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Video May 1993

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

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

P.: It was memory not imagination?

I.: That’s right. It was reality.

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

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

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

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

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

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

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

Video September 1994

The Importance of Trust

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

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

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

P.: Right.

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

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

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

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

I.: Yeh.

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

I.: I did, yeh.

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

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

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

I.: With Jenny.

P.: . . . betweentimes.

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

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

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

Detachment

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

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

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

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

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

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

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

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

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

Crucial Caveats

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

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

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

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

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

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

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

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

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

A Genuine Help

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

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

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

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

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

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

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

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

Ian’s Last Word on the Matter

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

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

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

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

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

I.: Yeh.

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

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

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

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

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

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

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

I.: Yeh.

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

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

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

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

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

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

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PTSD and war

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

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

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

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

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

keyesdouglas

Keith Douglas

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

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

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

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

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

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

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

What use is religious practice here?

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

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

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

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

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

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

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

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

Reflection

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

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

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

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

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

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

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

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

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

‘Abdu’l-Bahá

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

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

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

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

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

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

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

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

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

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

How might reflection help us find meaning?

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

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

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

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

Consultation

But there is one step further we can go.

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

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

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

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

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

Later he adds further illumination (page 215):

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

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

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

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

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‘Reflection takes a collective form through consultation.’

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

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

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

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

Trauma, Transliminality and Psychosis

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

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

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

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

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

Ian’s Experiences of Psychosis

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

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

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

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

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

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

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

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

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

I.: Constantly, yeh.

P.: Were they constant in the day?

I.: Yeh.

P.: Were they very loud?

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

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

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

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

I.: The spirit world.

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

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

P.: Yeh. You held back?

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

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

I.: No.

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

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

P.: Right.

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

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

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

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

Ian’s Life

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

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

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

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

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

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

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

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

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

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

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

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

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

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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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I found myself staring outside my window earlier today, but not the same day that triggered my recent poem on the death of trees. I looked past the silver birch immediately outside, with most of its green or golden leaves in place, to the bare branches of the denuded sycamore, left with only a handful of its leaves on this cold but sunny November day. As I looked the words of the sonnet penned 400 years ago came floating into my mind:

That time of year thou mayst in me behold
When yellow leaves, or none, or few, do hang
Upon those boughs which shake against the cold,
Bare ruin’d choirs, where late the sweet birds sang.

Shakespeare, of course: sonnet 73.

That led me to Don Paterson’s reflections from his book on ‘Reading Shakespeare’s Sonnets: a new commentary.’ A later line of the sonnet reads: ‘Death’s second self, that seals up all in rest.’ Paterson observes (page 212) that ‘WS is referring to night, though Death’s brother has long been sleep, whom he’s also invoking indirectly.’ Inevitably, we go further yet. He adds, ‘Remember Macbeth’s Come seeling night,/Scarf up the tender eye of pitiful day.’ He reminds us that ‘seel’ is to ‘stitch the eyelids shut, as one would a hawk’s.’

The reference to Macbeth reminded me of the fascinating book that I had just finished reading: Why We Sleep by Matthew Walker.

He couldn’t resist wheeling out Macbeth either (page 108):

Ironically, most of the “new,” twenty-first-century discoveries regarding sleep were delightfully summarized in 1611 in Macbeth, act two, scene two, where Shakespeare prophetically states that sleep is “the chief nourisher in life’s feast.”

He argues that our industrialised society is chronically sleep deprived. And he harvests acres of evidence to prove (page 107) that sleep, amongst other things, ‘enhances memory,’ ‘makes [us] more creative,’ ‘protects from cancer and dementia,’ lowers our ‘risk of heart attacks and stroke,’ and leads to our feeling ‘happier, less depressed, and less anxious.’ We need to wake up to the danger we are in by not sleeping enough.

Three examples

Because I’m still a clinical psychologist at heart, to prove the value of the book I want to focus on his discussion of three problems: Autism, ‘Schizophrenia’ and Attention Deficit and Hyperactivity Disorder (ADHD). I have called them problems rather than illnesses or disorders because I am deeply sceptical, as I have explained elsewhere, about the value of such labeling.

But I can set aside such quibbling for now and focus on his demonstration of how much sleep can do to mitigate such problems and how much the lack of it makes them worse.

Autism

His link between autism and sleep abnormality is dramatically strong (page 82):

Autistic individuals show a 30 to 50 percent deficit in the amount of REM sleep they obtain relative to children without autism.

A word of explanation might be necessary here.

