The core of Acceptance and Commitment Therapy, or ACT, is the idea of simply accepting, rather than trying to get rid of, disturbing or unwanted inner experiences like anxiety or voices, and then refocusing on a commitment to take action toward personally chosen values regardless of whether that seems to make the unwanted experiences increase or decrease.

The process of applying ACT to “psychotic” experiences is well described in the book Acceptance and Commitment Therapy and Mindfulness for Psychosis, which I recently finished reading.  I found a lot to like in the book and generally in the concept of applying ACT to psychotic experiences, but I also noticed some major limitations, which I will get to below.

There is, I think, great value in the notion of shifting attention away from attempts to eliminate experiences that might be labeled “psychotic” and focusing instead on increasing a person’s ability and willingness to move toward his or her values.  This idea is consistent with the emphasis in the recovery movement of finding a way to live a valued life despite any ongoing problems, but ACT has value because of the unique and effective strategies it offers to help people make this shift.

It is also a virtue of ACT that it is “transdiagnostic,” that is, it is not an approach designed for specific “mental disorders” but rather an approach designed to address problems in living which are understood to be universal for human beings, including for the professionals themselves.  ACT appreciates that life is tricky and that we can get caught up in strategies that are unhelpful to us, like focusing too much on trying to get rid of unwanted experiences and/or getting too taken over by, or “fused,” with them, but it also appreciates that we all retain the ability to turn toward more constructive, value-driven approaches. [continue reading…]

What would happen if professionals opened their minds about the nature of madness?  What new possibilities might be created if they questioned labels such as “schizophrenia” and if they instead showed curiosity about the person underneath the label, and interest in the way “psychosis” might be an understandable response to the person’s life?  How would it work if such professionals gathered for a conference, if they invited service users and survivors to help lead it, and then if they worked together to find a path forward? [continue reading…]

While some will frame Eleanor’s story, told in her awesome TED video, as the triumph of an individual struggling against “mental illness,” I believe the story might better be seen as a refutation of the whole “illness of the mind” metaphor, and as an indication of a desperate need for a new paradigm.

When human experiences like hearing voices are framed as “illness,” the strategy of attempting to eradicate them naturally follows.  When Eleanor was first hospitalized, she was trained in this model, which directly led to what she describes as her engagement in a “psychic civil war,” where the voices multiplied and became overwhelmingly nasty.  Unfortunately, this is not unusual:  research shows that fearing experiences, and attempting to avoid and/or suppressing them, often predicts the escalation of difficulties.

All humans experience inner conflict at times.  Consciously, we may want our mind to behave in a particular way; but we have impulses, emotions, thoughts, and sometimes voices that have other ideas.  Problems with this sort of inner rebellion can range from trivial to life threatening, from the seemingly everyday to disruptions that seem bizarre and overwhelming, such as some kinds of voice hearing that are common after experiences like severe trauma.

Most current mental health treatment is based on labeling those disruptive parts as being “symptoms” of a disorder or illness, and then attempting to suppress them by any means possible, especially with drugs.  Unfortunately, this can backfire in a number of ways:  the drugs and other means employed may suppress many kinds of functioning and not just the disturbance, the attempts at suppression can stir up more conflict, and finally, the person fails to notice that the disturbing experiences may have had something positive to offer if understood correctly.

Eleanor very definitely did not recover by “battling her mental illness.”  She recovered by considering the radical notion that the disturbing experiences and voices were not aspects of an illness or of something to be eliminated, but rather were signals from the parts of herself that had been most disturbed by events which had happened to her, parts of her that carried valuable messages if only she could learn to listen in the right way.

It is very difficult to heal when one is identifying parts of oneself as an illness or as symptoms of an illness.  It becomes possible to heal when one appreciates all the parts of oneself as having something to contribute, even if those same parts may be confused in some way, or in some way need to be subjected to limits.  Voices or impulses demanding self harm for example may seem to be entirely negative, but they can also be used as helpful indicators of underlying issues that need to be addressed.  Understood this way, both conflict with the voices or impulses, and instances of acting on them in destructive ways, can be reduced, while appropriate action to address the deeper issues can be facilitated.

Wise leaders learn how to find something of value in rebellion or dissent, and are always learning from that which resists them.  I believe that a wiser mental health system would aid people in being curious about and even learning from that which disturbs them, creating dialogue and negotiation rather than attempts at suppression.  Shifting to such an approach would require that professionals drop the pretense of being “experts” in understanding mental disorders, but it would allow them to actually practice expertise in helping people like Eleanor find their own version of peaceful coexistence within their complex inner selves.  It’s time to stop the suppression, and to begin creating the conditions for healing and peace making.

