Feeds:
Posts
Comments

Archive for the ‘Mental Health & Recovery’ Category

Depression

‘Drugs are having a positive effect for some people – but they clearly can’t be the main solution for the majority of us.’ Photograph: Alamy

For various reasons I needed recently to look into the current state of thinking about depression. As a result I stumbled upon this article by Johann Hari with which I strongly resonate. The closing paragraph hits a very important nail exactly on the head:

If you are depressed and anxious, you are not a machine with malfunctioning parts. You are a human being with unmet needs. The only real way out of our epidemic of despair is for all of us, together, to begin to meet those human needs – for deep connection, to the things that really matter in life.

Below is another short extract: for the full post see link.

I started to research my book, Lost Connections: Uncovering The Real Causes of Depression – and the Unexpected Solutions, because I was puzzled by two mysteries. Why was I still depressed when I was doing everything I had been told to do? I had identified the low serotonin in my brain, and I was boosting my serotonin levels – yet I still felt awful. But there was a deeper mystery still. Why were so many other people across the western world feeling like me? Around one in five US adults are taking at least one drug for a psychiatric problem. In Britain, antidepressant prescriptions have doubled in a decade, to the point where now one in 11 of us drug ourselves to deal with these feelings. What has been causing depression and its twin, anxiety, to spiral in this way? I began to ask myself: could it really be that in our separate heads, all of us had brain chemistries that were spontaneously malfunctioning at the same time?

To find the answers, I ended up going on a 40,000-mile journey across the world and back. I talked to the leading social scientists investigating these questions, and to people who have been overcoming depression in unexpected ways – from an Amish village in Indiana, to a Brazilian city that banned advertising and a laboratory in Baltimore conducting a startling wave of experiments. From these people, I learned the best scientific evidence about what really causes depression and anxiety. They taught me that it is not what we have been told it is up to now. I found there is evidence that seven specific factors in the way we are living today are causing depression and anxiety to rise – alongside two real biological factors (such as your genes) that can combine with these forces to make it worse.

Once I learned this, I was able to see that a very different set of solutions to my depression – and to our depression – had been waiting for me all along.

Advertisements

Read Full Post »

Video May 1993

In the main video interview transcript, an extract from which features at the beginning of the first post in this sequence, there is a very important passage focusing on one aspect of the impact of consultation on a key aspect of Ian’s difficulty with the voices. It concerns his memories of what he had done that made him feel so guilty.

I.: Well, when I was ill, it didn’t seem real. You know what I mean? My memory didn’t seem real. It was like a dream. And it was as if I’d never done anything. But talking to you reminded me that I’d actually done these things, you know? And that it was memory. And that I’d actually done the things.

P.: It was memory not imagination?

I.: That’s right. It was reality.

P.: And how did knowing that it was reality prove so helpful? What did it do?

I.: Well, it proved the voices wrong for a start.

P.: Ah. Why? Were they saying that they were real and your memories weren’t?

I.: Yeh. It proved the voices were wrong. And that my memory was right. And talking to you fetched it out into the open.

In a later video interview in September the following year, Ian explained that he felt as though talking helped get the feelings he had repressed ‘out into the open.’ He was in effect able to consult about them. Reflection had paved the way towards his being able to think about the feelings and begin to feel them. Talking about them brought them more fully into the open and enabled him to make better sense of them. The voices on the other hand fed on his habit of suppressing his feelings.

The September interview also explained how we had refined our understanding of his pattern of suppression. If he began to feel low, slightly depressed, he’d switch off his feelings which then brought the voices back.

But I must not make this process sound too simple. Yes, it is true that learning to reflect can pave the way both to a better understanding of our own mind and heart as well as potentially enabling us to share our discoveries with someone else and compare notes in a consultative fashion. But the transition is not necessarily automatic.

Video September 1994

The Importance of Trust

Take this extract from the May 1993 video. Jenny was his care worker.

P.: And it was in November that we first met, wasn’t it?

I.: Yeh. Jenny had started talking about you, you know? And it was coming up to the meeting with you. And I can remember going to the meeting with you that first time. And I can remember thinking who’s this bloke asking me all these questions, you know? And I didn’t trust you. But Jen was persistent that I could trust you, so I decided to trust Jenny . . .

P.: Right.

I.: . . . and to talk to you.

P.: And you actually asked if Jenny could come to sessions, didn’t you?

I.: Yeh, I asked if Jenny could come, yeh.

P.: Right. And I think she came about the second or third time you came.

I.: Yeh.

P.: And did you feel more comfortable with her there?

I.: I did, yeh.

P.: And did that make you feel more able to begin to trust me at least personally if not what I was doing?

I.: It took about a month to start to trust you. And that was with Jenny backing you up.

P.: And that was by being there in the sessions and by talking to you between whiles . . .

I.: With Jenny.

P.: . . . betweentimes.

I.: Inbetweentimes, yeh. And we’d talk about what we’d talked about, you know? And she supported you in what she said.

This extract testifies to how hard Ian found it to trust me. If it had not been for the fact that he had been living for some time, since his discharge from hospital, in a social services home specialising in the care of people with serious mental health problems, and if he had not had the time to build up a trust relationship with his care worker, Jenny, over that period, on an almost daily basis, who knows how long it would have taken him to trust me enough to work with me, or whether he would ever have been able to trust me enough at all, given we met only once a week. A sense of trust is not easy for someone who has been abused and a sense of safety is not easy for someone who has been traumatised. Ian had experienced both abuse and trauma.

After the May interview, the field of consultation had expanded beyond his Thursday meetings with me and his regular conversations with Jenny to include a Voicework Group, which had been set up at his instigation. He felt strongly that these opportunities for consultation were as important for him as his medication. Without Jenny, though, building sufficient trust to do effective work it would have taken far longer to reach this point, though he felt it would have happened in the end even so. I’m not so sure on that as he was.

