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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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doctoring-the-mindEven during the last few hectic weeks, I have managed to find time to read Richard Bentall’s brilliant demolition of standard psychiatric treatments. I realise it’s a bit late in the day to flag up my enthusiasm for this book which was first published in 2009, just after I retired. However, as it’s message is so important and resonates so strongly with my current preoccupations I feel obliged to sing its praises.

In subsequent posts, I intend to draw on 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. In the meantime for those who want a more detailed sense of this book’s perspective, the Guardian review of 2009 is a good place to start. Below is a short extract. For the full post see link.

Salley Vickers applauds a brave work that argues that mind-altering drugs do more harm than good to the mentally ill.

Richard Bentall, a clinical psychologist, is a controversial figure in the field of mental health. An example of the hostility that his conclusions provoke among those practising conventional (that is, drug-based) psychiatry is given in the preface to this book, which raises serious questions about the treatment of mental illness. Bentall describes an encounter with an amiable-seeming psychiatrist who responds to a talk he has given as follows: “Professor Bentall has told us he is a scientist. But he is not! Nothing that Professor Bentall has said – not one single word – is true.”

The unlikelihood of a professor of psychology delivering, in the sober environment of an NHS conference, a talk in which every word is fictitious and every opinion fallacious gives a flavour of the threat that Bentall’s theories pose. The response, as reported, sounds deranged and it is interesting to observe how debate among professionals over the causes of mental illness appears to induce its own version of madness, as if the topic itself were contagious. One sign of sanity, both in the individual and society, is the ability to deal with dissent.

In an earlier book, Madness Explained, Bentall was at pains to distinguish his approach from other anti-psychiatrists – for example, RD Laing, whose radical views were discredited because of his flamboyant lack of rigour and attendant inability to accept criticism. Bentall, as this book attests, is a different kettle of fish. With patient persistence and without recourse to rancorous diatribes, he has appraised the scientific evidence for the success of contemporary psychiatric treatments and come up with a dismal report. It is probably the very balance of his approach that drives his opponents crazy.

Doctoring the Mind is an attempt to clarify the dense array of evidence offered in Bentall’s earlier work. The result is a much easier read. It is also, for that reason, more disturbing. Other recent books (Lisa Appignanesi’s Mad, Bad and Sad, for example) have also traced the dark strains of misperception, mismanagement and downright cruelty in psychiatry’s chequered history, but Bentall’s achievement is to focus on contemporary psychiatric practices, especially those dedicated to treating serious psychoses (his own area of expertise).

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. . . .

As Bentall starkly says: “Without hope, the struggle for survival seems pointless.” At a time when dialogue in the presence of other human beings is becoming less and less available, this brave book gives a sense of why this could be disastrous.

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focus-of-exploration

In the last post, I reached a point where I felt that a different angle on the issue of transliminality was required.

Irreducible MindFrom Irreducible Mind 

This is where revisiting Irreducible Mind might pay off, even though it does not deal with psychosis as such.

So, here I go back to the Kellys, Myers and James. The core relevant material is between pages 606-39 in Irreducible Mind.

They distance themselves from the idea of a brain that faithfully transmits information from the subliminal to the supraliminal:

The related term ‘filter,’ which is like Aldous Huxley’s ‘reducing valve,’ suggests selection, narrowing, and loss, is much more appropriate to that relationship, and for that reason we greatly prefer it as a shorthand description of Myers’s theory.

So far so good.

They note this metaphor has since been updated to that of the brain as ‘a TV receiver.’ (Incidentally, Pim van Lommel’s analogy of the transceiver is more appropriate, and the computer analogy more appropriate still, in that the latter allows for the brain generating as well as transmitting and receiving a great deal of data both consciously and unconsciously: not that I accept in any other respect the idea that either the mind or the brain is a computer in the way it functions.)

The Kellys rightly warn us to be cautious before attributing too many high level functions to this capacity. I am also treading warily from now on as I am really not convinced that we can risk conflating creative subliminal uprush from within the brain with extrasensory stimuli from a transpersonal or transcendent dimension, though I am not ruling out the possibility that such experiences might first be registered subconsciously for later transfer to consciousness.

Anyhow let’s see where Edward Kelly, the author of this chapter, is going to take us.

It is at this point in his explanation that it becomes clear that Kelly is arguing from a perspective of mind-brain independence:

More generally, we wish now to argue that by thinking of the brain as an organ which somehow constrains, regulates, restricts, limits, and enables or permits expression of the mind in its full generality, we can obtain an account of mind-brain relations which potentially reconciles Myers’s theory of the Subliminal Self with the observed correlations between mind and brain, while circumventing the conceptual difficulties identified above in transmission models.

He then moves on to considering both dualist and monist theories of mind. Although evidence was marshalled early on that might seem to support the simple dualist position that the mind is separate from and to some degree independent of the body, he feels it was ‘insufficient to establish it, since alternative explanations based on the conventional viewpoint were nowhere decisively excluded.’

Sperry, he explains, opted for an ‘emergent property’ explanation, arguing that ‘mind and consciousness “emerge” from brain processes when these processes reach a certain threshold of complexity.’ The problem was that Perry stated this without accounting for how it might come about.

He then points out that thinking has shifted to increased acceptance of the possibility, entertained by Myers, that there may not be ‘any sharply defined distinction of mind and matter.’ This weakens the argument, used by critics against simple dualism, that if mind were so different from matter it could not affect it. It becomes easier and more plausible to entertain that possibility that if a brain can affect a mind the opposite could also be true.

This leads him to shift his argument to a consideration of the impact of quantum physics on our ideas about the relationship between consciousness and matter. This is a controversial area about which I am not competent to adjudicate. He ends by quoting Stapp as saying, ‘Contemporary physical theory allows, and in its orthodox von Neumann form entails, an interactive dualism.’ Though he accepts that much more work needs to be done to articulate and support this model he still contends:

The model also potentially explains in a natural way certain of the characteristic features of conscious experience, such as the attentional ‘bottleneck’ of Pashler… and the properties of the ‘global workspace’ as conceived by many contemporary brain theorists – broadly, the fact that a serial, integrated, and very limited stream of consciousness somehow emerges in association with a nervous system that is distributed, massively parallel, and of huge capacity.

