Objective: This article reviews evidence on the treatment of early episode schizophrenia spectrum disorders that contradicts, in some cases, the American Psychiatric Association's generic recommendation of antipsychotic medication treatment for at least a year. Method: Evidence on lack of diagnostic validity, absence of demonstrated long-term benefit from initial antipsychotic treatment, and existence of a large subgroup of early episode clients that may be successfully treated without antipsychotic medications is reviewed. Results: A time-limited initial trial of psychosocial intervention without antipsychotics may benefit many clients, especially by reducing long-term medication dependence and side effect exposure. Evidence suggests this can be done without substantial risk to those later found to need medications. A risk-benefit comparison of current practice to two alternate treatment protocols is presented. Conclusions: Developing and evaluating a psychosocial intervention for early episode psychosis presents a unique opportunity for social work to take leadership in acute mental health treatment. (Contains 1 table.)