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Making Remarkable Progress – Just by Helping People Feel Safe!

When mental health professionals encounter someone who seems to have “persecutory delusions,” they routinely assume there must be something wrong with the person’s brain, something that can only be treated by administering drugs. And to the extent that the drugs don’t work, it is often assumed that they must just live with a “chronic illness.”

Some have tried talk therapy approaches, but up till recently, the success rate seemed small, with most people not experiencing a lot of benefit.

That is why, over the past decade, Daniel Freeman and colleagues set out to develop a new cognitive treatment – translated from an empirically established theoretical model – that would produce large effect size reductions in persistent persecutory delusions. The primary outcome randomized controlled trial, published in the Lancet Psychiatry, reported success in reaching the aim of having 50% of patients experiencing recovery in their persistent persecutory delusion, and reported a treatment effect size several times higher than conventional CBT.

This approach reached its goals not by addressing delusions head on, but by addressing things that made people feel unsafe: things like sleep and worry problems, lack of self confidence, and patterns of avoidance that had become crippling.

In a webinar on 3/11/22, Daniel Freeman provided an overview of the principles underlying the development of the Feeling Safe programme; the theoretical model; a number of key empirical studies; the content and style of therapy, and the main randomised controlled trial outcome results. He argued that the Feeling Safe programme provides new optimism in the treatment of delusions. See below for a recording of that webinar.

About the presenter:

Daniel Freeman is a Professor of Clinical Psychology and NIHR Senior Investigator at the University of Oxford and a consultant clinical psychologist in Oxford Health NHS Foundation Trust. Professor Freeman’s research has focussed on using psychological theory to develop more powerful psychological treatments. He has also been pioneering the development of automated virtual reality treatments for mental health conditions. He is the recipient of the 2020 British Psychological Society Presidents’ Award for Distinguished Contributions to Psychological Knowledge. He presented the BBC Radio 4 series ‘A History of Delusions’.

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Rebuilding a Sense of Self & the World After Psychosis

Metacognitive Reflection and Insight Therapy (MERIT) is a form of integrative individual psychotherapy that seeks to assist adults diagnosed with psychosis to make sense and meaning of the challenges and possibilities in their lives and to find ways to manage these and direct their own recovery.

Building from advances in both cognitive and interpersonal research, MERIT seeks to expand the boundaries of cognitive-behavioral, personal centered and psychodynamic approaches to treatment by focusing on how persons make sense of their experiences of their own purposes and place in the world allowing the development of a sense of belonging to our larger communities.

One of the books on MERIT

In contrast to other approaches, MERIT focuses on core processes that should be present in a given session, rather than a predetermined curriculum. This allows for a therapy can be truly tailored to meet the needs of unique individuals in real world clinics while also unlocking therapists unique potential for creativity as they seek to jointly make meaning with the person diagnosed with psychosis.

I was happy to be involved in organizing a webinar during which Paul Lysaker presented the scientific basis for MERIT as well as detailed and inspiring descriptions of its practice allowing practitioners to begin to think about how to integrate this approach into their practice.

Paul H Lysaker has over 35 years of experience providing and supervising recovery oriented forms of psychosocial interventions to adults diagnosed with psychosis. He is also an active researcher and teacher with over 20 years of federal funding for projects related to recovery and the practice of psychosocial rehabilitation. This work has resulted in over 500 peer reviewed publications to date and several books. He is the primary architect of an emerging recovery oriented form of integrative psychotherapy: Metacognitive Reflection and Insight Therapy.

Paul also has a good sense of humor and a good appreciation of the difficulties people face, including the difficulties faced by those struggling with psychosis and those struggling to help them! So I hope you check out the video and let me know what you think of it.

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The Role of Radical Skepticism in Madness and Recovery

When we feel sane, we believe we possess accurate ways of knowing reality. Hidden within this understanding however lies a curious circularity. When asked how we know our method of discerning reality is correct, we inevitably circle around to asserting that our method can be relied upon because it arrives at the correct result, and confirms what we know to be true!

But what if the whole circle is in error?