While a 2 year outcome study by Wunderink et al has been cited as evidence that guided discontinuation of antipsychotics for people whose psychosis has remitted results in twice as much “relapse,” a followup of that study, extending it to 7 years using a naturalistic followup, finds that the guided discontinuation group had twice the recovery rates, and no greater overall relapse rate (with a trend toward the medication group having more relapse.)

A video of a presentation on this 7 year outcome study is at

http://iepa-vcl.eppic.org.au/content/remission-relapse-and-recovery-following-early-guided-discontinuation-antipsychotics-vs

Of course this study doesn’t prove that everyone will do better off medication.  In the study, they only tried to help people off medication if people seemed to be doing well on medication for 6 months, and they felt they couldn’t tolerate people experiencing “florid psychosis” while off medication.  But I think it does really support the contention that outcomes for long term use of antipsychotics varies from short term outcome, and that we should be trying to give more people a chance to experience the possible benefits of either never starting, or getting off, antipsychotics.

Nancy Andreason and colleagues recently released a study that indicated that both taking antipsychotic drugs, and having relapses into psychosis, cause a loss of brain tissue, but in different areas of the brain.  In their conclusions they stated their belief that the cautious use of antipsychotics is justified despite the damage they cause to the brain, because such use is in their opinion the best way to prevent relapse which would also result in brain damage.  But if, as the 7 year study above indicates, antipsychotics are not reducing relapse risk in the long term, it becomes more obvious that we should be looking hard for alternatives to antipsychotic use so we can help people find ways to avoid both the problems associated with relapse and the problems associated with antipsychotics themselves.

(And it may be that almost all the brain tissue loss is really due to the antipsychotics, see this critical analysis of the Andreason study, by psychiatrist Joanna Moncrieff.)

Robert Whitaker wrote a good summary of how the Wunderink study should be taken as a decisive piece of evidence indicating the need for a new standard of care.

When children do things like recoil in fear from monsters and ghosts in their darkened bedroom at night,  it’s easy to see the “out of touch with reality” aspect of their experience as being closely related to the faculty that gives them their ability to play – their imagination.  We help children through such challenging experiences by being with them, and by playing together, doing things like creating scary images together and then figuring out how to cope with them or laugh at them.  In the process we help them explore how to create a world view that works to at least some extent and has room for joy and originality (when their imagination helps them and maybe others see the world in new ways.)

In contrast, when adults see or believe in things others don’t, when they “go mad,” the situation is usually taken very “seriously,” and play is not seen as either part of the problem or as part of the solution.  Either the person is seen as having biological defects, or they are seen as simply a victim of distressing life events.  Either way, there is a sense we need to “take seriously” what is happening, and playing with it seems completely inappropriate.  But does an exclusive focus on seriousness really allow us to understand what is happening, and does it really work best in helping people recover?

Within popular culture, the notion that there is something positive about madness, at least up to a point, can be seen reflected in some very common ways that words related to madness are used.  For example, while an “insane” party can mean something bad it can also mean something very good; being “psychotic” can be a bad thing but it can also mean being “out there” in a good way for example related to creativity or spirituality.

Curiously, those convinced that the best way to reduce “stigma” is to portray madness as an “illness like any other” see it as part of their job to suppress any notion that there can be something fun  about madness.  For example, a NAMI page on stigma reduction contains the following paragraph:

Another triumph came in the field of advertising. Nestle’s line of Tasty, Tangy Taffy Bars featured wrappers bearing distorted cartoon faces of characters with names like “Psycho Sam,””Loony Jerry” and “Weird Wally.” Two alerts and even a letter from former First Lady Rosalynn Carter convinced Nestle to repackage the candies, minus the stigmatizing names and cartoons.

Of course, if madness is not an “illness like any other,” if it is more of a human thing, very multifaceted and containing potential for growth and change as well as hazards, then it might be a good thing to notice the fun side of madness; to notice not just the dangers, but also how it might be sometimes be liberating or even just amusing.

