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Posts Tagged ‘schizophrenia’

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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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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In the last post I ended up exploring James Davies’ perspective in his recent book Cracked. I was focusing upon his emphasis on relationships rather then medication as the more effective way to help those with psychotic experiences.

Pseudo-Science

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.

This resonates strongly with the Bahá’í position as expressed, for instance, in Century of Light (page 136):

What [Bahá’ís]  find themselves struggling against daily is the pressure of a dogmatic materialism, claiming to be the voice of “science“, that seeks systematically to exclude from intellectual life all impulses arising from the spiritual level of human consciousness.

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.’

He quotes Bracken’s view on how 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.

Instinctive Incredulity

However, we are even further away from generally accepting that some experiences labelled psychotic may have spiritual dimensions.

Christina and Stefan Grof’s indictment of our civilisation in their book The Stormy Search for the Self: understanding and living with spiritual emergency sings from essentially the same hymn sheet as Davies (page 235):

Though the problems in the world have many different forms, they are nothing but symptoms of one underlying condition: the emotional, moral, and spiritual state of modern humanity. In the last analysis, they are the collective result of the present level of consciousness of individual human beings. The only effective and lasting solution to these problems would, therefore, be a radical inner transformation of humanity on a large scale and its consequent rise to a higher level of awareness and maturity.

David Fontana also writes from direct experience of this painful level of materialism and its default stance of resolute incredulity when faced with any evidence, no matter how compelling, in favour of a spiritual dimension to reality. He had to combat it at almost every turn of his investigations. He even bravely admits to being contaminated by it himself. In the in-depth survey of his book Is there an afterlife? he writes (page 335):

My difficulty in writing about Scole [a long and detailed exploration of psychic phenomena including material effects] is not because the experiences we had with a group have faded. They are as clear as if they happened only weeks ago. The difficulty is to make them sound believable. It is a strange fact of life that whereas most psychical researchers interested in fieldwork are able to accept – or at least greet with open minds – the events of many years ago connected with the mediumship of physical mediums such as Home, Palladino, and Florence Cook, a strain of scepticism fostered by scientific training makes it much harder for them to accept that similar events may happen today, and may even be witnessed by those of us fortunate enough to be there when they occur. I mentioned in my discussion of the Cardiff poltergeist case… the struggle I had with my own belief system after seeing the phenomena concerned. When in the room while they were taking place I had no doubt they were genuine, but as soon as I began to drive home I started to doubt. . . . . The whole thing seemed simply unbelievable.

He adds:

It took a lengthy investigation, including one occasion when I witnessed phenomena while I was on my own in one of the rooms where the disturbances took place and the owners were two hundred miles away on holiday, before I could fully accept that poltergeist phenomena can indeed be genuine, and provide evidence not only of paranormality but, at least in some cases, of survival.

The Grofs articulate the challenge exactly (page 236)

The task of creating an entirely different set of values and tendencies for humanity might appear to be too unrealistic and utopian to offer any hope. What would it take to transform contemporary mankind into a species of individuals capable of peaceful coexistence with their fellow men and women regardless of colour, language, or political conviction – much less with other species?

They list our current characteristics in detail including violence, greed, habitual dissatisfaction and a severe lack of awareness that we are connected with nature. They conclude, ‘In the last analysis, all these characteristics seem to be symptomatic of severe alienation from inner life and loss of spiritual values.’

To describe it as an uphill struggle would be an understatement. Climbing Everest alone and unequipped seems closer to the mark.

They see at least one window through which the light of hope shines (page 237)

[M]any researchers in the field of transpersonal psychology believe that the growing interest in spirituality and the increasing incidence of spontaneous mystical experiences represent an evolutionary trend toward an entirely new level of human consciousness.

As we will see in the final two posts, our medicalisation of schizophrenia and psychosis might well be slowing this process down. If so there is all the more reason to give the Grofs’ case a fair and careful hearing. This will not be easy for the reasons that Fontana has explained.

