It’s now widely known that a good relationship between helper and person to be helped is one of the very most important factors determining the outcome from many different types of mental health treatment.
But when people are in an extreme state such as the kind we call “psychosis,” forming a good relationship is not an easy thing to do.
And unfortunately, the typical interaction between professionals and clients seen as psychotic in our current mental health system has characteristics which make a positive human relationship almost impossible. To start with, rather than starting from a place of equality, where two people negotiate to see each other and to define reality, the professional holds onto a position of assumed superiority and declares himself or herself as able to define both the other person and the overall nature of reality, without any need to reconcile that view with the viewpoint of the “psychotic” person. This makes sense within the standard paradigm, as once a person’s mental process is defined as “psychotic” it is understood to be determined by illness, and to be senseless, with nothing of any value to offer.
While taking this position allows to professional to feel comfortably secure and affirms the professional’s “grip on reality,” the person defined as psychotic now feels forced to choose between either digging in and insisting on the validity of his or her own experience (and so appearing to the professional as “lacking insight into their illness”) or joining with the professional in defining their own experience and mental process as invalid and sick, and in attempting to suppress it.
Unfortunately, it typically doesn’t work very well for people to define their own mental process as invalid or sick or psychotic: this is likely to set off what Eleanor Longden calls a “psychic civil war” where the person attempts to suppress aspects of their own mental process, which in turn fight back: this fighting can intensify distress and can last a lifetime if no resolution is found, if no peacemaking is attempted.
In other words, when we define people as definitely mentally ill, or “psychotic” in a way that has no possible redeeming value, we frame things such that the only way a person can form a good relationship with us is to turn against significant parts of themselves and of their own process.
Under such circumstances, true dialogue, in which the experience of the professional meets the full experience of the other, is impossible. It is only when we professionals accept and communicate the uncertainty of our own position, which includes uncertainty about what truly is “illness” or “psychosis,” that we can engage people in conversations which are sufficiently non-polarized as to allow exploring options for mutual improved understanding and perhaps mutual recovery from our difficulties and misunderstandings.
Professionals of course gain their identity by virtue of being defined as “knowing something” and so it can be quite difficult for them to imagine that their “knowledge” may be incorrect! Yet without being able to imagine this possibility, professionals become incompetent at really dialoguing with people in extreme states about their experiences and understandings.
What we call “psychosis” often involves the radical rejection or dropping away of established ways of making sense, and then experimentation with often unconsciously produced alternative ways of making sense. If we look at the natural history of madness, we see this can lead to both disaster and to the emergence of new visions that can be helpful or even possibly “save the world” as Paris Williams recently proposed. Learning how to stay with the uncertainty can also lead to a mystical or transcendent state, as I’ve written about in an earlier article “Distinguishing Mysticism from Psychosis: Is That the Wrong Idea?” In that article, I touched on how it was my own discovery of how to be radically uncertain about both what I and what others claimed to know that allowed me to find balance in relationship to my own extreme process and perspectives that I experienced as a young man.
So is it possible for professionals and other helpers learn to take a position of radical uncertainty, while also continuing to be curious and to be continually learning and avoiding being so uncertain that they are simply ignorant?
I definitely believe the answer is yes! Within more progressive practices ranging from Open Dialogue to CBT for Psychosis, and certainly within any truly “peer” intervention, there is awareness of the need to be uncertain, and to explore with others what might possibly be going on rather than insisting on the helper’s own conclusions as correct. This doesn’t mean coming into the interaction with a sense of “knowing nothing” but rather of holding one’s own knowledge in a provisional way, being open to the possibility that much of it may only be half truths or that it will look very different once a wider context, a wider story, is understood.
Consider a case where the “patient” says that he has become convinced by his voices that his parent is an alien. Following standard procedures, the clinician will conclude simply that the patient is hallucinating, or hearing something that isn’t present, and delusional, or believing something that is totally untrue. There will be no conversation exploring for any possible truth in what is being expressed. And yet, what the patient is hearing is at least in some sense “present” within the person’s mental process, and so the person is hearing something that is “present” and that might have valuable messages to convey if listened to in the right way. And what exactly might it mean to say that the parent is an alien? An exploration of this assertion might uncover ways the patient has become alienated from the parent, or perhaps something else of real significance.
Just the other day, a client of mine expressed fear that the government could monitor where he was in his house, from outside his house or even by flying overhead. I was tempted to see this as a “delusional” fear because I thought this was impossible, but instead we talked about how my client had decided it was possible: it turned out that my client was being realistic and it was my belief that was “delusional” because technology does indeed exist to allow such monitoring. Of course, it is often the case that our client’s claims instead lack much independent backing, but even then it can be interesting to inquire into what makes them seem to our client to be true, and be open to the idea that in some cases minority viewpoints may be partly or entirely correct while “consensus” views are not.