He is keen to find ways of undermining the assumption that the brain produces experience rather than transmits or permits it. He is encouraged by findings from neuroimaging that suggest that far from the brain operating exclusively in a modular way, it seems rather to function as a ‘global workspace.’ He sees this as supporting the idea of the brain as ‘an instrument adapted by evolution to enable the mind to gain information about, and to act upon, the everyday physical environment.’ He argues we are moving towards a picture of the mind as residing ‘in the associated psychic entity, which is at least in part outside the brain as conventionally conceived.’

We will be returning to this in more detail in the next post. It is perhaps worth flagging up that Mario Beauregard, in a chapter in Exploring the Frontiers of the Mind-Brain Relationship, offers a mind-brain interaction model of his own design (page 133):

In line with [William] James’s view, I recently proposed the Psychoneural Translation Hypothesis (or PTH) . . . . This hypothesis posits that the mind (the psychological world, the first-person perspective) and the brain (which is part of the ‘physical’ world, the third-person perspective) represent two epistemologically and ontologically distinct domains that can interact because they are complementary aspects of the same underlying reality. . . . [M]entalese (the language of the mind) is translated into neuronese (the language of the brain). This . . . . allows mental processes to causally influence brain activity in a very precise manner.

This all is hopefully indicating that we might have a mind which is not completely reducible to the brain.

We still have a very long way to go though:

The traditional dualist problems regarding mental causation and energy conservation seem to be overcome, but there remain further deep problems with no good solutions in sight. We still have no real understanding of the ultimate nature of the relationship between brain processes and mental activity, and certainly no solution of Chalmers’s ‘hard problem’ – why conscious experiences with their specific qualitative characteristics should arise at all in connection with the associated patterns of brain activity. It is not clear which aspects of the ‘cognitive unconscious’ go with the brain, which with the associated psyche, and how their respective contributions get co-ordinated.

filter-spectrum-v2

This last question exactly matches the problem highlighted in the earlier diagram.

He turns to monist possibilities for further possible enlightenment. Hard questions are raised about the nature of matter:

In our attempt to develop the non-Cartesian dualist-interactionist model we relied heavily on a first major consequence of quantum theory, that it brings consciousness back into physics at the foundational level and in a causally effective manner. There is a second major consequence, however, no less profound but even less widely appreciated. It is this: there is no such thing as matter as classically conceived.

He quotes Stapp again:

The new conception essentially fulfils the age-old philosophical idea that nature should be made out of a kind of stuff that combines in an integrated and natural way certain mind-like and matter-like qualities, without being reduced to either classically conceived mind or classically conceived matter.

He goes back to Whitehead’s thinking (1938):

Whitehead’s fundamental move is… to re-situate mind in matter as the fundamental factor by which determinate events emerge out of the background of possibilities.

He also argues for ‘a global interconnectedness that is fundamental to nature’ and adds in a footnote: ‘How far down nature can plausibly be viewed as manifesting such “mentalistic” properties remains an open question, but the threshold, if one exists, is undoubtedly much further down than most of us commonly assume.’

Kelly suggests that Whitehead’s ‘original philosophical system is being progressively “modernised” in light of continuing developments in physics,’ while acknowledging it is anything but problem-free.

From a spiritual point of view I know where I want the evidence to point.

The Conscious Universe IRMA very delicate balance

I am heartened but not completely satisfied that there are bodies of carefully gathered evidence that confirm the idea that there is a transcendent dimension which is not reducible to matter. I am aware that the strongest evidence there is points to the reality of psi, at least. Dean Radin’s book, The Conscious Universe, marshalls it compellingly, as I have already explored on this blog.

His response to ill-informed scepticism is worth quoting once more. He quotes Paul Churchland as a not untypical example (page 207):

‘… There is not a single parapsychological effect that can be repeatedly or reliably produced in any laboratory suitably equipped to perform and control the experiment. Not one.’

Radin’s reposte, which his book proves is completely warranted is (ibid.):

Wrong. As we’ve seen, there are a half dozen psi effects that have been replicated dozens to hundreds of times in laboratories around the world.

Radin goes onto explain that such sceptics as Churchland have not even bothered to find out what the tiny handful of well-informed sceptics had come to accept (page 209):

Today, informed sceptics no longer claim that the outcomes of psi experiments are due to mere chance because we know that some parapsychological effects are, to use sceptical psychologist Ray Hyman’s words, “astronomically significant.” This is a key concession because it shifts the focus of the debate away from the mere existence of interesting effects to their proper interpretation.

Mario Beauregard endorses this view in his book The Spiritual Brain.

He ends up on Alvin Plantinga’s ground at one point (Kindle Reference: 2520):

We regard promissory materialism as superstition without a rational foundation. The more we discover about the brain, the more clearly do we distinguish between the brain events and the mental phenomena, and the more wonderful do both the brain events and the mental phenomena become. Promissory materialism is simply a religious belief held by dogmatic materialists…who often confuse their religion with their science.

He refers in summary to the areas of exploration he has adduced which he feels a nonmaterialist view can explain more adequately, and includes the research on psi (2528):

For example, a nonmaterialist view can account for the neuroimaging studies that show human subjects in the very act of self-regulating their emotions by concentrating on them. It can account for the placebo effect (the sugar pill that cures, provided the patient is convinced that it is a potent remedy). A nonmaterialist view can also offer science-based explanations of puzzling phenomena that are currently shelved by materialist views. One of these is psi, the apparent ability of some humans to consistently score above chance in controlled studies of mental influences on events. Another is the claim, encountered surprisingly often among patients who have undergone trauma or major surgery, that they experienced a life-changing mystical awareness while unconscious.

And these near-death experiences are more controversial than psi, if that is possible, as we will see next time.

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focus-of-exploration

Given that there is clear evidence that a head injury or smoking skunk can damage the brain’s ability to filter out unwanted information, it is relatively easy to demonstrate that, at least on some occasions this decrement can contribute to the experience of psychosis.

For example, Shields claims (Psychosis as Coping), on the basis of evidence he adduces, that one difference commonly observed in psychotic individuals is a functional reduction in activity in the lateral pre-frontal cortex. As he puts it ‘impairing the lPFC entails a diminished ability to avoid dealing with unwanted thoughts and memories.’

That is not the same, of course, as demonstrating that it is causative. What I was hoping to find at some point are studies that demonstrate whether or not psychosis occurs in the absence of comparable damage to the brain’s ability to filter, and whether or not such damage is a significant contributor if present. I am frustrated at present by my inability to gain access to the necessary material.