During waking hours, in terms of information, we are in reception mode, he argues. Non-rapid eye movement (NREM) sleep performs a kind of reflective function (page 52) and stores and strengthens the ‘raw ingredients of new facts and skills’ whereas rapid eye movement (REM) sleep (dreaming sleep) integrates the information, ‘interconnecting the raw ingredients with each other, with all past experiences, and, in doing so, building an ever more accurate model of how the world works.’

He accepts that this correlation does not prove that the sleep problem in humans is the cause of autism or vice versa. However, research using animals suggests that when infant rats are deprived of REM sleep ‘aberrant patterns of neural connectivity, or synaptogenesis’ occur in the brain, and the rats affected ‘go on to become socially withdrawn and isolated.’

He adds that, since ‘alcohol is one of the most powerful suppressors of REM sleep that we know of’ it can ‘inflict the same selective removal of REM sleep.’ ‘Vibrant electrical activity’ is the detectable sign of REM sleep. The infants (page 83) ‘of heavy-drinking mothers showed a 200 percent reduction in this measure of vibrant electrical activity relative to the infants born of non-alcohol-consuming mothers.’ However, even when pregnant mothers consumed only two glasses of wine (pages 83-84), it ‘significantly reduced the amount of time that the unborn babies spent in REM sleep, relative to the non-alcohol condition.’

While he acknowledges that for humans (page 85) ‘we do not yet fully understand what the long-term effects are of fetal or neonate REM sleep disruption, alcohol-triggered or otherwise,’ the abnormalities caused in adult animals is clear.

I also feel that the evidence adduced by Raine in his masterly book The Anatomy of Violence may be partly explicable in these terms, though Walker makes no reference to it. In this study of violent offenders, Raine finds that foetal alcohol exposure is very much a factor needing to be taken into account, and not just with violent offenders, the main focus of his book, as it has implications for cognitive functioning including memory as well as impulse control in general (pages 163-164):

Part of the reason for this is its effects upon the hippocampus. The hippocampus patrols the dangerous waters of emotion. It is critically important in associating a specific place with punishment – something that helps fear conditioning. Criminals have clear deficits in these areas. The hippocampus is also a key structure in the limbic circuit that regulates emotional behaviour . . .

This impairment then interacts with early experiences of attachment, and disruptions to attachment make the likelihood of later personality problems much higher. Sleep strongly impacts upon the functioning of the hippocampus as Walker explains (page 155):

The very latest work in this area has revealed that sleep deprivation even impacts the DNA and the learning-related genes in the brain cells of the hippocampus itself.

So, whatever the exact direction of causation, and regardless of what other factors may or may not be involved, REM sleep disruption and autism are undoubtedly linked.

‘Schizophrenia’:

Even though I worked in mental health over thirty years, until I read his book I never realised fully the important role of sleep in the problems I was looking at, even though I used to explain to lay audiences that psychosis, as it is termed, was a kind of waking dream, which, I used to say, meant that we all became psychotic at night, whether we remembered our dreams or not.

There is an additional twist to the role of NREM sleep here (page 89): ‘Of the many functions carried out by deep NREM sleep… it is that of synaptic pruning that features prominently during adolescence.’

He goes on to explain how important adequate sleep is for the adolescent brain, given that it is critically involved in determining what synapses (neuronal connections) are removed to mature the brain appropriately. Then he makes his key point early on in the book (page 92):

Individuals who developed schizophrenia had an abnormal pattern of brain maturation that was associated with synaptic pruning, especially in the frontal lobe regions where rational, logical thoughts are controlled – the inability to do so being a major symptom of schizophrenia. In a separate series of studies, we have also observed that in young individuals who are at a high risk of developing schizophrenia, and in teenagers and young adults with schizophrenia, there is a two- to three-fold reduction in deep NREM (non-rapid eye movement) sleep. . . . Faulty pruning of brain connections in schizophrenia caused by sleep abnormalities is now one of the most exciting areas of investigation in psychiatric illness.

He does not deal with this here except in terms of correlation. This therefore does not exclude the possibility that there are other causative elements at work.

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

I am well aware, for example, of the strong evidence for the role of trauma in the development of so-called schizophrenia. His treatment of trauma is quite separate from his discussion of schizophrenia, as he is content to term it, and he relates the persistence of nightmares in the aftermath of trauma to the failure of the brain to suppress noradrenaline, a failure that keeps the terror alive. Normally the brain suppresses noradrenaline in sleep so that dream experiences do not create strong feelings of fear and the mind is desensitised to the terror by the calming dreams – a very different process from the NREM one he is describing here.