When people talk about madness this way, they are often accused of “romanticizing madness.”  But the establishment usually doesn’t stop to notice that when they only look at the negative side of madness, they end up “awfulizing it,” and they amplify the fear of madness, which in turn increases distress and psychological problems.  It seems time for a more balanced view, where we actively discuss and explore the positive sides of madness as well as the problems.  This could help people put their own “mad” internal states into perspective, and also help enrich our culture by drawing on the positive side of these experiences and sharing them with others. [continue reading…]

While some people find their lives ruined by belief in imagined conspiracies that affect them personally – they may isolate from, or even attack, friends and family, and get diagnosed with psychosis – many other people believe in conspiracies on the basis of little evidence, yet have prominent places in society or even bodies like the US Senate.

Yet it seems clear to me that the same dynamics are often involved in both.  The recent article, Why People Believe in Conspiracy Theories suggests we need to better understand the needs that are filled by conspiracy theories, and I believe such an understanding would be useful both in addressing political and social dynamics and in creating better mental health services.

One obvious purpose of beliefs in conspiracies is that they allow us to maintain the stability of our behavior patterns when we get information that would otherwise cause us to interrupt our behavior.  Sometimes of course maintaining stability can be a good thing, other times not.  If I am investing in a company for example, and someone tells me the company is about to collapse, I may suspect that the information about the imminent collapse could be simply a conspiracy to get me to sell, and decide to keep my money where it is, to maintain stability.  This will end up being a good decision if the information about the company collapsing turns out for whatever reason to have been incorrect, but a bad decision if the information was correct.

In short, it can be costly to change our minds all the time, so belief that information that contradicts what we are doing is the result of a conspiracy can help us avoid those costs.  It can also lead us to disaster when the information that challenged us turns out to have been true.

Many Democrats decided 9/11 was a conspiracy, probably because they didn’t want to get sucked into supporting costly national changes designed to confront terrorism, just as many Republicans decided global warming is a conspiracy, because they don’t want to support government regulations designed to combat it.  In each case, the conspiracy belief serves a need by providing a justification for less reactivity to a perceived threat, but also in each case, there is plenty of danger that can result from belief in the conspiracy if in fact it does not exist.

Another good reason for developing conspiracy  theories is simply to develop the ability to think independently, to remember that appearances can be deceiving.  The preponderance of the evidence may point in a particular direction, but this is not proof that such a direction is accurate:  there could be hidden factors, hidden manipulation, which led to the apparently convincing appearances.  Conspiracy theories can provide us with some alternative viewpoints, ways of thinking other than just robotically believing appearances and going along with consensus views.  Such independence of mind can be valuable, though also very hazardous if one simply slips into robotically believing in the conspiracy theory rather than just seeing it as one alternative view among a huge number of alternative possibilities, of which any one, or none, may be true. [continue reading…]

Earth Day 2013 is a good time to reflect on how problems in our mental health system reflect deep flaws in “normal” conceptions of what it means to be a human being.  These flawed conceptions then contribute in a critical way to the climate crisis that threatens us all.

In noticing the connection between flawed ideas about “normality” and the environmental crisis that threatens to bring down our civilization, I’m following in the footsteps of David Oaks, director of MindFreedom, who would likely be writing about this himself if he wasn’t too busy working in rehab, trying to get back functioning after breaking his neck last December.  (By the way,  MindFreedom really needs donations right now to take it through a period of financial crisis:  read why here , or go to http://www.mindfreedom.org/join-donate to make donations.)

A key problem is that within most of the mental health system, individuals are seen as healthy when they “fit in” or adjust to the overall society.  To the extent that they don’t adjust, they are seen as “having issues,” and those most out of adjustment are seen as “psychotic.”

At times, it seems to make sense to look at things this way:  adjustment seems to solve problems, and not fitting in, or being maladjusted, gets in the way of solving them.  People who are severely maladjusted may endanger their own lives or those of others.

Unfortunately, humanity is finding out that in the absence of wisdom, people can fit in with each other and be socially “well adjusted” and yet be causing catastrophic problems, such as by undermining the health of the ecosystems they live within and depend on for survival.   Or, as David Oaks likes to put it, “normal people are destroying the planet!”

R.D. Laing once said “It is of fundamental importance not to make the positivist mistake of assuming that because a group’s members are in formation this means that they’re necessarily on course.”  Of course, those who break from formation are not necessarily on course either, but if the crowd is heading over a cliff, it is important at some point to break away and start experimenting with other directions.  Unfortunately, in our society, young people who experience trouble while they experiment with new directions are simply labeled as “ill” and are seen as in need of being drugged back to some semblance of what is “normal” within the culture, even though the culture itself is headed straight for environmental catastrophe.

