Earlier today I was informed by the director of our county mental health agency, where I work only a few hours per week, that I am now officially banned from sending emails to the psychiatrists, unless it concerns a particular client. The reason for this ban? I sent them a list of suggestions about how the agency might work to reduce the high death rate among the mentally ill (see below for the text of the email I sent.) Apparently, the new chief psychiatrist was offended, and decided I was simply too radical to be allowed to speak to the medical staff. So much for willingness to hear different points of view…..

There are some advantages to being censored however, as anyone knows who has ever had a book or movie banned. People start wondering, why did that happen? So the next step (after talking personally to the director about it) will be for me to go public, and question why my suggestions were seen as so radical as to require censorship, and why the county refuses to even allow discussion of alternatives to current forms of treatment, even as people are dying. I’m sure the local newspapers will be open to a column in the editorial section on the subject……

Here’s the text of my email, sent to all the county mental health workers:

LCMH’s program to integrate primary care with mental health care is great as one angle to take on reducing death rates in our clients, and there also has been some focus on shifting to neuroleptics with somewhat less hazardous known side effect profiles for clients who do OK on those other neuroleptics, but I think we need to address much more than that if we are to really have a sufficient impact on minimizing deaths.

A few thoughts on what LCMH might additionally do to reduce deaths caused or partly caused by neuroleptics:

Let consumers know that we want to collaborate with them in safely minimizing the use of neuroleptics. Let them know that our success in this will partly depend on their willingness to use alternatives and to learn more about other ways of managing their issues.

Make sure consumers are fully informed about the risks to their health from taking neuroleptics, so they are more likely to be interested in working to reduce their use, and so they don’t end up being exposed to risks from neuroleptics without informed consent. (This means not just telling them once, but making sure they really “get it” about the risks.)

Provide groups to educate consumers in how to shift to relying more on alternatives to medications, so they will experience less need for medications.

Provide written material that educates consumers on how to shift to relying more on alternatives to medications.

Attempt to identify types of clients who are currently getting started on neuroleptics, but where alternative approaches that are available in the community might work if tried. Figure out how to encourage trying these alternatives and giving them a reasonable chance to work before neuroleptics are tried.

Identify clients who may have needed a certain level of neuroleptics in the past, but who now might possibly do well with less or no neuroleptics. Work out with them a process of weaning off, which would include assistance in handling withdrawal reactions and with gradually shifting to alternate forms of coping. Have a good relapse plan in place which includes the possibility of resuming higher levels of medication as one option, if necessary.

Specifically avoid using forms of psychoeducation that imply that certain forms of mental problems can only be handled by medication, as these discourage attempts to handle the problems in other ways. Instead, always frame medication as a possibly temporary measure, which could become unnecessary in the future if other forms of coping become more successful.

Make sure consumers are informed about the likelihood of withdrawal effects when neuroleptics are discontinued abrubtly (the fact that relapse is 3-5 times more likely in abrubt withdrawal.) This will help consumers avoid mistaking withdrawal effects for a need to constantly maintain medication.

Make sure alternative treatments are as available in the community as possible. For example, make sure that clinicians are available who are trained in psychological approaches to psychosis, so they don’t just see “more medication” as the only option when a client experiences a psychotic symptom.

Rather than just focus on the risk to clients of reducing or getting off neuroleptic medications, acknowledge that risks of reducing or getting off must be weighed against the possibly life threatening consequences of staying on the medications, and acknowledge that the balance of risk is different for each person, and varies as well over time. For example, trying a reduction may be too risky at one point in time, but may make good sense later.

All of these steps could be done without really adding new programs, though adding new programs, such as an early intervention program for psychosis that prioritized a non-medication approach, could also be an important part of the solution.

I’d be curious to hear your thoughts about these options and their potential role in reducing death rates…….

Ron Unger

Many people are still convinced that the “scientific” understanding is that if a person is diagnosed with a “mental illness” such as “schizophrenia” then this means they have a genetically determined brain dysfunction that has nothing to do with what happened to the person. Of course, such a view is really about as scientific as the flat earth theory!