It took five weeks before I received my copy of Exploring Frontiers of the Mind-Brain Relationship – Mindfulness in Behavioral Health edited by Alexander Moreira-Almeida and Franklin Santana Santos. It is mostly somewhat disappointing in terms of this issue. I’ve shared a couple of faintly useful ideas from it so far (see previous post for examples). However, there is an extremely useful section of a chapter by Mario Beauregard which I’ll be quoting from in the next post, as well as additional insights from Peter Fenwick and Penny Sartori.

Primary sources are almost impossible to access as I no longer subscribe to academic sources. I hope to resolve this problem as soon as I have time. In the meantime and in full awareness that compelling evidence may be lacking, what have I got to go on?

The main sources of information are Psychosis and Spirituality and Irreducible Mind, the latter not focusing on psychosis specifically.

psychosis-spiritualityPsychosis and Spirituality continued

In the first source Isabel Clarke (Chapters 9 and 20) and Gordon Claridge (Chapter 7) are the clearest proponents of the psychosis/transliminality link.

She sees three aspects to transliminality (page 103) ‘which embraces both the spiritual and psychotic’ and ‘extends to the interpersonal, so that group phenomena, and the collective unconscious are included. All live beyond the limen, the threshold or boundary of the individual self.’

Our ordinary method of construing reality, which she refers to as ‘the construct system’ is transcended (pages 105-06) so ‘[i]t means moving into the unknown. Challengingly, according to this model, as my understanding of the self is essentially a construction, I lose touch with this when I pass beyond the horizon, along with other constructs, and thereby lose the means of making predictions.’

She quotes Hemsley as noting that psychotic experience can be explained by: ‘the failure to relate current sensory input to stored regularities’ and adds ‘The neurophysiological substrate of high schizotypy, implying easier accessibility of the transliminal, is described in the schizotypy literature thus: “The positive schizotypal nervous system has been described as an ‘open nervous system […] where excitatory mechanisms are high and inhibitory processes low” (McCreery and Claridge, 1996).’

She unpacks further the implications for the self (page 110):

I have already mentioned that the construct of self is among the concepts to be lost in the transition, which can lead to an exhilarating feeling of unity and interconnectedness, as well as the bewilderment of loss of self. . . . . I would argue that the characteristic themes of psychotic material, whether in the form of voices or delusions, concern issues of self worth, acceptability, sexuality and personal significance, which are all relevant to understanding the self.

It is obvious how the themes she highlights here relate to the impact of trauma, especially in the form of sexual abuse.

In her later chapter she explores other aspects of this dynamic, which can be both positive and negative (page 249):

[A] reconceptualisation [of psychosis] recognises opening to the transliminal as a part of the journey of life which can be problematic but has great potential. Such openings can compromise normal functioning; they can bring the individual face-to-face with unresolved issues and be acutely frightening and distressing; however, they can also present the opportunity to break out of a mould that had become constricting and embrace a fuller way of being, through opening the self to the whole.

This, she feels, would be an important counterbalance to our society’s left-brain overemphasis, to use McGilchrist’s language here. She writes (page 251):

I am suggesting that we need that connectedness with the whole, but not to expect to grasp it with our intellect and ability to manipulate the environment, as it is literally beyond this grasp. This un-graspability has led to its marginalisation in a technical era. Perhaps we need that connectedness that takes us beyond the individual, towards other humans, other species, and yet wider, within the whole. We need the mystery, the unknowable, to feel at home in the world, with our fellow human and non-human creatures, and with our natural environment; to connect with whatever source of sacredness envelops all of this. . . . . Perhaps our subjective sense of separateness is more illusory than we would like to think.

While I resonate emotionally to this rhetoric, it is evidence I’m looking for here, and I am finding none.

Before we move on to Chadwick’s perspective it is worth quoting Natalie Tobert (page 46) She quotes the psychiatrist Barett as suggesting that ‘patients with schizophrenia are in a state of ‘suspended liminality.” Barett suggests that psychiatric institutions may ‘freeze liminality into a permanent state.’ This maps onto my discussion in an earlier sequence of how important it is to have an accepting environment if a positive journey towards integration and healing is to be facilitated.

Chadwick shares Clarke’s sense of there being a mixture of positive and negative (page 67):

This openness to without and within can have advantages for inside, sensitivity and creativity and also for access to spiritual experiences but on an everyday level such ‘skinlessness’ undoubtedly is a burden – and a fear-inducing burden at that.

We have already seen in an earlier post that he believes, as Thalbourne does, that the subliminal content that crosses through to consciousness is both spiritual and personal in nature (page 82). The presence of spiritual content is not inevitable though:

. . . . . . . other questions lurk here. Not all, perhaps relatively few, people who suffer clinical psychosis also report experiences of a positive, spiritual kind.

I sense that here we again are meeting two sources of experience, thankfully not conflated: the ‘without,’ by which I presume he means the extrasensory transcendent dimension, and the ‘within,’ our brain generated subliminal signals. He seems to relate creativity to inner stimuli.

He feels that the quality of early experience might be a factor here (page 84):

Where nourishing as opposed to abusive early experience obtained, the same biological susceptibility to transliminality, the break with ordinary reality could be much less threatening, even psychologically rewarding.

What I am uneasy about here is the use of transliminality to refer to both inner and outer sources of experience. I am going to stick to my guns here and state that filtering operates within the brain and a spectrum/bandwidth model applies to whatever comes from outside the brain.

The closest I have been able to get to the original work by Thalbourne and Delin on this issue is the reference they themselves make in 1999 to their 1994 paper (Transliminality: its Relation to Dream Life, Religiosity and Mystical Experience in The International Journal of the Psychology of Religion 9:1). They write (page 45):

. . . evidence was presented that there exists a common thread underlying creative personality, mystical experience, psychopathology (both schizotypal and manic-depressive), and belief in the paranormal. This common factor was named transliminality and was tentatively defined as ‘a largely involuntary susceptibility to, and awareness of, large volumes of inwardly generated psychological phenomena of an ideational and affective kind’ (page 25).

