I just did a rough draft of a handout which surveys the possible options when responding to voices and other intrusive experiences.  I’m curious to hear what some of you might think about this.  Notice that I am lumping unwanted and disturbing voices in with unwanted and disturbing thoughts, impulses, and emotions, since I think the dynamics are much the same in any case.

I have spent years trying to help people who have problems with voices and other sorts of mental events, and I have noticed that whenever I thing I have “the answer” someone comes along with a situation for which that answer does not work.  So a better approach, I think, is to have a number of possible answers or approaches, and then move among them flexibly, choosing what best fits the situation.  It is not good to rely too much on any particular method, because each method has disadvantages as well as advantages. 

The handout may not make much sense without more explanation:  if that is your reaction, let me know about that too……

Options for dealing with “Voices” and other “Intrusions”

 It is common for human beings to experience things in their mind that they didn’t expect or want.  These might appear to be coming from outside the person, as “voices” commonly do, or they might be more obviously coming from somewhere inside the person, as do unexpected and/or unwanted thoughts, impulses, images, feelings, emotions, memories, etc.  (All of these are called “intrusions” by psychologists, because they seem to intrude into one’s consciousness.) 

 So, what can people do when experiencing such unwanted mental events?  While there are innumerable possible responses, it is here being proposed that all the possible responses can be sorted into five basic categories.  Those categories are fight, flight or distraction, submission, mindfulness, and selective integration. [continue reading…]

When a person has a voice that tells one to kill oneself or others, or to do other irrational or horrible things, it is easy to decide that the voice, and whatever is producing the voice, is “sick” and needs to be somehow eliminated.  This naturally leads to things like an emphasis on fighting with and trying to destroy the voice, or “running away” from it through distraction, or attempting to drug it into oblivion by taking more and more medications.  Unfortunately, all such methods tend to be destructive to the person who hears the voice, and are usually not successful in facilitating long term recovery.  What might work better?

A very different perspective is one that sees the voice as representing a part of oneself which may be important and valuable, even though it is currently advocating some “bad ideas.”  From this perspective, the goal is to resist giving in to the “bad ideas” while at the same time working to make friends with that part of oneself, and to integrate what that part of the self has to offer. 

It is common for example for parts of the self that want radical change in one’s life to represent that wish in thoughts about suicide, or killing one’s existing self:  a person who recognizes this can make friends with the urge for radical change, and explore various ideas for change, while resisting the idea of destroying one’s whole life.  It is also common, especially for people who are not skilled in balanced assertiveness, to experience a desire to “kill” others, when one is not good at setting boundaries with them:  but once this is recognized, one can make friends with these aggressive impulses and re-channel them into assertive boundary setting.  There are many other possible examples.

One story I like is about a woman who finds that part of herself seems to be a serial killer.  With help however, she learns to not freak out about this part of herself, and finds that underneath, it is a good and protective part of herself, which can be retrained to focus on liking ice cream and cartoons instead of mass murder.  (OK, I know it sounds like a weird shift, but read the story yourself: it’s called “Making friends with voices: hearing voices and dissociation.”)

I just finished Whitaker’s “Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America.”  I thought I would probably take few weeks to read it, as I have so much other stuff going on, but it kind of took over my weekend.  While Whitaker can be faulted with at times making things seem simpler than they really are, I think his overall thesis, that psychiatric medications in general are on average making long term outcomes worse instead of better, is accurate and well supported (you can browse the evidence for his thesis at his website.)

What I am struck by is the similarity between the dynamics around the delusions of those who get psychiatric labels, and the delusions of the mental health system itself.

Why does the mental health system think medications are routinely helpful, when the long term data suggests they tend to be harmful?  Let me list the reasons: [continue reading…]

 Many of you have probably been aware of two prior World Health Organization (WHO) studies that showed almost twice the recovery rates from “schizophrenia” in developing countries as in developed countries.  While critics of current psychiatric practice attributed the better outcome in developing countries to the fact that most were not on medication, others suggested that cultural factors were mostly responsible for the better outcomes.

A new study though, that looked only at people on medication in a wide variety of countries, found little difference in outcome between developing and developed countries.  While not noted in the article, this apparently provides new backing for those who would maintain that it was the greater use of antipsychotic medication in developed countries that resulted in the greatly reduced recovery rates in those first two studies. 

For those who want to know more about the assertion that long term use of antipsychotics is highly detrimental to real recovery and contributes to long term disability, this issue is covered in depth in Robert Whitaker’s new book, Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America

My county, Lane County, Oregon, is one of a number of places around the country just starting to participate in a new “early intervention” program sponsored by NIMH, called RAISE, that says it aims to help people soon after they begin experiencing their first psychotic episode.  While there are some good reasons to offer help to young people as soon as they start having problems that might be labeled psychosis, I have serious doubts about the program here being offered.

For one thing, the very name of the program (RAISE stands for “Recovery After an Initial Schizophrenic Episode”) suggests the program will be reckless in applying labels and stigma.  Even the DSM cautions against calling a psychotic episode “schizophrenia” unless the mental health condition has lasted at least 6 months, but people will be recruited into the RAISE program as soon as possible after their problems with psychosis begin, a much shorter time period.  Nevertheless, just due to the name of the program, they will feel defined  as having had a “schizophrenic” episode. 

Second, the NIMH website advertises that the program involves “intense and sustained pharmacological intervention.”  This implies a reckless use of medication as well as of labeling.  (Of course, the two go together – the sooner a person is labeled with “schizophrenia” the more justification can be made for “intense and sustained” drugging.) 