None the less, the correlation is significant and potentially valuable therapeutically. I would hope that future research is less diagnostically naïve and includes other potentially relevant factors in the mix.

Attention Deficit and Hyperactivity Disorder (ADHD)

His exposure of the way in which sleep deprivation is ignored as a fundamental factor in ADHD was music to my ears. He launches it by saying (page 314):

An added reason for making sleep a top priority in the education and lives of our children concerns the link between sleep deficiency and the epidemic of ADHD. … If you make a composite of the symptoms (unable to maintain focus and attention, deficient learning, behaviourally difficult, with mental health instability), and then strip away the label of ADHD, the symptoms are nearly identical to those caused by a lack of sleep.

The drugs we prescribe to treat it further prevent sleep.

He is not claiming there is no such thing as ADHD, simply that many people to whom the diagnosis has been attached are simply sleep deprived. The treatment makes it worse not better. He quotes the figures (page 316):

Based on recent surveys and clinical evaluations, we estimate that more than 50 percent of all children with an ADHD diagnosis actually have a sleep disorder, yet a small fraction know of their sleep condition and its ramifications.

And more than that. Because our society undervalues sleep (ibid.):

Well over 70 percent of parents [believe] their child gets enough sleep, when in reality, less than 25 percent of children aged 11 to 18 actually obtain the necessary amount.

He points to early starting times in schools as one of the culprits and late bedtimes as another. This blind spot in our culture is damaging lives, he argues. We have to change.

Dreams

I can’t resist a quick postscript on dreams. Oliver Burkeman, in a recent Guardian article, nails the difficulty I have with Walker’s reductionist approach, which he describes accurately: ‘recent work by researchers including Matthew Walker, author of the new book Why We Sleep, strongly suggests dreams are a kind of “overnight therapy”: in REM sleep, we get to reprocess emotionally trying experiences, but without the presence of the anxiety-inducing neurotransmitter noradrenaline. In experiments, people exposed to emotional images reacted much more calmly to seeing them again after a good night’s dreaming.

He rightly argues that Jung would not have agreed that this was all there was to it, and neither would I. He even provides a counteracting argument that retains the magic of dreams even while conceding they might be random:

So you wrote down a dream, then studied it, with or without a therapist, trying out different interpretations, and if one rang true – if it gave you goosebumps or triggered strong emotions – you pursued it further. What’s striking, you may have noticed, is that this approach would work even if Jung were wrong, and dreams were just random. If you treat them as potentially meaningful, retaining only those interpretations that really “click”, you’re going to end up with meaningful insights anyway. I’ve dabbled in this, and highly recommend it. To ask what your dreams might be trying to tell you is to ask deep and difficult questions you’d otherwise avoid – even if, in reality, they weren’t trying to tell you anything at all.

Walker’s disappointing take on dreams does not for me diminish one jot the fundamental importance of his book. Sleep really matters and he marshals convincing evidence to prove just how vital it is that we recognise this and act accordingly. It’s a compelling, accessible, credible and critically important read.

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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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So, as I asked at the end of the previous post, what chance do Christina and Stefan Grof stand in their efforts to prove the mystical component of psychosis?

I need to repeat the caveats I voiced at the start of this sequence about their book, The Stormy Search for the Self: understanding and living with spiritual emergency, so that I do not come across as easily taken in. It is not easy to tread the razor’s edge between the default positions of intransigent incredulity and irremediable gullibility, but here goes.

Their book has echoes for me of Hillman’s The Soul’s Code in that it combines deep insights with what read like wild flights of fancy and carefully substantiated accounts of concrete experience with vague waves at unspecified bodies of invisible evidence. Even so, so much of it is clearly derived from careful observation and direct experience, and goes a long way towards defining what look convincingly like spiritual manifestations which are currently dismissed as mere madness. It seemed important to flag the book up at this point.

I am going to focus on what I feel are their strongest points: concrete experiences that illustrate their perspective and their brave and, in my opinion, largely successful attempts to make a clear distinction between mystic and merely disturbed experiences, not that the latter are to be dismissed as meaningless. It’s just that their meaning is to be found in life events not in the transcendent.

First I’ll deal with their account of one person’s spiritual crisis. In the last post I’ll be looking at their scheme of diagnostic distinction.