Detachment

There is one quality that has been implicit in much that I’ve said so far. It is both the fruit of even the early stages of reflection and the soil from which a further ability to reflect more deeply springs. It is also an essential prerequisite of consultation. Those who are too attached to their own perspective will always find it hard to consult. I am speaking of the quality of detachment. Its power goes even further than this. Bahá’u’lláh, the Founder of the Bahá’í Faith, wrote (Arabic Hidden Words No 68 – my emphases):

Know ye not why We created you all from the same dust? That no one should exalt himself over the other. Ponder at all times in your hearts how ye were created. Since We have created you all from one same substance it is incumbent on you to be even as one soul, to walk with the same feet, eat with the same mouth and dwell in the same land, that from your inmost being, by your deeds and actions, the signs of oneness and the essence of detachment may be made manifest.’

If we are divided against ourselves we are also going to be in conflict with others. If we can, by a process of reflection, become both more detached and more integrated, we can transcend both our inner conflicts and our conflicts with others.

‘Abdu’l-Bahá describes this possibility in the following words (Selections from the Writings of ‘Abdu’l-Bahá 1978 – page 76):

. . . .all souls [must] become as one soul, and all hearts as one heart. Let all be set free from the multiple identities that were born of passion and desire, and in the oneness of their love for God find a new way of life.

Even if we do not believe in a God but at least have faith in the essential oneness of all humanity, this will help remedy our current conflicted state, wherein we are at war with ourselves as well as with others. This is Bahá’u’lláh’s description of the challenge we face compared with the reality most of us are blind to (Gleanings from the Writings of Bahá’u’lláh = CXII):

No two men can be found who may be said to be outwardly and inwardly united. The evidences of discord and malice are apparent everywhere, though all were made for harmony and union. The Great Being saith: O well-beloved ones! The tabernacle of unity hath been raised; regard ye not one another as strangers. Ye are the fruits of one tree, and the leaves of one branch.

This is another two way street. As individuals in harmony with ourselves we become more able to love and care for others, and as communities in harmony with one another we become more able to support and care for our fellow human beings.

Such levels of detachment, reflection and consultation are not easy to reach and are even harder to sustain, but the effort of attempting to do so is amply rewarded. Usually the effort is more than compensated for by the benefits gained.

Crucial Caveats

However, it would be too simplistic to suggest that people struggling with challenges as monumental as those Ian had to battle with can always achieve these benefits in a sustainable way. I am not arguing that reflection and consultation are always possible for people in such extreme distress.

Many of the contexts in which a person struggling with psychosis is placed seem neither safe not trustworthy. Sometimes the contents of a client’s consciousness prove so terrifying or distressing they cannot feel safe dealing with them nor trust their ability to manage them.

There came a point where the lady with the history of abuse chose mind-numbing medication rather than deal with the worst of her experiences.

After almost a year of our work together things seemed to be going well. Then came the unexpected. She found herself in a building that closely resembled the building strongly connected with the worst episode of abuse she had experienced at the hands of her father. Just being there was more than she could cope with. She became retraumatised in a way we none of us could have anticipated or prevented. The next time we met she could not stop sobbing.

We discussed what she might do. There were two main options.

She could, if she wished, continue on her current low levels of medication and move into a social services hostel where she would be well supported while we continued our work together, or she could be admitted onto the ward and given higher levels of medication in order to tranquillise her out of all awareness of her pain.

She chose the second option and I could not blame her in any way for doing so. It would be a betrayal of the word’s meaning to suppose she had any real choice at that point but to remain psychotic while the medication kicked in rather than deal with the toxic emotions in which she felt herself to be drowning.

Ian did the same when it came to his memories of slaughter from his army days. It was in June that he experienced a devastating return of the voices that led to his hospitalisation. Further exploration discovered a link between a traumatic army experience, which had occurred at that time of year, and an overwhelming reactivation of the voice-inducing guilt – far stronger than anything he had experienced in connection with his breach with his alcoholic partner. Each year after that he preferred to allow himself to become psychotic rather than attempt to process the intolerable guilt. He chose increased medication and admission to hospital till the anniversary effect was over, when he would be discharged to resume a relatively normal life until the next anniversary.

Graph of the Model that states Psychosis is on a continuum with Normal Functioning (Source: The route to psychosis by Dr Emmanuelle Peters)

A Genuine Help

What I am contending from my decades working with ‘psychosis’ in the NHS is that my CBT training was made more effective by my spiritual practice and the facilitation of those twin skills: reflection and consultation. The meanings achieved as a result facilitated flexibility and personal integration, as against the distressing rigidity and disturbing inner and outer conflict of the psychotic experience.

Hopefully one day these conclusions from personal practice will be validated in systematic studies.

An additional point to mention is that this is not just a model for psychosis. Take Laura for example, with her diagnosis of endogenous depression, ie one that her doctor felt was not explicable in terms of her life situation. She used to believe that her parents were more or less perfect. The work we were doing became very stuck and seemed to be going nowhere.

We had plateaued on bleak and distressing terrain, more tolerable than her previous habitat but too unwelcoming to live on comfortably for the rest of her life, and yet with no detectable path towards more hospitable ground.

Frustrated by the protracted lack of movement, I began to see discharge as a very attractive option. I discussed this with my peer supervision group.

Effective group supervision provides a context where fruitful consultation can take place and better decisions about the most fruitful line of action can be made. We decided that I should continue with the processes of exploration but make sure that I did not continue my habit of stepping in relatively early to rescue her in sessions from her frequent experiences of intense distress.

I continued to see her. Laura and I consulted carefully and jointly agreed that I would allow her to sink right into the “heart of darkness” in order to explore it more fully and understand it more clearly. The very next session, when we first put this plan into action, after I had left her alone in her silence for something like half an hour, Laura came to a powerful realisation at the heart of a very intense darkness. She said: “I think my mother threw me away even before I was born.” Thankfully consultation had helped me manage to avoid doing something similar by discharging her before we had resolved the causes of her depression.

This paved the way for deeper and more fruitful explorations of the reality of her childhood, continuing to use the same reflective and consultative process I have been describing in this sequence of posts.

Ian’s Last Word on the Matter

P.: Is there anything else that you feel that you want to say that I haven’t brought out by the questions I’ve asked you?

I.: No, except that the pain, you know, the questions you asked were painful. And I didn’t want to answer them.

P.: And you didn’t see the point of answering them either, did you?

I.: No, I didn’t see the point in answering them because I didn’t recognise myself that the problem lay there. But once I could see where the problem was I could bargain with the voices.

