Dear Sir/Madam:

Thank you for your recent inquiry about the treatment of psychosis with little or no psychiatric medication. I presume you contacted me after finding my website, on personal recommendation or having read one or another of my publications. Unfortunately, the treatment facility mentioned in many of the publications and on the website - Soteria House - is closed. There are no current American replications of its special social environment and treatment principles. Interestingly, the Soteria model (and variations on it) of care is becoming available in the Scandinavian countries, Germany and Switzerland. 

The materials presented in the website (www.moshersoteria.com) make clear my views on the overuse and misuse of the psychotropic drugs, in particular the so called "neuroleptics" or "anti-psychotic" medications. These drugs, even the newer so-called "atypicals", have serious "side effects" and toxicities associated with their use. Some of their toxicities are life threatening (neuroleptic malignant syndrome), while others, like tardive dyskinesia and tardive dementia are usually irreversible and result in seriously diminished functioning. Numerous other toxicities, both physical and cognitive, are associated with their short and long term use. Hence, if possible, it seems prudent to avoid or minimize their use. 

Unfortunately, many psychiatrist's believe the myths that these drugs are the only real treatment for "serious mental illnesses" (they may give lip service to psychosocial interventions) and that they have improved the long-term outcomes of patients receiving them. Many studies show that these two beliefs are indeed myths. In fact, long term social, vocational and symptom outcomes are probably worse now than before these drugs were introduced. However, since it does not fit the currently fashionable belief system this research is given little credence and is discouraged by funding sources and journal editors. 

Moreover, it is common (but as far as I am concerned questionable) practice these days to give many patients a "cocktail" of a combination of different types of drugs to try to treat the many different kinds of symptoms a single patient may present-independent of his/her actual problem(s). Unfortunately, both type of problem and treatment are non-specific. That is, the various "disorders" are difficult to distinguish and a given treatment may be useful for several types of problems. Hence, psychiatrist's tend to "cover all the bases" with their medication regimes. This practice has never been subjected to clinical trials and no credible scientific evidence exists concerning any efficacy it may have for treating psychotic symptoms. Each additional drug has its own set of side effects and toxicities thereby exposing patients to a larger number of possible medication related problems.

In addition to their short and long term unwanted effects all psychiatric drugs have withdrawal reactions that vary in time of onset, severity and type of symptoms experienced. There is also great inter-individual variability as to if, when and how withdrawal is experienced. As a rule of thumb the longer a drug has been taken and the higher the dose the more severe the withdrawal reaction will be. Do not stop your drug(s) suddenly or reduce your dose quickly, as this usually increases the chances of developing severe withdrawal reactions. Dose reduction and discontinuation should always be done slowly while under the care of a thoughtful and competent physician-not necessarily a psychiatrist. You should be aware that it is generally considered to be malpractice for a physician to prescribe (including a withdrawal regime) for patients he has not seen-except in emergency situations. Hence, because I am not your doctor I am not able to give you specific advice about what to do about the drugs (if any) you are currently taking or being asked to consider. I would counsel that you find a physician you like, trust and will form a collaborative relationship with you to discuss your concerns and wishes. Based on my experience you are more likely to find a non-psychiatric physician who is willing to consider dose reduction and discontinuation than a psychiatrist is. Hopefully the doctor will provide you with the information you need to make an informed decision. Be very careful of information derived from pharmaceutical manufacturers, especially about their newest "breakthrough" product(s). A fairly complete list of potential withdrawal reactions from neuroleptics, as well as a prudent withdrawal program to be undertaken in conjunction with your physician, are discussed in "Your Drug May Be Your Problem: How and Why to Stop Taking Psychiatric Medications," by Peter Breggin & David Cohen (PerseusBooks, 2000).


My own thinking about psychiatric drugs is that they should be avoided if at all possible. My approach would be first to establish a safe and protective social context-preferably at a residence. Then I would take a psychotherapeutic approach-including the family if possible-based on developing an understanding of, and finding meaningfulness in, the situation presented. This is easy to say but hard to do in these days of managed care, practitioners lacking training in basic listening skills, and a lack of non-coercive in- residence mobile crisis teams, communities lacking safe places (like Soteria House) and support networks-all of which can dedramatize crises. If for some reason drugs are necessary, and agreed upon by all parties, I start with the lowest dosage possible of the least toxic drug for the shortest period of time needed to address a specific behavior. The commonest reason I have found it necessary to use medications has been when it has not been possible to assemble enough caregivers to assure everyone's safety. Unfortunately, my views are not widely shared by my fellow psychiatrists or the drug companies. There is an extensive discussion of why drugs should be avoided if possible and how they should be given when necessary in chapter 5, "Is Psychotropic Drug Dependence Really Necessary?" of Mosher and Burti's "Community Mental Health: A Practical Guide" NY. Norton, 1994. Norton's phone order number is 800-233-4830.

If you are in touch because of an immediate, severe personal/family emotional crisis (however defined) I cannot tell you what to do because I am neither your doctor nor do I know you or the resources and options available in your area. There are, however, several generic principles that might be useful in your decision making:
1. Try to remain in as normal an environment as possible-at home, at a friend's house, or at a residential setting that is home like-even if staffed by paid caregivers. Try to use natural resources like family, friends, clerics etc. to help by providing support and common sense advice. If professional intervention is needed they should come to where you are. Try, at all costs, to avoid medicalization of whatever the "problem" is. Do not let mental health professionals take away your power to control your own life by the use of coercion. The problem with the power and authority of psychiatrization is that it comes with the nearly inevitable consequences of labeling, stigmatization, discrimination and marginalization. Once you have been diagnosed, it will be impossible to remove a diagnosis from your medical records, regardless of the haste with which it was applied, or regardless of whether the diagnosis may be even remotely considered "correct." What I am saying- try to stay away from emergency rooms and hospitals unless it is clear to someone that the problem probably has a physical origin. This should be determinable by a call to your primary care doctor.
2. Most crises arise in a family and its historical context. Hence, the focus of intervention usually should be the family. Given this conceptualization it becomes very difficult to decide whom, if anyone, should be medicated. I would not object personally to medication being given to all those who have been sleep deprived as a result of the crisis. The drug of choice for such situations is Benadryl, available without a prescription. Other sedatives would need to be prescribed by your physician.
3. Interventions should focus on the life events that are temporally related to the beginning of the crisis-e.g. loss of a job, breakup of a relationship, a death, failure at school, leaving home etc., etc. Each situation is unique so there is no one answer to what went wrong and how it might be fixed. However, it is good to remember that the more normally people are treated the more normally they will behave. In addition, crises offer opportunities for growth and change in a positive direction and are usually self-limited if not dealt with in a way that prevents their resolution. One of my major objections to the use of the anti-psychotic drugs in acute crisis situations is that because they are such powerful central nervous system suppressants they may well have the effect of preventing crisis resolution. 

It may not be easy to follow the generic principles I outlined above. They should be regarded as guidelines that will likely have to be compromised. There are only a handful of crisis teams or programs (in the U.S.) of which I am aware that operate more or less in accordance with them. Basically, the use of psychotropic drugs is required by most residential treatment programs-thus immediately excluding them from the list. Crisis teams are usually coercive and medication oriented. A list of programs not requiring the use of psychotropic drugs will be sent if it was requested in your communication to me. If you requested written materials about my work they will be sent so long as a snail mail address was included.

Should you, your family and/or social network or program wish to schedule a face to face consultation around the questions you have raised you may contact me at the above address, email, phone or fax. 

Sincerely,  Loren R. Mosher M.D.