Why recovery & open dialogue work
This article explores the work of David Cooper (1931-1986), a South African-born psychiatrist who made significant contributions to the existential view of ‘schizophrenia’ and was a key figure in the anti-psychiatry movement. It also addresses valid criticisms of his work and incorporates later research findings.
Cooper’s Existential Approach to ‘Schizophrenia’
Cooper’s work represents a unique integration of existential, psychodynamic, and social perspectives on ‘schizophrenia’. He viewed ‘schizophrenic’ reactions not as mere symptoms to be eliminated, but as potentially meaningful processes in the individual’s struggle for authentic existence in the face of social and ontological challenges. His approach emphasized understanding the lived experience of individuals labelled as ‘schizophrenic’ and challenged the medical model of mental illness.
Social events and ontological development
- Cooper emphasised that an individual’s sense of being (ontology) is deeply influenced by social contexts.
- He argued that societal norms, family dynamics, and cultural expectations play a crucial role in shaping one’s fundamental experience of existence.
- In his view, ‘schizophrenia’ often emerges when there’s a significant dissonance between an individual’s authentic self and the social roles/expectations imposed upon them.
Psychodynamic reactions to developmental failure
When ontological development is disrupted due to social pressures or traumatic events, Cooper observed several psychodynamic reactions:
- Regression
- Intense introspection.
- Withdrawal
Family dynamics
Cooper placed significant emphasis on family dynamics in this process, arguing that families often enforce rigid roles and expectations that can stifle authentic development, leading to ontological crises and subsequent psychodynamic reactions.
Critiques and Refinements of Cooper’s Approach
Cooper’s term “Innocent Sane” can be misleading. It does seem to imply a “blank slate” view of human nature, which is a contentious philosophical and scientific debate. Terms like “basic” or “native” beingness are more neutral. These terms allow for the possibility of innate characteristics while also acknowledging the profound influence of early experiences.
Critics of Cooper’s work have argued that his focus on family dynamics could be seen as blaming families for ‘schizophrenia’. However, a more nuanced interpretation of Cooper’s ideas focuses on the individual’s reaction to feelings of alienation, rather than on specific sources of those feelings.
It’s true that while some parents may have significant issues, children themselves are not perfect beings either. Each brings their own temperament, needs, and developing personality to the relationship.
Focusing on the overall family dynamics without assigning blame is likely to be more productive and allows for a more nuanced understanding of how family members interact and influence each other.
A fundamental concept that is often overlooked in the healing professions is that what defines a person is not the events that happen to them, but rather their reaction to these events. This idea has profound implications for our understanding of ‘schizophrenia’ and other mental health conditions:
Instead of concentrating solely on the traumatic or stressful events in a person’s life, we need to pay equal, if not more, attention to how the individual has interpreted and reacted to these events. In the case of people labeled ‘schizophrenic’ we are looking at the Introspection/Regression/Withdrawal downward spiral. By forming an inclusive non-judgmental relationship, we can handle feelings of alienation and reverse this spiral.
John Nash recovered when a graduate student helped him with his research. My mother’s friend recovered when the ward nurse asked her to help make the beds. This illustrates that instead of trying to eliminate the symptoms, find a cure or a label it is more effective to reverse the downward spiral by forming a positive relationship. This approach has the advantage of being simple to apply while being effective. The more severe the disturbance the lighter the touch.
This refined model can be applied more broadly, addressing the major criticisms of Cooper’s work. By emphasizing the formation of a non-judgmental inclusive relationship to address feelings of alienation, regardless of their source, we can better understand Cooper’s assertion that “all the patient needs is a witness.”
Supporting Evidence: The Harding Longitudinal Studies
The Vermont Longitudinal Study by Courtenay Harding and colleagues provides significant support for many of Cooper’s ideas. This 32-year study followed patients discharged from Vermont State Hospital, using rigorous diagnostic criteria and assessment methods and the key findings of the Harding study align with Cooper’s
- Long-term recovery: Approximately 70% of participants significantly improved or recovered over the long-term follow-up period, supporting Cooper’s more optimistic view of potential positive change in individuals experiencing psychosis.
- Social factors: The study highlighted the importance of social factors in recovery, such as employment and community integration, resonating with Cooper’s emphasis on social context.
- Individual variation: The study revealed considerable variation in outcomes, supporting Cooper’s view that standardized treatments may not be appropriate for all individuals.
- Questioning chronicity: Harding’s findings challenged the notion of ‘schizophrenia’ as an inevitably chronic and deteriorating condition, aligning with Cooper’s critique of traditional psychiatric models.
- Importance of hope: Both Harding’s work and Cooper’s approach emphasize the importance of maintaining hope for recovery and viewing the individual as capable of growth and change.
The Role of Psychiatric Drugs in ‘Schizophrenia’
Originally, psychotropic psychiatric drugs were developed to facilitate treatment, not as standalone interventions. Early developers viewed these drugs as a means to calm patients sufficiently to engage in psychosocial treatments. The shift towards viewing psychiatric drugs as primary treatments came later, influenced by various factors including the biological model of mental illness and pharmaceutical marketing.