P.: Yeh. And you had to know where the problem lay, roughly . . .

I.: Yeh.

P.: . . . before you could bargain with them?

I.: And talking to you showed me where the problem was. So, I was able to deal with the voices in a positive way.

P.: Yeh. But before you had gone through this whole process there was no way you would have realised that the problems were what they turned out to be.

I.: No. I thought it was just schizophrenia.

P.: Yeh. And that was the end of it.

I.: And that was the end of it. I was schizophrenic and that was it. And I had nothing to look forward to except hospital and more medication. And I couldn’t stand the thought of that, you know? So that jumping under a train was looking very attractive. But it doesn’t look attractive now.

P.: Because life seems to have more to offer?

I.: Yeh.

I need to add here, though, to put all this fully into context, that I visited him in the hospice when he was dying of emphysema and other complications consequent upon what he knew was his self-damaging habit of heavy smoking. He was well aware of the implications of the injury to his lungs caused by the bomb blast that led to his being discharged from the army on health grounds.

I sat by his bed watching him breath in oxygen from the cylinder at his bedside. When he had taken in sufficient oxygen, I felt moved to ask him the question I had asked once before during our therapeutic relationship.

‘In the light of all you know now, were the gains you made worth the pain you had to go through?’

‘No,’ was the answer he gave. ‘They weren’t in the end.’

As he did not spell out exactly why not, I did not feel it right to press him for his reasons. Even so, his answer taught me a lot, not least how difficult it is to be sure you have obtained fully informed consent before embarking on any intervention.

I’ll leave it there until the New Year, and pause my posts until then as I did last year. I wish all my readers well over this festive season.

Read Full Post »

PTSD and war

Before we plunge further in from where we got to last time, I need to look briefly at what is known about the impact of war trauma on those affected by killing other human beings. This will help clarify just how disabling the effects of Ian’s experiences were likely to be on someone who was already undoubtedly very vulnerable.

There was an in-depth look at this in a television documentary in the wake of the Falklands War. The programme adduced a wealth of evidence that most human beings have a powerful and deep-seated aversion to killing other people. Approximately 98% of us are to varying degrees averse. For example, there were soldiers in the days of muzzle-loading muskets, who died with their muskets in their hands, the barrel full of undischarged ammunition balls. They had faked reloading without firing, so reluctant were they to risk killing anyone. Others, using rifles, were known to aim to miss or to wound slightly rather than to kill.

There are two outliers, representing about 1% in each case, who have no such inhibitions. One such exception is, not surprisingly, the psychopath. The other exception, which is very surprising, is an otherwise morally and emotionally normal individual who has no compunction about killing.

Psychologists, to their shame, devised training methods, using probable battle scenarios, that made rapid and automatic shooting to kill seem easy and unproblematic. These scenarios were practiced repeatedly until the lethal reaction was instinctive. What no one predicted was how traumatic many soldiers found it, to be confronted in battle with the consequence of their training: a dead soldier they had killed without a moment’s thought. As with Ian, the post-traumatic reactions were often devastating, with guilt and horror as key components of flashbacks and nightmares. In his case the signs of trauma were the unrelenting voices, a waking nightmare in effect.

Some of the horror of this is captured in Keith Douglas’s poem of the Second World War, How to Kill.

keyesdouglas

Keith Douglas

Under the parabola of a ball,
a child turning into a man,
I looked into the air too long.
The ball fell in my hand, it sang
in the closed fist: Open Open
Behold a gift designed to kill.

Now in my dial of glass appears
the soldier who is going to die.
He smiles, and moves about in ways
his mother knows, habits of his.
The wires touch his face: I cry
NOW. Death, like a familiar, hears

And look, has made a man of dust
of a man of flesh. This sorcery
I do. Being damned, I am amused
to see the centre of love diffused
and the wave of love travel into vacancy.
How easy it is to make a ghost.

The weightless mosquito touches
her tiny shadow on the stone,
and with how like, how infinite
a lightness, man and shadow meet.
They fuse. A shadow is a man
when the mosquito death approaches.

This is an equally disturbing but different kind of trauma from the kind captured in Wilfred Owen’s poems, such as Dulce et Decorum Est.

The intense guilt Ian harboured about his army experiences was too hard to bear and he had buried it. However, his subsequent guilt over throwing his alcoholic partner out of the house because her drinking was consuming his income from three jobs and he couldn’t cope any longer, reactivated the earlier even more intense guilt, because he thought she might die on the street, meaning that he might in a sense have killed her.

During the first period of therapy he felt that he was dealing only with his guilt about her, and that this was the main problem in terms of his voices. This was hard enough. Only later did he come to realise, by the impact of an anniversary effect I’ll come to in the next post, that the far darker army experiences, that he hadn’t yet dealt with, lay still active in this respect underneath.

What use is religious practice here?

There is much evidence that faith and religion are beneficial to mental (and physical) health. They reduce amongst other difficulties: depression, anxiety, suicide, & psychosis. The protectors they provide include: greater meaning and purpose, higher self-esteem, social support, less loneliness and more hope. (Harold Koenig at al. in Religion and Health’ Chapter 15)

My focus now will be on two aspects: reflection and consultation. Buddhism offers the most obvious example of powerful reflective processes. There is also a wealth of information that suggests most strongly that the process of collaborative conversation (Andersen and Swim), of consultation in the Bahá’í sense (see John Kolstoe), of inquiry (see Senge), of interthinking, can achieve remarkable results: Neil Mercer talks of the crucial function of language and says:

it enables human brains to combine their intellects into a mega-brain, a problem-solving device whose power can be greater than that of its individual components. With language we are able not only to share or exchange information, but also to work together on it. We are able not only to influence the actions of other people, but also to alter their understandings. . . . . Language does not only enable us to interact, it enables us to interthink.

It is the special combination of both these processes that is unique to the Bahá’í Faith as far as I am aware, though variations of each alone can be found in other either religious or educational/therapeutic contexts.

After I qualified and became a member of the Bahá’í community, fully integrating my understanding and practice of these processes into my clinical repertoire took a couple of years. I came to feel the benefits of that were considerable.