At times, we may become deeply skeptical, or even paranoid, and lose trust in that circle. Then, it may seem that solid ground disappears, and so we tumble in an abyss, or madness In this “cloud of unknowing,” it may seem that nothing is real, or that everything is real (since anything now has as much seeming claim to reality as anything else.) Or, overwhelmed by the infinity of possibilities, we may grasp onto some alternative “mad” reality, or swing from wildly positive to terrifying perspectives.

Since it was radical skepticism that led into the abyss, it may seem that climbing out would require a rejection of skepticism. But without deep skepticism, how can we question our mad perceptions or beliefs?

An alternative is to continue to value skepticism, but now in a flexible way that also allows for skepticism about skepticism itself. Then we can balance having definite perceptions and ideas about reality with an awareness that they may also be completely wrong.

Currently, the mainstream approach to helping the mad involves maintaining an absence of skepticism about dominant forms of “sanity,” paired with complete skepticism toward finding value in madness. But recovery might better be promoted by helpers who can accept the lack of a solid foundation for knowledge, and who instead promote a lively evolving dialogue in which all, including the mad, have something to contribute.

Below is a link to a talk on this subject I gave on 11/7/21, for the ISPS-US Annual Conference.

I hope you do check out the video, and let me know what you think!

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The Oppressed, and Those Who Resist Oppression

“I would like to dedicate this award to all the other mad kids, to all the outsiders, the weirdos, the bullied, the ones so strange they had no choice but to be misunderstood by the world and those around them,” said Jason Mott, in his recent acceptance speech for the National Book Award.

I don’t think it is just a coincidence that it was a Black writer who made this point. Unfortunately, simply having skin color other than white is enough to make one an “outsider” of sorts in the US – and those pushed to the outside in this way may more easily develop insight into all those who are marginalized.

Those seen as mad or psychotic of course may be seriously lost and highly distressed, and this should not be forgotten. But what is seen as madness can also at times be something worth affirming, in the sense of affirming difference, and affirming resistance to oppression, a resistance to the forces that say we have to fit one mold or be dismissed as defective.

Another powerful Black voice writing about madness and oppression is that of La Marr Jurelle Bruce, whose recent book is titled “How to Go Mad Without Losing Your Mind: Madness and Black Radical Creativity.”

“Hold tight. The way to go mad without losing your mind is sometimes unruly.” So begins La Marr Jurelle Bruce’s urgent provocation and poignant meditation on madness in black radical art, How to Go Mad without Losing Your Mind: Madness and Black Radical Creativity, published in April 2021. Bruce theorizes four overlapping meanings of madness: the lived experience of an unruly mind, the psychiatric category of serious mental illness, the emotional state also known as “rage,” and any drastic deviation from psychosocial norms. With care and verve, he explores the mad in the literature of Amiri Baraka, Gayl Jones, and Ntozake Shange; in the jazz repertoires of Buddy Bolden, Sun Ra, and Charles Mingus; in the comedic performances of Richard Pryor and Dave Chappelle; in the protest music of Nina Simone, Lauryn Hill, and Kendrick Lamar, and beyond. These artists activate madness as content, form, aesthetic, strategy, philosophy, and energy in an enduring black radical tradition. Joining this tradition, Bruce mobilizes a set of interpretive practices, affective dispositions, political principles, and existential orientations that he calls “mad methodology.” Ultimately, How to Go Mad without Losing Your Mind is both a study and an act of critical, ethical, radical madness.”

You can buy “How to Go Mad without Losing Your Mind” from Word Up Community Bookshop/Librería Comunitaria here:

Or, for an eloquent introduction to the topic, watch this:

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Resources for Learning to Provide Therapy for Psychosis

We now know that therapy can be helpful for psychosis. But there is still a lot of confusion around what type of therapy approach is helpful, and especially about how professionals can find training by experts in how to work with these experiences.

One thing I’ve done to remedy this is to put together a list of mostly online places that offer training in various approaches to psychosis. You can access that list here. I hope you get some use out of it, and pass this information on to others who may be interested!

Also, I recently offered a webinar on “Cognitive Behavioral & Related Therapies for Psychosis: Diverse Approaches to Supporting Recovery

Here’s the description of what it covers:

People experiencing psychosis are often feeling stuck in bewildering mental states, and it’s easy for professionals to get lost when they attempt to help. This may explain why for many decades, the consensus among professionals was that therapy could not be effective for those with psychosis! Fortunately, research has emerged showing that cognitive behavioral therapy (CBT) as well as many related therapies can be modified to work reasonably well for people with various kinds of psychotic experiences.