Cooper’s View on Psychiatric Drugs
David Cooper, as part of the anti-psychiatry movement, was critical of the overreliance on psychiatric drugs in treating ‘schizophrenia’. He argued that excessive use of antipsychotic drugs could suppress the individual’s ability to work through their existential crisis and achieve authentic selfhood. However, Cooper did not entirely reject the use of psychiatric drugs; rather, he advocated for a more judicious and person-centered approach to its use.
Psychiatric Drugs in Light of the Harding Study
The Harding Longitudinal Study provides interesting insights into the long-term use of psychiatric drugs in ‘schizophrenia’:
Recovery without psychiatric drugs: The study found that 68% of recovered participants were not taking psychiatric drugs at follow-up. This challenges the notion that lifelong psychiatric drugs are necessary for all individuals diagnosed with ‘schizophrenia’
Individualized approach: The study’s findings suggest that the need for psychiatric drugs varies greatly among individuals, supporting Cooper’s emphasis on personalized treatment.
Psychiatric drugs as a tool, not a solution: The high recovery rates in the absence of psychiatric drugs suggest that other factors, such as social support and meaningful engagement, play crucial roles in recovery.
Integrating Psychiatric Drugs into a Holistic Approach
Drawing from Cooper’s ideas and supported by the Harding study, we can propose a more nuanced approach to the use of psychiatric drugs in ‘schizophrenia’:
- Careful assessment: The decision to use psychiatric drugs should be based on a thorough understanding of the individual’s unique situation, including their social context and personal narrative.
- Targeted use: When used, psychiatric drugs should be employed strategically to help individuals engage more fully in psychosocial interventions and their recovery process.
- Regular review: The need for psychiatric drugs should be regularly reassessed, with the goal of minimizing use, when possible, without compromising wellbeing.
- Informed choice: Individuals should be fully informed about the potential benefits and risks of psychiatric drugs, and their preferences should be central to decision-making.
- Complementary approaches: Psychiatric drugs, when used, should be part of a broader treatment plan that includes psychosocial interventions, support for social integration, and efforts to address existential and ontological issues.
Open Dialogue
Open Dialogue’s approach aligns with Cooper’s views and Harding’s findings in several ways:
- Emphasizing relationships: The approach prioritizes building therapeutic relationships not just with the individual experiencing mental health challenges, but also with their family and social network.
- Respecting individual autonomy: Open Dialogue strives to include the person in all discussions and decisions about their care, promoting a sense of agency and self-determination.
- Minimal use of drugs: In contrast to some traditional psychiatric approaches, Open Dialogue tends to be cautious about introducing psychotropic drugs, especially in early interventions. When drugs are used, they are typically introduced at lower doses and with careful consideration.
- Focus on dialogue: By promoting open communication and multiple perspectives, this approach aims to understand the person’s experiences in their own context, rather than solely through a medical or diagnostic lens.
- Flexibility in treatment: The approach adapts to each individual’s unique situation and needs, rather than applying a one-size-fits-all treatment model.
Conclusion
David Cooper’s existential approach to ‘schizophrenia’, supported by later longitudinal studies like Harding’s, challenges us to rethink our understanding and treatment of this condition. This perspective emphasises the importance of social context, individual meaning-making, and the therapeutic relationship in supporting individuals diagnosed with ‘schizophrenia’ on their journey towards recovery.
The role of psychiatric drugs in this framework is not dismissed but reimagined. Rather than being seen as a lifelong necessity for all individuals with ‘schizophrenia’, psychiatric drugs are viewed as one of many potential tools in a personalized, holistic approach to any intervention. This nuanced view aligns with Cooper’s emphasis on individual experience and the findings of the Harding study, which demonstrate the possibility of recovery through various means, including but not limited to psychiatric drugs.
By integrating these perspectives, we can work towards a more compassionate, effective, and person-centered approach to supporting individuals diagnosed with ‘schizophrenia’. This approach respects the potential benefits of psychiatric drugs while also recognizing the paramount importance of addressing the needs of the patients.
References
- Cooper, D. (1967). Psychiatry and Anti-Psychiatry. Tavistock Publications.
- Monitor on Psychology, New hope for people with schizophrenia https://psychrights.org/research/digest/effective/APAMonV31No2.htm
- Hearing Voices Network. (n.d.). About Hearing Voices. https://www.hearing-voices.org/voices-visions/about/
- Open Dialogue UK. (n.d.). What is Open Dialogue? https://opendialogueapproach.co.uk
- Paris Williams 2018 Brain Disease or Existential Crisis?https://www.madinamerica.com/2012/08/op-ed-schizophreniapsychosis-brain-disease-or-existential-crisis/
- Whitaker, R. (2010). Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America. Crown Publishers.s.
- Moncrieff, J. (2008). The Myth of the Chemical Cure: A Critique of Psychiatric Drug Treatment. Palgrave Macmillan
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- Soteria: Through Madness to Deliverance. Xlibris Corporation.
- Nasar, S. (1998). A Beautiful Mind: The Life of Mathematical Genius and Nobel Laureate John Nash. Simon & Schuster
- New England Journal of Medicine, 353(12), 1209-1223.
- Slade, M., & Longden, E. (2015). Empirical evidence about recovery and mental health. https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-015-0678-4
- Moncrieff, J. (2013). Long-term Antipsychotics: Making Sense of the Evidence. https://joannamoncrieff.com/2013/12/09/long-term-antipsychotics-making-sense-of-the-evidence/