These weren’t the only factors I tried to accommodate. The hardest to digest was the belief that the mind is not dependent upon the brain. I have dealt with that in detail elsewhere.

The easiest was the notion that not only is the spiritual core of all religions essentially the same, but also humanity is in essence one: we are all part of the human family and all interconnected, not just at a material level but at a spiritual one as well. This is relevant here. This concept of unity not only serves to dispel any residual sense we might have that someone with a diagnosis of schizophrenia is somehow a different kind of being from us, but it also clarified that being inwardly divided, as many of us are, is not only a betrayal of our own essential inner oneness but an obstacle to our connecting with others, not just as a therapist but in any relationship. Similarly a community that is at odds with itself with find it hard to connect with everyone on a harmonious basis. I will be returning to that point.

My shorthand description of reflection is to say that it involves separating consciousness from its contents. Consultation, in similarly brisk terms, is the dispassionate comparison of notes, with the emphasis here on the word ‘dispassionate.’

Reflection

In discussing the nature and power of reflection I usually start with Peter Koestenbaum’s book, New Image of the Person: Theory and Practice of Clinical Philosophy.

Reflection, he says (page 99): ‘. . . releases consciousness from its objects and gives us the opportunity to experience our conscious inwardness in all its purity.’ I will look more closely at exactly what this might mean in a moment. Before we move on from his take on the matter, what he says at another point is even more intriguing (page 49): ‘The name Western Civilisation has given to . . . the extreme inward region of consciousness is God.’

I am quoting this upfront so that, if you find what I’m going to say from a faith perspective hard to accept, this might help.

In earlier posts I have discussed how psychosis is a very rigid and inflexible state of mind. I believe it is simply at the end of a continuum along which we all are placed. We all to some degree at times overvalue our beliefs, our perceptions, our simulation of reality. This can bring about a degree of attachment to them that makes us inflexible and highly resistant to contradictory evidence or different perspectives. This does not create a huge problem if our take on reality is not also destructive or frightening or both.

Fixity in the face of often extremely unpleasant phenomena causes an unacceptable and virtually inescapable amount of distress to the sufferer and of anxiety in his friends and family. The distress is what brings the sufferer to the attention of the psychiatric services. Psychiatry then applies the label schizophrenia. This label, in my view, mixes up the content of the experiences with the person’s relationship to those experiences in what can be a most unhelpful way.

Just as it is important to separate our perceptions (voices, visions and other internally generated experiences in other sensory modalities) from our understanding (beliefs, models, assumptions, meaning systems etc), it is crucial also to separate out, from the nature of these experiences in themselves, this loss of perspective and flexibility which I am calling fixity.

I have examined elsewhere on this blog the various ways that this fixity can be dispelled. Here I plan to focus simply on reflection. This is not because they are irrelevant. One, which I term disowning, by which I meant discounting or suppressing uncomfortable contents of consciousness such as pain, grief or guilt, was something Ian described in in the process of our shared reflections: he saw himself as increasingly ‘recognising’ his feelings rather than ‘repressing’ them.

My focus though will be on how reflection enables us to contain unpleasant material in consciousness, giving us time to think about and explore it, prior to integrating it.

Bahá’u’lláh, the Founder of the Bahá’í Faith, in the Kitáb-i-Íqán (Book of Certitude) quoted a hadith from the Islamic tradition: ‘One hour’s reflection is preferable to 70 years’ pious worship.’

‘Abdu’l-Bahá

His son ‘Abdu’l-Bahá, explored this in a talk he gave at a Friends’ Meeting House in London in 1913. He spoke of reflection, meditation and contemplation as virtually equivalent concepts. He went on to explain their power (Paris Talks – pages 174-176):

This faculty of meditation frees man from the animal nature, discerns the reality of things, puts man in touch with God. . . .

Through this faculty man enters into the very Kingdom of God. . .

The meditative faculty is akin to the mirror; if you put it before earthly objects it will reflect them. Therefore if the spirit of man is contemplating earthly subjects he will be informed of these. . . .

What he says for me maps onto Koestenbaum but in more directly spiritual terms. It explains why reflection, also connected with meditation and contemplation, is so powerful from a Bahá’í point of view.

The mirror analogy along with Bahá’u’lláh’s various references to the human heart as a mirror, led me to ask: what are the possible similarities between consciousness and a mirror?

Basically, a mirror is NOT what is reflected in it. In the same way, consciousness is not its contents. We are not what we think, feel, sense, plan, intend, remember, imagine and so on. This is also known as Disidentification in Psychosynthesis. In Jessica Davidson’s very brief summary, the affirmation exercise this form of therapy uses reads like this:

I have a body and sensations, but I am not my body and sensations. I have feelings and emotions, but I am not my feelings and emotions. I have a mind and thoughts, but I am not my mind and thoughts. I am I, a centre of Pure Awareness and Power.

Less controversially for most people I suspect, I would prefer to affirm that I have sensations, but these change from moment to moment so I cannot be my sensations. I am the capacity to sense. And so on with feelings, thoughts, plans, memories and imaginings, including our ideas about ourselves and what or who we are. Assagioli’s final affirmation was, as I remember, ‘I am a centre of pure consciousness and will.’

Reflection enables us to find meaning in what we are tempted to call ‘madness.’ It gives us the freedom to examine it even if only in our own minds. Psychosis is almost always meaningfully rooted in a client’s experience.

How might reflection help us find meaning?

Reflection helps counteract the fixity of attachment to the contents of consciousness that characterises what is called the ‘psychotic’ experience. The crucial stepping back relates not just to the experiences themselves, such as visions and voices, but to the explanations the sufferer has created for the experiences, which then cease to be delusional.

What Ian thought was just schizophrenia had meaning. Understanding and integrating that meaning released him from his voices. To understand his psychotic experiences he had to neither suppress them nor surrender to them: he had to contain them so he could examine them.

Recognising that they were simply the contents of his consciousness enabled him to step back, experience and think about them. They no longer had power over him.

I will sharing some of his thoughts on this in the final post.

Consultation

But there is one step further we can go.

When Ian loosened his identification with his experiences, he was able not just to think about them, he could also compare notes with others about what they might mean: he could consult in a Bahá’í sense of that undervalued word.

