I was at a seminar recently where Ron Coleman asserted that the experience of hearing voices may commonly be the cause of what seems to be disordered thinking, so that in fact there may be nothing wrong with a person’s ability to think in an orderly way, it is just that the experience of hearing voices is temporarily disrupting the order of the thinking.   I started wondering if something similar might be going on in the cases of  people who have disordered thinking, but who do not report hearing  voices. (For example, as a young guy, I heard voices only on a few days
 total, but engaged in a lot of “disordered thinking!”)
 
 It occurred to me that one explanation could be that it is having  multiple perspectives that intrude into each other that results in  disordered thinking. These perspectives can manifest just as intrusive  thoughts, or as voices that are heard. 

Of course, an intrusive  perspective is at least metaphorically a “voice” even if it doesn’t have  an auditory component. So the two experiences are not completely  different, just on a continuum. And any human who is confused about an
 issue and is experiencing contradictory perspectives on something may  have some level of “disordered thinking” till it is sorted out. 

I think this way of looking at it normalizes both voices and disordered thinking and offers a suggestion for a way to move toward healing.  That is, as the person becomes more capable of accepting that there is something of value in each perspective, and as the person develops a meta-perspective that incorporates the various contradictory perspectives, the apparent “disorder” may fade away, and the various voices may integrate into smooth functioning.

Magical thinking commonly thought to be a positive symtom of schizophrenia, or at least of disorder related to schizophrenia like schizotypal personality disorder.  An example of magical thinking might be thinking that one has the power to heal oneself just by thinking about it in a certain way, or healing oneself by putting the power of one’s belief into an otherwise inert substance and then using the substance for healing.

What is strange about this is that scientific research actually confirms that magic such at described above happens at least a significant portion of the time.  It’s called the placebo effect.  People think they are going to be healed or helped, and somehow they are.  While it is typically believed that people have to think that at least possibly the substance they are taking is one that will physically cause a certain effect, a recent bit of research suggests that this is not true, and healing effects can occur even if the person knows the substance they are taking is inert.

http://slatest.slate.com/id/2279164/?wpisrc=newsletter “People taking placebos don’t have to think they’re getting real drugs to enjoy the placebo effect. A new study published in the journal PLoS reports on patients who had irritable bowel syndrome and were told they were being given a placebo as part of a novel experiment. They took pills from a big bottle clearly marked “placebo”—and got better, anyway. “In addition to the bogus medication, the volunteers were given a true story—the story of the placebo effect,” Steve Silberman explains explains on the PLoS blog. “The combination of the story and a supportive clinical environment were enough to prevail over the knowledge that there was really nothing in the pills. People in the placebo arm of the trial got better—clinically, measurably, significantly better—on standard scales of symptom severity and overall quality of life. In fact, the volunteers in the placebo group experienced improvement comparable to patients taking a drug called alosetron, the standard of care for IBS. ” Scientists believe the remarkable findings are the result of the body’s “powerful self-healing network,” which can be activated by “nothing more or less than a belief that one is receiving effective treatment.” And while placebos aren’t going to replace pharmaceuticals any time soon, Silberman calls the development “good news to anyone but investors in Pfizer, Roche, and GlaxoSmithKline.” Read original story in PLoS | Thursday, Dec. 23, 2010 http://ow.ly/1azDHS ”

It’s important to note that it wasn’t just interaction with researchers that led to the positive effects, because the control group had an equivalent amount of interaction with researchers.  The positive results seemed to come from the researchers encouraging people to believe they could do magic with the pill, and so they could.

While the placebo effect is a healing or positive one, it should be noted that there is also a “nocebo effect” which is where something causes a negative effect just because someone thinks that it will.  (The placebo effect is “white magic” while the nocebo effect is “black magic.”)

While not all magical beliefs are true, it seems it is also a delusion to think that magic isn’t real.  This is perhaps a thought some of you will appreciate as we currently experience the holidays.  Because religious thinking isn’t all that much different from magical thinking – even those of us that hate religious dogma can respect that there is a place for recognition of mystery and a role for that which goes beyond what we already understand.