I’m sorry this is a bit of a hall of mirrors – a reference within a reference – but it’s the best I can do right now. It is extremely useful though in confirming that they are speaking exclusively of ‘inwardly generated’ material, suggesting that for them this would be a filtering not a spectrum/bandwidth issue. For me, it still begs the question then of what exactly is the status of mystical experience. If it is inwardly generated, is it therefore imaginary rather than objectively valid and externally existent?

Their later comments in this paper suggest that they are very much inclined to believe there is no external reality, even though their conclusions are none the less intriguing and make no distinction, except for intensity, between religious and psychotic upsurges from the subliminal[1] (pages 58-59):

. . . atheists are lowest in degree of transliminality, followed by agnostics. Christian theists have a level that is close to that for the sample as a whole, but non-Christian theists has the highest levels of transliminality of all. We suggest that belief in God may derive partly from external sources [i.e. socio-cultural] and partly from within the person. Atheists and agnostics tend to reject external authority and find little evidence within themselves to persuade them of the existence of a deity. Christian theists appear not to have much inner experience suggestive of a God but may rely more on tradition and authority. Non-Christian theists, however, may be basing their belief predominantly on inner experience, their high degree of transliminality providing them with the food for their conclusion that a deity exists.

. . . . Clearly, the outpourings produced by high transliminality are often enough taken to be not almost but actually miraculous, or to derive from the Godhead itself. Perhaps in some cases they do!

Returning to Chadwick, even with negative early experiences he does not rule out the possibility of input leaking from the transpersonal (page 87):

If we were to try to confront how the same formulation might also account for spiritual or mystical experience, then we might logically be forced to consider that the psychotic person’s skinlessess (or transliminality) could even extend to what in conventional terms would be called the supernatural.

This is where I need to find a reason why what has created a greater leakage across the filtering processes of the brain would also cause a retuning to a wider bandwidth, giving access to externally valid transpersonal experiences. It seems improbable that damage enhances receptivity in this way, although, if the brain tends to block rather than permit information flow, maybe a damaged brain will paradoxically become a better transceiver. If we are simply talking about the process by which the brain’s own subliminal contents are filtered, there is of course, no such problem for a materialist: it’s all imagination anyway and if you damage the filter you’ll obviously get more stuff coming through. I don’t think the writers of this book though would be happy with that position: they mean something more than imagination when they use the word spiritual.

Returning to Chadwick’s point once more, it could of course in that context be dark rather than uplifting material that leaks in through the cracks.

A problem for me at present is that none of this is backed up by clear and compelling proof that what they are defining as spiritual is true and transcendent. At best, it is mostly hypothetical, ambiguous, anecdotal or, frankly, even metaphorical.

Even so, Chadwick’s own personal experience warrants inclusion here. I personally am convinced of its authenticity, but am aware that a sceptic would find reasons to dismiss it as at best anecdotal.

This is a slightly abbreviated account of his experiences with sounds that could be heard accompanying his thoughts (page 71):

There was only one brief crisis in my recovery period that is worthy of note, particularly in the context of this volume. It is important for the reader to realise that the rappings I referred to that began in Charing Cross were actually audible to other people. They were not hallucinations. I have them at times to this day and even our cats can hear them and orient their heads quickly to the source. They particularly come from a wood and metal.

In September 1981, two years after the [psychotic] episode, I was living in a basement flat in Perham Road… with my future wife Jill… The rapping began again over a period of a couple of weeks…. Jill could hear them and would flee the kitchen when they built up. They were now frequently tapping ‘Yes’ to the thought that I should rush out and throw myself under a lorry.

At times like this, one sees and fully realises how useless the attitude of sceptics in the field of the paranormal can be. In that situation, a sceptic would not have had the faintest idea what to do. It seemed to me that as the rappings began to really gallop, science and psychology were of no use to me now. I asked Jill if you could find my Bible and when she brought it to me I sat at the kitchen table… and began to read. It seemed to me that I really needed to call upon a Higher Power to defeat what was definitely looking like a manifestation of The Demonic. . . . . .

As I started to read the New Testament the timing of the rappings started, very slightly at first, to go awry… By the second page, their timing was definitely ‘off,’ by the third they were ‘missing thoughts’ and not tapping at all to some things that crossed my mind. By the fourth and fifth pages, their timing was totally haywire, it was like the sound of machine that was completely malfunctioning… Then very suddenly they stopped completely. The kitchen was quiet.

My sense is that much more systematic research needs to be done in this area. There is little institutional support for this even yet, I suspect. This may suggest that not only are spiritual experiences in the context of psychosis likely to be discounted, but also they will be rare in a culture that devalues any such experiences in general. The priority of the brain as a product of evolution is physical survival, as many writers point out. Spiritual dimensions are tuned out as irrelevant. Opening up such channels against the grain of a culture such as ours is almost impossible for most people.

filter-spectrum-v2

Given that this is the level we seem to be working at, what hypothesis seems best?

At the end of my sequence on Shelley I made reference to three possible routes that the transcendent might take into consciousness:

  1. a seed in the soil of an artist’s subconscious (subliminal in the diagram),
  2. a reflection in the mirror of his consciousness (when reflection has separated it from the clutter of its contents), or
  3. a light from the lamp of his mind (assuming we accept that mind is independent of the brain, which is simply a transceiver that can pick up even the subtlest waves if it is tuned correctly, which it usually isn’t).

Even though the focus there was on creativity, this can be blended up to a point with the problem raised in my earlier diagram as my notes in brackets indicate.

It is time now to revisit Irreducible Mind in the next post.

Footnote:

[1] They feel that the frequency of religious content in psychosis is to do with the prevalence of religious ideas in American society.

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filter-spectrum-v2

As I indicated last time, after exploring some of the complexities of the transliminality concept,  I am just going to start from the brain and work my way up from there.

So, we need to answer some basic questions first.

psychosis-spiritualityWhat is the Threshold?

What might this threshold be that Claridge referred to and how does it operate? Note that he has mixed psychosis and magic into its effects (Psychosis and Spirituality – page 82):

As defined by Thalbourne, transliminality refers to a individual differences in the extent to which ideas, affects and other mental contents cross the threshold between subliminal and supraliminal: in some people, he argues, the barrier is simply more permeable. . . . . Quoting a range of psychometric, clinical and experimental evidence, he argues that a high degree of transliminality is associated with strong belief in and reporting of paranormal phenomena; enhanced creativity; a greater tendency to indulge in magical thinking; more frequent mystical experiences: and a susceptibility to psychotic and psychotic-like symptoms.

