02 Jan 2011

Lloyd Sederer Got it Wrong: Response to Lloyd Sederer’s Negative Review of TREATING the ‘UNTREATABLE’ in the American Journal of Psychiatry

I was surprised when Lloyd Sederer, in his review of my book, TREATING the ‘UNTREATABLE’: Healing in the Realms of Madness, said “If my family member were ill, I would sure want to reduce the risks…But not Dr. Steinman, I guess.”.

Dr. Sederer’s guess is mistaken. If my family member were schizophrenic, I definitely would want antipsychotic medication used. In contrast to Dr. Sederer, though, I would want more than antipsychotic medication. I would also want a clinician skillful in helping my family member gradually understand the symbols and metaphor contained in delusions and hallucinations, a clinician able to aid in integrating affect and psychological content.

As TREATING the ‘UNTREATABLE’ makes clear, some seemingly ‘untreatable’ patients may work through psychotic material via an intensive psychotherapy, slowly diminishing and sometimes stopping antipsychotic medication, even after years of previous use. The book shows that patients successfully treated with an intensive psychotherapy are at far less risk than patients who have had the best evidence- based care and remain profoundly hallucinating or delusional.

Dr Sederer seems to view me as a wild eyed advocate for the psychotherapy of schizophrenia and delusional disorders, without antipsychotic medication. I am puzzled by the implication that I do not use interventions such as antipsychotic medication to reduce risk to patients. I say repeatedly and the case vignettes demonstrate that I use antipsychotic medications and try to use them judiciously.(pp.xiv,xviii, 23, 32, 87,188,189 for eg ).

In fact, the American Journal of Psychiatry has issued a clarification to Dr Sederer’s polemic against TREATING the ‘UNTREATABLE’ in the September 2010 edition, as well as online.

“CLARIFICATION: In response to the review of his book in the March 2010 issue (Sederer L: Book Review: Treating the “Untreatable”: Healing in the Realms of Madness. Am J Psychiatry 2010; 167:356-357), Dr. Steinman wishes to clarify that his book advocates the judicious use of antipsychotic medication in the treatment of patients who are delusional.” Unfortunately, the Journal does not allow authors to respond directly to book reviews and would not publish these comments.

There are several points which Dr. Sederer has skewed in a fashion biased against the private practice of intensive psychotherapy with severely disturbed patients. First of all, these patients were often viewed as ‘untreatable’ by other psychiatrists, hospitals and day care facilities, having been through the best evidence based approaches available, often for many years in other excellent treatment settings, before coming to see me in my office for an out-patient intensive psychotherapy of schizophrenia and/or delusional disorder. The fact that they responded so favorably to an insight oriented approach, sometimes being able to titrate down and stop previous antipsychotic medication and go on to live a life of relationships and function—often off all drugs—is the point of my book and does raise a number of questions about the usual treatment of schizophrenia in this country. Dr Sederer talks like one of those authoritarian doctors who sees no psychological components to severe psychological disturbance, only a brain disease requiring medication.

Contrary to Dr. Sederer’s statements, those patients who came directly from the hospital were anything but recovered. One was actively hallucinating; another was discharged against medical advice to my care. I leave the conclusion to the reader of TREATING the ‘UNTREATABLE’ as to whether or not intensive psychotherapeutic work aided these patients out of the morass of psychotic thinking.

Secondly, his statement that I tend to accept patient material as fact and blame the parents is untrue; the important issue is the psychological effect on the patient of perceived events. The reality is that several of these horrendous histories have been corroborated by other family members, as stated in the book.

Most importantly, I am a bit puzzled by Dr. Sederer’s statement that I do not use interventions such as antipsychotic medication that reduce risk to patients, since I say repeatedly that I believe in the judicious use of antipsychotic medications.

