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Posts Tagged ‘diagnosis’

After all this whinging about what Peterson has written it’s about time I tried to explain what it all looks like to me.

What do I think?

I’m not sure yet whether all I have said undermines his basic argument.

I am still struggling to articulate exactly how I would develop a model to bring it closer to what I experience as reality. In a way, I am grateful to him for having pushed me to think more deeply about this issue, even though I am uneasy about a basic aspect of his model.

Anyhow this is how my thinking goes so far. And in case any of you need to know I’m handing over the writing of this to my right-brain, which, when I have the patience to listen to it on such matters, is almost always right.

First things first. I firmly believe that labels, dichotomies and categories, when employed in the social or cultural field are almost always not only false, but potentially fatal. I am not saying this as a reward to my right-brain for having had the patience to let my left-brain bang on about everything it’s read on the subject for the last ten years. My left-brain believes it too, but can’t always act on it in the heat of the moment. It’s so much easier to slap a sticky label over the complexity of social experience: it makes deciding what to do so much quicker and easier.

So, you can see why I’m so uncomfortable when I feel that Peterson, in spite of all the good things he says, seems to be happily dwelling in the land of opposites. If he was distancing himself from the categorising tendency he ascribes to our interpretation of the world, instead of seeming to be contentedly identifying with it, I’d be more inclined to agree with him. Yes, he sees its limitations, but seems to feel that it is an inescapable feature of our perception of the world, one which we have to be aware of, and adapt to, even if we need to soften its hard edges, if we are to function wisely in the world.

He seems to have decided, perhaps not consciously, to live in the left-brain world of, to use McGilchrist’s words I quoted earlier, ‘language, logic and linearity.’ He doesn’t seem to entertain, at least in the first half of the book, the possibility that we could give more space in our perspective to the paradoxical and ambiguous take on the world of the right-hemisphere as McGilchrist describes it. This suggests to me that the part of his analysis, which contrasts chaos and order so definitively, is buying into the left-brain’s perceptual bias in favour of categories.

He does eventually produce an admission of the dangerous weakness of the left-brain approach (page 217):

The capacity of the rational mind to deceive, manipulate, scheme, trick, falsify, minimise, mislead, betray, prevaricate, deny, omit, rationalise, bias, exaggerate and obscure is so endless, so remarkable, centuries of prescientific thought, concentrating on clarifying the nature of moral endeavour, regarded it as positively demonic. This is not because of rationality itself, as a process. That process can produce clarity and progress. It is because rationality is subject to the single worst temptation – to raise what it knows now to the status of an absolute.

However, he reverts, in my view, to overstating the value of words again later (page 281):

The past can be redeemed, when reduced by precise language to its essence. The present can flow by without robbing the future if its realities are spoken out clearly. With careful thought and language, the singular, stellar destiny that justifies existence can be extracted from the multitude of murky and unpleasant futures that are far more likely to manifest themselves of their own accord.

An ‘essence’ or ‘stellar destiny’ of any kind is more elusive than that. Peterson’s lack of coherence in the presentation of his ideas sometimes allows him to believe that he can have his cake and eat it too. Believing language can accurately capture the essence of experience is one of the things that can lead to our succumbing to the temptation of believing that what we know is the absolute truth.

Again I need to acknowledge that an earlier discussion on genuine conversation (pages 253-56) illustrates how we can enhance our understanding by the use of words, rather in the same manner as I would argue can be done by consultation, in the Bahá’í sense of that word.

In addition, I must add that what the right-brain would see as beautiful, if we let it, comes to seem scary rather than promising when the left-brain dominates with too little restraint. As McGilchrist puts it: ‘This is much like the problem of the analytic versus holistic understanding of what a metaphor is: to one hemisphere a perhaps beautiful, but ultimately irrelevant, lie; to the other the only path to truth.’

Only when we refuse to categorise, and can rise to the challenge of absorbing the blending of parts that is reality, can we have any hope of accessing the truth. Not a possibility Peterson seems to recognise. Without linguistic analysis, he claims (page 282): ‘Everything will bleed into everything else. This makes the world too complex to be managed.’