This webinar will provide an overview of the research behind CBT for psychosis, and of the style and strategies used. There will then be discussion of approaches that can easily be integrated with CBT such as compassion focused therapy, acceptance and commitment therapy, psychodynamic therapy, mindfulness, family systems and dialogical approaches, and approaches developed within the hearing voices network. Resources for getting training in CBT for psychosis and related approaches will also be described.

This webinar was co-sponsored by Mad in America Continuing Education and by ISPS-US. You can find the recording of the webinar at this link (note you have to scroll to the bottom of the page to find it.)

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Healing the Parts in Our Internal Worlds

When we go into severe mental health crisis, it can feel like a civil war inside, with various voices, demons, or other entities engaged in battle with each other. When the chaos is great, the idea that we might ever come back together might seem unbelievable.

One thing that can help though is recognizing that even when things are going smoothly, we still have different parts inside. And even when things are at their worst, we still have the ability to access something inside us that can guide us toward healing.

This is a subject that was explored in a webinar titled “Internal Family Systems (IFS) and the Inner World in Non-Ordinary States” that took place on Friday, Aug 6, 2021.

This webinar explored how IFS understands and works with people experiencing voices, visions, paranoia, and other non-ordinary states.

IFS posits that there is no such thing as a ‘Unitary mind’, indeed the mind is made up of multiple ‘parts’ who interact internally in the same way that we interact in external relationships. These parts can become wounded by life’s adversities, and take on extreme roles in order to protect the person from further wounding. Each of these inner parts holds its own unique feelings, thoughts, experiences and core beliefs.

A core tenet of IFS is that every part has a positive intent no matter how extreme their actions to protect the person.

IFS believes that under all these parts is a person’s ‘core Self’ and this Self cannot be damaged by life’s adversities and contains qualities of compassion and wisdom. Self is the natural leader of the system once parts are unburdened and trust Self’s leadership.

The IFS method promotes internal harmony by befriending parts and bringing healing to the parts who have been wounded.

About the presenter:

Stephanie Mitchell is a Level 3 trained IFS practitioner, psychotherapist, trainer and supervisor in private practice in Adelaide Australia. She specialises in working with complex trauma and experiences which often get labelled as ‘mental illness’. She is interested in how healing and change occur in the human to human relationship, within spaces of safety and acceptance and outside the constructs of diagnostic labels. Stephanie has almost a decade working in Mental Health settings including 3 years co-facilitating a Hearing Voices group.

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Paradoxes of Madness and Philosophy

Have you ever met people who reported that “asking too many questions” was what seemed to have led them into madness?

Or maybe you noticed yourself that the more you looked into the deeper aspects of existence, the more paradoxical, and maddening, reality seemed to become?

If these sorts of issues interest you, and if you think understanding them may help us provide better help to people who are struggling, then you may want to view this recording of the webinar “How Can the Uncontainable Be Contained? Paradoxes of Madness & Philosophy:”

In this talk, Wouter explains a bit about himself, and how he came to write the book, and gives an overview of its main arguments and perspectives. He presents three text fragments, pertaining to both philosophy and madness, that address the themes of nothingness, infinity, and fragmentation, then shows a 13 minutes video, “Unravelling Reality,” that lets these themes come to life in a modern, metropolitan setting (that is, Brussels in Belgium), and also engages in dialogue and discussion with an audience.
About the presenter: Wouter Kusters (1966) obtained a Ph.D. in linguistics and earned an MA on the philosophy of psychosis. In the Netherlands, he is known for his books on the experience of psychosis and its relation to philosophy. For his Pure Madness (2004), and A Philosophy of Madness (2014), he won the Dutch Socrates Award for the best philosophy book of the year in Dutch. The latter has recently been translated into English (2020, MIT Press). Wouter Kusters works as an independent writer, researcher and teacher in the Netherlands, see:

“…madness is less about living in another private bizarre reality and more about living in our ordinary reality but then stumbling on problems that are hidden in (or ‘under’ the pavement of) ‘realism,’ and being haunted by them, which grow the more attention you pay to them.”

