse as a risk factor for psychotic experiences. Acta Psychiatrica Scandinavica, 109, 38-45.

20. Liang, H., Olsen, J., Yuan, W., Cnattingus, S., Vestergaard, M., Obel, C., Gissler, M., & Li, J. (2016). Early life bereavement and schizophrenia: A nationwide cohort study in Denmark and Sweden. Medicine, 3. Doi: 10.1097/MD. 0000000000002434.

Source: https://www.madinamerica.com/2016/02...ly-discovered/

Over in Europe they've done a lot of research into the links between adverse life events and risk of getting a schizophrenia diagnosis. It's a pretty strong link, not really a sectarian position to take...

And yeah, I agree drugs can reduce severe distress in the short term - although reducing distress is different from "treating a brain disease", given our lack of knowledge about whether or not there is one unitary brain disease called schizophrenia, and the problem with identifying the entity's biomarkers. However, the Sohler data I was referencing earlier showed that we lack good evidence that antipsychotic drugs have a beneficial effect for most people beyond one year:

http://psycnet.apa.org/?&fa=main.doi...037/ort0000106

So, there is a contrast between the presence of many long-term longitudinal studies of adverse life experiences correlated to chances of receiving the schizophrenia diagnosis on the one hand... and the mostly short term nature of drug trials on the other.

All of these studies based on correlations and assumptions to varying degrees, thus should be interpreted cautiously across a range of settings. I've read some books on the science of brain differences and gender... what they taught me is that no one study of humans really says anything close to definitive, and these studies must be interpreted much more cautiously than with hard sciences. I can't remember the titles now.

Thank you bpdtransformation, I am going to check them.

Crazy, inside and aside

"Outwardly: dumbly, I shamble about, a thing that could never have been known as human, a
thing whose shape is so alien a travesty that humanity becomes more obscene for the vague resemblance."
I have no mouth and I must scream -Harlan Ellison-

Even though i argue for the biological team, i think this thread has inadvertantly inspired me to go back to my psychologist and see it through to the end. But i do agree with an earlier post saying meds was 90% and therapy 10% . I didnt realise that risperidone helped intrusive thoughts i did think it was me doing sumthing wrong but i think a bit of hypomania triggers it.
I also looked up books on negative symptoms its so so hard to find books that you can understand on schizoaffective

That it is wiser for the non-specialists to follow the academic consensus (the DSM worshipers).

Your are not defending the position of your previous post:

"I view these experiences (negative symptoms of EVERY schizophrenic) as understandable responses to things going wrong in one's life"

but a different position:

"the survivors of SERIOUS AND RARE childhood traumas are more likely to develop psychosis, but they are a minority of the people with schizophrenia"

I'll cite again the article of Pies:
most psychiatrists who have treated severely impaired patients with schizophrenia have little doubt that long-term antipsychotic treatment is both effective and necessary to avoid relapse of psychotic illness.

Long-term Antipsychotic Treatment: Effective and Often Necessary, with Caveats | Psychiatric Times

This seems to be the academic consensus that the non-specialists should follow.

Eeyore,

Then let me ask you this: has following the academic consensus resulted in you reclaiming a "good" life, i.e. being able to have a meaningful career, have good friendships and romantic relationships, feel fulfilled and alive... or whatever it is you want to do?

To the degree that mainstream treatment promotes desired outcomes, I would support them. I just don't think that they do nearly often enough... the long-term functional outcomes of mainstream treatment are pretty abysmal - for most, not all. Approaches that I cited earlier, like Benedetti, Siani, Martindale, Open Dialogue, Gottdiener, etc... show a lot better functional outcomes for a bigger proportion of people, if you develop a really in-depth relationship with a person, something that is rarely done in mainstream treatment of schizophrenia.

Also Eeyore, I have to wonder if you have not read the research I linked carefully.

The whole point of that research is that these traumas are not rare in those diagnosed with schizophrenia. They are common - and much more common than anything abnormal found genetically or biologically.

Here's a talk with more detail about how common adverse experiences are for those diagnosed with schizophrenia, Trauma and Psychosis: From Heresy to Certainty:

https://www.youtube.com/watch?v=Y6do5bkUEys

If you have research saying that people with serious adverse experiences are only a small minority of those labeled schizophrenic, please post it here.