I feel the right-brain can make a better fist of grasping the blended complexity of reality than he allows for. Einstein, after all, describes how he sensed the truths that he was groping for, at first as almost kinaesthetic shapes in his mind or as a kind of music: ‘If… I were not a physicist, I would probably be a musician. I often think in music.’

In consequence, I even think that not just our social world, but developments in modern post-Newtonian science are forcing us to accept this as a fundamental characteristic of reality. Flux, unpredictability and ambiguity confront us the more deeply we seek to penetrate below the surface of our world. Machado captures this brilliantly when he says: ‘cambian la mar y el monte y el ojo que los mira’ (sea and mountain change, as does the eye that sees them’ – quoted in Xon de Ros The Poetry of Antonio Machado, page 5). If we refuse to let the way we see change, we will never see the world as it is, only as we think it should be. Seeing the world more as it is may be scary, but it’s not chaos, and it need not be dangerous.

One thinker quotes convincing evidence to confirm that this fluidity and chaos underpins not just quantum matter but our biology as well. Jonah Lehrer writes in Proust was a Neuroscientist (page 47):

Molecular biology, confronted with the unruliness of life, is also forced to accept chaos. Just as physics discovered the indeterminate quantum world – a discovery that erased classical notions about the fixed reality of time and space – so biology is uncovering the unknowable mess at its core. Life is built on an edifice randomness.

It seems we can’t escape it.

What needs to change is our attitude to what our analytical mind, with its fixation on the maps it already has, finds disturbing. If we can trust our flexible right-brain intuitions more, what is new to us will feel less scary, and we will also tune in earlier to subtle shifts in the familiar, which are telegraphing imminent change, in a way that will help us deal with it more effectively. What I am striving for a lot of the time is to let my right-brain lead when I have to process complexity. After that, I need to integrate what it shows me into my left-brain maps without distorting or discounting anything essential.

Much of our way of seeing, when we use the categorising tendency that Peterson both critiques and yet accepts as somehow inevitable, creates avoidable problems, even becomes toxic, lethal. More of that in a moment.

I am not convinced that replacing categories with dimensions will in the end be a completely satisfactory way of interpreting the world. For a start it’s hard to use the difference between the known and the unknown as ends of a dimension anymore than to see it as indicating two categories.

I have concluded, as I explained earlier, that knowing/unknowing are not identical, as Peterson seems to think, with chaos and order, which I am also saying may not be so easily distinguished either. This is because knowing and not knowing are characteristics of consciousness. The diagram on the left attempts to express that relationship.

The dotted line around the edge of the known indicates my sense that the boundary, if there is one, is at best fluid. How do we deal with the forgotten – what was once known, is now not consciously remembered and yet almost certainly subliminally influences how we see the world and how we react to it?

The dark area around the outer circle is meant to represent where physical consciousness of any kind ends – death if you like. Even this needs a dotted line, I think, given my belief that physical consciousness is not all there is. As I have explored that at length elsewhere, I’ve decided not to go there in this sequence which is already long enough, and I have to keep my left-brain quiet long enough to finish even this much.

If we accept for now that thinking in terms of dimensions is legitimate, there are at least two categories of dimension active here, within the zones, if that is the right word, of knowing and unknowing. One concerns perceived reality, which stretches along a dimension relating to order and disorder between the extremes of order on the one hand, which can become tyranny, and on the other of chaos, which can be creative. The other dimension concerns the preference pattern of the mind that interacts with those perceived possibilities: among many other possibilities, in addition to the holistic and analytical I’ve already touched on, there will be risk-takers and risk avoiders, as Peterson makes clear he is aware towards the end of his book. Please hold in mind my fundamental scepticism about the need to accept that we have to split reality up, either in terms of order/disorder or degrees of risk taking, whether as dimensions or categories. Let’s accept for now that they hold good up to a point.

A risk-taker will delight in what they experience as the excitement of what the risk-avoider will see as the dangers of chaos, and conversely will feel stifled by the perceived order a risk-avoider thrives in.