If you are trying to communicate with such a person, on bit of suggested reading might be the article described below:
“Childhood trauma and psychosis: Evidence, pathways, and implications”, W Larkin, J Read. J Postgrad Med [serial online] 2008 [cited 2008 Nov 2];54:287-93. Available from: http://www.jpgmonline.com/text.asp?2008/54/4/287/41437 Description of the article: There is currently a growing body of research examining environmental factors in the etiology of psychosis. Much recent interest has focused on the relationship between childhood trauma and the risk of developing psychotic experiences later in life. Numerous studies of psychiatric patients where the majority are diagnosed psychotic indicate that the prevalence of traumatic experiences in this group is high. This body of research now includes many large-scale population-based studies controlling for possible mediating variables, which together provide persuasive evidence of a dose-response association and are indicative of a causal relationship. Several psychological and biological models have been proposed which offer credible accounts of the processes by which trauma may increase risk of psychotic experience. Clinically it is imperative to routinely enquire about traumatic experiences, to respond appropriately and to offer psychosocial treatments to those who report traumatic life events in the context of psychotic experiences.

If the person you are trying to communicate with still denies a possible role of trauma after reading that article, unless he or she comes up with a good point by point refutation of the article, I would get more curious about what are the advantages to the person to believe that trauma has no connection to psychosis and schizophrenia. Because mental health professionals and others who belief themselves “experts” are really no different from people who get called clients in one respect: both groups often believe things for emotional reasons rather than due to real evidence or logic.

Of course, the person you are talking to might just maintain that there is a huge pile of evidence pointing to the existence of brain dysfunction in people who have been diagnosed with schizophrenia – certainly there is evidence of brains operating differently when people are psychotic, but then again, so is there evidence in the cases of people who have been traumatized in general. And there is evidence that at least very frequently, the brains of people with schizophrenia have many structural differences from the average person – but then again, the same turns out to be true for people who have been traumatized, and many of the brain differences show to be the same for both groups.

As for whether or not people end up labeled with schizophrenia due to genetic differences – I think we could really waste our time trying to argue that there is no such thing as a person who is more genetically vulnerable to schizophrenia than another person. More likely, some people are genetically more vulnerable, just as it is also likely that some people are more genetically vulnerable to get PTSD (and studies exist that at least suggest this.) But that doesn’t mean that we know that just because a person fits the diagnostic criteria for PTSD or schizophrenia, that this person has any genetic vulnerability. It could be that life events and trauma hit that person hard enough, for a variety of reasons, to cause the disorder even though the person had no greater than average vulnerability. One thing that doesn’t exist is any evidence to show that there exists a sub-population that is invulnerable to schizophrenia, or to PTSD.

Anyway, I hope this information and these arguments are helpful to any of you who have to communicate with people who are still believers in the exclusively biological theories about mental health difficulties.

If “schizophrenia” and “bipolar disorder” and such are not real “biologically based brain disorders” or “biochemical imbalances” then what does account for the difficult experiences and problems that get people these sorts of labels?

One way of explaining them is as imbalances, though not necessarily “biochemically based” imbalances. (That isn’t to say biochemistry isn’t involved, since as living beings our bodies and brains function through biochemistry.) Instead, the idea is that in responding to life events, some of which may be difficult or overwhelming, our mind can go to extremes of one kind or another, and lose its balance. It can then be difficult, though not impossible, to get back to balance.

Obviously traumatic experience is the most obvious example of this. To get through a traumatic situation, people go to extremes of fight, flight, freeze, and/or submit, in order to survive. The very thing we do to survive may also threaten our wellbeing, so later we might go to an opposite extreme to protect ourselves from the first extreme. Pretty soon, we may feel crazy, and fear that we might be crazy drives us, and often the people around us, to even more extremes. Vicious circles are created.

“Flipping” from one extreme to another is pretty obvious in “bipolar disorder” as people go from very excited to very depressed and lethargic, etc. It isn’t so obvious in “schizophrenia” as the people with these labels often manifest two extremes at once, or they identify as one extreme while fearing persecution by another extreme that manifests as a “voice,” or some other combination. And things get more confused when mental health professionals label extreme versions of normal mental states as pathological, rather than understandable.

I believe the most humanistic way of looking at “mad” mental states is to see them as extreme versions of everyday mental states. When people look at them that way, they can see that they are not so different from other people, and that they do have the option of moderating their extreme states, of finding a middle ground, to come back to the world shared by others.

