Wednesday, April 26, 2017

Comments by Ron Unger, LCSW

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  • Berezin writes that “I am opposed to the taking of all psychoactive drugs…” I wonder if that includes caffeine? I personally am not at all opposed to all use of psychoactive drugs, what I am opposed to is people pretending to be helpful and then offering (or sometimes forcing) drugs that are actually harmful to people in the circumstances in which they are offered. That’s something a little more complex.

    Speaking in very general terms, the problem with most psychiatric drugs is that they function to suppress something, so you have to keep taking them to keep whatever it is suppressed, and then the suppression gets in the way of emotional development in the long run. Or something like that. Psychedelic drugs have their own dangers, but their striking effects are around what they release rather than what they suppress (so they can often have profound effects when used only once.) How what is released is handled is then profoundly important, which is why I wouldn’t trust the average psychiatrist to have anything to do with the administration of these drugs. Helpers in this field would need a different kind of ethic.

    Society in general has been scared of psychedelics, because they tend to send people out of their conventional mind, rather than restrict or numb mental functioning as most psychiatric drugs do. But healing often does require getting out of the conventional mind, it requires going to places that look mad from conventional viewpoints. And while psychedelics are not the only way to do this, I think they could have their place if used with some wisdom.

  • Thanks to those who have already criticized Berezin’s post: the post itself seems unfortunately far from a thoughtful analysis of this complex subject.

    It might be worth bringing up a large study done a few years ago looking at the mental health consequences of doing psychedelics, outside of any “mental health” setting. Here’s what they found:

    “21,967 respondents (13.4% weighted) reported lifetime psychedelic use. There were no significant associations between lifetime use of any psychedelics, lifetime use of specific psychedelics (LSD, psilocybin, mescaline, peyote), or past year use of LSD and increased rate of any of the mental health outcomes. Rather, in several cases psychedelic use was associated with lower rate of mental health problems.” That’s from Psychedelics and Mental Health: A Population Study – http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0063972

    Anyway, that’s kind of hard to reconcile with the notion that psychedelic use will create hospital wards “full of psychedelically induced schizophrenia” as Berezin suggests.

    The truth may be much more complex. In random use of psychedelics, some people may have healing experiences that save them from otherwise going mad: others may go mad and end up in the system. With proper guidance, outcomes might be much more positive. Of course, if “guidance” is left up to those currently running the mental health system, there could be huge problems! But it would be nice to see a more thoughtful analysis of all the issues involved here.

  • Hi Ed, thanks for your comments. I agree with you that it’s very unfortunate that more people aren’t interested in really relating to people with “psychotic” experiences. I think our culture, and especially those in charge, want everything to be easily understandable and digestible, with appropriate boxes for everything – so a model that puts a label on people and then matches them with the appropriate pill is much more comprehensible than one that says there might be meaning and something worth listening to in even “crazy” talk!

    Fortunately there are at least some who are interested in this kind of psychological work. If you haven’t already, I suggest you check out ISPS, the international society for psychological and social approaches for psychosis. the US chapter’s website is http://isps-us.org/ and they will be having a conference in Portland OR this November.

  • I’ve been told by some others, after I wrote this article, that ACT does go further than I suggested, and could involve reflecting on some truth that may be within disturbing feelings etc. I don’t doubt that they are correct. But I would point out that common ACT metaphors are presented in a much more black and white way, as when people are just instructed to essentially ignore the behavior of the “passengers on the bus” while thinking about where to drive the bus.

    I would contrast that with the way people in the hearing voices network tend to talk about as a preferred way of handling voices. There the emphasis is more explicitly on having a dual method: there’s a time both for listening to the voices and a time for not listening (and when they are listened to, they don’t need to be taken literally – just as one may listen to a child, and “hear” that the child needs a nap, which wasn’t what the child literally said.