Incidentally, after acknowledging that absolutely convincing proof of the paranormal seems permanently elusive, after all his years of meticulous investigation Fontana reaches a conclusion very close to that put forward by John Hick (op. cit.: page 327):

Professor William James may have been right when he lamented that it rather looks as if the Almighty has decreed that this area should forever retain its mystery. If this is indeed the case, then I assume it is because the Almighty has decreed that the personal search for meaning and purpose in life and in death are of more value than having meaning and purpose handed down as certainties from others.

In his book The Fifth Dimension, John Hick contends that experiencing the spiritual world in this material one would compel belief whereas God wants us to be free to choose whether to believe or not (pages 37-38):

In terms of the monotheistic traditions first, why should not the personal divine presence be unmistakably evident to us? The answer is that in order for us to exist as autonomous finite persons in God’s presence, God must not be compulsorily evident to us. To make space for human freedom, God must be deus absconditus, the hidden God – hidden and yet so readily found by those who are willing to exist in the divine presence, . . . . . This is why religious awareness does not share the compulsory character of sense awareness. Our physical environment must force itself upon our attention if we are to survive within it. But our supra-natural environment, the fifth dimension of the universe, must not be forced upon our attention if we are to exist within it as free spiritual beings. . . . To be a person is, amongst many other things, to be a (relatively) free agent in relation to those aspects of reality that place us under a moral or spiritual claim.

So what chance do Christina and Stefan Grof stand in their efforts to prove the mystical component of psychosis?

More of that next time.

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

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

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

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

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

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

psychosis-spiritualityPsychosis and Spirituality continued

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

filter-spectrum-v2

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

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

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

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

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

Footnote:

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

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

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

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

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

Additional Factors

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

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

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

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

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

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

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

 

Lucretia by Rembrandt

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

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

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

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

The Brain

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

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

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

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

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

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

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

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

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

Implications for Therapy

How might this realisation help?

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

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

(1) clarifying sources of distress and

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

As human beings we are constantly making sense of our world. Sometimes the conclusions we come to are frightening, and sometimes we’re mistaken. Sometimes we see or hear things that aren’t there. Sometimes our judgements are affected by our past experiences – if we’ve survived bullying, abuse or racism, for example, it might be difficult to trust people and we might understandably become a bit paranoid. Sometimes – for example when we’ve drunk alcohol or taken drugs, or sometimes even when we haven’t – the way our brain is functioning can affect our judgement. But in each case, we are actively making sense of our world. Recent research into ‘psychotic’ experiences has found that often this sense-making or interpretation of events (‘cognitive factors’ in technical language) can play an important role.

(From Understanding Psychosis and Schizophrenia published by the British Psychological Society – page 47)

The Purpose of Psychosis

Longden and Read’s thorough exploration of the relationship between psychosis and trauma, which was the focus of my last post, paves the way for a crucial insight, which currently carries too little weight with professionals dizzy from spending too long going round in psychiatric circles (page 10): ‘the conceptualisation of the psychological aftermath of adversity (including complex experiences like hearing voices, or extremely paranoid beliefs) as a meaningful way of responding to, or coping with, distressing and overwhelming events.’

This idea we have already met in my earlier post on out-of-the-ordinary experiences (OOEs). Charles Herriot-Maitland et al contend that there seems to be some direct relevance of OOEs to the context of participants’ existential questioning. From this, it could be interpreted that the OOE actually emerged as a direct expression of, or indeed solution to, some kind of psychological crisis.’

To build on this understanding and to place it in a more ‘normal’ context to reinforce that psychotic experience may simply be at one end of a normal continuum, I want to pick up on my work with Laura again, the lady who thought that her mother had thrown her away the day she was born. Admittedly her diagnosis was endogenous depression (ie deep sadness with no obvious cause), but that may not rule out any relevance to our current concerns as we will see.

She initially had no sense that life had given her any reason to be depressed. She was an articulate lady who gave clear descriptions of her history, which included a basically contented childhood, and of her current feelings, which were often suicidal, though she did not understand why.

However, some part of her mind knew perfectly well where the problem really lay and recognized its exact nature. This awareness broke through in the metaphorical form of her dreams, a psychotic experience we all share at night whether we remember them or not.