Of course, it isn’t always as simple as a need to move toward “balance.” Living creatures are not meant to be perfectly balanced; instead, as complexity scientists tell us, life happens “far from equilibrium,” or as a “balance between balance and imbalance.” We are moving systems, and total balance would mean perfect stillness, not a property associated with life! This means that people’s extreme states may also at times have something to contribute, and not just be a problem. So sometimes it is normality that is the problem, and being “more extreme” is actually wise or helpful in a given situation.

I have spent some time mapping out some of the issues people go out of balance around, and identifying what a middle ground might be. I have put many of these issues into a PowerPoint display, which is available here. (Or, if that doesn’t work for you, try here.) I have found it helpful with people to just identify these issues (which are issues we all face) and help people see where they have been going to one extreme or the other, and to help them see they also have the option of trying out the middle ground. Because often when people are “freaked out” they and others around them can’t identify that option.

I think people are healthiest when they see themselves as having options, from the extremes to the middle, and they can pick what best seems to fit a situation. I hope the ideas I am presenting here will help some of you see more options, for yourselves and for those you help. There’s a lot more I could say about all this, so much so that I may write a book around this someday.

At least here and there, mental health authorities are recognizing that it is a problem that people in the public mental health system are dying 25 years earlier than the average person, and they are starting to talk about it. (For more information on these death rates, see http://healingattention.org/presentations/unger07.ppt.) But while they are often willing to talk about how to reduce death by improving medical care or reducing smoking, they are often much less likely to discuss the role of neuroleptic (“anti-psychotic”) medication in causing many of the deaths, or how to reduce that impact.

Below is a list of suggestions that if followed could really reduce deaths from neuroleptics, by attempting as much as possible to safely reduce their use, and substitute alternatives wherever possible. You might take this list to your local mental health administrator……

Let consumers know that we want to collaborate with them in safely minimizing the use of neuroleptics. Let them know that our success in this will partly depend on their willingness to use alternatives and to learn more about other ways of managing their issues.

Make sure consumers are fully informed about the risks to their health from taking neuroleptics, so they are more likely to be interested in working to reduce their use, and so they don’t end up being exposed to risks from neuroleptics without informed consent. (This means not just telling them once, but making sure they really “get it” about the risks.)

Provide groups to educate consumers in how to shift to relying more on alternatives to medications, so they will experience less need for medications.

Provide written material that educates consumers on how to shift to relying more on alternatives to medications.

Attempt to identify types of clients who are currently getting started on neuroleptics, but where alternative approaches that are available in the community might work if tried. Figure out how to encourage trying these alternatives and giving them a reasonable chance to work before neuroleptics are tried.

Identify clients who may have needed a certain level of neuroleptics in the past, but who now might possibly do well with less or no neuroleptics. Work out with them a process of weaning off, which would include assistance in handling withdrawal reactions and with gradually shifting to alternate forms of coping. Have a good relapse plan in place which includes the possibility of resuming higher levels of medication as one option, if necessary.

Specifically avoid using forms of psychoeducation that imply that certain forms of mental problems can only be handled by medication, as these discourage attempts to handle the problems in other ways. Instead, always frame medication as a possibly temporary measure, which could become unnecessary in the future if other forms of coping become more successful.

Make sure consumers are informed about the likelihood of withdrawal effects when neuroleptics are discontinued abrubtly (the fact that relapse is 3-5 times more likely in abrubt withdrawal.) This will help consumers avoid mistaking withdrawal effects for a need to constantly maintain medication.

Make sure alternative treatments are as available in the community as possible. For example, make sure that clinicians are available who are trained in psychological approaches to psychosis, so they don’t just see “more medication” as the only option when a client experiences a psychotic symptom.

Rather than just focus on the risk to clients of reducing or getting off neuroleptic medications, acknowledge that risks of reducing or getting off must be weighed against the possibly life threatening consequences of staying on the medications, and acknowledge that the balance of risk is different for each person, and varies as well over time. For example, trying a reduction may be too risky at one point in time, but may make good sense later.

Too often, our mental health systems are more oriented toward “drug and keep out of trouble” than they are toward recovery (even when they say they are about recovery!)