Georgiana Houghton‘s ‘Glory Be to God’ (image scanned from ‘Spirit Drawings’ – the Courtauld Gallery)

A Concrete Example

What follows is a highly condensed summary of one person’s story. A key point to hold in mind is one the Grofs made earlier in the book (page 71):

Often, individuals benefit from their encounter with the divine but have problems with the environment. In some instances, people talk to those close to them about a powerful mystical state. If their family, friends, or therapists do not understand the healing potential of these dimensions, they may not treat them as valid or may automatically become concerned about the sanity of the loved one or client. If the person who has had the experience is at all hesitant about its validity or concerned about his or her state of mind, the concern of others may exaggerate these doubts, compromising, clouding, or obscuring the richness of the original feelings and sensations.

Karen’s Story

They begin by providing some background (pages 191-92):

[S]he had a difficult childhood; her mother committed suicide when she was three, and she grew up with an alcoholic father and his second wife. Leaving home in her late teens, she lived through periods of depression and struggled periodically with compulsive eating.

Assuming that her subsequent experiences were what they seem to be, and I do, then it is clear that just because there is trauma in someone’s background does mean that the unusual experiences they report are entirely reducible to some form of post-traumatic stress response any more than they can be explained satisfactorily simply in terms of brain malfunction. Whatever is going on in the brain is just a correlate but not a cause, and previous trauma may have rendered any filter susceptible to leaks from a transcendent reality. I am restraining myself from leaping too soon to that last and much desired conclusion.

Interestingly, it’s possible that there was an organic trigger to her spiritual crisis (page 192):

. . . [F]ive days before her episode, Karen had begun taking medication for an intestinal parasite, stopping as the daily experience started. . . . . It is difficult to accurately assess its role in the onset of this event. . . . Whatever the source, her crisis contained all the elements of a true spiritual emergency. It lasted three-and-a-half weeks and completely interrupted her ordinary functioning, necessitating twenty-four-hour attention.

Her friends asked the Grofs to become involved in her care so they were able to observe the whole situation as it unfolded.

That Karen was able to avoid being admitted to psychiatric hospital was down to the support of a wide circle of friends. That this meant that she did not have to take any medication is important, according to the Grofs and other sources. Anti-pychotic medication has the effect of blocking the very processes that a successful integration of the challenging experiences requires. They describe the lay nature of her support (pages 192-93):

[B]ecause of Karen’s obvious need and the reluctance of those around her to involve her in traditional psychiatric approaches, her care was largely improvised. Most of the people who became involved were not primarily dedicated to working with spiritual emergencies.

What were her experiences like during this period of what they call ‘spiritual emergency’?

Their description covers several pages (page 194-196). This is a very brief selection of some of the main aspects. To Karen her vision seemed clearer. She also ‘heard women’s voices telling her that she was entering a benign and important experience. . . .’ Observers noted that ‘heat radiated throughout Karen’s body and it was noted that ‘she saw visions of fire and fields of red, at times feeling herself consumed by flames. . . .’

What is also particularly interesting is her re-experience of previous life crises: ‘[S]he struggled through the physical and emotional pain of her own biological birth and repeatedly relived the delivery of her daughter,’ as well as confronting ‘death many times and in many forms, and her preoccupation with dying caused her sitters to become concerned about the possibility of a suicide attempt.’ She was too well protected for that to be a serious risk.

In the last post I will be linking a therapeutic technique the Grofs advocate, Holotropic Breathwork, with some of my own experiences. This makes their description of how this technique can uncover repressed memories of traumatic experiences all the more credible to me. More of that later. That Karen should have been triggered into such regressions is not therefore surprising to me.

By way of supporting her through this, ‘telling her that it was possible to experience death symbolically without actually dying physically, her sitters asked her to keep her eyes closed and encouraged her to fully experience the sequences of dying inwardly and to express the difficult emotions involved.’ It is significant for their model that encouragement and support in facing what we might otherwise be tempted to flee from helps. ‘She complied, and in a short time she moved past the intense confrontation with death to other experiences. . . .’

Given my interest in the relationship between apparently disturbed mental states and creativity, it was noteworthy that ‘[f]or several days, Karen tapped directly into a powerful stream of creativity, expressing many of her experiences in the form of songs. It was amazing to witness: after an inner theme would surface into awareness, she would either make up a song about it or recall one from memory, lustily singing herself through that phase of her process.’

They describe her during this period as ‘extremely psychic, highly sensitive, and acutely attuned to the world around her.’ For example she was ‘able to “see through” everyone around her, often anticipating their comments and actions.’