It is important to note that perception is indeed an unavoidable mediator of all these interactions between reality and consciousness. I don’t think Peterson attaches sufficient importance to the flexibility of perception, and even fails to consider the possibility of its using dimensions rather than discrete categories. Nowhere that I’ve read so far does he deal with the possibility that we could potentially transcend even dimensional thinking when it is necessary to do so, either because it ceases to be useful or becomes potentially dangerous. Left-brain perception is his default mode, just as much as it is that of our culture. The rich potential of right-brain perception, in spite of the value he clearly sets on myths (reduced though to his left-brain interpretations of his selection from them), doesn’t really feature.

Why should we exert ourselves to go against our left-brain tendencies? They’ve lifted us out of the middle ages. Why can’t they lift us further?

That’s a complex issue, parts of which I’ve addressed at length elsewhere on this blog in terms of altruism, compassion and civilisation building.

In the light of the various references I quoted in the earlier two posts in the context of why human beings can perpetrate such evil, I’m going to focus briefly on why labelling, a left-brain temptation with emotional consequences, is so toxic.

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

I have worked for more than thirty years in mental health. I have seen at close quarters the costs and benefits of diagnostic labels. Yes, getting the label of schizophrenia will open the door to the benefits system and give you access at least to some form of drug treatment. But drugs are a double-edged sword as I have discussed before. One edge can, if the patient is lucky, cut through the tormenting ropes woven around the mind by derogatory voices, but the other edge all too often clouds any clarity of thought and stupefies the mind. The diagnosis also carries, as so many labels do, a heavy weight of social stigma, which all too often more than outweighs any benefits. It’s far better, in my view, to look at the person as a whole, and tackle the more complex question of what these so-called psychotic experiences mean, and where their roots are in the felt life of the person.

Other labels are often at least as bad if not worse: abnormal, disabled, backward, black, unclean, alien, outsider, mad, cockroach, sewer rat, immigrant – the list is potentially endless.

If we see ourselves as in the normal, able, white, clean, insider, sane, human, legitimate citizen category, we can smugly comfort ourselves that we deserve all the good things we have whereas these people don’t and perhaps even couldn’t. It’s very cosy. It gives us no motivation to change anything. It even justifies to us in our own minds taking steps to protect what we are and what we have from ‘contamination’ or destruction, even if that means harming other people perceived as coming from any of those completely false categories. It wouldn’t take long, given the right circumstances, to tipple over into enthusiastic eugenics or even forms of genocide. We can see these toxic options unfolding around us even now.

Using only our left-brain analytic mind it is hard for us to experience the world except in such categorising ways. Yet, experiencing the world holistically is exactly what we have to do, especially in terms of our perceptions of our fellow human beings, and also the life-world around us. Labels won’t work if we’re going to survive. We are interconnected. In fact we are in essence one family, even one huge multi-minded entity. Only by operationalising this insight can we transcend this problem. And I think, from the evidence I’ve quoted earlier in this sequence, it’s not just Bahá’ís that see it this way.

View of the Terraces above the Shrine of the Báb on Mount Carmel, Haifa

We believe that this will not be an easy vision to bring into reality. The Universal House of Justice, our central body, wrote in a letter to Bahá’ís of Iran (2 March 2013 – my emphasis):

The rejection of deeply ingrained prejudices and a growing sense of world citizenship are among the signs of [a] heightened awareness. Yet, however promising the rise in collective consciousness may be, it should be seen as only the first step of a process that will take decades—nay, centuries—to unfold. For the principle of the oneness of humankind, as proclaimed by Bahá’u’lláh, asks not merely for cooperation among people and nations. It calls for a complete reconceptualization of the relationships that sustain society.

The bar is raised very high, as the Universal House of Justice explained to all those gathered on Mount Carmel to mark the completion of the Shrine and Terraces project there on 24th May 2001:

Humanity’s crying need will not be met by a struggle among competing ambitions or by protest against one or another of the countless wrongs afflicting a desperate age. It calls, rather, for a fundamental change of consciousness, for a wholehearted embrace of Bahá’u’lláh’s teaching that the time has come when each human being on earth must learn to accept responsibility for the welfare of the entire human family. Commitment to this revolutionizing principle will increasingly empower individual believers and Bahá’í institutions alike in awakening others to the Day of God and to the latent spiritual and moral capacities that can change this world into another world.