Pies' statement is an appeal to opinion, not to actual scientific studies. He doesn't even cite any data supporting the idea that most psychiatrists (where?) believe what he says. Although I think it is very probably true that most of them believe this. But then again, when your only tool is a hammer... And again, I think these drugs do quiet people down pretty effectively. But the question is, what are they effective at, and how effective are they? That could be a whole other discussion...

But, I am in favor of choice. If people want these drugs they should be free to take them. I do not think, however, that professionals should impose antipsychotics onto every person so-labeled. Many can get better without. From my earlier citations, the majority of formerly schizophrenic people in the Benedetti study, from the 388 Quebec program, from Sandin's work in Sweden, and from Open Dialogue came off or were never on antipsychotics. This suggests that they may not be necessary for a large group of people labeled schizophrenic, with sufficient support. I met many psychiatrists in ISPS (like Ira Steinman and Bert Karon) who do not use drugs heavily or for long periods, and talked with them about how and why they do or do not use the drugs. I really recommend to you Ira's book, Treating the Untreatable - he is not against all drugs, and he is very hopeful about people recovering with or without drugs.

Here is his bio - Ira Steinman

Hi Van Gore,

I'm glad to hear some things in here were a bit encouraging, whether from me or others. I think even if talking and relationships are only a small bit of what helps someone that is good. Again I am for whatever works for a particular individual, and if that includes drugs then good for them!

You might be interested to see how early psychiatrists (60s/70s) defined schizoaffective disorder along a continuum:

https://bpdtransformation.files.word...157update2.png

It actually overlaps into schizophrenia and is not clearly separable from schizophrenia on the severe end, or from less severe conditions on the lower end. So I think a lot of what is said about schizophrenia or borderline states would also apply to schizoaffective. And in my view, any of these conditions can be moved through or out of with enough help, i.e. they are not incurable lifelong illnesses.

There are a couple of good books about severe schizoid states and how to work with them psychologically: Schizoid Phenomena, Object Relations, and the Self, by Guntrip, and The Empty Core by Seinfeld. These should be available used online. Also, Disorders of the Self by Masterson... Ralph Klein writes about severe schizoid conditions in there. To me the distinctions between these similar labels are somewhat arbitrary and unreliable. The more important thing is to understand what is going on in an individual's life, what they want and how to get there.

I'm not psychotic but only depressed and no, I hadn't a good life with or without the consensus; but the only little improvements were from the tablets.

My mother is a schizophrenic with no insight and my father always opposed the standard psychiatric treatment in favor of "social and familial support". She only got worse until she was hospitalized after that she kidnapped me when I was a child and escaped in another country. Finally she was put on invega that stopped her delirious behavior, but my father interrupted shortly after her treatment and so she came back to her delusional ravings.

Yes, but the mainstream treatment has been the most effective one and led to the closure of most asylums.

Sure thing that it is rarely done, it is impossible in many cases!

I read your quote, 40%-50%. It is not "much more common than anything abnormal found genetically or biologically", those under the Ultra High Risk Criteria and those genetically close to the schizophrenic (twins, sons of two schizophrenic parents) have a similar risk.

I don't have any research about the % of those that had a child abuse among the schizophrenics and I have not the mental energy to listen to the 60 minutes talk. Does he give us some numbers?

Even if you accept the consensus that Sometimes psychotic cited, there is still big room for improvement.

How can you know in which group they are if they don't try them?

Could you quote some passage about some highly delirious and delusional case like my mother? Thanks.

Eeyore,

Here is one case study from psychiatrist Ira Steinman about intensive psychodynamic psychotherapy of delusions: Three Rats and the Extraterrestrial -

Curing Schizophrenia Via an Intensive Psychotherapy « IRA STEINMAN M.D.

And in this free book, Rethinking Madness, are six long case studies of a variety of social / psychological supports leading to recovery:

http://www.rethinkingmadness.com/dow...s_complete.pdf

I don't know if these are like your mother, because I don't know her. The most severe cases of delusions and withdrawal and paranoia that recovered are in the books Treating the Untreatable by Steinman, and Weathering the Storms by Murray Jackson... especially Weathering the Storms. If you want something hopeful try to find that used.

Where do you get the idea that mainstream treatment has been the most effective? Again please provide some studies with data, not just professionals' opinions. And again the question is effective at what... making people silent , numb or compliant, or making them truly alive, functional, and engaged in fulfilling relationships?