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If you are interested in further exploration of how to practice in this sort of way, I encourage you to join me for the next ISPS online meeting/webinar, which will happen on Friday, 7/24/15, at noon EDT (that’s 9 AM for those of us on the West Coast). I’ll be presenting on “Admitting Uncertainty about “Illness” and “Reality”: A Key Step Toward Dialogue” and following my presentation of about ½ hour there will be question/answer and discussion. I hope everyone who attends will go away with an understanding of how to better set the stage for healing by “knowing less!” These meetings are free to ISPS members, with a donation of $5-$20 requested from others, though you can also sign up if you can’t or don’t want to donate. Please do register if you want to attend, at https://admittinguncertainty.eventbrite.com
Here’s an excerpt from the description for that webinar:
“This presentation will draw on ideas from the Hearing Voices Movement, CBT for psychosis, Open Dialogue, and from various spiritual traditions as well as personal stories and experiences in order to highlight the value of dialogues that transcend certainty, and to identify practical ways to do this even when talking with someone whose experience is extremely different, disturbing and/or apparently dangerous. We will explore ways use such dialogue to find positive value at times in psychotic experiences as well as to cope with distressing aspects. In the process of letting go of our own certainty in this way, we can model for the person we are helping how they might let go a bit of their own certainty, allowing us to meet in a way that is squarely centered in our mutual fallible humanity, a great starting place!”
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.
The attitude that most psychiatrists have towards their “patients” is that of dehumanization. No wonder that they don’t consider what the person is trying to tell them – they don’t listen.
B, You are so right. I have never known a psychiatrist to listen; to truly listen. I imagine that there are some somewhere; I just have not found them. Most of the “therapists” never really hear you either. I think all they hear is based on some irresponsible theory made up by some academic and the truth that is there; well is never heard. All the psychiatrist wants to do is prescribe medication. All the therapist wants to do is get you into some type of “therapy” or “program” that further dehumanizes you, demeans you, and reinforces to you the unmitigated LIE that you are defective. Please forgive my cynicism after years in the mental illness industry; I am just so very tired of being considered less a human being than I am, not having any intelligence, and being involved in meaningless activities that are alleged to be “therapeutic.” I do not want any more therapy. I just want to be considered the gifted human being that the Good Lord “so wonderfully made.” Is that too much to ask of this world?
I think those of us who were wise enough to escape the system, and found our way here, are amoung the gifted human beings who the Good Lord “so wonderfully made.” Believe in God’s gifts and insights, not psychiatry’s lies, ignorance, and insults. And I believe God’s entrusted us much loved people with the task of shedding light on the deplorable psychiatric system, so we may help change it.
Speaking of which, your presentation sounds wonderful, Ron. I’m quite certain it’s long past time for psychiatry to let go of their certainty in their DSM “bible” belief system. Especially since it’s scientifically invalid, and not consistent with what the physicists or anyone else are finding to be true in regards to the nature of reality. I hope more of the psychiatric practitioners are capable of overcoming their delusions / cognative dissidence, and choose to join the rest of us within our uncertain and “mutually fallible humanity,” or what most of us call reality.
It’s ironic how these psychiatrists often resonate with or repeat the “rejecting” or “authoritarian” parental experiences that psychotic or borderline persons have had, the very experiences that have brought them to their distressed state.
The “patient” meeting a new doctor often harbors a secret hope for a new experience with a understanding parent figure that will be different from the misattunement or rejection that they experienced in past relationships. I believe this type of understanding is provided by approaches like Open Dialogue or good psychodynamic or cognitive-behavioral psychotherapy. Harold Searles wrote about this in his concepts of the ambivalent and therapeutic symbioses in schizophrenic people, and Jeffrey Seinfeld discussed it in his notion that the severely distressed client attempts via projective identification to “cure” the bad parent-figure of its inability to show love.
Unfortunately, the primary viewpoint of most psychiatrists is: “I am the authority, you are sick, what happened to you is not relevant, and you need medication.”
Given the horribly negative messages implicit in such a stance, the vulnerable self of the distressed person doesn’t even begin to be engaged. Instead, the person senses danger and the psychiatrist is usually “spat out” of the patient’s mind as a replica of the original rejecting parental figure. No meaningful dialogue occurs, and the internal bad-object situation in the client’s mind is maintained and strengthened.
In my opinion most psychiatrists are doomed to fail their clients not only because they inappropriately manage medications, but also because, via labeling the client with an “illness” from their cool Olympian heights, they inadvertently repeat the traumas of their clients’ past.