Not for nothing do they describe it as the work of centuries, and Paul Lample, clarifying this is not just the work of the Bahá’í community, writes (Revelation and Social Reality – page 48):

Generation after generation of believers will strive to translate the teachings into a new social reality… It is not a project in which Baha’is engage apart from the rest of humanity.

The diagram at the bottom of this post seeks to represent the magnitude of the task we face, moving as we must from the self-centred and short-term processing our bodies are programmed for, to the transcendent vision of our ultimate goal, far in the future though it may be, of a united humanity working together in harmony.

We acknowledge that religion has been and sometimes still is an obstacle in the path. ‘Abdu’l-Bahá, anticipating by at least six decades Robert Wright’s caveat quoted in the first post, made it quite clear that ‘religion must be conducive to love and unity among mankind; for if it be the cause of enmity and strife, the absence of religion is preferable.’ (Promulgation of Universal Peacepage 128).

Treading this long and difficult road will involve resolving conflicts within us as well as between us. Most of us are still divided selves, as Bahá’u’lláh indicated (Tablets of Bahá’u’lláh – page 163):

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.

And the way forward, we believe, lies in recognising a higher and inspiring source of value that will help us lift our game in a way that can be sustained over centuries. For us that is God (From Selected Writings of ‘Abdu’l-Bahá – page 76):

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.

For others, such as Rifkin, it is awareness of the supreme importance of preserving our planetary homeland.

Whatever the source of our inspiration, it has to bring the warring selves within us into harmony before we can create a truly peaceful world. Whatever the value is that we find, it has to be a very powerfully motivating one, but essentially benign nonetheless. It must not replicate the self-righteous crusading we can still see around us, which believes that if you are not for us we can kill you.

A commonly used phrase captures an important aspect of this vision: unity in diversity. It allows for perceived differences within an essential unity, but does not fossilise them or make them an excuse for discrimination.

I am fairly sure that Peterson would not disagree, at least, with this sense of our common humanity, and the imperative need confronting us to recognise and act upon it. Because he comes from a Christian perspective, I’m sure he would recognise the importance of God as well.

I hope I have not been attacking a straw man in all this. Even if I have, I hope I managed to avoid placing him in a separate category of human being from my more enlightened self. In many ways he seems to have thought more deeply than I have about whole aspects of this problem, and I owe him a debt of gratitude for forcing me to think more deeply about my own model of the world.

Oh, and in case you hadn’t realised, his book, 12 Rules for Life, though its over-assertive and somewhat divisive in tone, confusingly organised, very left-brain in most of its language and at times testingly macho in style, has flashes of insight that might make it worth reading despite all I’ve said, even though I abandoned it before finishing the last chapter. Before going out and buying a copy it might be worth reading someone who has had the patience to wade through far more of Peterson’s prose than I did and probed more deeply into the problems and challenges his perspective creates. Nathan J. Robinson concludes at the end of a long critique:

. . . since Jordan Peterson does indeed have a good claim to being the most influential intellectual in the Western world, we need to think seriously about what has gone wrong. What have we done to end up with this man? His success is our failure, and while it’s easy to scoff at him, it’s more important to inquire into how we got to this point. He is a symptom. He shows a culture bereft of ideas, a politics without inspiration or principle. Jordan Peterson may not be the intellectual we want. But he is probably the intellectual we deserve.

‘You finished now?’ I hear my right-brain snap. ‘Can we get back to the poetry again please?’

‘I guess so,’ my left-brain sighs wearily. ‘This last lot was all your idea though!’ it growls, trying to fight back, but in the end can’t be bothered. ‘I’m too tired to argue after scribbling your stuff down for so long. I’m not doing this again though. Take my word for it.’

My right-brain smiles quietly, thinks ‘Fat chance!’ but says nothing.

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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?

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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.

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The previous post looked at the Grof’s account of Karen’s experience of a spiritual emergency and how it was dealt with. Now we need to look at some of the implications as well as other aspects of their approach.

