Tuesday, October 20, 2015

Coaching Schizophrenics

Writing in The New York Times today Benedict Carey announces that clinical trials have shown that schizophrenics benefit more from medication mixed with talk therapy than they do from medication alone.

Naturally, some people see the words “talk therapy” and think of Freudian psychoanalysis. After all, Freud called psychoanalysis the “talking cure” and therefore it must follow that talk therapy must therefore be referring to the talking cure.

This is a mistake, of the grasping-at-straws variety. When you read through the article you will learn that talk therapy refers to a form of cognitive treatment that has much in common with coaching.

As has been well known for decades, Freudian and post-Freudian psychoanalysis has never provided a therapeutic benefit for schizophrenics. True enough, back in the day some benighted souls tried to psychoanalyze schizophrenia, but it never worked.

To take an example from yesteryear, in the mid 1970s I was working at a psychiatric clinic in the Loire Valley. It was run by people who had been psychoanalyzed by Jacques Lacan, who were being supervised by Lacan and who were members of his School. They were qualified Freudian psychoanalysts.

And yet, they refused to allow anyone in their clinic to psychoanalyze a schizophrenic or any other psychotic. They considered it counterproductive and even dangerous. They treated psychotics with medication and what they called institutional psychotherapy. The latter attempted to socialize the the patients within the context of the clinic.

This approach was surely moving in the right direction. It created a more congenial environment than could be found in psychiatric hospitals. The problem was, it placed too much emphasis on getting along with people within the clinic, to the point where a certain number of patients became permanent residents of the clinic. The new approach, reported by Carey, emphasizes socialization in the context of the outside world.

Read the Times description of “talk therapy” and you will be disabused of the idea that anyone is talking about psychoanalysis:

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.

Treatment involves helping these patients to get along with other people, not giving them insight into their mental functioning.

And it does not, of course, preclude medication. Today’s psychiatrists have good evidence to suggest that schizophrenia is a brain disease. Thus, these patients should receive medication. It is not perfect but the it is far better than the way schizophrenics were treated and the way they behaved before the new medications were discovered:

The drugs used to treat schizophrenia, called antipsychotics, work extremely well for some people, eliminating psychosis with few side effects; but most who take them find that their bad effects, whether weight gain, extreme drowsiness, or emotional numbing, are hard to live with. Nearly three quarters of people prescribed medications for the disorder stop taking them within a year and a half, studies find.

The new medications and some of the old ones did have disagreeable side effects. Yet, they are far better than the old days when there were no effective antipsychotic medication. One needs to mention that some schizophrenics are very dangerous and, in my view ought to be committed and treated involuntarily. Think Jared Loughner of Tucson, AZ, James Holmes of Aurora, CO and Adam Lanza of Newtown, CT.

The important point is that when patients receive coaching along with the medication, their physicians can reduce the dosage:

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. 

Anyone who thinks that these studies suggest that Freud is coming back from the dead should think again.


Ares Olympus said...

This 3.5 year old article says the same thing, with more details on the talk treatment as CBT specifically.
A recent study in the Archives of General Psychiatry by Paul Grant, Aaron Beck, and their colleagues found that a modified version of cognitive-behavioral therapy (CBT), a specific type of talk therapy, can produce clinically significant improvement in patients with schizophrenia.

Importantly, significant improvement was seen in certain negative symptoms—apathy/avolition (lack of drive)—as well as in positive symptoms. These results are impressive, especially considering that the participants had been ill for an average of 18 years and suffered from severe symptoms. In this study, study participants were divided into two groups. One group received CBT in addition to “standard treatment,” which included treatment with antipsychotic medications. The other group received standard treatment alone.

CBT has been shown to be effective in a variety of psychiatric illnesses. It uses pragmatic techniques to help a person correct inaccurate or dysfunctional thoughts and emotions by promoting critical comparison of those thoughts with observable facts. For example, if a person believes that he/she is “doing absolutely nothing,” one CBT technique would be to encourage the person to keep a detailed diary of daily activities. The therapist would later review this diary with the patient and facts would be compared to perceptions. Homework assignments would include strategies to increase productive activities.

In the study mentioned above, the researchers focused CBT “on identifying and promoting concrete goals for improving quality of life and reintegration into society.” Therapy sessions utilized a variety of specifically designed activities, and patients were given assignments to complete between sessions (homework). On average, the research patients participated in about 50 sessions over 18 months, each lasting 50 minutes. Although the patients and therapists knew whether the patient was receiving CBT, the members of the research team measuring outcomes were unaware of the participant’s treatment group. In fact, when these researchers were asked to guess which treatment group a person was in, they couldn’t tell, i.e., they were correct only half the time.

In our opinion, this is a very important study because it demonstrates that a specific type of talk therapy can be effective in helping the most difficult symptoms of schizophrenia. While this study requires replication by other investigators, we believe it is likely that CBT techniques help the brain “learn” and that this learning may result in rewiring the brain in a manner that corrects or by-passes brain circuits that are not functioning correctly due to the underlying illness. A key feature of CBT may be its emphasis on refocusing attention from automatic and non-productive negative thoughts to more effective and appropriate ways of thinking and behaving. In effect, this may be a form of cognitive rehabilitation that helps to correct defects in attention and working memory.

Utilizing several different treatment approaches in combination can sometimes have additive effects. Some studies have demonstrated that combining CBT with pharmacotherapy (medication treatment) can lead to more improvement than either treatment alone. Whenever possible, the decision to combine treatments should be based on clinical evidence. Far too often, physicians combine a variety of medications without evidence that such combinations do more good than harm. We are optimistic that combining evidence-based talk therapies with evidence-based medication treatments will result in better and longer lasting outcomes. On the other hand, treating a patient with several antidepressants together with several mood stabilizers, antipsychotics, and anti-anxiety agents may do more harm than good.


Sam L. said...

Encouraging news!

KCFleming said...

"Anyone who thinks that these studies suggest that Freud is coming back from the dead should think again."

Zombie Freud is a frightening thought.

Turns out you can make one out of paper!

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