One amazing song that celebrates this is http://www.youtube.com/watch?v=FhmeroR20lc  I have to think that if we had more respect for magic and mystery, we would be slower to think that those with apparently “psychotic” thinking had nothing to teach us.

Usually, we think of a person diagnosed with schizophrenia as a person who sees the world less accurately than we do.  But there are illusions that so-called “normal” people are more vulnerable to than are people diagnosed with schizophrenia……

You can check out one of those (a rotating mask) for yourself here.  (They say “normal” people will see the illusion of a face looking at them even when they know it is really the inverse side of the mask and they are trying to see it that way.  But when I first looked at it, I didn’t see the illusion – I saw just the inverse mask when that side faced me!  But then I looked away after a few rotations, and when I glanced back I saw the illusionary face, and since then it has become more difficult for me to see anything but the illusionary face.  Everyone else I showed this too by the way saw the illusionary face right away, except for one of my brothers – something genetic there?)

This effect is allegedly produced because “normal” people engage in “top down” processing, which follows rules of expectations such as “noses are always pointed towards me, never inversed” and so they come up with the wrong result in the case of the hollow mask.  The researchers propose that the brains of the people diagnosed with schizophrenia are incapable of this top down processing, but another possible explanation is that they are more likely to be in a possibly temporary mode or mental state where top down processing is switched off, which allows them to look at aspects of the world which defy our assumptions.  “Bottom up” processing for example can be helpful in creativity, putting the world together in new ways.

Another possible explanation might follow from the observed result that people who are drunk, or high on pot, were also less likely to see the illusion.  The researchers didn’t mention it, but it seems likely that all their test subjects diagnosed with schizophrenia were on neuroleptics.  These drugs might function just like alcohol or pot, resulting in a drugged state were the illusion is less likely to be seen.

Below is an outline I made of all the forms of bias that would have to be corrected in order to insure that people received the “optimum” amount of medication and emphasis  on medication.  This outline could use more work, it may be missing some things, and could use references being added, but I wanted to see what you all would think of it so far.

Barriers to Medication Optimization in Mental Health Treatment

 “Medication optimization” is here defined as a state where individuals receive no less and no more medications than what is optimal for their long term health.

It has become apparent that huge numbers of people are receiving more medication, over longer periods of time, than what is optimal for their long term mental health.(Whitaker, 2010)  What are the factors in the current mental health system that biases it toward greater use of medication than what is optimal?  It is important that all of these areas be identified, since efforts to achieve medication optimization are likely to achieve only partial success at best if significant areas of bias remain unchallenged.

Bias exists both in what is communicated about mental health issues and treatments, and in how mental health services are structured and provided. 

Since use of medication is commonly negotiated between professionals and consumers, and is also influenced by third parties, it follows that medication optimization is most likely to be achieved when professionals, consumers, and the public all have access to balanced information about mental health problems, medications, and possible alternative approaches.

Areas of bias in information include:

• What people are told about the nature of mental health problems
• What people are told about the likely effectiveness of the medications
• What people are told about the possible hazards of medications
• What people are told about the possibility for alternative treatments, and the possibility of recovery to a point where treatment is no longer needed

The bias in the flow of information is complex.  One problem is that many professionals often are misinformed or uninformed about key issues.  In addition to this, there also appear to be cases where professionals are fully informed about particular issues but deliberately choose to misinform consumers, in order to elicit behavior preferred by the professionals.   In a recent example of this, psychiatrist Daniel Carlat freely admitted in a 7/19/2010 NPR interview that he tells his patients that SSRI’s work by relieving a serotonin deficiency, even though he knows this theory lacks evidence, because he dislikes the alternative of letting the patient know he has no idea as to how the medication might work.  In yet other cases, professionals do not themselves spread misinformation but fail to communicate in a way that would counter misinformation that consumers have picked up from the media, medication commercials, etc. 

Even if all parties are accurately informed however, the system can still be tilted toward excessive use of medication through the way particular services are or aren’t made available.