Earlier I cited the Jaaskelainen meta-analysis, which shows that throughout the time in the mid-to-late 20th century when antipsychotic drugs became available, outcomes for people labeled schizophrenia did not improve and have gradually been worsening:

https://www.yellowbrickprogram.com/A...eview-Bull.pdf

Closing the asylums has led to loads of people in prison and on the streets. That's not a great achievement.

Talking to delusional people and understanding them is not impossible, although it is rarely attempted due to lack of money and lack of understanding of how to do this type of work.

Where is the data for your comments about abnormal genes being commonly found in people with a given label (and again, that label is arbitrary because there are no reliable biomarkes for schizophrenia)?

Read does give numbers, yes – here's some - http://www.integration.samhsa.gov/pb..._Psychosis.pdf

You can see adverse social experiences like poverty and trauma are very common in people receiving severe psychiatric diagnose. But looking at these things is not profitable and is disturbing to profesionals.

My point with drugs is that some people don't want them, so given the uncertainty around the schizophrenia diagnosis ab initio and the fact that drugs don't cure, why force them on people... let them pursue other avenues of help, as Open Dialogue does. There's no one-size fits all treatment. But if people want drugs let them take them... if it improves their condition, all the better. That is Ira Steinman's position with his cases like the one given above.

The twin research inflates the proportion of risk attributable to genes; for more detail see here from Brian Koehler of NYU -

https://www.madinamerica.com/2015/12...d-epigenomics/

I see we could keep going back and forth on this stuff. But thanks for your interest in discussing.

Just wanted to comment on abnormal genes....they actually have found some trends but feel everyone has different mutations....in my case I have two mutant copies of the metabotropic glutamate receptor called grm3. It's a splice variant thing...sometimes during some conditions the cytoplasmic tail is cut off...so it can't signal. So in my case glutamate sensing is disrupted part of the time. The meds work for me because dopamine feeds back Into glutamate signaling....not because there are changes in neurotransmitter levels. so at least in some cases there is a clear genetic component but that doesn't mean that therapy doesn't help anyway....I like to think it's a mix....meds plus therapy just like how there is a social and genetic component to psychosis.

Thank you for the material.

Thank you for the material but unfortunately my mother has also some severe thought disorders and some strong negative symptoms that would made a psychotherapy like these very hard. Her hallucinations and delusions are also so realistic and 'plausible' that the approach of Dr. Ira with the patient of the rats wouldn't help.

Where do you get the idea that there is a more effective treatment?

Here is a study that compares many antipsychotic medications with placebo:
[...] We identified 212 suitable trials, with data for 43 049 participants. All drugs were significantly more effective than placebo. [...]
https://www.ncbi.nlm.nih.gov/pubmed/23810019

Another study:

[...] We identified 116 suitable reports from 65 trials, with data for 6493 patients. Antipsychotic drugs significantly reduced relapse rates at 1 year (drugs 27% vs placebo 64%; risk ratio [RR] 0·40, 95% CI 0·33–0·49; number needed to treat to benefit [NNTB] 3, 95% CI 2–3). Fewer patients given antipsychotic drugs than placebo were readmitted (10% vs 26%; RR 0·38, 95% CI 0·27–0·55; NNTB 5, 4–9), but less than a third of relapsed patients had to be admitted. Limited evidence suggested better quality of life (standardised mean difference −0·62, 95% CI −1·15 to −0·09) and fewer aggressive acts (2% vs 12%; RR 0·27, 95% CI 0·15–0·52; NNTB 11, 6–100) with antipsychotic drugs than with placebo. [...]
http://www.thelancet.com/journals/la...239-6/fulltext

Another study concludes:
"[...] Although pharmacological treatment has indicated various kinds and levels of adverse effects, most currently used psychosocial interventions cannot demonstrate wide-ranging or long-term (ie, >18 months) effects on patients’ psychosocial and functional outcomes and quality of life. In addition, there are wide variations in the treatment responses among these patients, resulting in an inability to accurately predict the treatment efficacy to a particular patient, and in turn making the optimal patient-focused treatment difficult. In addition, little is known about the therapeutic components or mechanisms of most of the current psychosocial interventions, through which they can produce their effects. With continuous increased understanding about the etiology, psychopathology, and clinical manifestations of schizophrenia, more effective methods and personalized treatment plans are developing or emerging to allow mental health professionals to better define and manage the course of and patient recovery from the illness. [...] "
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3792827/

Lead researcher, Professor Anthony Morrison from the University of Manchester, said: “Antipsychotic drugs are the mainstay of treatment for schizophrenia, but as many as half of all individuals with schizophrenia choose not to take drugs because of common, potentially severe side-effects, because the treatment is not felt to be effective, or because they do not perceive that they have an illness. Currently no evidence-based safe and effective treatment alternative exists.”
https://www.dur.ac.uk/news/newsitem/?itemno=20017

Effective on easing their psychotic symptoms and their suffering.

