Early Intervention EthicsWith an estimate of a little over 1% of the population attracting a diagnosis of schizophrenia, it is reckoned that 1 new case for every 10,000 people will be identified each year by mental health workers as deserving this diagnosis.  As a result of the effectiveness of the neuroleptics, especially the atypicals, to arrest the symptoms, the focus of an increasing number of services as been towards intervening at earlier stages, and to base services in the community – especially the individual’s home.  This is known as Early Intervention programmes.  The rationale is that there are a number of early indicators that someone maybe developing a disorder which will eventually attract a diagnosis of schizophrenia.  This is being called the Prodromal phase, and is characterised by social withdrawal, sleep and appetite disturbances, peculiar speech and behaviour, and some loss of warmth in relationships.  The Narrative therapists have called this an “in-the-corner lifestyle”.  There is some evidence that intervention at this stage can prevent a full “psychotic break” from occurring; and given the poor prognosis following hospitalisation (where only 1 in 5 will recover), and the cost to both society and the individual that ensues, early intervention is considered warranted by some psychiatrists.

However it is a domain rife with potentially difficult ethical dilemmas, especially when approached from a pathogenic perspective.  In November 1999 a conference in Washington focused on these ethical issues.  “The conundrum people in this field deal with, is the closer you get to the actual appearance of the psychotic symptoms, the more reliably you can make the diagnosis,” says Dr Paul Appelbaum, vice-president of the American Psychiatric Association.  “But the value also becomes greater the earlier you can identify the people who will later develop the disorder, so that you can slow the deterioration and slide that people experience as they enter the schizophrenic illness.”  The dilemma then, is, if we are treating people before they become “ill”, how do we know that we are actually treating the right people?  Some bioethicists at the conference expressed concern that as there are no concrete predictors at this point, individuals who would never develop schizophrenia maybe being roped into the category of “at risk”, treated and left to face the consequences.

One of the conference attendees was Dr Nikki Erlenmeyer-Kimling, a professor of psychiatry at Columbia University, who has been following the children of those who have attracted a diagnosis of schizophrenia for 28 years.  She, and others, have developed a number of quite sophisticated tests, many outside of the range of what would be practical for most clinics and general practitioners to utilise, such as a range of neurological scans, and time consuming psychological tests.  With these she has managed to identify as many as 83 percent of those who eventually attracted a diagnosis of schizophrenia.  But most importantly, she noted that there were many false positives (people who fit all the designated criteria for developing schizophrenia but didn’t), and false negatives.  And this was with a population considered to be at heightened risk – first degree relatives.  Most Early Intervention centres are reporting that about 40 percent of the people whom they have given the diagnosis of “prodromal” to, are later found to not belong in that class.  Of course subjecting people who display these rather vague prodromal symptoms to the more sophisticated tests utilised by Dr Erlenmeyer-Kimling and others, in order to increase the probability of a “correct” diagnosis, should not only be excluded for reasons of costs, but for reasons of the potential iatrogenic harm such tests may create.  For the concern is that people may well suffer as a result of the invitation to an extremely toxic social identity that comes from being labelled a ‘schizophrenic’.

But, the argument goes, if mental health services listen to those voicing concern that early intervention efforts may rope in too many ‘false positives’, then by doing nothing a large group of people will be put at risk for potentially getting worse.  Doing nothing, its argued, can be seen as a further indictment of the laissez-faire attitudes of many psychiatric services that, in the face of decades of protest from professional groups, consumers, and their families, are refusing to incorporate clinical advances into their practices.  As Thomas McGlashan, head of the Yale Psychiatric Institute argued at the conference, “There are risks both ways: risks for doing treatment and risks for not doing treatment.”  So are there ways of minimising or avoiding the potential iatrogenic effects that early intervention may create?

The major risk against early intervention is not just the risk of serious drug side effects, but the concern that people might suffer as a result of the invitation to a pejorative identity that comes from being labeled or even associated with schizophrenia.  The task of Early Intervention then is to take a path which reduces these risks by minimizing the utilization of drug treatment, and by not making a diagnosis when actively treating the symptoms displayed.  This is a major break from traditional approaches to psychiatric services and will require dialogue with funding managers who remain entrenched in only providing services to clearly defined DSM-IV axis 1 diagnoses.  Just such an approach is being advocated by our own NZ Mental Health Commissioner in his ‘Guide to Early Intervention’ booklet, and a number of the Early Intervention services which have arisen globally in the last decade.  For some reason, most, judging by their literature, appear to be blissfully unaware that there is 50 years of family therapy literature advocating much the same.

With regards to the use of medication during a suspected ‘prodromal’ phase, our Mental Health Commissioner’s Guide, in keeping with a number of other Early Intervention programs, advocates against the use of medication.  Professor Ian Falloon, at Auckland Medical School, a recognised leader in Early Intervention, has suggested that a very small dose of an oral tranquillizer (say 50 to 100mg Melleril a day) may be tried for a very brief period (say a week), just to target a specific symptom such as sleep disturbance.  Such a small dose for such a brief period is unlikely to carry the implicit message that the individual has a major disorder; and there is less likelihood of long-term negative drug effects.  However, the pharmaceutical juggernaught, smelling a further health dollar, has entered the Early Intervention arena, and begun to fund research.  Janssen Pharmaceutica, which manufactures Risperiden, is funding research by Professor Patrick McGorry in Melbourne; whilst Eli Lilly, which manufactures Olanzapine, is funding research by McGlashan at Yale.  At the Washington conference, even Fuller Torrey questioned the wisdom of this development.  Erlenmeyer-Kimling said that whilst we may have a reasonable basis for treating these adolescents with an innocuous treatment, such as some sort of psychotherapy, “….but treating them with drugs is, in my mind, a little premature.”