Thanks bpdtransformation, I think you are talking about some important dynamics. Let me say a little about my take on it.
I think the process of “going mad” is something like having a revolution in the mind (of course, there is also counter-revolutionary process as well.) The revolution happens in the first place because the existing order had been oppressive or ineffective (which could be due to anything from parenting problems, social problems, or reactions to past trauma), and the revolution aims to improve things, though of course also has its own excesses.
It is tempting for outsiders to see the disorder caused by the revolution as being the problem, and to intervene on behalf of suppressing the revolution by any means necessary. That’s what our mental health system usually does, though this approach as you say does repeat traumas and reinforces an order of things that really does need to be shaken up in order for health to emerge!
It is trickier to just be with the chaos, to be unsure exactly what is right, but to be with the different factions within the psyche and to support the emergence of a process that can bring them all back together again in a possibly more open and less oppressive system.
Thank you for your comment. I agree that being able to be uncertain or not knowing what is “wrong”, and being willing to be with the chaos, is an important factor in helping someone who is very distressed. Unfortunately, it is the opposite of the one of predominant attitudes demonstrated by many mental health workers, as we have both alluded to, i.e. the attitude that someone’s “illness” can be diagnosed and that there is a specific treatment for that illness.
I so agree with you! I think the DSM diagnostic process is more damaging than the drugs in the long run, because the psychiatrist/therapist becomes allied with the forces in the client’s world that have told him/her, directly or indirectly, that s/he is no good. The concept of trying to cure the bad parent/authority figure of his/her abusive ways is a powerful one that I find is essential to doing good therapy. If you haven’t read Alice Miller, you should do so – she talks about this as the central concept of therapy. We have to learn how to stop making excuses for our parents, and taking on our our own parents’ failings and trying to fix them, instead accepting that our parents have hurt us or failed us and that there is nothing we could have done or can do now to make it better, and really feel the grief of that loss. But instead, the labeling and distancing process inherent in DSM diagnosis conveys that YOU are the one with the problem, and that YOU need to be fixed, and that your feelings toward your parents or toward the psychiatrist are part of the problem, because you SHOULD be happy with what you got and the fact that you aren’t is proof that YOU are failing, not your parents.
It is a sick, sick system full of the very delusions they accuse their patients of harboring. If anyone “lacks insight,” it’s the people who take these made-up childish diagnoses the least bit seriously.
Thanks for your comment.
What I mean by curing the bad object is actually different from what you described. Let me explain. Firstly, I agree with you absolutely that protecting the parents from blame, taking on their faults, and accepting the bad things that happened and our helplessness in the face of these losses, is all important. I know Alice Miller’s writing in general (e.g. Drama of the Gifted Child). There is also the writer Ronald Fairbairn who wrote about these ideas in concepts such as the “moral defense” – i.e. the idea that the helpless abused child blamed himself for his parent’s abuse because it felt safer than admitting he really was helpless and that the parents were the cause of his problems.
But when I say curing the bad object, I mean becoming able to trust a new person, i.e. stopping the projective processes based on past bad relationships that constantly interfere with forming newer healthy relationships with new people. I’m sure you are familiar with how if someone is abused/neglected, they will internalize the “bad object relationship” and then replay it in later relationships by mispercieving others as being identical or similar to the original abusers. For example, abused people will often notice only the “critical” things and not the kind things that a therapist says.
So in curing the bad object, I mean correcting one’s representation of another person as “bad”, and coming to trust and sense that another person can be “good”, i.e. trustworthy. This involves sensing clearly that not everyone in the present is like the bad parents or bad peers of the past. In some cases it means working through the fear or expectation that the therapist will react or respond punitively or neglectfully – i.e. projecting the bad object into the therapist, but seeing that they respond differently and are actually kind. In this way a kind of emotional learning occurs – i.e. that other people really can be good and helpful. This is what I mean by “curing the bad object” – it means curing the internal all-bad representation of other people that one has by experiencing a healthier “good” relationship with a new person, and eventually of course seeing things as both good and bad together.
Harold Searles wrote about this process in his writing about treatment of schizophrenic clients at Chestnut Lodge. He called the distrustful phase where the therapist was misperceived as a bad parent the “ambivalent symbiosis” and the loving phase where the therapist was perceived as a good parent as the “therapeutic symbiosis.” Jeffrey Seinfeld also describes these phases in abused (“borderline”) clients in his book The Bad Object.
This is an interesting topic to discuss – if you want to discuss any more, email me at bpdtransformation (at) gmail (dot) com. I have some writing about this I do on my own site.
