First Break Psychosis: Alternative to the Medical Model of Care

Boa constrictor, snake, vintage engraved illustration of Boa constrictor.

A short while ago I met with a friend who I have known for many years.  He told me a story of when he was young and how he had gone through a period of severe confusion and had become manic, wild in thought and overwhelmed by strange thoughts and bizarre sensations.  My friend told me he eventually ended up being hospitalized and treated with a combination of a mood stabilizer and an antipsychotic  He felt like his world had been ripped from him and he was hospitalized multiple times over a period of months.  Eventually he returned to college and stayed on his medication regime but felt apathetic, depressed and anhedonic.


The counselors he met encouraged him to stay on this course of meds and the psychiatrist stated plainly that he had bipolar disorder, a permanent condition that required a lifetime of treatment.  My friend stayed on the meds for quite a while but felt like he was doing worse and worse and felt disconnected from everyday life.  He finally made the decision to stop taking his medications and described going to his psychologist and informing him of his decision.  The psychologist was horrified at this decision and told him that it was a very bad mistake.


After he tapered off his medications, my friend decided to take some time away from college and went and lived a fairly simple life in a ski town and met some good hearted friends and in time he began to feel a sense of his old joy back.  Soon he started to feel as if he regained his sense of self and the psychosis that overtook him never returned.  Today he is a happily married man and he has carved out a full and enriching life.


I was interested in hjs story because it mirrored mine in many ways.  I had also gone through a period of severe confusion, bizarre thoughts and experiences as a young man, but I had never been hospitalized and I turned down the medications offered to me.   I have also heard many stories similar to my friends and as a therapist I have worked with people who have felt that the medical model was the wrong approach for what they were going through.



First Break Treatment



In our modern mental health system, when a young man or woman goes through a psychosis like this, they are strongly encouraged to go to a hospital and to get treatment.  These experiences are almost always described as “first breaks”, evidence of the start of a long period of illness that requires psychiatric drug intervention.  The usual course of medications offered is often antipsychotics such as seroquel and/or mood stabilizers such as lithium.


Many people in this arena believe that it is important to aggressively treat someone going through a “break” with strong neuroleptics because an episode of psychosis is seen as neurodegenerative and medications are needed for making sure someone does not descend into worsening illness.  The problem is that there is increasing evidence that taking these neuroleptics on a long term basis can actually lead to worsening outcomes.


sandra steingard

Sandra Steingard

Recently, Dr. Sandra Steingard wrote a column for the Washington Post  entitled “A psychiatrist thinks some patients are better off without antipsychotic drugs” in which she talks about her change of heart when she reviewed long term studies of the effects of medications on people diagnosed with a serious mental illness suchas schizophrenia and bipolar disorder.  From longitudinal studies, she found that there is actually worse prognosis for people who have been on neuroleptics for many years.  There is also continuing evidence that the long term use of these medications lead to worsening health in the form of the potential for diabetes, higher blood pressure, weight gain, cardiac issues, cognitive degeneration and libido loss.  The long term studies showed those who stopped the meds after a period of time did better in terms of steady employment, relationships and avoiding disability.


There is complexity in these issues because some people do seem to do well long term on small doses of neuroleptic medications and some feel that warding off psychosis is worth the risk to health.   There is also complexity because once one has been taking a course of meds for a long time, it can be increasingly hard to discontinue them.  Withdrawing off of neuroleptics can lead to severe anxiety, confusion, insomnia, disorganization and psychosis that is often mistaken for underlying mental illness instead of simply a very challenging withdrawal process.  Going off heroin can often lead to visual and tactile hallucinations, severe anxiety and insomnia but most people do not think that those symptoms are evidence of a hidden mental illness.


For further discussion of the findings of these long term studies, I urge people to read the analysis here of them by Robert Whitaker,  journalist and author of Anatomy of an Epidemic.




Towards a Sanctuary Model




So when we speak of a first break, implying that it is one of many to come, I worry that we rush too quickly to medicate with very strong and harsh drugs that can have long term implications on health and wellbeing.  Once a person starts down the road of taking these medications it can be challenging to change course and stop them.


As someone who went through a set of extreme states that would have likely been described as evidence of a first psychotic break, and then went on to recover without the need of medications, I question the idea that these initial states are evidence of a long term disease that will likely worsen without effective medication treatment.  Because longitudinal studies show better prognosis after medication discontinuation I am concerned that we are not giving people who are going through “first breaks” the best care.


Instead of considering these experiences a disease in need of a medical intervention, perhaps we should view them as complex states that are best helped by compassionate support, an understanding community and places of sanctuary.    Certainly we should offer the most clear and up to date longitudinal information so that individuals and their families can make the best choices about how to manage these challenging emotional states.






This article written by Jon Keyes, Licensed Professional Counselor and  herbalist.  For more articles like this, please go to


You can also find me at the Facebook group Herbs for Mental Health.


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  1. Marcia Stillwell says:

    Just wanted to thank you for your very interesting article on first break psychosis. We have been through the medical model here in Australia, with our son, who was diagnosed a bipolar, hospitalised, and given meds. He is planning to come off meds slowly in the next few months.
    Your approach is wonderful and I am so heartened that there are people like you out there!!! I have ALWAYS thought a sanctuary would a great idea, and have fantasised about kidnapping our son and taking him to Plum Village in France or somewhere similar.
    Smiling and breathing
    Marcia Stillwell

    • hearthside says:

      Thanks for commenting Marcia. Yes, it can be deeply challenging to know how to help family members who are going through crisis/psychosis. Really the only main option we have is to view the situation medically and offer drug treatment as the prime way of working with people in these states. Yes we really need alternative sanctuaries for people like your son who don’t feel that the medical model serves them, but sadly they are out of reach- or far too expensive for the average person. Sending good thoughts your way- and to your son…:)

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