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People who hear voices commonly want to get rid of the voices, and the mental health system, that sees voices as a sign of illness, pretty universally wants to get rid of voices as well.  Yet, there is a lot of evidence that shows that trying to get rid of mental events is often likely to make them more frequent.  And there is also evidence that voices are a dissociative experience, which means that they actually represent part of a person’s mind that is not well integrated.  That is, they carry important meaning, even if what they say taken literally is very wrong.

Those who have recovered from psychological crisis, yet who continue to hear voices, commonly talk about the way voices are valuable as a sign of something, for example, they often indicate that a certain kind of stress is present.  But if voices are actually potentially useful as a sign of an underlying reality, then they cannot be truly seen as “psychotic” or out of touch with reality.  In fact, it would be completely ignoring them that could contribute to “psychosis” since it would leave the person in a position of ignoring a clue about reality.

One way of getting in better touch with what might be behind the voices is to dialog with them, and to actually work at developing empathy for the voice’s perspective.  For example, consider the example of a voice that calls the voice hearer an “idiot.”  How did the voice come to believe that the voice hearer was an idiot?  If this belief is the result of life events, how did the voice feel about those events, what was it like for the voice to see those events happening?  What feelings did the voice go through?  What is the voice hoping to accomplish by calling the voice hearer an idiot now?

Developing empathy for the voice does not mean that one cannot also set limits with the voice.  In fact, developing empathy and setting limits often are best done together.  An example of this is the way that good parents combine empathy with discipline:  see the book “Unleashing Parental Love” as an example of this.

Incidentally, the same approach is useful for all of us, even those of us who don’t hear voices, in dealing with unwanted thoughts and emotions.  For example, even those of us who don’t hear voices that call ourselves “idiot” will typically have thoughts at times that call us “stupid” or various sorts of criticisms.  The best way to deal with these is to combine setting limits on how much we believe them, while being interested in exploring the thoughts and feelings that underly the criticisms, in other words, working on empathy for the critical part of ourselves.

A problem though is that this typically breaks down when dealing with extreme or vehement condemnations of ourselves.  Then the condemnation seems so extreme we can’t deal with it, it seems like it comes from a completely different person or being or spirit, and we can think of nothing to do but try to get rid of it.  Empathy seems impossible.  We lose track of how to dialog with ourselves about what is going on behind it.  The mental health system jumps on the bandwagon, agrees that the voice is just an illness, it won’t talk with the person about it and tries to get rid of the voice by any means necessary.  Voices are talked about only in the context of trying to get rid of them.

It’s very different to turn around and face the voice, and become curious about it, and wonder what led to it’s vehement and extreme expressions, such as “you must kill yourself right now.”  What is the voice feeling, and how did those feelings come about?  This doesn’t mean giving in to the voice or seeing its views as 100% correct, just seeing it as having something to say.  Often the voice had a perception of traumatic events that was different than that held by the conscious self, but really listening to the perspective of the voice can help the voice hearer develop a broader understanding of the impact of the trauma and assist in healing.  And as the person understands the feelings and perceptions behind the voice, the voice itself becomes less essential to the person and may integrate in a way that makes it no longer stand out or distract.

Even if a voice does not seem to directly respond to efforts to dialog with it, the voice hearer can reflect on what might be going on for the voice, attempting to be as empathetic as possible.  (A similar strategy can also be helpful in trying to heal relationships with actual people with whom one has been having conflict.)  Often as the result of seeing such genuine reflection or attempts at understanding, real communication begins to open up.

Interested readers might want to look more into the voice dialog way of working with voices.  Also, for more on the key role played by accepting that voices have a meaning, see this recent article on voices by Rufus May and Eleanor Longden.

The Open Dialogue method has the best reported outcomes for any method of assisting those who are beginning to show “psychotic symptoms.”  Rather than relying primarily on medications, it aims to facilitate dialogue throughout a person’s close social network.  You can find out a lot about it just by clicking on the links below.