I don't know what did happen in the USA but here in EU with the reduction of their psychotic symptoms many people were able to live with their family or in a non-restrictive institutional environment.

These positions are sectarian :

[...] The overall impression created by the review of Read et al is that there is a wealth of evidence suggestive of a causal relationship between childhood trauma and psychosis. For example, Read et al produce weighted averages for females and males of reported child sexual abuse (48% females, 28% males), incest (29% females, 7% males), and child physical abuse (48% females, 50% males) from 51 studies of psychiatric inpatients and of outpatients when half or more were diagnosed with a psychotic illness. In terms of understanding the relationship between childhood trauma and psychosis, however, these estimates are misleading.

And after having reviewed the major recent population-based Studies of Childhood Trauma and Psychosis, this meta-study concludes:

The evidence that childhood trauma causes psychosis is controversial and contestable. Child abuse certainly causes prolonged suffering, and it may increase the distress experienced by those who develop a psychotic mental illness in adulthood and lead to worse outcomes. The implications of this for clinical practice require careful consideration. There is not, in our view, a large body of research supporting a causal connection, contrary to the impression gained from the review of Read et al.

https://academic.oup.com/schizophren...-Environmental

Another study states:

[...] There have been suggestions of a link between child sexual abuse and schizophrenia, a hypothesis that has claimed considerable public, if not professional, attention (Sansonnet-Hayden et al, 1987; Briere et al, 1997; Read & Argyle, 1999). The differences between cases and controls for schizophrenic disorders did not reach significance in this analysis and a discussion of trends is unlikely to be contributory. The findings to date do not support an association between child sexual abuse and schizophrenia. [...]
Impact of child sexual abuse on mental health | The British Journal of Psychiatry

Other studies give much more small numbers:

[...] An association between childhood abuse and psychotic symptoms was consistently reported by large cross sectional surveys with an effect ranging from 1.7 to 15. However, we cannot conclude that the relationship is causal as lack of longitudinal studies prevent us from fully excluding alternative explanations such as reverse causality. [...] However, specificity of childhood abuse in psychotic disorders and, particularly, in schizophrenia has not been demonstrated. [...] So far none of the studies reported support the hypothesis that childhood abuse is either sufficient or necessary to develop a psychotic disorder. It seems likely that any effect of childhood abuse on schizophrenia needs to be understood in terms of genetic susceptibility and interaction with other environmental risk factors. [...]
https://synapse.koreamed.org/DOIx.ph...pi.2012.9.2.87

[...] Rates were significantly higher among child sexual abuse subjects compared with controls for psychosis in general (2.8% vs 1.4%; odds ratio, 2.1; 95% confidence interval, 1.4-3.1; P < .001) and schizophrenic disorders in particular (1.9% vs 0.7%; odds ratio, 2.6; 95% confidence interval, 1.6-4.4; P < .001). Those exposed to penetrative abuse had even higher rates of psychosis (3.4%) and schizophrenia (2.4%). Abuse without penetration was not associated with significant increases in psychosis or schizophrenia. [...]
Schizophrenia and Other Psychotic Disorders in a Cohort of Sexually Abused Children | Child Abuse | JAMA Psychiatry | The JAMA Network

Another article concludes that Mainstream psychiatrists are not impressed. “There are no methodologically robust studies showing that schizophrenia is caused by childhood abuse,” says Robin Murray of the Institute of Psychiatry. “The strongest predictor of schizophrenia is a family history of the disorder.”

Peter McGuffin, also at the institute, warns that refocusing on abuse risks a return to the 1960s “when it was fashionable to blame the parents for ‘causing’ schizophrenia”. “A hazard is that it demonises the family,” he says.
https://www.newscientist.com/article...hrenia-linked/

Thank you too.

Eeyore,

In Steinman's book, Treating the Untreatable, there is one case of a man, George, with much more severe delusions than the rat case. This man had been in and out of psych hospitals and halfway houses for 20 years and never able to function, and he had all manner of plausible delusions. You should check out that case. It's a 20 page case so I cannot type it up here, plus I lack a copyright.