Isabel Clarke, in the same book, seeks to tackle this using Teasdale and Barnard’s model of interacting cognitive systems. She writes (pages 108-09 – my italics):

[The ICS model concerns two central subsystems of the brain with imperfect intercommunication]. The implicational subsystem communicates directly with, and is much influenced by, the various sense modalities and the body’s arousal system, whereas the propositional system is more removed from this emotional area, and indeed, the vital communication between the two systems, which makes good cognitive functioning possible, can become temporarily disabled by a state of high or low arousal.

She clarifies what she feels is the distinction between

. . . . the everyday, scientific state . . . where the propositional and implicational subsystems are working nicely together in balance, [and] the spiritual/psychotic state . . . where the two are disjointed, and the system is essentially driven by the implicational subsystem.

She spells out the core issue concerning shifts into the implicational mode:

For the person with psychosis, the barrier that makes this sort of experience hard to access for most of us, is dangerously loose. . . . . When the asynchrony persists and there is not a rapid reconnection of the two main subsystems, this will be followed by loss of bearings because of having drifted out of reach of the construct system, or the propositional system, which people rely on to make sense of their environment.

It is not just that the ‘barrier’ is ‘loose.’ There are times when:

. . .  the orderly return does not happen. The individual finds themselves stranded beyond the reach of their constructs or propositional subsystem, trying to operate in the world. Not surprisingly this is extraordinarily difficult. . . . . The desperate sufferer tries to make sense of the unfamiliar environment, clutching at whatever connections come to hand. In this way, delusions, which usually have their origin in the early stages of the breakdown, are born. In another dissolution of normal boundaries, internal concerns are experienced as external communication and the person hears voices. Normal thought is disrupted – or as the psychiatrist would say, disordered.

It is clear that what she is describing is captured entirely by the concept of filter or the process of filtering. I am probably tilting towards a process rather than a object word, so the idea of filtering is beginning to appeal more to me than the idea of a filter. I have found it frustrating that I cannot access primary sources very easily on this aspect of filtering. The nearest reference I have found summarises its use of the ICS model as follows (Gumley et al 1999 – An Interacting Cognitive Subsystems Model of Relapse and the Course of Psychosis – page 275):

The ICS [interacting cognitive systems] approach enables a detailed view of how multiple sources of information interact to establish self-organizing, self-perpetuating, processing configurations that act to maintain persistent cognitive-affective states. The model predicts that implicational meaning is critically involved in the processes of initiation, acceleration and maintenance of relapse in psychosis.

Master and Emissary

They make no mention of filters or thresholds.

Isabelle Clarke’s book, published in 2010, relies exclusively for its explanation of transliminality upon Teasdale and Barnard’s 1993 interacting cognitive subsystems model, being presumably unaware at that point of McGilchrist’s 2009 hemispheric model brilliantly explored in The Master & his Emissary. He has much to say that sheds further light on what might be going on here. The key passages for our purposes fall between pages 211-233.

He is looking at the problem from the point of view that the two hemispheres of the brain have two separate ways of operating. The left hemisphere, to be a touch simplistic, is predominantly linguistic and analytical, the right holistic and metaphorical. McGilchrist uses his book not only to illustrate how they work but also to argue that our culture is dangerously privileging the left hemisphere mode. I have dealt with that in more detail elsewhere. I will only say more on that aspect here where it is helpful.

McGilchrist is not arguing that the two hemispheres have to be in each other’s pockets all the time:

My thesis is that the hemispheres have complementary but conflicting tasks to fulfil, and need to maintain a high degree of mutual ignorance. At the same time they need to cooperate.

How does this work, he asks.

There is a communication bridge between them called the corpus callosum:

If one thinks of the relationship between the hemispheres as being like that between the two hands of the pianist . . . one can see that the task of the corpus callosum has to be as much to do with inhibition of process as it is with facilitation of information transfer, and cooperation requires the correct balance to be maintained

If the corpus callosum is damaged there is more information transfer between the hemispheres:

This apparently paradoxical finding makes sense if the main purpose of the corpus callosum is to maintain separation of the hemispheres.

We can already see that this is heading in the same direction as Clarke’s explanation of Teasdale and Barnard’s ICS model. There is a filter between one aspect of consciousness and another, which can break down.

This at least lends strength to the proven way that the skunk form of marijuana can trigger psychosis:

Dr. Paola Dazzan, reader in neurobiology of psychosis from the Institute of Psychiatry, Psychology & Neuroscience (IoPPN) at King’s College London, and senior researcher on the study, said in a statement: “We found that frequent use of high potency cannabis significantly affects the structure of white matter fibres in the brain, whether you have psychosis or not. This reflects a sliding scale where the more cannabis you smoke and the higher the potency, the worse the damage will be.”

White matter is made of large bundles of nerve cells called axons, which connect the grey matter in different regions of the brain, enabling fast communication between them. The corpus callosum, a band of nerve fibers that connect the left and right hemispheres, is the largest white matter structure within the brain. The corpus callosum is rich in cannabinoid receptors that are affected by the tetrahydrocannabinol (THC) in cannabis.

Interestingly McGilchrist brings a quote from the Upanishads into the mix at this point:

All in all, my view is that the corpus callosum does act principally as the agent to differentiation rather than integration, though ultimately differentiation may be in the service of integration. . . . . . [The] Upanishads] say: “in the space within the heart lies the controller of all… He is the bridge that serves as a boundary to keep the different worlds apart.

Routinely we blunder along automatically at what McGilchrist refers to as level one. But that is not always enough:

In the discussion of level one, the emphasis was on the necessary inhibition of one hemisphere by the other, since they each need to work separately. However, at a higher level, and over a longer time span, they also need to work together, not just because some important human factors, such as imagination, appear to depend on the synthesis of the workings of both hemispheres.

Without getting embroiled in the detail, the key point is this:

The right hemisphere certainly needs the left, but the left hemisphere depends on the right. Much that marks us out, in the positive sense as well as the negative sense, as human beings requires the intervention of the left hemisphere, as long as it is acting in concert with the right hemisphere. Important human faculties depend on the synthesis of their activity. In the absence of such concerted action, the left hemisphere comes to believe its territory actually is the world.

As he sees it, ‘one field of consciousness’ has to ‘accommodate two wills.’