“Five-year experience of first-episode nonaffective psychosis in open-dialogue approach: Treatment principles, follow-up outcomes, and two case studies”  Psychotherapy Research, March 2006; 16(2): 214_/228  http://bit.ly/Am67HE

“Healing Elements of Therapeutic Conversation: Dialogue as an Embodiment of Love”  Fam Proc 44:461–475, 2005  http://bit.ly/hR4raW

“Open Dialogue Approach: Treatment Principles and Preliminary Results of a Two- year Follow-up on First Episode Schizophrenia” Ethical and Human Sciences and Services, 2003, 5(3), 163-182.  http://bit.ly/xV7eX4

An Interview with Dr. Russell Razzaque, who is a leader in a pioneering multi-centre Open Dialogue pilot in the UK National Health Service.

“Open Dialogue in Psychosis II:  A Comparison of Good and Poor Outcome Cases” Journal of Constructivist Psychology, 14:267-284, 2001  http://bit.ly/yLlQq6

“The Open Dialog Approach to Acute Psychosis: It’s Poetics and Micropolitics” Family Process, Vol 42, No 3, 2003 http://www.easacommunity.org/files/Open%20Dialog%20Approach%20to%20Acute%20Psychosis.pdf

“Inner and outer voices in the present moment of family and network therapy” Journal of Family Therapy (2008) 30: 478–491  http://www.theicarusproject.net/files/OpenDialog-InnerOuterVoicesFamilyNetworkDialogSeikkula.pdf

“Open Dialogues with Good And Poor Outcomes For Psychotic Crises: Examples From Families With Violence”  Journal of Marital and Family Therapy  July 2002 Vol 28 No 3 263-274  http://bit.ly/zNz9tO

Family and Network Therapy Training for a System of Care: “A Pedagogy of Hope:” [In Lightburn, A. & Sessions, P. (Editors). (in press). The handbook of community-based clinical practice. New York: Oxford University Press.]  http://www.theicarusproject.net/files/OpenDialog-PedagogyOfHopeFamilyNetworkCurriculumOlson.pdf

Book chapter on Scandinavia/Finland approach to psychosis:  http://www.theicarusproject.net/files/OpenDialog-KjellbergChildAdolescentPsychiatryNorthernSweden.pdf

“A TWO YEAR FOLLOW-UP ON OPEN DIALOGUE TREATMENT IN FIRST EPISODE PSYCHOSIS: NEED FOR HOSPITALIZATION AND NEUROLEPTIC MEDICATION DECREASES”  Published in Social and Clinical Psychiatry. 2000, 10(2), 20-29.  http://bit.ly/I0ozU0

“Dialogue Is the Change: Understanding Psychotherapy as a Semiotic Process of Bakhtin, Voloshinov, and Vygotsk”  http://spiritualrecoveries.blogspot.com/2006/05/dr-jaakko-seikkula-dialogue-is-change.html

Becoming Dialogical: Psychotherapy or a Way of Life? by Jaakko Seikkula http://bit.ly/I0oL5S

The Australian and New Zealand Journal of Family Therapy has a whole issue, available online, concerning “dialogical practices” (approaches which have some components of Open Dialogue) at http://onlinelibrary.wiley.com/doi/10.1111/anzf.2015.36.issue-1/issuetoc

Madness Radio: Open Dialog Alternative, interview with Mary Olson  http://www.madnessradio.net/madness-radio-mary-olson-open-dialog

Mary Olson on VoiceAmerica http://www.voiceamerica.com/voiceamerica/vepisode.aspx?aid=44519

A PowerPoint:  http://www.health.bcu.ac.uk/ccmh/2008update/JS.pdf

A film about the Open Dialogue approach is available on a DVD which you can buy at http://wildtruth.net/dvd/opendialogue/ Or, you can watch the whole film for free on YouTube, https://www.youtube.com/watch?v=HDVhZHJagfQ

Training in the methods used in the Open Dialogue Approach is available in the US:  Details at http://www.dialogicpractice.net/ or for training in Tacoma WA see http://opendialoguewashington.com/foundation-training/

“Preparing the Open Dialogue Approach for Implementation in the U.S.” and “THE KEY ELEMENTS OF DIALOGIC PRACTICE IN OPEN DIALOGUE: FIDELITY CRITERIA” by Olson, M., Seikkula, J., & Ziedonis, D. at http://umassmed.edu/psychiatry/globalinitiatives/opendialogue/

Jaakko Seikkula – Challenges in Developing Open Dialogue Practice – a 1:11 long talk on youtube, https://www.youtube.com/watch?v=VQoRGfskKUA

Mary Olson, “An Introduction to Dialogical Practice” is a recorded webinar with Q/A that reviews the basics of Open Dialogue, tells the story of how Mary got involved with it, and also touches on how to use dialogical approaches when working in other settings.