“Now, an important difference for many ‘madmen’ is that they just find themselves in these abysses, without preparation, with no language or tools to navigate there, with no others, and without any sense of freedom within the fall. The seduction to reduce it to a psychological crisis, or even a neurobiological crisis is then overwhelming — and from a practical point of view it is quite prudent to do so. Nevertheless, many of the questions and problems that continue to haunt those deemed mad or psychotic have nothing to do with a personal or neurological problem, but all with the greater questions. Being in a condition of madness means you are trying to resolve the most fundamental questions of existence, but in an uncontrolled, wildly associative way. You want to know what it’s all about, what good and evil are, what is at the very heart of existence: you want to know the meaning of life and the cosmos. “

Those two quotes are from

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Robert Whitaker: The Rising Non-Pharmaceutical Paradigm for “Psychosis”

In a talk linked to below, award winning medical journalist Robert Whitaker reviews the science that indicates the need for a radical change in psychiatric care, and describes pilot projects that tell of a new way.

Starting in the 1980s, our society organized its thinking and systems of care around a “disease model” narrative that was promoted by the American Psychiatric Association and the pharmaceutical industry. That narrative has collapsed. The biology of mental disorders remains unknown; the diagnoses in the DSM have not been validated as discrete illnesses; the burden of “mental illness” in our society has risen; and there is an increasing body of evidence that tells of how psychiatric drugs, over the long-term, increase the chronicity of psychiatric disorders.

The collapse of that paradigm provides an opportunity for radical change. In Norway, the health ministry has ordered that “medication—free” treatment be made available to psychiatric patients in hospital settings. A private hospital in Norway has opened that seeks to help chronic patients taper from their psychiatric drugs, or to be treated without the use of such drugs. In Israel, a number of “Soteria” houses have sprung up, which provide residential treatment to psychotic patients and minimize the use of antipsychotics in such settings. Research into Hearing Voice Networks is providing evidence of their “efficacy” for helping people recover. Open Dialogue treatment, which was developed in northern Finland and involved minimizing use of antipsychotics, is being adopted in many settings in the United States and abroad.

About the presenter: Robert Whitaker has written three books on the history of psychiatry: Mad in America, Anatomy of an Epidemic, and Psychiatry Under the Influence (the latter book he co-authored with Lisa Cosgrove.) He is the president of Mad in America Foundation, which—through its webzine, radio podcasts, continuing education webinars, and town halls—promotes an exploration of these issues. He is also on the adjunct faculty at Temple Medical School, in the psychiatry department.

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Exploring the Promise and the Pitfalls of “Mad Pride”

When people talk about finding something of value in “mad” or “psychotic” or “extreme” experiences, they are usually accused by those in mainstream psychiatry of “romanticizing an illness,” and overlooking how disruptive and distressing these states can be. But when only the negatives about mad experiences are noticed, the focus goes to attempts at suppression, despite increasing evidence that attempts at suppression can contributes to long term dysfunction.

In an ISPS-US webinar – Exploring the Promise and the Pitfalls of “Mad Pride” – I explored a middle ground approach, which balances an awareness of the hazards of mad experiences with a willingness to notice what might be positive about them. Starting with a more open mind, it becomes possible to help people to eventually understand their experiences in life promoting ways, rather than being stuck in either avoiding and suppressing them or being overwhelmingly immersed in them. Methods of applying this approach to improving interactions with “mad” people, and with the “mad” portions of our own minds, were discussed.

Check it out for yourself!

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Psychedelic Drugs, Psychosis, and Spiritual Awakening

What are the relationships between the experiences caused by psychedelic drugs, and those we call “psychosis?” And what are the relationships between both those types of experiences, and experiences that seem to be a “spiritual awakening?”

There may be a number of answers to those questions. Many different perspectives were shared and discussed at an conference, titled Psychedelics, Madness, & Awakening: Harm Reduction and Future Visions. This conference was held January – April 2021, and the recorded videos can be found on the website (click on the “schedule” tab, then select a panel, then scroll to the bottom of the page to find the videos.)

I was one of the panelists, I talked about ‘Revolution Within the Mind: A Common Factor in Psychedelic Experience, Madness, and Spiritual Awakening.’ Check out the video:

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