While Psychiatry Slept (Part II)

This is the second in a series of articles titled While Psychiatry Slept (the first can be found here). It is an attempt to look at the way mainstream psychiatry has been in an amnestic slumber, turning away from the imagination and thereby literalizing its treatments into only brain chemistry and the use of medications and ECT. This is seen most egregiously in the realm of psychosis and its hegemonic theoretical position witnessed in the Goff et al meta-analysis recently published in the American Journal of Psychiatry, May 2017. Robert Whitaker, Philip Hickey, Joanna Moncrieff and Miriam Larsen-Barr have all written excellent rebuttals to Goff’s paper on this site.

I would like to question the paper from another direction and represent the stance of the well-documented psychological literature that Goff et al, along with Nassir Ghaemi in his paper “The Psychology Fallacy” and other researchers coming from a strictly biological position, seem to eschew.

These verified therapeutic successes date back to at least 4000 BC when a suicidal Egyptian man held hallucinatory conversations with his ba soul, known as “The Dialogue of a World Weary Man with his Ba” and documented in Barbara Hannah’s book Encounters with the Soul. These reports have continued down through the centuries with John Perceval’s recovery from his 1830 psychotic break reported in Gregory Bateson’s wonderful book Perceval’s Narrative and Anton Boisen’s amazing story in his Exploration of the Inner World. We also have Harry Stack Sullivan’s documented successes with his method of interpersonal psychotherapy, along with Karl Menninger’s famous quote of his patients who had experienced a psychotic episode often becoming “weller than well.”

One of my favorite comments about psychosis is from Jung — who had remarkable success with psychotic patients throughout his long career — when he said in 1922 in his book The Psychogenesis of Mental Disease that “Modern psychiatry behaved like someone who thinks he can decipher the meaning and purpose of a building by a mineralogical analysis of its stones.”¹ He then added statistics from that time, showing it was rare in any case of schizophrenia, no matter how chronic, to find anatomical brain changes on autopsy. In his opinion this “proved that the purely anatomical approach of psychiatry does not lead adequately to the questions of understanding the psychic disturbance… The way to a psychiatry of the future, which would need to come to grips with the essence of matter, was clearly therefore marked out: it could only be by way of psychology.” This dogma, he finished saying, “can only lead to an absolute sterility (of thought and research) as soon as it is assumed to be generally valid.”

This belief in psychosocial approaches can be seen in the work championed by Kazimierz Dabrowski and Frieda Fromm-Reichmann, and later by Loren Mosher at Soteria House, John Perry at Diabasis and RD Laing at Kingsley Hall in London. It is now being followed up by a plethora of therapists from all over the world, many involved with the Hearing Voices Movement and the International Society for the Psychosocial Treatment of Psychosis. These would include but are not limited to Bertram Karon, Brian Martindale, David Garfield, Ira Steinman, YO Alanen, Johan Cullberg, Richard Bental, David Downing, Marilyn Charles, Tracy Morgan, and Murray Jackson.

When Goff, Lieberman and Ghaemi can leave some of the greatest minds in the field from both past and present out of the discussion, claiming that antipsychotic medications are always the best treatment for psychosis and that approaching psychosis psychologically is a logical fallacy, then I would state that these arguments don’t show a scientific candor but instead border on disrespect and the most egregious fallacy in any civil debate: an ad hominem position.

I would like in today’s post to concentrate on my last time with one of the great thinkers on psychosis in the 20th century, John Perry. John had come to my home to stay the night before we drove together to a conference focused on treating psychosis without medication and with psychotherapeutic approaches. We were both presenters along with Joseph Goodbread and Arnold Mindell, the featured leader of the conference run by his Process Work organization. Mindell had written a book on the topic titled City Shadows, where he had outlined practical and useful methods for working with psychotic states. I was asked to give the opening lecture to the conference and was still struggling that evening to get the first words on paper. At that time in my life, I was also studying for the psychiatric boards and had been reading the section on psychosis out of what was considered the bible of psychiatric information: Freedman, Kaplan and Sadock’s Comprehensive Textbook of Psychiatry. I had awakened anxiously the night before John arrived with this dream:

I am back at the Milwaukee County Mental Health Center, where I had worked for many years post residency. I called the medical director about an escaped chronic psychotic patient who is planning to murder me. He is finally caught and brought to talk with me. A huge man, slumped over with arms that droop and hang down apelike. He tells me his name is Al de Half. He looks absolutely enraged with me, saying that I have been reading the wrong books. He pulls out a book and says, “This is my Bible.” It is A Separate Reality, Carlos Castaneda’s book about Don Juan, the Mexican shaman. I tell him I have read it, but he comments sarcastically, “Apparently not very well.” He begins showing me a page from the book with eight principles on it, when I awake.

John and I sat up late, talking about the hoped-for paper and also about my meeting with Al de Half. He felt that a visitation by an unknown man in the dream was very important and related somehow to the conference. He also thought that even though most dreams are personal, this dream was making a comment about ways of looking at and working with psychotic or extreme states of reality.

Al de Half, Al de Half, he kept saying over and over again — then suddenly, with a look of apparent discovery said, “Say it very fast and keep repeating it.” I began repeating the name, quicker and quicker, one on top of the next, until suddenly it began to sound like ‘my other half.’

“Yes, that’s it,” said John. “Al de Half is your other half, a deeper wisdom than your everyday ego identity. Jung might call him an image of the Self and he clearly lives in another world, separate from our everyday reality, with its own rules — what Jung called the collective unconscious. I would write your paper from that point of view, wondering what Al might say those eight principles are.”

“John, that is a great idea,” I responded, clearly excited. “I don’t think that Al de Half is meaning techniques, but I imagine that he was most concerned about the background attitudes and feelings we bring to our work, what Amy and Arnold Mindell have called meta-skills. Techniques and methods only become useful after the crucial background beliefs and attitudes are brought to awareness.”

“I agree,” John quickly replied. “I am heading off to bed so as to let you get to your writing. This sounds just right.”

John headed off to bed and I stayed up most of the night imagining what Al would have said. Here are a few of those eight principles, written back in 1994, but still as cogent today when working with extreme states of consciousness.

1. Hercules’ sword be damned

There are many stories of Hercules’ adventures, but for the purposes of this paper, I would like to focus on his journey to Hades. As he drops down into the underworld, he finds it hazy, his vision fogged, moonlight and mist, nothing clear; certainly not his preferred bright and intelligible light of the sun. As he tries to acclimate to this new and unfamiliar world, two shades (ghosts of the dead) approach him. In a flash, Hercules draws his sword and beheads them. No questions, no sense of what they wanted, no relationship.

Hercules responds exactly as one would expect if he had been trained in our current schools of psychotherapy. The heroic ego is still our ideal, capturing new ground from the id, making knowing interpretations and usurping more power and mastery for itself. The schools are all grounded in psychotherapeutic techniques aimed at getting rid of the ghosts (symptoms) that approach us before allowing them any voice of their own. But even though this may appear to work in the day-world of neurosis, the world of psychosis is much different. It is bathed in moonlight and the separations of good and bad, black and white are not so distinct. Here, lack of clarity and being open to what Keats called “negative capability” is key — the ability to sit in confusion and not reach for the dividing sword of intellect and explanation so quickly. To be open to what Mindell calls “Deep Democracy.” This allows for the realization that you are not the only ruler of your psychic house and that all inner figures deserve a voice.

2. Panic can be the deadliest enemy

We can see from this last story that panic leads to Hercules’ precipitous reaction toward the shades. Panic is an extreme affective reaction brought on by the sympathetic nervous system responding to an overwhelming fear of the unknown. But what if Hercules could have been with someone encouraging a more understanding attitude toward the contents arising from the unconscious? Jung comments on this same idea in his introduction to John Perry’s book The Self in Psychotic Process when he says:

“One should not underrate the disastrous shock which patients undergo when they find themselves assailed by the intrusion of strange contents which they are unable to integrate. The mere fact that they have such ideas isolates them from their fellow women and men, and exposes them to irresistible panic, which often marks the outbreak of manifest psychosis. If, on the other hand, they meet with adequate understanding from their physician, they do not fall into panic because they are still understood by a human being and thus preserved from the disastrous shock of complete isolation.”²

In R.D. Laing’s book The Politics of Experience, he wrote a chapter called “The Ten Day Voyage.” In it, the patient was asked what would have made a difference in his treatment and he responded, “A sheet anchor, the feeling that someone understood.”³ These ideas of Laing’s and Jung’s were well-tested in the 1970s in facilities such as Diabasis and Soteria House, hospitalization alternative treatment facilities for people in psychotic states. When helpers met acute psychotic experiences (the shades of Hercules) with an attitude of openness and validation, they found that patients often came through these extreme states more rapidly than similar patients treated in more classic psychiatric hospital wards.^{4 5}

3. Random firing neurons do not exist

I took this comment from Sir Francis Crick,⁶ winner of the Nobel Prize for discovering the structure of DNA with James Watson and who later went on to become a dream researcher after his DNA fame. He implied that dreams were random neuron firings with a purely biological purpose. This theory when applied would make it very hard to validate a person’s dreaming experience as psychologically meaningful. Armed with this attitude, psychiatrists can easily compare psychosis to chronic physical illnesses caused by biochemical abnormalities and genetic predispositions. However, no matter how useful the biologic theory has been for science and somatic medicine and no matter what a patient’s genetic and medical history, they always have a psychology. That means that no matter how difficult to understand, the images and symbols that are arising still form a possible communication system. I believe in the irreducibility of a person’s psychology. This belief allows us to continue to look for new ways to work and communicate with patients in extreme states of consciousness, no matter what the prevailing biologic theories. The idea that a patient’s attitude could effect the long range outcome of their psychosis was shown in research by Soskis and Bower’s in 1969.⁷ They found that patients who were interested in how to make sense of their psychotic experiences had a much lower rate of recidivism that did the clients who considered the experiences as ‘nothing but’ part of a biochemical illness.

These are just a few of Al de Half’s imagined recommendations. I continue to believe that these are as useful and crucial today as they were when John and I worked on this dream over twenty years ago. In re-working this lecture for my book, I finished by saying this:

Nihilo tamen initium [ending yet beginning]

How could this be, that so much of what is laid out in this work is still not agreed upon or considered generally accepted knowledge in the field? I believe that we have been lulled to sleep by the biochemical model, and as Jung said, it has led to a sterility of thought. There is a dearth of funded research that offers exploration of psychotherapy for the psychoses, though the investigations out of Finland involving the ‘Need-Adapted Model,’ and the immensely successful ‘Open Dialogue’ programs along with NIMH’s RAISE studies in the United States are at least beginning to move the pendulum. This new wave of psychosocial treatments is encouraging, especially with the advent of the Hearing Voices Movement and the excitement and worldwide growth of The International Society for Psychological and Social Approaches to Psychosis.

However, no matter these very important and necessary moves away from the devastating beliefs of ‘The Age of the Brain’ era of the nineteen nineties, led by the bias of the P.R.A. May studies that denigrated milieu therapy for schizophrenia,⁸ it still does not go far enough in recognizing psychosis as an attempt by the psyche to heal itself. The most important message I take from Al de Half is the crucial realization that his world is a ‘separate reality’ and requires a radical change of imagination if we are to truly understand the patients that have entered this foreign land with him. Until psychiatric hospitals and their treatment units move back in time toward therapeutic milieus, longer stays, less medication and validating the environment as affecting the outcome of the process; until psychiatrists receive training in metaphor and symbol, finalistic causality and the idea that the psyche is capable of destroying itself to bring forth something new and possibly better, then we psychiatrists will stay enamored by quick medication interventions. We will continue gluing the pieces of Humpty-Dumpty back together again, into his old self, rather than realizing that the psyche was attempting, all along, to reimagine the person into their higher and truer self.

I will discuss in my next blog the continued adversarial attitude psychiatry and pharmacological researchers hold toward the amazing healing effects of placebos.