‘Evidence regarding overestimation of the efficacy of antipsychotics and underestimation of their toxicity, as well as emerging data regarding alternative treatment options, suggests it may be time to introduce patient choice…’ So say four leading psychiatrists in a recent issue of the British Journal of Psychiatry.¹

This article states what people with severe mental health problems have been saying for years: antipsychotic medication does damage to people, causes physical health problems and makes it difficult to think and feel.

It goes on to suggest that people with a diagnosis of schizophrenia should be afforded more choice: not just a choice of medication, but also the choice to refuse medication and to be given access to alternatives.

More significantly perhaps, the article exposes the shortcomings in our evidence base: research is not as objective as we assume it is and the evidence for the effectiveness of antipsychotic medication is thin.

Whatever their diagnosis, surely everyone should be treated with the basic respect that says you can have a say in your own treatment? That many people are not treated in this way says a lot about our mental health services.

This isn’t an easy argument: antipsychotics have long been psychiatrists’ first response to psychosis. To this day, people with a diagnosis of severe mental illness may not be offered talking therapies and may also not be listened to well. Even the above-mentioned article refers to people ‘without insight’ resisting medication. And yet, given the unwanted effects of the drugs, it seems to me that they are showing considerable insight in so doing.

CBT is increasingly recognised as an effective intervention for people with a diagnosis of some form of psychosis. I suspect that this too has something to do with ‘insight’. CBT is a more solution-focused therapy. Psychotherapists who practise the more psychoanalytic forms of therapy have tended to seek clients who have what they refer to as ‘insight’ or ‘capacity’, and are less likely to work with someone who has a diagnosis of psychosis. However there are many other forms of psychological therapy than just these two.

There is a long history of interest in the ‘talking therapies’ among service users and user groups, which is reflected in studies of service users’ views. What is more difficult to determine is whether this reflects a genuine demand for psychological therapies, or whether it reflects people’s need for mental health services to adopt a more humane response to them: to respect and listen to them. Does it reflect the oft-repeated call for ‘someone to talk to’? All too often we hear that people in inpatient wards are largely left to their own devices, not encouraged to talk about what is happening to them and not listened to.²

When I was involved in a survey of service users’ views of therapies and treatments some 15 years ago,³ it was no surprise to find that people with a diagnosis of schizophrenia were the least likely to have been offered talking therapies. Conversely, a large majority of participants, regardless of diagnosis, wanted ‘someone to talk to’ – someone who would listen to them and believe them – particularly in a crisis but at other times too, in order to make sense of their lives and their difficulties. Of course psychological therapies can offer this – perhaps particularly person-centred counselling – but so can other things. Many people value the support of peers  – people who have similar experiences and difficulties and who listen to them and respect them and offer suggestions based on experience. Peer support is increasingly seen as a valuable resource for people using mental health services.⁴

Access to psychological therapies has perhaps improved for some people (mostly those with depression and anxiety) with the greater availability of CBT. However, this brings with it another complication. If we are concerned about patient choice, then why should someone not have the same choice about the type of psychological therapy they engage in? These days we are led to believe that CBT is the only form of therapy that is effective and has the research evidence to support it. But have these researchers been asking the right questions, are they free from the kinds of reporting bias mentioned earlier, and do they involve service users in their research? I wonder.

Alison Faulkner is a researcher, trainer and mental health service user.

1. Morrison AP, Hutton P, Shiers D, Turkington D. Antipsychotics: is it time to introduce patient choice? British Journal of Psychiatry 2012; 201: 83–84.
2. Mind. Listening to experience: an independent inquiry into acute and crisis mental health care. London: Mind, 2011.
3. Faulkner A. Knowing our own minds. London: The Mental Health Foundation, 1997.
4. Faulkner A, Basset T. A helping hand: consultations with service users about peer support. London: Together, 2010.