That was the emphatic response from my grad school psychopathology professor 35 years ago, after I’d stated in her class that anyone could become psychotic given sufficient life stressors, losses and trauma.
How many current mental health professionals, especially psychiatrists, also believe they have such strong egos that they never could experience extreme states?
In the absence of any bio-markers, blood tests, or diagnostic imaging to validate a psychiatric, disease-model based DSM theory of psychosis, we still are being asked to accept the diagnosis’ validity as a disease entity on faith. Faith that what causes — and is called — psychosis is what psychiatry says it is. But what if the disease model of extreme states grew out of, and contains, a phobic dread at its core? What if the disease model of extreme states is a codified expression of deep primitive fear of the irrational? An inchoate fear of the emotionally wild unpredictability of madness? A fear of the terrifying existential disintegration — that really may be the occasion for a deep reorganization of the psyche, if the extreme state process is not pathologized, but instead allowed to freely express itself and be nurtured?
To attempt to address these questions, the following conjecture is based on my work as a radical therapist after going through my own lived experience of madness, as well as my experience on treatment teams alongside psychiatrists every day for almost 30 years in a large public-sector mental health system where I specialized in serving people in extreme states.
From decades of conversations with psychiatrist co-workers about the possible causes and most effective treatments for psychosis, where I challenged their belief system with my radical views, my sense is that almost all those docs believed what the psychopathology professor believed – that they really were invulnerable to any form of psychosis.
It seemed they partly believed that this had been proven because their strong egos and “grasp on reality” had gotten them through the rigors of medical school, but also because, after absorbing the frightening disease model theory/dogma about what gets called psychosis that they were taught in psychiatric training, they felt comforted in believing that it could never happen to them.
They appeared to me to believe that their egos were so strong that they would always be safe from experiencing psychosis.
That stance looked to me like the possibility that some self-serving cognitive dissonance was at work. We sometimes come up with comforting stories to tell ourselves to ward off experiencing the fear of what we are really afraid of.
I remember a psychiatrist co-worker and friend telling me, with real anguish, that she hated starting children as young as six years old that she’d diagnosed as bipolar on Abilify and other powerful psych meds, but she believed she had no choice but to protect their brains from psychosis. She said that was what she had been taught at one of the best medical schools in the country; that every minute a person of any age was experiencing psychosis, their brains were undergoing irreparable damage.
I disagreed with her about that fatalistic and unfounded belief, and gave her research articles challenging the disease model of psychosis, but she still believed what she had been taught in her psychiatric training and what the APA constantly advances as scientific proof.
I think it’s possible that some of the often aloof clinical detachment and “othering” that negatively effects people in extreme states, people who need a warmer, compassionate response from providers, stems from the fear of extreme states that providers carry into their face-to-face time. As I’ve noted, this fear is memorialized in the disease model that providers have been taught is true.
The failure of empathy, and the resulting lack of deep compassion for those in extreme states, may be a not-so-hidden unintended consequence of the belief – and hope – that psychosis is possible only for those who are fundamentally different than the provider; that the dreaded psychosis exists in potential only in people who lack the “ego strength” of the defended and emotionally distant provider.
Isn’t it more difficult to have empathy for someone if we can’t imagine ever being in their situation or ever experiencing what they are experiencing? Don’t we subjectively have more empathy if we recognize that there but for fortune would our own suffering take us, instead of believing we could never suffer that way? The compassion that someone in an extreme state needs to feel from others is limited if the provider isn’t first sufficiently engaged to feel a degree of empathy.
It seems to me that a subtle form of hubris – a.k.a. “ableism” – is present when mental health providers look at the people they serve and almost triumphantly say to themselves, “I could never be like you!”
I haven’t seen the psychopathology professor again in all these years, but I’ll never forget our exchange in her class that evening when she responded to my assertion that anyone could become psychotic given sufficient trauma, life stressors and loss. (Recent research, in fact, left the researchers “‘Amazed’ at the range of experiences associated with schizophrenia that were induced in ordinary people after just twenty-four hours of deliberately-induced sleep deprivation.”) I was surprised by how emphatically and personally she responded to me in front of the class –
“Michael, my ego strength is too developed for me ever to become psychotic. I have been through an extensive training analysis and nothing that could happen to me in my life could ever cause me to become psychotic!”
There was a long pause as the other students turned and looked over at me.
I replied, “Based on my personal experience, for your sake, I hope your ego strength is never put to that test.”
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.