“All in the Mind” in Australia taped an insightful interview on Open Dialogue,http://www.abc.net.au/radionational/programs/allinthemind/open-dialogue/7174084

If you have a bit of money to spend, a recorded 2 day training in Open Dialogue is available for $45.45 at http://www.isps.org.au/product/product-1/  Presented by Markku Sutela, MA, who was the Chief Psychologist at Keropudas Hospital in Western Lapland, recorded in 2014.

There are additional resources on Will Hall’s collection of resources.

We are learning more about what people labeled with mental disorders like “schizophrenia” have in common with people who are creative and successful. 

One of the most basic differences between the average “normal” person and the average person diagnosed with “schizophrenia” has been found to be a difference in “latent inhibition,” which can generally be described as the capacity to ignore things that seem to be irrelevant.   But now, it has been found that students who had been rated as “eminent creative achievers” were SEVEN TIMES more likely to “suffer” from having low “latent inhibition.”  See “Are Distractible People More Creative?”  What could be going on?

Another article, “The Essential Psychopathology of Creativity” goes into more detail into the common factors in disorder and creativity, and also what distinguishes those more lost in disorder from those more likely to succeed with something creative.  A key factor is what psychologists call “executive control” which involves an ability to sort through all the chaos of the creative mind, and make some sense out of the madness.

Of course, if our mental health system ever took seriously the link between disorder and creativity, they would be seeking to teach apparently “disordered” people more executive control, so they would be able to sort out for themselves what was of value in the disorder and what was trouble.  This would highly contrast with most current methods of treatment, which just try to suppress the mental activity and make it “normal.” 

Lots more data is coming out all the time on how disorders like “psychosis” and “schizophrenia” are more common after people have been traumatized and had experiences of “social defeat.”  When people are feeling that nothing normal is working for them, they are more likely to engage in “divergent thinking” which is the part of creativity that leads to having a more chaotic mind.  To be successful with creativity however, it is also necessary to learn “convergent thinking” or using executive control to weed through the chaos that results from divergent thinking, to come up with ideas, solutions, visions etc. that might work.  This sort of thinking sees value in the chaos, but a value that has to be extracted with hard work. 

Just as “mad people” have to learn to wrestle with the chaos in their own mind to find what is of value in it, I think we as a society have to learn to look for the value that can be found in relating to “mad people” rather than attempting to suppress their experience.

Ron Coleman, and Paul Baker of Intervoice will be in Eugene on November 15, 2010, to do a seminar on Working with Voices.  I’ve been working to set this up, because I’ll be happy to have two people who have done so much to help people with distressing voices share their ideas in my home town!  If you happen to live nearby, and might want to attend, you can download the flyer for this event here.

In the immediately preceding post, I wrote that:

Where do all the distortions that are common to what we see as psychosis come from?  That’s the question I took on in a short series of PowerPoint slides that I created this morning.  In these slides, I suggest that these distortions come about out of attempts to resolve two kinds of stress.  One type is stress that can result when we are over-estimating the level of external threat, and the second is stress that can result when we under-estimate such threat and so are vulnerable to jarring encounters that we hadn’t anticipated.

I will be using these slides in presentations I do, where I will be able to explain the concepts in more detail.  But I just thought I would post them here, to see how much sense they might make to  you standing on their own.  [Note:  there is an option to look at the slides in full screen, and you may have to pick that mode to see all of the slides.]

I realized later that these issues needed more explanation than was offered, so I am adding a lot more explanation below.  Let me know if it helps, or still seems too unclear!

What I was trying to do was to address a sort of confusion that all human beings face when confronted with severe stress and trauma, and that has to do with a bind caused by the stress that is usually not articulated.  The bind is as follows: [continue reading…]