For example, on p. 189 of the conclusion of the book the text reads: “Using an intensive psychodynamic psychotherapy, in conjunction with judicious antipsychotic drug use, these previously hopeless and “untreatable” schizophrenic and delusional patients have been given the opportunity for recovery healing and cure, where the best previously achieved with a supportive approach and antipsychotics was a chronic delusional orientation and disintegration.” Of course, each case differs, but most of the patients presented in the book were on high doses of antipsychotics and very delusional for years in their previous treatments; the thrust of the book is that as insight into the meaning of delusions and hallucinations progressed, a number of the patients presented were able to gradually titrate down—and sometimes stop—antipsychotic medication as insight into the personal meaning of hallucinations and delusions developed.

Contrary to the impression of Dr. Sederer’s diatribe against my straw man of the psychiatrist advocating psychodynamic psychotherapy and no antipsychotic medication for psychosis, I say very clearly things to the effect of “If antipsychotic medication works, so much the better. All too often, however, antipsychotic medication merely covers over the disturbed and confused thinking that underlies such severe conditions. Gradually, patients may go through a revolving door of psychiatric hospitalization, drug treatment, day hospitals and half way houses. Some continue to deteriorate in spite of these efforts and become “untreatable” in the eyes of most mental health practitioners and psychiatrists.” (p.xiv)

I conclude the preface (pxviii) with the following statement. ”It is my conviction that a thorough understanding of the origin of the beliefs of the most severely disturbed people via an exploratory intensive psychodynamic psychotherapy, with judicious and appropriate medications as needed, can lead to gradual intrapsychic change, healing and eventual relinquishing of delusional beliefs and schizophrenic thought.”

Again, on p 188 I directly reiterate this position:

“Antipsychotic medications help many patients. If so, fine; then our task is easier. But, if delusions and schizophrenic thinking and hallucinations persist, an attempt should be made to help the patient understand the psychological underpinnings of his or her delusions. Once understood through an exploratory psychotherapy of the whole person, delusions and schizophrenic thinking included, an attempt may be made to diminish antipsychotics. As some of these cases demonstrate, delusional patients may have medications titrated down and stopped, as an understanding of delusional thought and psychotic thinking and behaviour take hold.”

A little further along on p188, I say: “This is not to throw out the baby with the bath water. I certainly use antipsychotic medication.”

Perhaps Dr. Sederer misunderstood some of what I said. Perhaps he was unsuccessful in the intensive psychotherapy of schizophrenia or delusional states; most likely, he never tried it. Perhaps, being in the public sector, he thinks that antipsychotic medication may be the best that we can do for all the disturbed patients with the limited availability of funds and trained personnel. I definitely can understand that position. Yet, even in the public sector, more work can be done by inquiring as to the content and meaning of hallucinations and delusions, thereby opening up an avenue for healing, in the process lowering costs, disturbance and disability, as the following vignette demonstrates.

R was a 35 year old man, diagnosed as paranoid schizophrenic by a number of other psychiatrists and institutions, with a nearly 20 year history of psychiatric care, including several hospitals and 30mg of abilify and 600 mg of clozaril given together, with a soupcon of zyprexa if he became too upset. He had been in the public sector for fifteen years, getting the best of evidence based care. He was quite agitated and very fearful and continued to hallucinate nearly constantly, even on such high doses of medication.

In the first few sessions, I asked what was agitating him? It was the voices. I asked about the voices, what they said, whether or not they reminded him of anything or anybody. As has happened with other patients, he said that no one had ever asked him about the content and meaning of the voices. Within two sessions, he told me of being molested and that the voices had to do with the molester pursuing and threatening him. The voices diminished and stopped, returning for short times and with lesser intensity during stressful periods, which were readily understood. When understood the voices went into abeyance. Medications were only very gradually titrated down.

So much for the usual practice of public sector evidence based psychiatry that Dr Sederer advocates.

This is the thrust of TREATING the ‘UNTREATABLE’: the necessity of trying to help the patient understand the personal meaning of hallucinations and delusions, in the process diminishing anxiety as one realizes that what appeared to be coming from the outside– and was so uncontrollable– was really related to one’s own individual psychological issues and could be looked at, talked about and perhaps worked through..