Georgiana Houghton‘s ‘The Glory of the Lord’ (image scanned from ‘Spirit Drawings’ – the Courtauld Gallery)

 

Things began to take a more positive turn (page 196):

After about two weeks, some of the difficult, painful states started to subside and Karen receive increasingly benevolent, light-filled experiences and felt more and more connected with a divine source.

Perhaps I need to clarify that I am not attempting to adduce this as evidence of the reality of the spiritual world. People like David Fontana and Leslie Kean have collated such evidence far better than I ever could, and sorted out the wheat from the chaff with honesty and discernment.

What I am hoping to do is use this as a demonstration that sometimes at least what could be written off as meaningless and irrational brain noise might not only be significantly related to early experiences in life, as the trauma work suggests, but also to a spiritual dimension whose reality our culture usually denies with the result that the experiences are pathologised. The outcome in this case strongly suggests that pathologising them needlessly prolongs them and blocks life-enhancing changes that would otherwise have resulted.

They go onto describe the end of the episode and its aftermath (ibid.):

. . . . As Karen began to come through her experience, she became less and less absorbed by her in the world and more interested in her daughter and the other people around her. She began to eat and sleep more regularly and was increasingly able to care for some of her daily needs. . . .

Rather as was the case with Fontana and his poltergeist investigation, as the vividness of the experiences receded, doubts beganset in (ibid.:)

As she became increasingly in touch with ordinary reality, Karen’s mind started to analyse her experiences, and she began to feel for the first time that she had been involved in a negative process. The only logical way of explaining these events to herself was that something had gone wrong, that perhaps she had truly lost her mind. Self-doubt is a common stage in spiritual emergencies, appearing when people begin to surface from the dramatic manifestations . . .

She was not blind to the positives in the end (page 197):

Two years later, when we discussed her experience with her, Karen said that she has mixed feelings about the episode. She is able to appreciate many aspects of what happened to her. She says that she has learnt a great deal of value about herself and her capacities, feeling that through her crisis she gained wisdom that she can tap any time. Karen has visited realms within herself that she previously had no idea were there, has felt enormous creativity flow through her, and has survived the previously frightening experiences of birth, death, and madness. Her depressions have disappeared, as well as her tendency toward compulsive overeating.

But her doubts persisted, and may have been to some extent fuelled by her family and friends’ reactions and the lack of informed support (page 198):

On the other hand, Karen also has some criticisms. Even though she could not have resisted the powerful states during her episode, she feels that she was unprepared for the hard, painful work involved. In spite of the fact that she received a great deal of assistance during the three weeks, she feels that she was not yet ready to venture forth into the daily world when she was required to do so by the exhaustion of the resources of those around her. Since that time, she has lacked contact with people with whom to further process her experiences. She considers herself somewhat “different” for having had the episode (an opinion also indirectly expressed by her family and some of her friends) and has tended to downgrade it by concentrating on its negative effects.

The support had to be reduced after the three-week peak period because the support network was burning out. The Grofs felt (ibid.:)

Many of these problems could have been avoided if Karen had had consistent and knowledgeable support immediately following her crisis, perhaps in a halfway house, and follow-up help – in the form of ongoing therapy, support groups, and spiritual practice – for a more extended period of time.

It is dangerous to extrapolate too wildly but I feel that in Karen’s story there are real grounds for hope. She recovered from an apparently devastating episode of mental disturbance without drugs. She demonstrated modest but lasting mental health gains in terms of no subsequent depression or compulsive eating. There is every reason to suppose given this experience and the evidence of Dr Sami Timimi’s study, adduced by James Davies in Cracked and described in the previous post, that an outcome like this could apply far more widely across the so-called psychotic spectrum. Yes, the intervention was time intensive, but it was brief and successful. This compares with long-term interventions involving medication resulting in symptoms that continue to simmer for years or even decades, blighting the whole life of the sufferer and the lives of close family.

The Grofs then explore models of help and aftercare, which I won’t go into now as the main focus I want to take is on their ideas of how to distinguish a spiritual emergency such as Karen’s from other forms of disturbance. This is clearly an important distinction to be able to make as the approaches taken when dealing with trauma-related disturbances and spiritual crises will be somewhat different, though Karen’s case implies there might well be an overlap.

However, all the evidence that has accumulated since they wrote suggests that all such so-called psychotic episodes are better dealt with in a non-diagnostic way, which is an issue that the Grofs do not fully address, probably because at the time of their writing placing spiritual emergency on the agenda seemed a more urgent issue, given that it was and still is doubly disparaged.

Now for the difficult distinction in the next post, along with a brief description of their recommended intervention.

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