Almost everywhere in the world, programs set up to do early intervention in psychosis rush to start people on antipsychotics.  This is widely seen to be an evidence based practice:  in fact, it is thought that the evidence is so strong, it would be unethical to withhold the drugs.

Many of us are aware that from a longer term perspective, the use of antipsychotics is likely making things worse instead of better.  But we probably at least assume that evidence does exist that in short term studies, measured against placebo, people just recently diagnosed with psychosis will appear to do better on antipsychotics.  However, a new review by John Bola, Dennis Kao, and Haluk Soydan, “Antipsychotic medication for early episode schizophrenia” shows that very few studies have even been done focusing specifically on early episode schizophrenia, and the evidence from those studies is inconclusive.

So the notion that everyone in an early episode needs antipsychotics is not evidence based, even for the short term.

The problem is that researchers have just been assuming that studies done with groups of people who mostly were not in an early episode could be generalized to apply to early episode groups.  There is much reason however to think that early episode groups may be different in how they respond to medications on average.

So in this case, the emperor clearly has no clothes (well evidence in this case) and we can can start to ask the question, why have so many overlooked this lack of evidence for so long?  What will it take to get more studies going that weigh medication use in early episodes versus competent psychosocial interventions?

See http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006374.pub2/abstract;jsessionid=D780DF4FC7AD910C466DE41552E9AFBD.d02t03

Recovery from mental health problems can involve some paradoxes, of which the following is one. Stress tends to contribute to mental health problems. If you try hard to accomplish something, your stress level is likely to go up, so it follows that if you try too hard to recover from mental health problems, your stress level is likely to go up to a point where you will be creating mental health problems through your efforts to recover!

Don’t despair though, people without mental health problems face the same kinds of paradoxes. For example, people like enjoyable experiences, and people have found out that money often allows one to pay for things that are enjoyable. So people like money. They like money so much, it turns out, that just looking at a pile of money can distract people from …. from enjoying things they would otherwise appreciate! Researchers showed also that the more money people had, the less able they were to savor the simple pleasures of life. You can read a summary of the research on this blog or you can read the original academic article here

I think what this means is that while it is helpful to be goal oriented at times, we also need to slow down frequently to enjoy what we already have. So even if we have some problems in our lives, and even though it makes sense to work on those problems sometimes, we also need to remember that there’s plenty to enjoy or savor or have gratitude about even if we never solve those problems. We don’t need to “recover” before we start appreciating ourselves and others around us and the sunset and a bar of chocolate. In fact, if we try too hard to “recover” or get rich or whatever, we might lose much of our ability to enjoy the simple stuff, and then we get stuck on a treadmill of needing more and more while we get less and less out of what we get.

The person who can forget about “recovery” and other goals enough to really enjoy and be grateful for some simple stuff – and hopefully to share that simple stuff with someone else – is probably making awesome progress toward recovery by doing so. [continue reading…]

I just finished reading a book called “Madness, Mystery and the Survival of God” by Isabel Clarke.

Isabel Clarke is a psychological therapist, at home in her work with the experience of people diagnosed with psychosis and other severe mental health problems. Familiarity with their experience, together with a knowledge of the spiritual literature and of research into the processing capacity of the brain, led to her central conclusion:that psychosis and spiritual experience both inhabit that other reality – a reality that is integral and vital for all humans.

While our culture tends to value both creativity and spirituality, at least the forms of it that have “made it” into acceptability, it tends to deny that either are risky or that less valued experiences, such as psychosis, might be very closely related to the more valued states. But Clarke makes a good argument that the relationship is very close indeed: spirituality and creativity result from what might be seen as successful forays into, or opening up to, the “transliminal,” while “madness” results from getting lost in it or overwhelmed by it.

As for what the “transliminal” is, she sees it as just the way the world looks when we view it in a way dominated by one of our two primary “cognitive subsystems.” Normally, we draw from both the propositional subsystem – that dominated by either/or logic – and from the implicational subsystem, which uses a “both/and” logic, and is more involved in affect, association, and the “unconscious.” Normally, we synchronize the operation of both these two subsystems in a way that leaves us not even aware there are two different systems. But when they become desynchronized, the implicational system dominates without a sense of containment or interpretation from the propositional.