The key feature of successful Early Intervention is the active engagement of the potential client in their own treatment.  As it is largely targeted at people in their late adolescence, many of whom are reluctant to engage in dialogue with a ‘mental health professional’, it is best conducted in their preferred environment, usually their home.  It is usually the parents or care-givers who first become concerned about the apparent withdrawal of the teen, and they are usually willing to invite a therapist into their home.  Family therapists have developed a number of strategies for engaging the so-called ‘reluctant’ client (see Insoo Kim Berg’s great tactics in the ‘hot tips’ section of her web site); such as asking the young person whether they would like to listen-in to the conversation your parents and I will be having about you; and/or “I wonder what it would take to get these people off your back”.  Those schools of family therapy informed by strengths and systemic thinking, tend to take what has been called a ‘salutogenic’ approach.  This contrasts with the pathogenic approach of mainstream health where health workers are detectives of pathology; and instead searches for solutions, or those aspects of behaviour and thinking which are health promoting.  Such an approach takes some revision of thought by most working in mental health, because even terms like “empowerment” are avoided, because it carries with it the suggestion of doing something to people and the idea that they have a deficit which requires ‘empowering’.  The view is taken in solution-oriented approaches that everything an individual is doing is part of an attempted solution to life’s dilemmas, including the so-called ‘symptoms’.

Adolescence can be a volatile time in life, and it is obviously difficult to differentiate someone who may well be in the ‘prodromal’ phase from usual teenager mood swings.  If therapists remain fully cognisant of the informed consent rights of their clients and potential clients, then they will perhaps be more tempered in their desire to push caution to the wayside because of an earnest desire to prevent the horrors of what can happen if there is a hospitalisation following a psychotic break. For family therapists ‘informed consent’ means having the active participation of the client in the dialogue, rather than the passive assent of the client going along with the doctor’s monologue. Treating these clients and their families as they would any other family experiencing difficulties during adolescence, has been central to family therapy for 50 years.  The only difference that Early Intervention makes is that it signals the importance of fully funding a family therapy service instead of relegating it to the role of a quirky luxurious adjunct to mental health services.  This offers our best hope to date of keeping people out of the hospitalization cycle.

If a ‘psychotic break’ does occur, most Early Intervention programmes are recommending that treatment remain in the home, unless there are dangers which mitigate against that.  Those that do recommend the introduction of an atypical antipsychotic, suggest only small doses at first, with only slow increments; and not the massive cocktail of antipsychotics which some practitioners seem to prefer.  The recommendation is for any medication to be oral, so that the client can maintain their sense of active participation; and if a good therapeutic relationship has been established it is recommended that this be maintained rather than have some other health professional take over the case.  As we have known for a long time, the watershed of the break is a particularly high-risk time for suicide, possibly because of the bizarre thought processes that occur, but more likely I think because of the invitation to identity entailed.  Thus most Early Intervention programmes are recommending that the therapeutic relationships established during the prodromal phase be maintained and supported, rather than allowing the ‘break’ to become a rationale for making a transition in treatment.  Outcome studies from Early Intervention centres where this approach is taken are showing far more favourable results than hospital based treatments.  So let’s encourage more services to get with the times.

Jaakko SeikkulaPerhaps the most promising approach at this point in time (2000) is that being offered by Jaakko Seikkula and his colleagues in northern Finland, which they are called ‘Open Dialogue’. They take a team of 4 clinicians to the home or a community venue of the identified client and engage the social network in conversation. They take the view that some sort of rupture has occurred in the dialogue of this social network, where identified client and social network have retreated from each other in isolating ‘aboutness’ conversations about each other. All their team are trained in family therapy, and task themselves with getting dialogue flowing again. To date their outcomes look highly promising, and they are utilizing very little in the way of medication. Let’s study and watch this development over the coming years.

Coleman, L. (1972) Reign of Error: Psychiatry, Authority, and the Law.  Boston: Beacon Press
Dumont, M. (1990) In bed together at the market: Psychiatry and the pharmaceutical industry.  American Journal of Orthopsychiatry. 60: 484-485.
Leifer, R. (1990) The medical model as the ideology of the therapeutic state.  Journal of Mind and Behavior. 11(3-4): 247-258.
Mohl, S.J. (1978) Predicting Dangerousness: The Social Construction of Psychiatric Reality.  Lexington, Mass: Lexington Books.
Seikkula, J., Aaltonen, J., Alakare, B. Haarakangas, K., Keranen, J. and Sutela, M. (1995)
Treating psychosis by means of open dialogue. In S. Freidman (Ed.), The Reflecting Team
in Action. New York: Guilford Press.