It could be different. In Lane County Oregon, activists, especially consumers, have organized to propose guidelines directing the mental health system to practice with recovery in mind from the beginning. This would mean professionals would have to avoid presenting biological speculations which are likely to make a consumer feel they have a difference which is beyond their control (such as, “you have an illness of the brain” or “you have a biochemilcal imbalance.”) Medications would be seen as only one tool among many, accurate information about benefits and risks would be available, and help would be available in getting off medications as well as getting onto them. The consumer voice and consumer choice would be considered at each level of mental health treatment, to reduce trauma and increase the chances that treatment offered would match individual needs.

You can take a look at the guidelines we have drafted, at lane-guidelines-revised If you like these guidelines, feel free to modify them and propose them to your local mental health system!

When people dream, they are “completely out of touch with reality” and they take totally seriously the most fantastic and improbable perceptions. When people are psychotic, they do pretty much the same thing. Could there be a connection? Actually there seem to be many connections, some of which are discussed at http://www.hgi.org.uk/archive/psychosis.htm.

Dreaming and creativity are highly associated. I know some people who have questioned the notion that psychosis (considered an illness) could be linked to creativity (considered one of the highest human functions) but the evidence just keeps getting stronger. Just this morning, I was reading in one book that in testing brain differences, physiological differences, and cognitive differences, the very strongest predictor of a schizophrenia diagnosis was being low in a thing called “latent inhibition” which is the ability to screen things out of awareness that were previously tagged as irrelevant. Most of the places I have seen this discussed, it is looked at as nothing but a “brain defect” that predisposes a person to psychosis. But is being low in latent inhibition always a bad thing? It turns out not: highly creative people are also low in latent inhibition! Of course, those who are successfully creative have learned how to handle this difference.

More on this at http://blogs.psychologytoday.com/blog/beautiful-minds/200903/schizophrenic-thought-madness-or-potential-genius or in more detail at http://pantheon.yale.edu/~sbk22/Scott_Barry_Kaufman/Publications_files/Kaufman%20%282009%29.pdf

Before most of my blog vanished into cyberspace, I had posted a link to a MindFreedom document that compares the myths that people are told about “mental illness” with what people would hear if they were told the truth. You can access this document at http://www.mindfreedom.org/truth/mental-health-myths

Will Hall was recently interviewed about Mad Pride in Newsweek, see http://www.newsweek.com/id/195694

In response to this article, a mental health worker I know questioned how people could say that madness is just a “difference” and not an illness, and yet also claim that people who are mad deserve disability payments. In response, I wrote the following, which attempts to sort out the connections between mad pride and gay pride, and how both might relate to the topic of “disability.”

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I agree that the issue of what is just a difference, that one can realistically be proud of, and what is a disability, is an interesting one.

One may be blind, and be to some extent disabled by that, and yet feel that one’s life has been enriched and not deprived overall as a result of the experience. One might need help from others at various times due to being blind, yet also have unique gifts and perspectives to offer to others as a result of one’s blindness.

Mental differences are even more complex.

Years ago, if a young man came into a psychiatrist’s office, reporting that he could not work because he was distracted by overwhelming anxiety and suicidal thoughts prompted by strong feelings of attraction to other men, his affliction would be considered to be his homosexuality and efforts would be made to turn him straight so he could be happy and not disabled. These efforts would likely have just made things worse. The same young man, coming into a psychiatrist’s office now, would hopefully be told he could learn to accept himself as different than others, that this difference was not itself an illness, and that once he did accept it and learn to live successfully with it he would not be ill at all. The young guy might even be referred to people who will teach him to take pride in his differences, and to find others who will appreciate him just for those differences. (He will still make a lousy husband for your daughter, and to that extent will be disabled, but on the other hand he may make a great boyfriend for your gay nephew, so overall there is no disability.)

These days, if a person comes into a psychiatrist’s office and reports that he or she is distressed due to hearing voices and having various kinds of strange experiences and perspectives, he or she is likely to be told that all of this is due to the person’s mental illness, and the psychiatrist will attempt to change it all as much as possible, to make the person “normal.” Yet, research on the general population shows that many people are living fine out in the world who regularly hear voices and have strange beliefs and experiences. Somehow, they manage all this without a lot of distress or disability. What “mad pride” is about is helping people with strange experiences and perspectives to make the shift from being distressed and disabled by their differences, to learning how to accept and enjoy them, and even see them as having value.