It seems we need a more complex idea about what constitutes health, and sickness.  I think the notion of “creative maladjustment” as described in Sophie Faught’s previous Mad in America post, “Taking Martin Luther King Jr’s Call For Creative Maladjustment Seriously” is exactly what we need as the foundation for a definition of “mental health” that would lead us towards both a functional mental health system and a functional society.

There seems to be little question that being maladjusted to something that is healthy is problematic.  So for example the person who has healthy food but thinks it is all poisoned will have difficulties.  But being adjusted to something that is not healthy is also problematic, and can be a much bigger problem.  The notion of “creative maladjustment” addresses both sides of this dilemma, suggesting the use of creative discretion in when and how to be maladjusted, rather than either supporting either blind conformity and adjustment, or reckless and undiscriminating maladjustment.

When mental health workers become able to recognize the possible value of maladjustment, they become less sure they have complete answers, and become able to relate to those they intend to help from a position of being fellow human beings searching for positive approaches to life rather than from a role of being authorities in what it means to be “sane.”   Mental health workers who recognize the value of searching, and of being maladjusted, can see possible value in “mad” experiences, and can connect on a peer level even when they are relating to people who have experiences that are very different from their own.  Being able to connect in this way is, I think, a precondition to being able to be genuinely helpful.

Of course, if one talks about seeing something positive in psychotic experiences, one can expect to be accused of “romanticizing madness.”  But somehow, those who worry that people will go too far in seeing something positive in mad experience never worry about the opposite, the possibility that people will “awfulize” madness, that they will see only the negative in it, and so will increase fear of madness and mental health stigma.  (It’s actually pretty bizarre that our mental health system will work so hard to convince people that mad experience is nothing but bad, and then turns around and tries to run “anti-stigma campaigns”!)

Recognizing “creative maladjustment” as a better definition of mental health allows mental health workers to honor the spirit of mad rebellion as being of potential value, even if not every manifestation of that spirit is helpful, and even if some manifestations can be highly dangerous!  Young people need to know that their efforts to be maladjusted to much of what is going on makes sense, even as they also need to know that it typically takes work and reflection to refine that maladjustment into something that is usefully creative.

Another part of making maladjustment creative is finding ways to come together with others in carrying it out.  This need to reconnect with others can seem paradoxical, because there is always the danger that if one connects too much, one will be right back “in formation” with a dysfunctional way of being organized, and a dysfunctional society!  The trick is to find a way to be autonomous enough to find a direction based on something deeper than just fitting in or being normal, while also being connected enough to cooperate with others in getting support and in sharing ideas and perspectives.  This is much easier to do when the culture, or at least a subculture, supports the idea of something like creative maladjustment.

When I was an alienated young man, it helped me greatly to find others who were maladjusted in their own ways and to find that we could work together in ways that were a lot of fun!  It was extremely helpful for us to support each other’s ability to move and create independently, even when the creativity was more silly than serious.  A long time friend of mine, John Law, coauthored a book coming out in May on the Cacophony Society, an organization closely related to the Suicide Club, which was the group he and  participated in together back in the 1970’s.  For me, it was the coordinated maladjustment in the events we created that helped me reconnect with the larger world, and I think we need to give greater recognition to the value of such ways of connecting.

MindFreedom’s current promotion of a “Creative Maladjustment Week” can be seen as just one small step toward the creation of a new ideal in our culture, the ideal of always aiming to be maladjusted toward what is destructive, rather than the flawed idea of mental health as “adjustment.”  Communicating the ideal of creative maladjustment to the public can also be a way of increasing awareness about how the process of being “mad” may be part of exploration toward new ways of being, with some of those new ways being possibly that which may ultimately save us from catastrophe.

It will be of little long term use to reform society and the mental health system if the ecological crisis then completely undermines civilization, leading to massive famine, die offs, migrations and wars.  Any mental health reforms would likely get lost in the chaos.  But I believe mental health reform is still worth working toward at this point, because changing the aim of mental health work, from adjustment to creative maladjustment, could shift the mental health system toward actually supporting exploration in new ways of thinking and being instead of always attempting to suppress it.  We need such exploration at this time more than perhaps any other.