Given my Entish tendencies he quotes what for me is a brilliant and beautiful metaphor to convey a key aspect of his model. I need to start one step back though.

He writes: ‘. . . the core of the self, is affective and deep-lying: its roots lie at a level below the hemispheric divide, a level, however, with which each cognitively aware hemisphere at the highest level is still in touch.’

I need to emphasise, before anyone gets too mystical, he is still dealing with the brain here.

Later I will have cause to refer once more to the point he makes now. He goes on:

So much of our experience, and our sense of our self, comes from low down in the ‘tree’ of consciousness, below hemispheric level: ‘integration’ does not need to be achieved. All the corpus callosum has to do is to help maintain moment-to-moment independence of the hemispheres, not integration of the self.

Panksepp, whose description he is drawing on, sees consciousness as ‘not all or nothing, but has a continuous existence, transforming itself as it travels upwards, through the branches, to what he calls, by analogy with the forest canopy, the “cerebral canopy”, until in the frontal cortices it becomes high-level cognitive awareness.’ McGilchrist emphasises that he prefers this analogy as it makes clear that consciousness is not a bird but ‘a tree, its roots deep inside us.’ He spells out that for him it is not ‘an entity but a process.’

I’ve already made clear that this preference for process over reification is one I share.

McGilchrist makes a key point about this filtering process and the holistic mode of the right-hemisphere:

Most, if not all, of the ‘functions’ mediated by the right hemisphere fall into this category of what has to remain outside the focus of awareness – implicit, intuitive, unattended to.

psychotic-art

Painting by David Chuck of a psychotic experience (Image scanned from ‘The Master & his Emissary’ plate 2)

He adds something of relevance also to the issue of psychosis:

The idea that self-consciousness, in the sense of being aware of ourselves doing or being something, is the left hemisphere inspecting the right is supported by a number of observations. The attentional ‘spotlight’ . . . is a function of the left hemisphere. The casualties in self consciousness are all right hemisphere based, social or empathic skills. And schizophrenic subjects, whose psychopathology depends on a reflexive hyperconsciousness, and who often depict a detached observing eye in their paintings, show a relative hypofunction of the right hemisphere in relation to the left.

This has contrary implications for the psychosis/transliminality hypothesis. It implies the operation of a hypervigilant left-hemisphere rather than a leaking filter system. However, such hypervigilance would not rule a filter issue completely and the overall model McGilchrist is advocating supports the possibility of systemic cross pollination: he quotes Ramachandran as saying ‘[The brain’s] connections are extraordinarily labile and dynamic. Perceptions emerge as a result of reverberations of signals between different levels of the sensory hierarchy, indeed across different senses.’

We are not done with McGilchrist yet, but this seems a reasonably good place at which to pause.

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Validating [psychotic] experience and linking it with that of the mystic wherever relevant was an obvious first step. This was coupled with a realistic appraisal of the problems of trying to conduct life from the transliminal (which I often compare with trying to drive a car from the back seat, without proper access to the controls) and encouragement to join the ordinary world along with strategies for managing this.

(From Psychosis and Spirituality edited by Isabel Clarke – page 196)

focus-of-exploration

As I said at the beginning of the last sequence of posts, I am aware that the full focus of my current enquiries spreads across this whole diagram. However, I needed to start somewhere manageable and progress from there, or else my next blog post will have to wait several years until I have had time to explore the whole diagram.

It should be surprise to regular readers of this blog that I decided to start with the left side. I’m not sure what the brain laterality implications of that are exactly, but I’m very clear that I’m trying to play to my strengths here. The most enriching part of my career was spent working with the experiencers of psychosis. That’s the work I loved most and where I learned most.

Even so this is not going to be plain sailing and this voyage is probably not for the faint-hearted blogger.

As I have hopefully shown in the first sequence of posts, it’s now easy to demonstrate that trauma plays some kind of causative role in psychosis, as well as in other distressing problems.

What I hope to illustrate is how transliminality, a permeable threshold of consciousness, or something like it, appears to correlate with some experiences of psychosis. My first problem there will be trying to clarify exactly what transliminality is.

After that, what may not be so easily supported by evidence is the idea that transliminality is also playing a causative role. It may simply be another consequence of trauma: in fact, there is some evidence to that effect. To close in on resolving this I will need to search for evidence that transliminality, at least with some people, is present prior to both trauma and psychotic experiences: I am still in the process of trying to pull that evidence together, but it is not proving easy. What I will be giving here is more of a progress report rather than a final position on the matter.

What is Transliminality?

I think we have to start by attempting to define what transliminality might be. Gordon Claridge in Psychosis and Spirituality pins his colours to Thalbourne’s mast (page 82):

As defined by Thalbourne, transliminality refers to a individual differences in the extent to which ideas, affects and other mental contents cross the threshold between subliminal and supraliminal: in some people, he argues, the barrier is simply more permeable. . . . . Quoting a range of psychometric, clinical and experimental evidence, he argues that a high degree of transliminality is associated with strong belief in and reporting of paranormal phenomena; enhanced creativity; a greater tendency to indulge in magical thinking; more frequent mystical experiences: and a susceptibility to psychotic and psychotic-like symptoms.

This though, I think, jumps too far ahead for present purposes.

For a start, it is necessary to flag up one fundamental complication that I will be seeking to address, though I may be unable to come to any definitive conclusion empirically on the basis of the evidence that is available to me at present.

I am sensing that two distinct possibilities are being conflated, perhaps through my distorting one of the sources I’m consulting (Psychosis and Spirituality), or perhaps because the overall picture conveyed by the text is confused on this point. I believe that there are two quite distinct processes which have been subsumed into the supposedly single concept of transliminality.

I’ll try and unpack my point as simply and clearly as I can.

One possibility is that of a filter within the brain to prevent consciousness being overwhelmed with brain data it does not need. This data is what I suspect Claridge means by ‘affects, ideas and other mental contents,’ but the inclusion of mystical experiences seems anomalous for reasons I will explore later.

The basic brain filter function has taken its present shape via evolutionary processes. As we will see this filtering process has both costs and benefits.

The other possibility is a spectrum issue. Just as our senses cannot detect sensory stimuli except within a relatively narrow range, so our brains within our Western culture mostly fail on a whole to detect any signals outside this physical spectrum.