One day, she spoke of a recurrent dream she was having. With variations, it was of being in a room with Hitler’s SS. They wanted information from her and were preparing to torture her.  Before the torture could begin she invariably woke in terror. Following the model I used for my own dreams I asked her to give me a full description of every aspect of her situation in the dream. She described not only the people, but also the size and shape of the room and the kind of furniture that was in it.

An Interrogation Room

An Interrogation Room

Naturally, we focused at first on the people, but, apart from the obvious link of her having been brought up in the aftermath of World War Two, there were no links with the SS officers who were threatening her. The room did not trigger any useful insights either. We were beginning to wonder whether this was simply a childhood nightmare of the war come back to haunt her, when I asked about her associations to the furniture. We were both instantly shocked by her first answer. It was exactly the same as the furniture in the kitchen of the house in which she had grown up.

It would not be right for me to go into any detail about where this led. I imagine everyone can see that the picture she had persuaded herself was real, of a contented childhood, was very wide of the mark. That she had no vivid memory of any one dramatically traumatic incident was because there were none to remember: her whole childhood, as we then gradually came to understand it, had been a subtle form of emotional starvation and neglect successfully disguised for her at least as normal parenting.

The key point for present purposes is that the bizarre and frightening dream contained a vital key to her greater self-understanding. My question is, ‘Why cannot a psychotic experience be the same?’ There may be reasons in terms of brain deficits why terrifying leaks from the subliminal mind create a waking dream, but there is evidence that such deficits are the result of the underlying trauma itself, as we have seen in the discussion of damage to the lateral prefrontal cortex, which can no longer act as an effective filter.

Many other people have been struggling to articulate similar perspectives.

Shields, for example, in his paper Psychosis as Coping, which I referred to earlier in the discussion of drugs, makes a similar case (page 143):

This paper proposes that . . . . one sees psychotic episodes for what they may be: a mechanism for coping with existential distress – a way of being that allows an individual to escape existential realities when that individual cannot avoid these things otherwise. . . . .

Escaping the Intolerable

He goes on to clarify what he means (page 145):

. . . if existential distress becomes unavoidable but unmanageable . . . . a psychotic episode can function as a dissociative mechanism for avoiding that distress.

My own work over 35 years confirms this perspective. In 1988 a young woman persuaded her GP to refer her to me. She had carried a diagnosis of schizophrenia since she was 16. Before that she had had a twelve year history of sexual abuse at the hands of her father which went undisclosed and unnoticed at the time. She wanted to talk about the abuse to someone. An OT and I saw her together, with some trepidation. After all, psychosis and psychotherapy weren’t supposed to mix in those days. I’m not sure yet how different it is now.

Voices

I allayed my fears with an article that argued that, although ‘schizophrenia,’ a label that is increasingly questioned nowadays, was not in itself amenable to a `talking cure’, people with this diagnosis could benefit from counselling for other problems. We plunged in.

It took more than a year for her to begin to describe the abuse, so painful was it for her. She could focus on it for no more than ten minutes in each hour at first. After that she became overwhelmed with terrifying hallucinations of her father, hallucinations which impinged upon all her senses – smell, touch, hearing, taste and vision. The only way she learned to determine afterwards that he had not really been there was to observe that she had no marks upon her body. Generally it would take the rest of the session to help her regain control of her own mind.

As the months went by she could bear to reveal more of her painful story, though always in small instalments. Her fears about telling it diminished, but she still had not really come to terms with the emotional pain and the anger. For reasons of confidentiality I cannot share any of the particulars of her story. She was able, eventually, to break free of an abusive marriage. She gained greater control over other hallucinations.

However, one day, as our work continued and she became gradually more able to tolerate working on the memories, she was readmitted back into hospital. When I next met with her she explained what had happened.

She had ended up in a place that reminded her of one of the worst experiences of abuse. She was overwhelmed by all the original pain and terror. In my jargon, she had been re-traumatised.

We discussed her options. She could either remain in hospital on high doses of medication until the impact of this faded, or she could move to a residential facility with the close support of staff she trusted to work on these feelings and memories with the minimum of medication. She thought about this as she sat there, her eyes full of tears on the edge of uncontrollable sobbing. She chose to stay in hospital rather than have to face these feelings anymore.

In the next post I will be looking at where all this leaves us.

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