The Bahá’í International Community, which represents the Faith at the United Nations, quotes Bahá’u’lláh on consultation (The Prosperity of Humankind Section III): ‘In all things it is necessary to consult. The maturity of the gift of understanding is made manifest through consultation.’

What might He mean by that. Paul Lample in his excellent book Revelation and Social Reality puts forward his view: (page 199):

Consultation is the method of Bahá’í discourse that allows decisions to be made from the bottom up and enacted, to the extent possible, through rational, dispassionate, and just means, while minimising personal machinations, argumentation, or self-interested manipulation.’

Key words and phrases here are: ‘from the bottom up’ which I take to mean not imposed in some condescending fashion by those who feel superior; ‘dispassionate’ meaning objective and detached (something I’ll come back to in more detail in the next and last post); and ‘minimising . . . manipulation,’ so no ulterior motives or advantage seeking creep in.

Later he adds further illumination (page 215):

[C]onsultation is the tool that enables a collective investigation of reality in order to search for truth and achieve a consensus of understanding in order to determine the best practical course of action to follow.… [C]onsultation serves to assess needs, apply principles, and make judgements in a manner suited to a particular context.’

The key concept here is the ‘collective investigation of reality.’ This means that all parties involved in consultation are comparing notes, sharing perspectives, without undue attachment to their own point of view and not in an attempt to win an argument but with a sincere striving to understand reality better.

Just as the client needs to reflect, so does the ‘therapist.’ It is a two way street. And the therapist needs to model what she wants the client to learn: reflection. If she does not consultation is not possible. She must be as detached from her conclusions as she wants the client to be. If both client and therapist can reflect together as equals they are genuinely consulting. They can achieve a higher level of understanding, a better simulation of reality, together, than they ever could alone.

We are now ready to explore the impact of these processes on Ian and to examine some other important factors and considerations. More of that next time.

Read Full Post »

‘Reflection takes a collective form through consultation.’

(Paul Lample in Revelation and Social Reality – page 212)

One evening, towards the end of last month, I gave a talk at Birmingham University, concerning a Bahá’í perspective on making sense of mental illness as derived from my own clinical experience. Even though I had two hours at my disposal, I still had more planned than I had time to say. This was partly because some of the comments and questions sparked a lengthier diversion than I had intended. Anyway, I thought I’d publish everything I intended to say on this blog.

The quote at the top defines what processes this sequence of posts will be exploring in more depth in terms of their positive impact upon helping people find meaning in their experiences when they are struggling to cope with psychotic phenomena.

But before we home in on those we need a helicopter view of the overall context of the problems and processes we’ll be examining here.

Trauma, Transliminality and Psychosis

Previous posts on this blog have explored the possible relationship between the factors captured by this diagram. The focus though right now will be on trauma and psychosis.

Hearing voices and strange but strongly held beliefs are two key supposedly correlated signs we will be looking at today. Thought disorder and extreme withdrawal from contact with other people are also taken to be signs. I don’t propose to delve into the validity of the label all too frequently attached when more two or more of these come together in distressing form. For anyone interested, see Mary Boyle’s Schizophrenia: a scientific delusion for a clear exposition of the sceptical case against the idea these form a real syndrome.

For an understanding of the evidence for a relationship between psychotic phenomena and trauma see Longden and Read’s The Role of Social Adversity in the Etiology of Psychosis. They deal extensively with this problem (pages 7-8):

Large-scale population studies have shown that associations between adversity and psychotic experience remain significant when controlling for possible confounders, including: family history of psychosis and other mental health problems (which negates the notion that psychosis only occurs in those genetically predisposed), age, sex, ethnicity, marital status, exposure to discrimination, other psychiatric diagnoses, education level, neuroticism, and substance use. Furthermore, the association has repeatedly demonstrated a dose-response relationship; that is, the likelihood of psychosis increases relative to the extent of adversity exposure.

Transliminality refers to the permeability of the filters surrounding our consciousness, whether that be from beneath (the brain’s subconscious) or above (some kind of transcendent level). Helpful analogies that illustrate the idea of such thresholds of access are our eye/brain system’s limited perception of light’s spectrum, a receiver such as a radio that only translates into intelligible sound the frequencies it is tuned into, or a transceiver such as a computer that can access and decode appropriate data stored in a cloud site as well on its own hard drive. Accessing outside those given ranges is taken to be impossible for the manmade devices. However whether the brain can access outside its normal range is a vex question. Good sources for evidence that this might be so can be found in Mario Beauregard’s The Spiritual Brain or in Irreducible Mind by the Kellys.

Ian’s Experiences of Psychosis

There are two people who were tormented by so-called psychotic phenomena from whom I learned a great deal more than they probably learned from me about what these are and how to deal with them. The lady in the poem above is one: Ian, whom I’ll consider in a moment, was another.

The lady had asked for help to deal with her childhood experiences of extreme abuse. Unlike with Ian, I do not have her permission to go into detail. However, what I can say to illustrate the depth of her problem is that the one-hour sessions dealing with her work on the abuse had to be divided into three roughly equal parts. The first part checked up on how things were going and that she wanted to continue the painful work. The second part looked at the abuse and her intensely painful memories of it, and the third part involved calming her down sufficiently after this to dispel the powerful and reactivated visual and auditory hallucinations of her father, the abuser.

I will look later in the sequence at one other indication of the painful and powerful hold the past abuse still had over her.

I can directly use Ian’s own words to convey the kinds of experiences he was grappling with. This is an extract from the transcript of a video interview which took place in late May 1993. Obviously P is me and I is Ian.

P. Could I ask you to describe at first how things were, say, a year ago before there was ever any question of our meeting and when things were not too good for you?

I.: Well, I’d got the voices nearly all the time. They used to wake me up at night, you know?

P.: Yeh. And can you say what kind of things they used to say, just as an example?

I.: `Get out of bed, you lazy bastard. Get up and wake up. Come flying with us. Go and jump in front of a train,’ you know?

P.: Right. And they were saying this to you constantly, were they?

I.: Constantly, yeh.

P.: Were they constant in the day?

I.: Yeh.

P.: Were they very loud?