Needless to say, I completely agree about the damage done by the DSM labeling process and all the negative implications inherent in it, as well as the mental health workers often lacking insight.
There is one more thing that has continually bothered me about psychiatry and psychiatrists and others who prescribe like medication in “so-called mental health clinics” I have know them to take my weight, my blood pressure, ask me if I am in any pain, ask me maybe a few other questions about how I might be feeling. But, nowhere, did these “alleged medical specialists” take a medical history or even inquire about a “family medical history” as I have know them to do even in the worst and most unethical of family practice doctors’s offices. They never did find out that there was diabetes and cancer in my family medical history and thus they prescribed heavy duty atypical anti-psychotics that could hasten these diseases in me. I do not believe that just because my father had cancer or diabetes that I would necessarily get these diseases on or off the medication; but it is terribly irresonsibily and unethical for them to consider this when prescribing or to not prescribe because of this. They also never inquired as to my own personal medical history which shows a great sensitivity and allergy to both the sun and heat which goes back to my early childhood; when as a child I was forbidden to go outside in the summer heat to safeguard my health. (This was difficult growing up in the Hot South.)
They still prescribed me lithium and other psychiatric medications which compromised my body’s health with the pressures of the heat. All of this while living in the “Hot South!.” To consider psychiatry as a legitimate “medical profession” seems incomprensible to me now. I am saddened and at times enraged with myself for putting my “faith” into a “science” that has almost killed me. I have seen so much unethical, non Hippocratic behavior in this profession. For instance, there is the psychiatrist who just dropped me at the end of the session as I went to make a new appointment; because she was afraid I could not pay her fees; due to my insurance deductible. I was on medication, of course, and she did not see any way to get me to another psychiatrist who could monitor me. I told this to another therapist that I had later in my “mental illness career” and she said; “Oh that psychiatrist was so great. I worked with her at so and so.” Now a defunct, bankrupt health care company. I do not know what to say anymore. Those of us who have sought help have I guess been abused. Now, this behavior has seeped into traditional medical arenas. The health of our nation is at stake. In retrospect, I think for all my health needs, I would be better off seeing an old “granny” in the mountains; rather than modern health doctors. I think I would live longer, be healthier, happier, stronger; and more energetic. The whole health care industry and especially the mental illness part is a tragedy beyond comprehension and is a threat to our nations security just as much as ISIS or any other terrorist organization is. Frontline on PBS did an expose in 2013 on the fact that Big Pharma is no longer producing antibiotics in favor of the drugs for long tern use; statins, diabetic drugs, and of course drugs for things like ADHD and people are now again dying and becoming disabled from biological illnesses that are becoming more awful. But, they only scratched the surface. Frontline needs to do an expose on some of the works listed on this website and some of our pain. You see, the drug companies insistence on creating these toxic, addictive drugs and avoiding the other drugs; like the antibiotic drugs might be the death of us all. It is not just the psychiatric drugs. What a drug company executive said to the reporter on this show; “It is a management portfolio decision.” Some of these companies are known to produce the psychiatric drugs. And yet, we suffer and die daily.
There is one other thing to consider about psychiatrists and their associated medication prescribers. Being jumped around from psychiatrist to psychiatrist, medication prescriber to medication prescriber; I have very rarely known to question me as to any side effects or adverse or allergic effects from any previously prescribed psychiatric medication from a previous presciber. They will prescribe a medication for you even over your protestions about the harm it caused you. Psychiatry is the most unethical branch of medicine; but, it really isn’t medicine at all. And, tragically, this type of behavior is seeping into otherwise formally legimatate types of medicine. The tragedy in our health care continues.
Some people who are mad, are in fact extremely antisocial, have no intent on getting help, and want to go about life their own broken way. And society doesn’t allow that. The therapist cannot connect to that.
The person ends up locked up, where only forced drugging to shut the person down occurs. This is why the medical model is prevolent, society is to be shut down and managed, with success – they don’t like to play games.
Many cases of people who aren’t antisocial get wrapped up in this system, abused, tied down, drugged, locked up, assaulted.. and denied any help or option.
Also I have been analyzing this from the stand point that the rich / policy makers in our society see everyone besides themselves as a threat in need of this type of “population management” so their policies are skewed in a “them versus us” way, where they have written the laws and policy in a way to save money, where we are disposable and throw awayable. If it hurts us, its actually good for them, because they aren’t typically subjected to the system they made for us.
If they aren’t trying to save money they try to profit, so that involves investments in stocks and companies, and new bills that improve state worker/policy maker wages and benefits. Or new laws that lock more people up, or funding for a new state hospital or prison where they can set up a nest to make bank off of.