The Context

I want to open this section with that part of Bahá’u’lláh’s Seven Valleys that has formed the focus of my morning meditations for the last few weeks. I have persisted so long in the hope that I will eventually understand it more fully. I believe that Shoghi Effendi, the great-grandson of Bahá’u’lláh and the one whom ‘Abdu’l-Bahá appointed as His successor, was of the opinion that one needed to read at least ten books by writers who were not Bahá’ís in order to have any hope of understanding a Bahá’í text fully. I may have conveniently chosen to believe that factoid in order to justify my own bookaholic tendencies.

Setting that aside for now, what matters at the moment are the resonances between the words of Bahá’u’lláh and the topic I am exploring more deeply here.

I have touched on how materialistic assumptions about reality will dismiss as rubbish or even pathologise phenomena their paradigm excludes from possibility.

Bahá’u’lláh directly addresses this point (page 33):

God, the Exalted, hath placed these signs in men, to the end that philosophers may not deny the mysteries of the life beyond nor belittle that which hath been promised them. For some hold to reason and deny whatever the reason comprehendeth not, and yet weak minds can never grasp the matters which we have related, but only the Supreme, Divine Intelligence can comprehend them:

How can feeble reason encompass the Qur’án,
Or the spider snare a phoenix in his web?

Our deification of reason has stripped the world we believe in of God and made it difficult, even impossible, in some cases for some people, to entertain the possibility that God in some form does exist, though that would not be as some white-bearded chariot-riding figure in the sky.

This is the Grofs take on this issue (page 247):

A system of thinking that deliberately discards everything that cannot be weighed and measured does not leave any opening for the recognition of creative cosmic intelligence, spiritual realities, or such entities as transpersonal experiences or the collective unconscious. . . . . . While they are clearly incompatible with traditional Newtonian-Cartesian thinking, they are actually in basic resonance with the revolutionary developments in various disciplines of modern science that are often referred to as the new paradigm.

This world-view seriously demeans us (page 248):

Human beings are described as material objects with Newtonian properties, more specifically as highly developed animals and thinking biological machines. . .

We have taken this model or simulation as the truth (ibid.):

In addition, the above description of the nature of reality and of human beings has in the past been generally seen not for what it is – a useful model organising the observations and knowledge available at a certain time in the history of science – but as a definitive and accurate description of reality itself. From a logical point of view, this would be considered a serious confusion of the ‘map’ with the ‘territory.’

This reductionist dogmatism has serious implications for psychosis (page 249):

Since the concept of objective reality and accurate reality testing are the key factors in determining whether the individual is mentally healthy, the scientific understanding of the nature of reality is absolutely critical in this regard. Therefore, any fundamental change in the scientific world-view has to have far-reaching consequences for the definition of psychosis.

A Holographic Approach

They contend that the paradigm is shifting (ibid.:)

. . . The physical universe has come to be viewed as a unified web of paradoxical, statistically determined events in which consciousness and creative intelligence play a critical role. . . This approach has become known as holographic because some of its remarkable features can be demonstrated with use of optical holograms as conceptual tools.

Their explanation of the holographic model is clear and straightforward (page 250):

The information in holographic systems is distributed in such a way that all of it is contained and available in each of its parts. . . .

It’s implications are profound:

If the individual and the brain are not isolated entities but integral parts of a universe with holographic properties – if they are in some way microcosms of a much larger system – then it is conceivable that they can have direct and immediate access to information outside themselves.

This resonates with what Bahá’u’lláh writes in the same section of the Seven Valleys:

Likewise, reflect upon the perfection of man’s creation, and that all these planes and states are folded up and hidden away within him.

Dost thou reckon thyself only a puny form
When within thee the universe is folded?

Then we must labor to destroy the animal condition, till the meaning of humanity shall come to light.

It is crucial for us all as well as for those labelled psychotic that we cease to reduce the mind to a machine. The Grofs spell out the implications for psychosis when we refuse to take the more transcendent perspective (page 252):

The discoveries of the last few decades strongly suggest that the psyche is not limited to postnatal biography and to the Freudian individual unconscious and confirm the perennial truth, found in many mystical traditions, that human beings might be commensurate with all there is. Transpersonal experiences and their extraordinary potential certainly attest to this fact.

. . . In traditional psychiatry, all holotropic experiences have been interpreted as pathological phenomena, in spite of the fact that the alleged disease process has never been identified; this reflects the fact that the old paradigm did not have an adequate explanation for these experiences and was not able to account for them in any other way.