I personally think that antipsychotic medications are very useful; but they often don’t do the whole trick. Most of the patients in TREATING the ‘UNTREATABLE’ had the best of evidence based treatments available, long courses of antipsychotic meds at high doses, psychiatric, day care, and in hospital stays of months or years with other psychiatrists. Skill building, case management, family psycho-education and problem solving approaches had all been tried. With the usual evidence based treatments, these patients remained very disturbed, responding only to an inquiring psychodynamic psychotherapy, Some have been off antipsychotic medication for more than 30 years as the result of such treatment, returning to a life of relationships and function.

Robert Wallerstein,MD, Past Chairman of the Department of Psychiatry at UCSF Medical Center Langley Porter Neuropsychiatric Institute—from the Karnac website—clearly understood that I use antipsychotic medications, as the following passage indicates..

‘What [this book] does is to demonstrate in a lucid and impressive way the possibilities for the intensive psychotherapy of severely ill psychiatric patients in a way that can lead to lasting benefit and restoration of full life functioning much beyond the kind of systematic management that can come with the use of psychoactive drugs (though of course such medications are indeed part of Dr Steinman’s treatments in selected cases). This kind of treatment was once quite in vogue in psychiatric and psychoanalytic circles back in the mid-2Oth century, associated then with the names of Frieda Fromm-Reichman, Margaret Sechehaye, Gertrud Schwing, Harry Stack Sullivan, and John Rosen, the best known of that generation, but has since been largely eclipsed by the rise of the use of psychoactive drugs, and this I feel has been a major curtailment of the restorative possibilities of these patients.

Dr Sederer has incorrectly and glibly portrayed me as a wild eyed advocate for the intensive psychotherapy of schizophrenia and delusional disorders without antipsychotic medication as a primary treatment for psychosis. As far as I’m concerned, I was presenting case examples of patients who had failed the best evidence based approaches available and had responded to an intensive psychotherapy with medication being used judiciously and gradually titrated down.. And of course, not all schizophrenic patients can have antipsychotic medication titrated down, even with the best of care. As TREATING the ‘UNTREATABLE’ makes clear, sometimes one gets lucky and the patient works through the underlying material, and is able to diminish or even go off antipsychotic medication.

I would have preferred that Dr Sederer saw the book as Herbert Sacks, MD, Past President of the American Psychiatric Association, does on the cover blurb:

”It’s a creative confirmation of the virtues of psychodynamic psychotherapy in the hands of a virtuoso for the most disturbed patients many of us are reluctant to engage. For our residents who have little psychotherapy training and for seasoned clinicians, the book is an awakening.”

Perhaps Dr Sederer’s opinion will be altered by the review of TREATING the ‘UNTREATABLE’in the Psychoanalytic Quarterly by the book review editor, Martin Silverman, MD which concludes:

“Steinman’s effort to demonstrate the effectiveness of psychodynamic psychotherapy for psychotic patients by providing multiple, convincing clinical examples was quite successful, and we can be very grateful to him for it. His book impresses me as one that should be required reading within all psychiatric and perhaps all psychoanalytic training programs.”

There is more to Dr. Sederer’s review that I could attend to, but my purpose in writing the book and in responding to Dr. Sederer’s review of TREATING the ‘UNTREATABLE’ has been to stimulate thought and discussion of the most useful ways to treat schizophrenic and delusional patients who have failed the usual evidence based practices. These are the ‘UNTREATABLES, as is made so clear in the book that Dr. Sederer castigates. I look forward to any responses.

I have a modest proposal. Perhaps Dr Sederer and I can engage in an AJP online debate on just what I have advocated in TREATING the ‘UNTREATABLE’, the efficacy of an intensive psychotherapy of schizophrenia and delusional disorders in previously “untreatable” patients, in conjunction with the judicious use of antipsychotic medication, as an attempt is made to aid patients in the understanding of their psychotic phenomena. Even better, perhaps we can have a panel discussion about the issue at an upcoming American Psychiatric Association National Meeting.

In such a forum, perhaps we can also look at some of the underlying reasons for Dr. Sederer’s disparaging and inaccurate view of TREATING the ‘UNTREATABLE’: Healing in the Realms of Madness.