I.: Yeh. They got loud when I was ill, you know, they got loud.

P.: Right. So, say last May, or last Spring, May, June, July, is this how it was with the voices . . .

I.: Yeh. They were pretty bad. They were loud, you know? They were right down in my ears. And – er – I was seeing things as well. I was seeing what I call the – the `Boss’, you know? He only come at night, yeh.

P.: Right. Where did you think these voices came from?

I.: The spirit world.

P.: So you thought they were ghosts of some kind, or . . .

I.: I thought they were spirits, come from the spirit world for me, you know? And that they wanted me to go with them. I didn’t think that I was going to hurt myself by killing myself, you see? But something inside me just wouldn’t let me do it, you know?

P.: Yeh. You held back?

I.: I think it was because I was afraid of hurting myself.

P.: Right. Because you did say at the time that unless you actually did it instantly it wouldn’t really count, would it?

I.: No.

P.: Right. So it was very important to you that you didn’t end up injured or in a worse state.

I.: Yeh. It was important not to get injured. It had to be a certain thing, you know? And the Express train looked the part.

P.: Right.

In an earlier exchange that month on audiotape, in response to my question as to whether his ‘experiences . . . were shutting [him] out from the world and shutting [him] out from the future,’ he replied, ‘Yeh. I was living in a dream world, you know.’ He also described it in the same interview as ‘brainwashing.’ He said:

They were so loud that I couldn’t hold a conversation, you know. And I couldn’t listen to the radio. They just blocked everything out. And I couldn’t think because they just sidetracked me, you know, saying the same thing over and over and over.

In an interview in September of the following year, he clarified further by saying that he no longer did what the voices told him to do, as he had in the beginning. He knew now they were not spirits but the products of his own head. Even so it was still hard work to keep them at bay.

In working with people experiencing psychotic phenomena, I found it important to distinguish the experience, with which I never sought to argue, from the explanation, which could be modified in helpful ways, for instance here in terms of the power of the voices. It is possible that this will lead, as in Ian’s case, to a recognition that the voices come from inside the person’s own head. This though is neither necessary nor inevitable. It is sufficient that a more benign explanation of the voices is arrived at that gives them far less power and, if possible, reduces any malignity.

Ian’s Life

For those interested in the full back ground to his psychotic experiences and how far back in his life traumatic events and situations began helping to shape his sensibility I have included at the end here a brief summary, which I helped him write, of his life up to the point I worked with him.  

By the time I was 14 months old my mother was dying of tuberculosis and I was failing to thrive. I was abandoned by my dad. My aunt rescued me and took me to live with her. She applied to the courts to adopt me. My dad, at the 11th hour, began to contest this. The proceedings dragged on until I’d started school. My situation with my aunt was not secure until I was six years old.

When I was seven my grandfather died suddenly. I was extremely close to him.  The pain of that still haunts me.

When I was nine I was walking to school through a farmyard, when I saw the farmer hanging in his barn. Shortly after that, the voices started, but they were nice and friendly, and kept me company as I walked the hills near home.

I went down the mines as soon as I left school. I wasn’t happy with that and joined the army. Within the first couple of years a bullying sergeant major triggered a psychotic episode. The voices turned nasty. I heard the voice of the sergeant major mocking and insulting me all the time. I faked my way out the army hospital by denying I was hearing voices any longer.

The army didn’t know what to do with me. As they reckoned people with schizophrenia were antisocial, they decided a solitary job within the army would be the best thing for me. They came up with what they felt was the ideal solution: they’d train me to be a sniper. You spend long periods alone and when anyone comes along to disturb you, you kill them – a great idea in their view. There’d be none of that stressful social contact!

At least two incidents in which I was involved in the army left me with strong feelings of guilt. The pain of the deaths I caused, I know now,underlay the later experiences of psychosis.

I was discharged from the army after I was seriously injured walking towards a bomb. I did this deliberately. It was part of a pattern. From time to time I felt I didn’t deserve to live so I put myself in danger. If I lived I felt I was meant to live and maybe I deserved to do so. When the feeling built up again, as it kept on doing even in civvy street because the guilt about the deaths never left me, I’d play the same kind of Russian Roulette.

Once out of the army I used to do this by lying down on a railway line in the early hours of the morning. If no train came within a certain period of time, I reckoned I deserved to continue living.

After leaving the army my marriage broke up and I ended up living with someone with a serious drink problem. I held down three jobs, working all hours, in order to make ends meet and finance her habit. Eventually, I got completely exhausted and depressed. I couldn’t cope any longer and threw her out.

That didn’t finish it though. I was so convinced that she would die on the streets, I felt like I’d killed her. I became tortured by guilt. I shut himself away in my room with my dog. I survived on frozen chips for six weeks, until my boss became so concerned he got the police to break in. They found me completely psychotic, they say. I think I was determined to die this way. They sectioned me. That began an eight year history of sections, medications, with long and frequent admissions, until I felt that life had nothing to offer me.

At the end of this eight year period our work together began. At the end of the first phase, the May 1993 video interview took place.

We are now at a point to move onto examining how far we were able to help Ian make sense of his psychotic experiences in terms of his life history. More of that next time.

Read Full Post »

Suffering is life.

(Thomas Szasz quoted by James Davies in Cracked – page 276)

I threatened in an earlier post to republish this one. Here is it.

I was walking back from town one day when my phone pinged. It was a message telling me my book was ready for collection from Waterstones. I was puzzled to begin with then the penny dropped. Just before my birthday someone spotted that I had scribbled, in my list of books to buy, the title of Cracked by James Davies.

I turned round and headed back to town again. When I picked up the book, for some reason I wasn’t impressed by its cover. Maybe the words ‘Mail on Sunday’ put me off, though Wilf Self’s comment helped to redress the balance.

Anyhow, for whatever reason, I didn’t get round to reading it until after I’d finished Rovelli’s Reality is not What it Seems. I’ll be doing a short review of that later, possibly.

Once I started Davies’s book I was hooked.