The Icarus Project, in which Will Hall is active, speaks of “negotiating the space between brilliance and madness.” So there is an implication that the person has to learn how to manage his or her “dangerous gifts.” With appropriate management skills, there is no longer disability.

What we really have to learn from the mad pride movement is similar to what we had to learn from gay pride: that it is to a great extent the person’s and society’s ignorance of what to do with differences, and not the differences themselves, that are the problem. People can still be disabled when they haven’t found out how to manage their differences, and so they really do deserve disability at that point, but they can also potentially learn how to navigate out of the disability and perhaps become something amazing. Or at least have an enjoyable life, while still being “different.” This is most likely to happen when both the person and the helpers see the possibility of it happening and have some kind of roadmap of how to get there.

So there’s a beginning of an answer. I know it’s hard for those who see “schizophrenia” as nothing but a “biological illness” to consider some of these possibilities, but I think if we really keep studying all the links between creativity and madness, and listen to people who have been there like Will, we will start to get it.

I was recently reviewing an article, (Nettle 2006) (see the abstract below) that makes some really interesting observations that pertain to the relationship between psychosis and creativity.

The author explores how “divergent thinking” (which I believe might also be characterized as a loosening of associations) is commonly experienced by poets and artists, while “convergent thinking” is more seen in mathematical types, (which I believe could also be seen as a tightening of associations.) Divergent thinking leads to having more unusual experiences such as are seen among both artistic types and those diagnosed as psychotic, while convergent thinking is associated with experiences on the negative symptom dimension, which are more seen amongst both mathematicians and those with autism.
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I think the author misses a point though when he associates convergent thinking with autism but not “schizophrenia.” Overly convergent thinking is definitely seen in people diagnosed with schizophrenia, it is often observed in autistic type reactions, and certainly fits with the negative symptom dimension commonly seen in people given this diagnosis.

One way the interplay of excessively divergent and then excessively convergent thinking is seen in people diagnosed with “schizophrenia” is in the way a person makes associations in response to a stimulus. The tendency is to have a much greater than average initial associations, which then are overwhelming, lead to a kind of “collapse” into having a smaller than average number of associations.

Another way this interplay is observed has to do with metaphor. People who tend to get diagnosed with schizophrenia use metaphor wildly, just as the mind does in dreams, but then also typically are not very good at understanding metaphors, much as people with autism fail to get them (this is the excessively convergent thinking.)

I believe this all has to do with a sort of underlying “bipolarity” to the processes common to psychosis. It’s kind of a chicken and egg thing. It could start with a person being in a mental rut, leading to divergent thinking in an attempt to get out of it, that then leads to some kind of trouble followed by an over-correction to overly convergent thinking, which deepens the rut, etc. Or it could start at the other end, with something inspiring the person into overly divergent thinking, which leads to trouble and etc.

At any rate, I think if we get better at understanding the parallels between human creative process, both divergent and convergent, we will be much better at helping people tease out the possible meaning in their psychotic experiences, both on the positive and negative dimension, while also helping them avoid the kind of over-corrections that keeps them cycling through “bipolar” extremes rather than finding a balance.

If someone wants a copy of this article, I can email it to you.

Ron Unger

Nettle, D. (2006). “Schizotypy and mental health amongst poets, visual artists, and mathematicians.” Journal of Research in Personality 40(6): 876-890.
Many researchers have found evidence of an association between creativity and the predisposition to mental illness. However, a number of questions remain unanswered. First, it is not clear whether healthy creatives have a milder loading on schizotypal traits than people who suffer serious psychopathology, or whether they have an equal loading, but other mediating characteristics. Second, most of the existing research has concentrated on artistic creativity, and the position of other creative domains is not yet clear. The present study compares schizotypy profiles using the O-LIFE inventory in a large sample of poets, artists, mathematicians, the general population, and psychiatric patients. Poets and
artists have levels of unusual experiences that are higher than controls, and as high as schizophrenia
patients. However, they are relatively low on the dimension of introvertive anhedonia. Mathematicians
are lower than controls on unusual experiences. The results suggest that artistic creatives and psychiatric
patients share a tendency to unusual ideas and experiences, but creative groups are distinguished
by the absence of anhedonia and avolition. Moreover, different domains of creativity require different
cognitive profiles, with poetry and art associated with divergent thinking, schizophrenia and affective
disorder, and mathematics associated with convergent thinking and autism.