Assuming that we do accept that possibility of a spiritual reality, what follows? They spell it out:

. . . . two important and frequently asked questions are how one can diagnose spiritual emergency and how it is possible to differentiate transformational crises from spiritual emergence and from mental illness.

This is only possible up to a point (page 253):

The psychological symptoms of… organic psychoses are clearly distinguishable from functional psychoses by means of psychiatric examination and psychological tests.

. . . . When the appropriate examinations and tests have excluded the possibility that the problem we are dealing with is organic in nature, the next task is to find out whether the client fits into the category of spiritual emergency – in other words, differentiate this state from functional psychoses. There is no way of establishing absolutely clear criteria for differentiation between spiritual emergency and psychosis or mental disease, since such terms themselves lack objective scientific validity. One should not confuse categories of this kind with such precisely defined disease entities as diabetes mellitus or pernicious anaemia. Functional psychoses are not diseases in a strictly medical sense and cannot be identified with the degree of accuracy that is required in medicine when establishing a differential diagnosis.

What they say next blends nicely with the points made in my recent posts about where the dubious basis of diagnosis takes us (page 256):

Since traditional psychiatry makes no distinction between psychotic reactions and mystical states, not the only crises of spiritual opening but also uncomplicated transpersonal experiences often receive a pathological label.

This has paved the way to dealing with their approach to intervention and their criteria for distinguishing spiritual emergencies that can be helped from other states.

Holotropic Breathwork

Before we look briefly at their attempt to create criteria by which we might distinguish spiritual from purely functional phenomena I want to look at their recommended method for helping people work through inner crises. This method applies what the non-organic origin. This technique they call Holotropic Breathwork.

First they define what they mean by holotropic (page 258):

We use the term holotropic in two different ways – the therapeutic technique we have developed and for the mode of consciousness it induces. The use of the word holotropic in relation to therapy suggests that the goal is to overcome inner fragmentation as well as the sense of separation between the individual and the environment. The relationship between wholeness and healing is reflected in the English language, since both words have the same root.

They then look at its components and their effects (page 259):

The reaction to [a] combination of accelerated reading, music, and introspective focus of attention varies from person to person. After a period of about fifteen minutes to half an hour, most of the participants show strong active response. Some experience a buildup of intense emotions, such as sadness, joy, anger, fear, or sexual arousal.

They feel that this approach unlocks blocks between our awareness and the contents of the unconscious:

. . . .  It seems that the nonordinary state of consciousness induced by holotropic breathing is associated with biochemical changes in the brain that make it possible for the contents of the unconscious to surface, to be consciously experienced, and – if necessary – to be physically expressed. In our bodies and in our psyches we carry imprints of various traumatic events that we have not fully digested and assimilated psychologically. Holographic breathing makes them available, so that we can fully experience them and release the emotions that are associated with them.

As Fontana makes clear in his book Is there an Afterlife?, experience is the most compelling way to confirm the validity of a paradigm of reality, so my experience of continuous conscious breathing in the 70s and 80s gives me a strong sense that what the Grofs are saying about Holotropic Breathwork had validity. My experience in the mid-70s confirms the dramatic power of some of the possible effects: my experience in the mid-80s confirms their sense that the body stores memories to which breathwork can give access. I will not repeat these accounts in full as I have explored them elsewhere. I’ve consigned brief accounts to the footnotes.[1]

They go on to explain the possible advantages of Holotropic Breathwork over alternative therapies (pages 261-263):

The technique of Holotropic Breathwork is extremely simple in comparison with traditional forms of verbal psychotherapy, which emphasise the therapist’s understanding of the process, correct and properly timed interpretations, and work with transference . . . . It has a much less technical emphasis than many of the new experiential methods, such as Gestalt therapy, Rolfing, and bioenergetics. . . . . .

In the holotropic model, the client is seen as the real source of healing and is encouraged to realise that and to develop a sense of mastery and independence.

. . . . . In a certain sense, he or she is ultimately the only real expert because of his or her immediate access to the experiential process that provides all the clues.