I am hoping to determine, from the evidence I am able to look at, whether psychosis is the result for the most part of leakage in the filter system. This would not mean that psychotic experiences should be dismissed as garbage: they are the meaningful responses to trauma and life experience and, if addressed respectfully and attentively, can catalyse a healing process as well as build a ladder to higher levels of emotional and cognitive understanding.

There may also be extended spectrum effects in operation: the factors that have altered the brain’s filtering mechanisms may also have enhanced its receptive capacities in other respects sometimes. That’s not as simple as it sounds as we will see.

Creativity would usually, I suspect, come from either increased filter permeability or extended spectrum perception. Psi and other mystical states would seem to me to be dependent only on the latter, though I’m not sure that this is the position Thalbourne would espouse — again something for later exploration.

filter-spectrum-v2

The simplest way I could express this in a diagram is the one above.

I know it begs a lot of questions at this point but basically it is showing consciousness as a narrow-angled access to only a small proportion of all that might possibly be known. I have broken with tradition in placing the segment symbolising what we can access, not at the centre, but at the side. This is both to emphasise my ignorance of how this spectrum works and to suggest that our consciousness is not necessarily focused on what is central and most important.

The darkness surrounding it assumes our finite minds could never grasp all that there is: assume the black is infinite. We can at times access aspects of our usually unconscious inner experiences. The diagram assumes, perhaps incorrectly, that external realities beyond the reach of our ordinary senses can sometimes leak into the internal subliminal where they can infrequently be accessed, though perhaps not in an accurate or easily intelligible form.

It also assumes that the only way access to aspects of the initially extrasensory can routinely occur is when our receptivity increases: I am not positing some kind of filter mechanism in this part of the process.

At present this is largely a speculation to be tested, but it will help you follow the trend of my examination of the evidence if you bear it in mind.

Where possible and appropriate, instead of, in my commentary on quotations, using the term transliminality all the time, I will see if making the tentative distinction between filter and spectrum language helps make things clearer, as well as drawing a distinction between extrasensory and subliminal.

Irreducible MindThis is where I found Myers’s language confusing in my first encounter with him in the book, Irreducible Mind. Subliminal for him was a catchall term for anything of which we are not conscious. None the less he also used the spectrum model, and I did not pick up, from the Kellys’ transmission of his ideas, whether he distinguished between outside elements that were beyond the reach of our radar and internal elements that were below the threshold of consciousness.

I think this distinction needs to be made and will be revisiting Irreducible Mind in case I have missed something there. What I suspect I will not be able to avoid considering at some point is the whole vexed question of the mind-brain relationship. This may or may not make it easier to resolve the possible tension between filter and spectrum theories.

For now though, I am just going to start in the next post from the brain basics and work my way up from there.

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focus-of-exploration

For many years it was believed that psychotic symptoms were discontinuous from `normal’ psychological functioning. This position is becoming increasingly untenable in the light of research evidence that positive psychotic symptoms can be understood with reference to normal psychological processes. This paper will outline the evidence from current psychological conceptualizations that psychotic symptoms are closely related to a person’s psychological functioning and that they are therefore amenable to psychological intervention (Yusupoff et al., 1996). Current psychological conceptualizations of hallucinations and delusions hold that the content of these symptoms contain material which is personally relevant to the individual. Indeed, this personal relevance is critical to the understanding of, and cognitive interventions with psychotic symptoms.

(From An Interacting Cognitive Subsystems Model of Relapse and the Course of Psychosis by Andrew Gumley, Craig A. White and Kevin Power – page 262)

In the previous post I began to outline a picture of the kind of traumatic life experiences which can give rise to psychosis.

There’s more to add to the list of factors.

Additional Factors

Many who experience psychosis also, for example, according to Murphy at al (Modelling the co-occurrence of psychosis-like experiences and childhood sexual abuse), have experienced heightened levels of social deprivation, discrimination and isolation even beyond the age of 16. Additionally, members of the group with no history of Childhood Sexual Abuse were more likely to have experienced Childhood Physical Abuse, PTSD, social isolation and neurotic disorder. Interestingly, members of this class were also more likely to be male.

This profile seemed to indicate that, in the absence of Childhood Sexual Abuse, individuals who experienced psychosis were likely to endure a wide range of other traumatic experiences. It seemed that the composition of this class, particularly in terms of sex, suggested that, while psychosis may be a phenomenon highly associated with traumatic experience and adversity, the precise nature of this trauma and adversity may be dependent upon the sex of the individual. The Child Sexual Abuse-only class was more likely to be female and was characterised by elevated probabilities of childhood physical abuse and adult sexual trauma, neurotic disorder and cannabis consumption.

It may be worth spending sometime teasing out the exact level of risk of psychosis represented by trauma.

Longden and Read (The Role of Social Adversity in the Etiology of Psychosis – page 7) focus on two substantial meta-analyses (ie collated data from a number of well validated studies). The first screened 736 articles, retaining 41 of the best designed. When results were pooled, individuals with a history of childhood trauma (child sexual abuse, physical abuse, emotional abuse, neglect, bullying, parental death) were shown to be 2.8 times more likely to develop psychotic symptoms than those who had not. The second meta-analysis retained 25 studies from a search result of 1104, and found that rates of childhood adversity (including child sexual abuse, physical abuse, emotional abuse, neglect, witnessing domestic violence, and loss events) were 3.6 times greater in people diagnosed with schizophrenia relative to “healthy controls.”

It is important that we make sure we are not being misled into attributing cause when we have only correlation. By this I mean that just because, when I am holding my key to either open or lock my front door, the light goes on, I should not jump to the conclusion that my door key is switching the light on. I need to understand that my mere presence with no key is enough to trigger the motion sensor. The key is a confounding variable that needs to be eliminated, for example by leaving the house without locking the door one night. I’d be wise not to go further than strictly necessary to prove the point though.

Longden and Read (pages 7-8) deal extensively with this problem:

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.