Some know how to visit the transliminal, then come back enriched by the experience, while others get lost in the experience and are seen as “mad.” Of course, some have both experiences – sometimes being successfully creative or spiritual, at other times being lost.

I would add that when people appear “lost” it is partly the deficit of those around the person and of the culture, that doesn’t know how to relate to them, to contain and define their experience.

Clarke works as a therapist in an inpatient setting, and she finds it helpful to teach her model to the people there, even though the time is just brief. She finds that it really helps reduce stigma, it avoids battles about whether or not someone is really “mentally ill,” it acknowledges that there is something potentially valid in people’s experience while also challenging them to find better ways to contain and communicate about it.

A recent New York Times article revealed that Ernest Hemingway spent the last year of his life fearing that the FBI was after him, snooping into details of his life…..and they really were doing that. But, as in many cases, they weren’t doing as much as he suspected they were; he even ended up suspecting close friends of being against him, which of course drove the friends away, leaving him more depressed and alone.

Someone I know, reacting to the story, wondered how much of Hemingway’s fears were due to the FBI being actually after him, and how much due to “mental illness.” I didn’t think that was a helpful way to try to understand what happened, and I wrote the following in response:

I think one reason a lot of people don’t like the term “mental illness” is the way it obscures the way people’s behavior can often be an understandable reaction to difficult life events.

If we look at Hemingway in terms of “mental illness” we would say that the “mental illness” made him be overly suspicious of his friends and of random strangers. If we think of “mental illness” as being the cause, we might think less about the role the FBI played, or less about how some of Hemingway’s personal strengths might have actually led him to be more vulnerable in some ways to the paranoia that engulfed him – for example if he had been less vigilant to start out with, and so have missed seeing that someone seemed to be “after” him, then he might never have nurtured the suspicions that grew into paranoia.
[continue reading…]

Registration is now open for the ISPS-US Twelfth Annual Meeting:

Beyond Pandora’s Box:
Exploring Integrative Approaches to Treating Psychosis

October 14-16th, 2011

Location:  San Francisco, CA

Keynote Speaker
Richard Bentall, Ph.D. Author of Madness Explained and Doctoring the Mind
“The Psychology of Paranoid Delusions “

Honoree
Ann-Louise Silver, M.D. Founding President, ISPS-US. 
“Early Onset Psychosis: Do We Want It in the DSM-5?“

I will also be presenting at that conference, with my topic being “Dialog at the edge of reason:  addressing spiritual issues within treatment for psychosis”

More information at http://www.isps-us.org/isps-us_2011mtg_information.html

You can find the program at http://www.isps-us.org/isps-us_2011_program.html

[continue reading…]

DBT is a major innovation in the modern therapy world, and we now know that it is largely the contribution of a psychiatric survivor, a woman diagnosed with schizophrenia at 18 years old and hospitalized.  Further, we now know that one of the key insights within the method was first revealed to her in an incident that was definitely hallucinatory, or as she described it,

“One night I was kneeling in there, looking up at the cross, and the whole place became gold — and suddenly I felt something coming toward me,” she said. “It was this shimmering experience, and I just ran back to my room and said, ‘I love myself.’ It was the first time I remember talking to myself in the first person. I felt transformed.”

Certainly this sort of experience would never have happened, or would never have been recalled as important, had Marsha Linehan been on an adequate dose of neuroleptics (antipsychotics)!  But fortunately she got off her medication (no doubt against doctor’s advice) after she left the hospital, and we all can be happy she did.

Below is a link to the news story about it.  Note that the page also has a short video of Marsha describing her hallucinatory experience and how it decisively transformed her life.

I recently encountered what seems to me one of the best ever handouts written to summarize how to change one’s relationship with voices.  Written by Rufus May, the guide simply and coherently explains how to collect objective information about the voices, how to strengthen one’s own mind so one is more capable of handling them, how to listen and how to make decisions about when to listen, how to create a useful dialogue, and how to deal with the emotional issues the voices bring up.

You can access this guide here.

I just got back a few days ago from spending 5 days at a retreat that was almost the exact opposite of a mental hospital.