Early intervention programs that really aim to help are very cautious about the use of both labels and drugs.  The lack of caution in the design of this program suggests that the true purpose of the program is the early recruitment of young people into a life as labeled consumers of psychiatric medication.  Tobacco companies have to recruit their own customers, but pharmaceutical companies have government assistance in capturing their market.

It’s interesting that an old friend of mine, John Bola, did a review of all the studies that ever compared programs that started people out on drugs immediately, with programs that didn’t, and where the comparison period was at least a year.  You can read his paper here.  What he found was that in each case, the program that didn’t rush people into drugs did better – and that was before taking into account the fact that the people not on drugs didn’t have to deal with drug side effects.  And of course the best effects reported for an early intervention program are those of the Open Dialogue program, which also avoids using drugs wherever possible.

I wait for the day when we will treat young people with “psychosis” based on the evidence, and not based on the wishes of those more interested in profit.

Will Hall brought to my attention an article called “A Find Madness:  Sanity and Creativity” that has some good stories that illustrate the need to go to a dangerous edge, to take risks, if one is truly to be creative.  And it also seemed to illustrate the need to accept failure at times in order to avoid going over the edge – sometimes the need was simply to accept that others could not see one’s success, even though it was indeed a success.  (I think lots of us have experienced having some great insight that we just couldn’t share, because others weren’t ready for it.  It comes with the territory of being creative – a trick is learning how to accept that this will happen.)

As I pointed out at a recent mental health system meeting in my county, people with mental health problems face two kinds of risks. 

The first sort of risk is from the mental health problem itself.  Unless the person finds effective treatment, mental health problems can often cause high distress, disability, and even result in death, such as from suicide.

The second sort of risk, however, is the possibility that the person may receive an unnecessarily hazardous treatment.  For example, some people recover from psychosis without antipsychotics, and some people aren’t helped by antipsychotics, and some are helped but not enough to justify the hazards, and some could be better helped by less hazardous methods if such methods were made available.  So when antipsychotics are used routinely for everyone with psychosis, it follows that many people will be exposed to a treatment which will be unnecessarily hazardous to them.  This treatment itself can often cause high distress, disability, and even result in death.

(Some argue that most psychiatric treatment offers more risk than help:  for a good summary of those arguments, see Robert Whitaker’s new book, Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America  If you click this link you can both find out more about the book as well as get many of the main points and the supporting data on the website.)

The mental health system is organized to prevent the first kind of risk, the risk from the mental problem itself.   Billions are spent to address this risk.

Strangely enough though, the second kind of risk is usually not even discussed within a mental health system.  At the meeting in which I was talking, we wanted a document on guidelines for treatment to mention this sort of risk, but our attempt to get it simply mentioned was labeled as “inflammatory” and was being denied.  Why? [continue reading…]

Richard Bentall, in his book Doctoring the Mind:  Is our current treatment of mental illness really any good? (p. 222) points out that antipsychotics seem to be ineffective in reducing psychotic experiences for something like 1/4 to 1/3 of all those who are given them.  And it is well known that antipsychotics come with many serious risks, including that of increased mortality, permanent movement disorders and others. 

So, given that these two things above are true, why is it that we never encounter anyone who has been told by his or her psychiatrist “well it seems antipsychotics aren’t working for you and since they are dangerous, you may be better off doing without them.”? 

Psychiatry has shown almost no interest in trying to find out who might be better off not being on antipsychotics, either because they are one of those who might be able to recover adequately using healthier alternative methods, or because they are one of those for whom antipsychotics don’t work in the first place.  In other words, while psychiatry claims to be working hard to protect people from risks caused by psychosis, it has been willing to do pretty much no work at all to protect people from the risks of what may be unnecessarily hazardous treatment for a particular individual.   This is a strangely “unbalanced” approach, especially from a profession that claims it is able to balance our minds and balance our biochemistry!

I recently read a very interesting and mostly helpful document by the UK charity Rethink, 100 ways to support recovery.  However, I had some reactions to their approach to defining recovery, and I thought I would share them here.

According to Rethink “Clinical recovery is an idea that has emerged from the expertise of mental health professionals, and involves getting rid of symptoms, restoring social functioning, and in other ways ‘getting back to normal’.”

Rethink contrasts this with Personal recovery, which they define as “an idea that has emerged from the expertise of people with lived experienced of mental illness, and means something different to clinical recovery. The most widely used definition of personal recovery is from Anthony (1993):  “…a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills, and/or roles. It is a way of living a satisfying, hopeful, and contributing life even within the limitations caused by illness.  Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness.”

Rethink further states that “It is generally acknowledged that most mental health services are currently organised to meet the goal of clinical recovery” and then goes on to advocate for a shift to a focus on personal recovery instead.

 I would argue that most mental health services for what the system calls “serious mental illness” are really not organized around any kind of recovery at all, but are organized instead around a desire to keep people out of acute crisis so they are less of a burden on the community.  Most services don’t even seriously contemplate the possibility of recovery once people have been in the system awhile, and indeed people are often told to expect that they will always be “mentally ill.”

 However, recovery and reorganizing the system to work toward recovery is at least being talked about more, so it is important to decide what recovery really is.  While I believe that Rethink correctly asserts that there are serious problems when or if people are led to exclusively focus on clinical recovery, there are also real problems caused by simply shifting to a focus on “personal recovery” instead.  [continue reading…]