I’ve already shared on this blog a review of Bentall’s book Doctoring the Mind, which brilliantly, for me at least, brings the more grandiose pretentions of psychiatry back to the earth with a bump. I quoted Salley Vickers’ verdict:

Bentall’s thesis is that, for all the apparent advances in understanding psychiatric disorders, psychiatric treatment has done little to improve human welfare, because the scientific research which has led to the favouring of mind-altering drugs is, as he puts it, “fatally flawed”. He cites some startling evidence from the World Health Organisation that suggests patients suffering psychotic episodes in developing countries recover “better” than those from the industrialised world and the aim of the book is broadly to suggest why this might be so. . . .

I summarised my own view by praising ‘its rigorous analysis of the misleading inadequacy of psychiatry’s diagnostic system, its powerful and carefully argued exposure of the myths surrounding psychotropic medications and their supposed efficacy, and its moving description of the critical importance of positive relationships to recovery.’

The Davies book also covers much of this same ground and is equally compelling. What needs to be acknowledged is that he also takes the argument to another level towards the end of his book. He is concerned that we are exporting our Western model with all its flaws to country after country and goes on to explore other implications as well.

In the chapter dealing with the export issue he first summarises his case up to that point (page 258 – square brackets pull in additional points he has made elsewhere):

Western psychiatry has just too many fissures in the system to warrant its wholesale exportation, not just because psychiatric diagnostic manuals are more products of culture than science (chapter 2) [and have labelled as disorders many normal responses to experience], or because the efficacy of our drugs is far from encouraging (Chapter 4), or because behind Western psychiatry lie a variety of cultural assumptions about human nature and the role of suffering of often questionable validity and utility (Chapter 9), or because pharmaceutical marketing can’t be relied on to report the facts unadulterated and unadorned [and its influence has helped consolidate the stranglehold of diagnosis and a simplistic psychiatric approach] (Chapter 10), or finally because our exported practices may undermine successful local ways of managing distress. If there is any conclusion to which the chapters of this book should point, it is that we must think twice before confidently imparting to unsuspecting people around the globe our particular brand of biological psychiatry, our wholly negative views of suffering, our medicalisation of everyday life, and our fearfulness of any emotion that may bring us down.

I can’t emphasise too strongly the value of reading through the details of his treatment of all these other aspects. I am of course aware that physical medicine, even though there are biological markers for diseases in this sphere unlike in mental health, has not been exempt from the disingenuous manipulation of data and unscrupulous marketing methods practiced by the pharmaceutical industry, as Malcolm Kendrick’s book Doctoring Data eloquently testifies, but the scale of that abuse is dwarfed in the arena of mental health – and I mean arena in the fullest sense of that word: the battle here is damaging more ‘patients’ and costing even more lives.

Davies’s examination of exactly how this exportation of the psychiatric perspective is coming about is also disturbing and compelling reading. He adduces for example how skilfully drug companies have learned to read the reality of cultures into which they want to make inroads with their products, how effectively they target key figures in the prescribing hierarchy of professionals, and how astutely they now reach out to the public themselves so they will go to their doctors and request what the drug company is selling – all this to detriment of the many ways the social cohesion of the receiving culture has often (though not always, of course) been supporting those who are suffering from some form of emotional distress.

Where he takes his case next, in Chapter 10, I found both compelling and resonant. He is in tune with Bentall in seeing the importance of supportive relationships but, I think, explores that aspect somewhat more deeply.

He repeats basic points, to begin with (page 266):

What the evidence shows… is that what matters most in mental health care is not diagnosing problems and prescribing medication, but developing meaningful relationships with sufferers with the aim of cultivating insight into their problems, so the right interventions can be individually tailored to their needs. Sometimes this means giving meds, but more often it does not.

He then quotes research done by a psychiatrist he interviewed (page 267). Using two existing MH teams, Dr Sami Timimi set up a study comparing the results from two groups, one diagnostic, the usual approach, and the other non-diagnostic, where medication was given only sparingly, diagnosis was hardly used at all, and individual treatment plans were tailored to the person’s unique needs.’

In the non-diagnostic group the psychiatrist spent far more time exploring with his clients the context of their problems.

The results were clear (page 269):

Only 9 per cent of patients treated by the non-diagnostic approach continued needing treatment after two years, compared with 34 per cent of patients who were being treated via the medical model. Furthermore, only one person from the non-diagnostic group ended up having to be hospitalised, whereas over 15 people in the medical-model team were referred for inpatient hospital treatment. Finally, the non-diagnostic approach led to more people being discharged more quickly, and to the lowest patient ‘no-show’ rate out of all the mental health teams in the county.

Davies also interviewed Dr Peter Breggin, a US psychiatrist who is critical of the medical model. Breggin explained his viewpoint (page 279):

Most problems are created by the contexts in which people live and therefore require contextual not chemical solutions. ‘People who are breaking down are often like canaries in a mineshafts,’ explained Breggin. ‘They are a signal of a severe family issue.’ .  . . . For Breggin, because the medical model fails to take context seriously – whether the family or the wider social context – it overlooks the importance of understanding and managing context to help the person in distress.

Davies quotes Dr Pat Bracken as singing from the same hymn sheet (page 273):

We should start turning the paradigm round, start seeing the non-medical approach as the real work of psychiatry, rather than as incidental to the main thrust of the job, which is about diagnosing people and then getting them on the right drugs.

It’s where he goes next that I found most unexpected but most welcome to my heart. He leads into it with an interview with Thomas Sasz just before his death at the age of 92 (page 276). He asks Szasz, ‘why do we believe as a culture that suffering must be removed chemically rather than understood in many cases as a natural human phenomenon, and possibly something from which we can learn and grow if worked through productively?’

Szasz’s response is fascinating:

Our age has replaced a religious point of view with a pseudo-scientific point of view. . .   Now everything is explained in terms of molecules and atoms and brain scans. It is a reduction of the human being to a biological machine. We don’t have existential or religious or mental suffering any more. Instead we have brain disorders.

Davies summarises Szasz’s position on psychiatry (page 277): ‘It had become deluded in its belief that its physical technologies, its ECT machines and laboratory-manufactured molecules, could solve the deeper dilemmas of the soul, society and self.