• The leaders were people who had visions and heard voices.
• Instead of trying to stop others from seeing visions and hearing voices, they were trying to help others have such experiences as well (and no, drugs were not involved in this process).
• When people had an experience that was overwhelming or seemed it could possibly be harmful to them, the “staff” gathered around them in a very supportive way, helping them to quickly find a way to handle it in a positive way
• Instead of trying to isolate those who had strange experiences from the rest of the community, those who had such experiences were looked to with curiosity and appreciation, to see what fresh perspective they might have to offer to others
• Instead of seeking to put people in categories, people were honored for their ability to “walk between” categories, such as gender categories or others.
• Instead of seeing the goal as immediately attempting to bring people out of painful experiences, there was an emphasis on how facing difficult experiences could contribute to long term welfare.

This retreat was not the total opposite of a mental hospital:  what it shared with a hospital, or with the mental health system in general, was an understanding that people could experience overwhelming things and would sometimes need help with them, to keep things from going in a bad way.  But the emphasis was on encountering difficult things and getting through them with the support of the community, so that something new could be discovered, which is very different from the normal “mental health” focus on just suppressing anything difficult so that nothing new emerges and “normality” can be maintained.

The retreat I went to defined its approach as “spiritual” but I think much of what happened there could eventually become part of how a more enlightened community would approach those who seem to be experiencing “psychosis.”

The “peer movement” in the mental health system is typically about having people who have had extreme experiences & who have been treated by the mental health system, and who then recovered at least somewhat, try to help others who are currently in the mental health system.  A further step in opening up the mental health system would be to bring in more of those who have had extreme experiences, and who learned how to handle them outside the mental health system in a way that enriched their lives, come into the mental health system to share their insights and methods.  This would allow a new level of “peer expertise” into the system, and would allow us to emulate what happened for eons in cultures where young people who spontaneously entered difficult visionary states where seen by the people as having spiritual potential, and then were helped by the shamans or spiritual leaders to get some mastery over the process rather than remaining lost or victimized by what was happening.

Unfortunately, there are many barriers to doing what I am proposing.  Some of these are related to the mental health system being closed and dogmatic, and unwilling to allow in other perspectives such as spiritual ones.  But other barriers exist within spiritual communities, which may feel threatened in a number of ways by recognizing any connection between their own “spiritual” experiences, and those which are seen as “mental illness.  Some of these threats are as follows:

• “Spirituality” may only be recognized when it presents itself in ways that conform to prevailing dogma:  experiences that run outside the dogma may appear too threatening to even be recognized as having a spiritual component.
• Those who are designated as “spiritual leaders” often don’t know how to help those who are having disturbing experiences:  it may be difficult for these “leaders” to admit that they don’t understand all aspects of the spiritual world, and much easier to just label the difficulty as belonging to “mental illness” instead.
• Those interested in “spirituality” want their unusual experiences to be valued, so they may be motivated to avoid stigma by  denying any connection between their own “spiritual experiences” and the experience of those who may be more troubled and confused, even when there are many similarities.

If we are really going to help people with the difficult experiences called “psychosis” we have to be willing to look at things outside our usual categories and dogma, because psychosis involves experience that does go outside those categories, and we have to be willing to go to where people are stuck.  I think if we rise to this challenge there will be huge benefits, not just to those with psychosis, who will have greater opportunities for recovery, but also for the rest of us who will benefit from our efforts to open up, from better understanding the possibilities that exist outside our usual boundaries, and how to relate to them in a good way.

The Mill River Institute for Dialogic Practice
Haydenville, MA 01039 • 413. 585. 1198
TRAINING PROGRAM IN DIALOGIC PRACTICE
INTERNATIONAL FACULTY
2 0 1 1 – 2 0 1 2

MARY OLSON, PH. D.
JAAKKO SEIKKULA, PH. D.
MARKKU SUTELA, M. A

The first of its kind in the US, this yearlong program provides an in-depth
introduction to the principles and practices of dialogic therapy, including Finnish
Open Dialogue. There will be lectures, videotapes, experiential exercises, and
reflecting consultations.

LEVEL 1 CERTIFICATION: 100 HOURS (4 Modules)
October 27 – 30, 2011
January 19 – 22, 2012
March 29 – April 1, 2012
June 11 – 15, 2012
Tuition: $4000. $1000 due upon acceptance, balance due on October 1.
$1000 due upon acceptance, $775 due on the 1st of October, January, March & June.
CEUs: 90
To apply and register, please send your CV/resume:
Mary Olson at brassworks.millriver@gmail.com