Challenging the “Soft Bigotry” of Low Expectations in Psychosis

This morning thanks to Twitter I caught a  blog post Thomas Insel wrote last summer about anti-psychotics.

Referring to a JAMA (2013) article, at seven years, a reduction/discontinuation group [following six months of antipsychotic treatment after first-episode psychosis] “had achieved twice the functional recovery” than a maintenance group in a Netherlands study headed by Wunderink and colleagues. In short, “antipsychotic medications . . . worsen prospects for recovery over the long-term.”

Insel made three points: (1) Both maintenance and discontinuation group had similar symptom experiences; (2) almost 30 percent of latter group achieved a “healthy outcome”; and (3) tapering off early may result in better outcome than long-term maintenance.

He wrapped up his post with a very un RDoC-like call for social integration of persons living with a diagnosis of psychosis:

Family education, supported employment, and cognitive behavioral therapy have all demonstrated efficacy in reducing the likelihood of relapse events, increasing the ability to function in daily life, and improving problem-solving and interpersonal skills. NIMH is supporting research on interventions that focus on a combination of approaches—symptom remission, family engagement, and functional recovery. The Recovery After Initial Schizophrenia Episode (RAISE) project combines low-dose medication with family psycho-education, supported education/employment, individual resilience training, and other interventions to focus on more than just the psychotic symptoms. Combining current treatments, as done in RAISE, looks like a promising approach.

This is similar to the call for “good enough” treatment made by Steve López said at last week’s FPR-CBDMH psychosis workshop, using a phrase from child-rearing literature made famous by Donald Winnicott and Bruno Bettleheim.

At this stage, a purely biological/reductionistic approach, like Bettleheim’s example of perfectionistic parenting, may be doomed to fail. As McGorry, Alvarez-Jimenez, and Killackey (2013) observe in their related editorial, the “‘soft bigotry of low expectations’ in psychosis is under serious challenge,” at least for those lucky enough to receive specialized care after first episodes. This form of care is more focused on recovery than relapse prevention.



McGorry, P., Alvarez-Jimenez, M., & Killackey, E. (2013). Antipsychotic medication during th critical period following remission from first-episode psychosis; Less is more. JAMA Psychiatry, 70(9), 898–900.

Wunderink, L., Nieboer, R. M., Wiersma, D., Sytema, S., Nienhuis, F. J. (2013). Recovery in remitted first-episode psychosis at 7 years of follow-up of an early dose reduction/discontinuation or maintenance treatment strategy. JAMA Psychiatry, 70(9), 913–920.