 

Lucretia by Rembrandt

Lucretia by Rembrandt (For source of image, see link)

Even this does not end the list of factors (ibid.):

Despite much emphasis on childhood abuse, this is by no means the only environmental adversity associated with psychosis. Other cited factors (Larkin & Morrison, 2006; Read, 2013a; Scott, Chant, Andrews, Martin, & McGrath, 2007) include discrimination, witnessing domestic violence, prenatal stress, war trauma, torture, adulthood rape and physical assault, excessive marijuana use in adolescence (in some instances this may represent attempts to self-medicate posttraumatic symptoms . . . ), and disturbed attachment relationships with one’s caregivers, including abandonment, being the result of an unwanted pregnancy, being raised in institutional care, dysfunctional parenting (often intergenerational), and parental death or separation. Another factor receiving significant attention is poverty and inequality . . .

Longden and Read feel (page 9): ‘that erroneous reports of sexual victimization are no different between patients diagnosed with schizophrenia and the general population,’ so we have as much reason to believe a patient diagnosed with schizophrenia as anyone else, and we have already established in the first post of this sequence that this level of credibility is basically compelling.

The Brain

Now is the time to return to a closer examination of the role of the brain in all this.

Longden and Read describe what they intimidatingly label (page 12) ‘the traumagenic neurodevelopmental (TN) model of psychosis’ by which they mean how, during our formative years, trauma can affect the brain in ways that make psychosis more likely. They argue that there are similarities between abnormalities in the brains of abused children and those of adult patients with psychosis.

A key point is this: ‘A major premise of the TN model is that the heightened stress sensitivity consistently found in patients with psychosis is not necessarily inherited, but caused by formative exposure to abuse and neglect.’ This is key because it moves the debate away from genes to life experience.

They give various examples of the research including (pages 20-21):

A . . . study with 45 individuals considered at clinical high risk for psychosis found significant positive associations between trauma exposure (psychological and/or physical bullying, emotional neglect, emotional abuse, physical abuse, Childhood Sexual Abuse) and feelings of being watched or followed, as well as false beliefs about power or status. . .

An equally important finding is the relationship between psychotic content and precipitating trauma (ibid.):

Comparable work with 41 patients experiencing a first episode of psychosis found that attributes of stressful events in the year preceding psychosis onset were significantly associated with core themes of both delusions and hallucinations.

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

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

Implications for Therapy

How might this realisation help?

Murphy et al (Modelling the co-occurrence of psychosis-like experiences and childhood sexual abuse) feel that:

. . . . identifying and evaluating trauma specificity in the onset and maintenance of psychological distress may aid clinicians and service users alike, in

(1) clarifying sources of distress and

(2) understanding symptom content and expression, while enhancing treatment design and efficacy also.

They emphasise that point that ‘symptoms of psychosis are often characterised by content that can be meaningfully attributed to past personally significant experiences.’

Longden and Read (page 22) feel that their evidence points in this same direction and  ‘reinforces a standpoint formed in the earliest days of psychiatry and that has gathered a striking momentum in the past two decades; that it is no longer a scientifically or morally tenable position to view psychosis as a purely biogenetic disease.’

This has clear implications for the approach we should adopt. They remind us that the British Psychological Society ([BPS] Division of Clinical Psychology) recently published a report emphasizing the utility of psychotherapeutic approaches to psychosis. The executive summary opens with the observation that “Hearing voices or feeling paranoid are common experiences which can often be a reaction to trauma, abuse or deprivation. Calling them symptoms of . . . psychosis or schizophrenia is only one way of thinking about them, with advantages and disadvantages” (BPS, 2014, p. 6)

Unfortunately the evidence I find in what I read now suggests that the situation that confronted someone I worked with in the 1990s may not have changed much. She wrote me as follows, after she moved to another city:

Today I saw my new CPN. He’s called D, and I’m feeling very upset as a result of our meeting. I’d be able to give you a ten foot long list of insensitive things he said, if I wanted to! His main objection was that I’m not out there working, earning money and contributing to the country. He said he’s going to phone the DRO tomorrow and get her to come out and see me to assess me for a job. . . . D was also very heavy-handed in his approach to “disability”. He said there’s people much worse off than I am and they’re using their abilities to the benefit of other people. I think one of the worst things that anyone can say to someone who’s got my kind of disability is that there are people worse off than they are. It has to come from the individuals themselves to say that sort of thing. I’ve applied to do a BA at the Open University — D wasn’t even satisfied with that, because it won’t lead to a “practical skill.” He questioned the intensity of my voices, the fact that I’m not sleeping . . . and he also physically tried to stop me rocking. I’m feeling really upset by it all.

[Later] My new CPN is . . . . refreshingly gentle and unassertive, but he’s only here for another couple of weeks. It’s very unsettling all this changing around, because I can’t work consistently with them, and by the time I feel ready to talk in confidence it’s time for them to move on to another post. I think it will be like this for the next six months until the permanent CPN comes back from maternity leave.

ThriveLayard and others certainly do not think things have changed for the better. It is an indictment of our society’s approach to mental health that effective treatment for many forms of mental problem is not sufficiently available to meet the need. Writing in 2014, Layard and Clark’s in their book – Thrive – draw this forcefully to our attention. The data the authors use to prove their case include the fact that (page 381):

. . . while over 90% of diabetes sufferers receive treatment for their condition, under a third of adults with diagnosable mental illness do so. This is largely because good evidence-based psychological therapy is not readily available

If anything things have got worse in the intervening period. The value of talking therapy for psychosis is clearly not sufficiently well recognised to guarantee that it will be funded and, if funded, that it will be safeguarded and prioritised. In the few areas seeking to provide some form of psychological support, Health Care Commissioners, even while knowing that CBT for psychosis should be available in 12 session packages, in itself a minimum requirement, frequently fund only six sessions or less. If this policy were followed for the prescription of antibiotics or the provision of cancer treatment there would be a national outcry.

Part of the reason for this blindness is the still prevailing implicit conviction that psychosis is basically a biological problem and is best treated with drugs not psychotherapy. Hopefully this sequence of posts will go some way to adding momentum to the increasingly powerful wave of dissent from this conveniently short-term cost-saving point of view.

In fact, it doesn’t save any costs at all in the long-term. With even the minimum basic intervention of CBT mounted early enough, sufficient benefits would accrue for enough patients to save the costs of relapse and readmission further down the road.

Beyond this though, in my view, we need more widely effective forms of ‘talking cures’ before we will see really major benefits long-term. But better half a loaf than none at this point.

So, having dealt at some length with the relatively straightforward issue of trauma and psychosis I plan to embark in the next sequence of posts on the trickier issue of thresholds of consciousness and psychosis. Wish me luck!

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