Bracken’s view on this brings in capitalism (page 278):

What complicates things more is that we also live in a capitalist society, where there is always going to be someone trying to sell you something… In fact, some people would argue that capitalism can only continue by constantly making us dissatisfied with our lives.… You know, if everybody said I am very happy with my television, my car and everything else I’ve got, and I’m perfectly content with my lifestyle, the whole economy would come shattering down around our ears.

He continues (page 279):

What we customarily call mental illness is not always illness in the medical sense. It’s often a natural outcome of struggling to make our way in a world where the traditional guides, props and understandings are rapidly disappearing… Not all mental strife is therefore due to an internal malfunction but often to the outcome of living in a malfunctioning world. The solution is not yet more medicalisation, but an overhaul of our cultural beliefs, a reinfusing of life with spiritual, religious or humanistic meaning with emphasis on the essential involvement of community, and with whatever helps bring us greater direction, understanding, courage and purpose.

Unfortunately psychiatry, as with economics according to the writers of Econocracy, is failing to train psychiatrists in the adoption of a critical perspective on their own practice. So, he concludes, the pressure to change perspective has to come from outside the psychiatric system. He quotes Timimi again (page 285):

The things that get powerful institutions to change don’t usually come from inside those institutions. They usually come from outside. So anything that can put pressure on psychiatry as an institution to critique its concepts and reform its ways must surely be a good thing.

So, it’s down to us then. For me, promoting this book is a start. We all need to think, though, what else could be done, whether as a patient, a volunteer, a friend, a family member, an MP, a clinician or simply a citizen.

Currently, help is often tied to diagnosis. One psychiatrist quoted in this book is concerned that if categories of mental disorder are not confirmed as diseases, services will never be funded at the required level, the level, say, at which cancer services are funded. Surely, though, if opinion shifts to a tipping point not only the greater humanity of non-diagnostic treatments but also their relative cost effectiveness must carry the day in the end. But opinion will only shift sufficiently if we all play our part.

I know! I’ve got it.

You all could start by reading these two books. How about that?

Read Full Post »

At the end of October  published an excellent article in the Guardian which further reinforces the scepticism about psychiatric diagnosis that I have explored earlier on this blog. She succinctly makes what is a key point for me:

. . . the DSM [Diagnostic and Statistical Manual] only focuses on . . . “symptoms” and does not take into account the individual’s context. This in itself is a value judgment.

Below is a short extract. For the full post see link.

Psychiatric diagnosis must serve an ethical purpose: relieving certain forms of suffering and disease. Science alone can’t do that.

How do we decide what emotions, thoughts and behaviours are normal, abnormal or pathological?

This is essentially what a select group of psychiatrists decide each time they revise the Diagnostic and Statistical Manual of Mental Disorders (DSM), considered a “bible” for mental health professionals worldwide.

The DSM was first published by the American Psychiatric Association in 1952 to create a common language and standard criteria for the way we classify mental disorders. It’s now used around the world by clinicians, researchers, insurance and pharmaceutical companies, the legal system, health regulators and policy makers, to name a few.

Now in its fifth edition, revisions have gradually expanded the number of mental disorders, while also removing some as understanding or values change. Over the years many of these amendments have courted controversy.

These days, criticisms of the DSM are that it medicalises normal behaviour such as fidgetiness, noisiness and shyness.

Read Full Post »

A DWP disability assessment questionnaire. Photograph: Alamy

In yesterday’s Guardian there was yet more evidence of the distressing and shameful  failure of our benefits system to understand the very real needs of those coping with mental health problems. Adam Jacques, the disabled husband of a claimant, writes movingly of his experience of his wife’s acute distress at being refused access to the personal independence payment system:

There’s nothing quite like witnessing your wife tumble through a gaping chasm, to see that there’s something rotten at the heart of a welfare assessment system. From what we experienced, the wrong people are doing the wrong assessments with the wrong tools, using incorrect assumptions. And it left me reeling: how could this happen to my wife? I discovered that her experience is just the calamitous tip of a PIP-denying iceberg.

Below is a short extract: for the full post see link.

My wife tried to kill herself in March. She took an overdose – while I was watching TV in the next room. Cue, in short succession: 30 minutes of heart-stopping panic, a nerve-jangling ambulance trip to A&E, an admission to a secure mental health unit, and a longer stay recovering in a crisis house.

Acute episodes such as this can be a recurring reality for someone with a longstanding mental health condition. From her battles with depression and struggles to get out of bed in the mornings, to anxiety so overpowering that a trip on a bus triggers a blind panic, for my wife (let’s call her Bea) life is a titanic battle to stay afloat. She experiences overwhelming feelings of worthlessness, guilt and impulsive urges to self-harm that can flood her mind and distort her thinking. Socialising with friends is hard, while work in the past year has been out of the question. But she’s also incredibly smart, funny, kind and brave.

Mental health is complex, but something simple triggered Bea’s overdose: a devastating letter from a “decision-maker” at the Department for Work and Pensions (DWP), informing her that her claim for personal independence payment, a disability benefit, had been unsuccessful. She’s not the first, and won’t be the last, to experience the dismissive treatment that people with severe mental health conditions can undergo when accessing the benefits system. And PIP, as the benefit is called, is one of the worst offenders.

PIP is supposed to offset some of the extra costs of a disability. Applicants are evaluated by health workers from the private firms Atos or Capita, who forward their assessments to a DWP decision-maker – who scores you on “daily living” and “mobility” (you need at least eight points for each to qualify). Currently nearly 3 million people claim some element of PIP, and my wife expected to be one of them. As did her benefits adviser, an NHS psychiatrist and a psychologist. So, armed with a dossier of supporting medical documentation, Bea applied. That was last November. I’ve seen glaciers move faster. . .

I discovered that her experience is just the calamitous tip of a PIP-denying iceberg. While the DWP claims it doesn’t operate quotas to save money, figures released in April, covering just six months of 2016, showed an enormous expansion in claimants receiving zero points, up to 83,000. That’s only 10,000 fewer than in the previous 12 months.

This raises huge concerns about the assessment process – especially given that, when rejected by the DWP, 65% of applicants who appeal to a tribunal get the ruling reversed. A panel of welfare experts told the work and pensions select committee earlier this year that the whole process was “inherently flawed”, with medical evidence often ignored by officials during the initial assessment.

Read Full Post »

Older Posts »