Distinguishing Criteria

Below is the table they devised to differentiate between the two categories of spiritual emergence and what they term psychiatric disorder. They explain the purpose of the criteria (page 253):

The task of deciding whether we are dealing with a spiritual emergency in a particular case means in practical terms that we must assess whether the client could benefit from the strategies described in this book or should be treated in traditional ways. This is their table of criteria.

They are certainly not claiming that they have an unerring way of distinguishing between these states, nor that some of those who are placed in the ‘psychiatric’ have no aspects of spiritual emergency in the phenomena they are experiencing. Readers will also know by now that I am a strong advocate of more enlightened ways of managing any such problems than those which are implied in the term ‘traditional.’

Coda

This last post turned out to  be much longer than I planned. I hope it conveys my sense of the value of their approach and of the validity of their concept of a spiritual emergency.

My feeling that their approach is a good one derives largely from my own dramatic experience of what was an almost identical method involving breathwork. In a previous sequence I have dealt with the way the breakthrough I experienced in the 70s had lasting beneficial effects on my my life, first of all in terms of opening my mind so I was able to take advantage of other therapeutic interventions. Perhaps most importantly though in the first instance was the way that the first breakthrough loosened the grip of my previous pattern of anaesthetising myself against earlier grief and pain mostly by cigarettes, gambling and heavy social drinking, so that I could realise that I needed to undertake more mindwork.

I also find it reinforcing of my trust in the basic validity of their perspective that it has led them to draw much the same conclusions as I have about the dangers of materialism and its negative impact upon the way we deal with mental health problems

It doesn’t end my quest though for more evidence to support my sense that psychosis can and often does have a spiritual dimension. Hopefully you will be hearing more on this.

Footnote:

[1] Rebirthing provided the experience that gave me my last major break-through in self-understanding by means of some form of psychotherapy. I heard first about it from a talk I attended on the subject at an alternative therapies fair in Malvern in early 1985. I then bought a book on the subject. The key was breathing:

Jim Leonard saw what the key elements were and refined them into the five elements theory.

The five elements are (1) breathing mechanics, (2) awareness in detail, (3) intentional relaxation, (4) embracing whatever arises, and (5) trusting intuition.  These elements have been defined a little differently in several versions, but are similar in meaning.  Jim Leonard found that if a person persists in the breathing mechanics, then he or she eventually integrates the suppressed emotion.

It was as though what is known as body scanning were linked to a continuous conscious breathing form of meditation. All the subsequent steps (2-5) took place in the context of the breathing.

After three hours I was trembling all over. I was resisting letting go and ‘embracing’ the experience. When I eventually did the quaking literally dissolved in an instant into a dazzling warmth that pervaded my whole body. I knew that I was in the hospital as a child of four, my parents nowhere to be seen, being held down by several adults and chloroformed for the second time in my short life, unable to prevent it – terrified and furious at the same time. I had always known that something like it happened. What was new was that I had vividly re-experienced the critical moment itself, the few seconds before I went unconscious. I remembered also what I had never got close to before, my feelings at the time, and even more than that I knew exactly what I had thought at the time as well.

I knew instantly that I had lost my faith in Christ, and therefore God – where was He right then? Nowhere. And they’d told me He would always look after me. I lost my faith in my family, especially my parents. Where were they? Nowhere to be seen. I obviously couldn’t rely on them. Then like a blaze of light from behind a cloud came the idea: ‘You’ve only yourself to rely on.’

The earlier experience had been more confusing, with no specific experience to explain it by.

Saturday was the day I dynamited my way into my basement. Suddenly, without any warning that I can remember, I was catapulted from my cushioned platform of bored breathing into the underground river of my tears – tears that I had never known existed.

It was an Emily Dickinson moment:

And then a Plank in Reason, broke,
And I dropped down, and down –
And hit a World, at every plunge, . . .

I’m just not as capable of conveying my experience in words as vividly as she did hers.

Drowning is probably the best word to describe how it felt. Yes, of course I could breath, but every breath plunged me deeper into the pain. Somehow I felt safe enough in that room full of unorthodox fellow travellers, pillow pounders and stretched out deep breathers alike, to continue exploring this bizarre dam-breaking flood of feeling, searching for what it meant.

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Suffering is life.

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

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?

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