I also want to point out that a key part of creative maladjustment is balancing personal fun, joy, and humor with activism and attention to the larger realities.  E.B. White is famous for having said ““I get up every morning determined to both change the world and have one hell of a good time. Sometimes this makes planning my day difficult.”  David Oaks helped me learn how to approach life this way, and I think it is key to being an activist and not burning out.  It is true that finding the balance can be difficult, but each step of the way can also be incredibly rewarding, and every other way of being in the world makes a lot less sense.

I’m hoping in the near future to write about how to create public events or spectacles that communicate to the public both about the role of creative maladjustment in cultural evolution and renewal, and about the vital necessity of doing something different before the climate crisis escalates into something that kills most all our possibilities.

Till then, I hope you persist in your own forms of creative maladjustment, and in connecting with others on that wavelength, and I also hope that you support MindFreedom International in continuing to do its work of linking together groups all over the planet which working to support people’s access to  human rights and to creative maladjustment.  Like I said earlier, it is a tricky period financially for MindFreedom as it copes with David being in rehab, but it’s vital we keep this group going that has done so much for keeping these issues alive all over the world.  Again, you can read why here , or go to http://www.mindfreedom.org/join-donate to make donations.

Thanks for all that you do to support mental health reform, creative maladjustment, groups like MindFreedom, and all the actions you take in support of insuring a future for the human race on this beautiful planet of ours!

Here’s a link to a 45 minute or so lecture by Richard Bentall, researcher and author of .  In it he reviews his perspective on the history of treatment for psychosis, with lots of interesting detail, stories, and science and statistics, and he really zeroes in on something pretty simple but also simpler said than done: having a good relationship with the person to be helped.

http://iai.tv/video/treating-psychosis

As I’ve been learning compassion focused therapy, I’ve been struck by the way our “threat system” can itself become a threat to our wellbeing when it comes to dominate our emotional life.  The question then becomes, how do we defend ourselves against the threats poised by the threat system, without further reinforcing that system itself, and so defeating our own efforts?

(The threat system shows itself in many forms, fight, flight, freeze, submit, the “critic” or critical voices, depressed mood, anxiety, etc.  All of these are responses to threat which themselves can become threatening to us.)

At a recent 3 day training in compassion focused therapy that I attended in Berkeley, there were some interesting discussions between some of us about whether parts of us like the critic could be helpful, or if they were really unhelpful and threatening and we would do better to replace them with more compassionate perspectives.

I don’t think there is a fixed answer to such questions.  One problem is that there can be great variation in how a person understands a critical voice – some people may find their morale completely eroded by such a voice, while another person (or even the same person at a different point in life) may find that the same sort of critical voice is helpful in accomplishing objectives, and that it is not taken so seriously as to undermine morale.  Same voice, different way of listening.

Another problem is that the voice itself may change its behavior while still being in some sense the “same” voice, and it may shift to being much more constructive and helpful in the things that it says.  A great example of the latter is the voice and voice hearer whose story Rufus May tells in a video I previously referenced,
http://www.youtube.com/watch?v=SARayODS_90 .  In this case, a very nasty voice that spent years telling the voice hearer that she was a whore and should kill herself, later became a helpful assistant in her recovery, and demonstrated compassion toward the voice hearer.

Some might say that the voice in the above example is “really” not the same as the original critical voice, or that it has been affected by “leakage” from the compassionate self, and in some sense that may be true, but from the viewpoint of the voice hearer, it is the same voice but with an evolving perspective.

It seems that what is really important is that the threat system, and critical voices, be themselves looked at from a perspective of compassion.  This means to me being open to seeing these systems as having positive intention, and even as being positively helpful in some situations, even as they go overboard in other situations.  Then, the question of whether we see the altered interactions that result as coming from a shift to compassionate thinking, or as coming from transformations in the behavior of the threat system and the critic, becomes itself more of a matter of how we define and talk about things than it is about the things themselves.

I think it is important that we find a way to compassionately see the threat system, and its sidekick “the critic” as allies in our lives, even as we guard against becoming too caught up in them.  This keeps us from getting caught up in loops or vicious circles where we see the activity of the threat system as itself a threat, and fight against it, while it fights back, in a disruptive and unnecessary “psychic civil war” to use Eleanor Longden’s term.

Another way of describing this might be to say that when we look compassionately at parts of ourselves, they can become transformed by the way we see them, and themselves become more compassionate.

Anyway, that’s the way I’ve been looking at it as a newcomer to this field of compassion focused therapy…….