In Murray Jackson's Weathering the Storms, there is the case of Conrad, which was extremely severe – a young man who became delusional in his early teens and remained that way for many years into adulthood.

These cases are very detailed and with enough time and patient support, they both got much better.

I get that idea (that there is something more effective, for many, in the long term) from sources like the Gottdiener meta-analysis, Siani's work, Sandin's work, Benedetti's work, from Karon's Michigan Psychotherapy Project, from the 388 project, Soteria, the NIPS Study, Open Dialogue, the World Health Organization studies of recovery in settings where drugs were not available but a lot of social support was, from talking to about 30 individual therapists within the ISPS group about their work, and so on. Taking these studies as a group, long-term recovery seems to be impacted most by psychological / social support, i.e. getting insight into delusions and being able to internalize love and support. Of course, that cannot be proven – just like we can't prove that drugs are the most effective treatment. It's also what worked in my individual case; of course that is not evidence generally.

Regarding the study of drugs you cite, these are mostly short term studies of a few weeks or months. They basically give the person a numbing agent / tranquilizer for a short period, and the person is understandably quieter and less distressed than those who get a placebo. Tranquilizers work. That is what “efficacy” means in these studies primarily. It doesn't refer to following a person for years and seeing them improve the quality of their relationship, being able to develop rewarding careers, developing a personal identity. To me it's pretty hollow and meaningless to define efficacy as “removing symptoms”. Still could be useful in the short term. As I said before, people should do whatever works for them.

Regarding the criticism of psychosocial treatments, I'm not sure why these researchers would criticize psychological interventions for lacking evidence of long-term efficacy... when the evidence for long-term effectiveness of drugs is equally lacking. That is what the Sohler meta-analysis I cited earlier concluded about drugs. One could also say that little is known about precisely how the drugs affect different neurotransmitter systems.

And as for how psychosocial interventions produce their effects, it's about understanding the causes of your problems, developing trusting and loving relationships, and getting insight into the functions of phenomena like delusions and hallucinations. These experiential processes are not easy to reduce into numbers or quantitative studies. You have to do them to understand them, and most of these researchers probably have very little experience being with psychotic people and developing a healing relationship with them, plus the fact that they are commonly funded by drug companies biases them against investigating therapy seriously.... lastly, a lot is known about the therapeutic mechanisms of psychotherapy in general. Check out Barry Duncan's compendium of research into what makes psychotherapy work, The Heart and Soul of Change. The most crucial thing is the quality of the therapeutic relationship as perceived by both sides, but especially by the client.

Well, Anthony Morrison is quite mistaken about the idea that there are no viable alternatives beyond drug treatment – how sad for him to think that... the Gottdiener meta-analysis I posted earlier showed that psychotherapy for psychosis produces similar rates of short-term improvement to drugs, but without the side effects. Just because some professor says something doesn't make it true. I'm glad I never believed stuff like that, otherwise I might not have a job and be in good relationships today.

If people can live with their family that's great, if it's a generally positive environment. Europe is way better than the USA absolutely. Conditions in the US for psychotic people are terrible. No one gives a f--- about them, generally speaking.

Of course, no one factor is the cause of severe psychosis. Various types of stress are involved and it depends on the individual case.

I do not think the family should be blamed at all. In some cases, abuse might be involved and that is one factor of many causing more distress leading to a psychotic breakdown. In many other cases, abuse is not involved. We should look at people as individuals. Even if parents do abuse their children; they're not evil parents... they are usually very troubled and stressed people themselves.

I saw what your research said about child abuse and psychosis. I would say the researchers are motivated to deny Read's claims because to see links between psychosocial trauma and psychosis threatens the biological model which support drug sales, and threatens these researchers' funding indirectly.

Robin Murray actually just admitted that he has given far too little attention to psychosocial factors and he regrets this:

https://academic.oup.com/schizophren...dFrom=fulltext

Sorry, I may not have a very coherent answer this time. I just played tennis for five hours and I'm pretty tired. But I'm still interested to see how someone with a mind very different than mine thinks about things.

Your move

I just found out that Mike Mahoney's website got up and running again so I thought that I would add it to this post. You can download both volumes of his book in pdf format for free at his site in case anyone is interested.

Schizophrenia - The Bearded Lady Disease