    So what I’m thinking is that if ACT would be more explicit up front about how both strategies are needed at different times – and if it would provide examples of how trouble can also be caused by getting too carried away with NOT listening to disturbing thoughts or feelings – then I would find it a more complete model.

  • My apologies, it turns out my post told people that non-professionals could enroll in the two online courses for free until 3/29/17, but then didn’t give the links for that! They are CBT for Psychosis at https://www.udemy.com/cbt-for-psychosis/?couponCode=SCHOLAR_SPRING_2017 , and Trauma, Dissociation and Psychosis at https://www.udemy.com/working-with-trauma-dissociation-and-psychosis/?couponCode=SCHOLAR_SPRING_2017 .

  • Yes, I’ve followed the thinking and strategies used in Acceptance and Commitment Therapy, and I use some of it. I wouldn’t though frame it as “modern CBT” but just a new “wave” of thinking and practice, sometimes bringing in genuinely new and helpful stuff, and sometimes only managing to sound new because of the way it distorts discussion of what came before, and sometimes even a bit shallow and not so helpful!

    Anyone interested in more about my thoughts on this might want to check out an earlier post of mine, “Acceptance and Commitment Therapy for Psychosis: A Valuable Contribution Despite Major Flaws” at https://www.madinamerica.com/2013/09/acceptance-commitment-therapy-psychosis-highly-valuable-contribution-despite-major-flaws/

  • Yes, I guess I could have said that better – I meant that people are sent to psychiatrists not to receive understanding, human connection, and exploring together, but rather just to receive pills, as you guessed.

    Bertram Karon is certainly one of the more important people in the history of therapy for psychosis! He wrote the book “Psychotherapy of Schizophrenia: The Treatment of Choice” and did research showing that experienced and motivated therapists could get better results with therapy and no drugs than conventional treatment could get with drugs. A recorded webinar with Bertram is available at http://isps-us.org/webinars.php (bottom of the page)

  • I agree with your points John. I’m in favor of noticing all the ways people can possibly be helped, and even when one way seems “better” I want to stay curious about how it may only be better in some circumstances and not others.

    It would be great to see mental health systems start seeing lived experience of psychosis as a plus rather than a minus for all mental health positions! At the same time, I hope we keep paying attention to all the factors that are involved in truly being helpful, and notice how it is indeed possible for people with lived experience to be unhelpful, and vice versa (and also having lived experience of some kind of “madness” is not the same as having lived experience of exactly what someone else is going through – we can notice similarities, but it is never the same.)

    And I think it helps to understand that we are all a bit mad, and for professionals who haven’t been overtly “psychotic” to still talk about their crazier experiences, perceptions, doubts, etc. As humans we are all peers in not being quite sure what true sanity is, and being on a turbulent quest to figure out what that might be. If we can meet on that dimension, their is hope for us.

  • Well, most grand visions are pretty hard to put into practice, and do require a lot of luck. but every now and again, progress does happen! Getting even some people to change their understanding then opens doors that some people slip through, even though the masses may still be stuck. Civil rights work did change social attitudes around racism some, even though it’s still a huge problem. So, maybe work for change, but don’t hold your breath?

  • Hi Nomadic,

    I certainly agree with you that just changing how one thinks, without taking action, and dealing with conflicts, is not going to work! But I “think” it is also a mistake to believe that changes in thinking have no role to play. Coming up with new strategies and perspectives about how to handle conflicts is often very helpful! If that makes sense to you, then maybe it also makes sense that at least some talk with others aimed at developing new thoughts or strategies for life etc. might be helpful and not harmful?

  • Hi Kayla, I agree change is difficult, but it does happen here or there. Sometimes someone in an organization starts to listen and opens things up, other times enough of the public might take an interest in pushing organizations to change.

    By the way, I encourage everyone to check out this pamphlet produced by the Felton Institute about trauma and psychosis. http://felton.org/wp-content/uploads/2016/11/Trauma-Early-Psychosis.pdf or this one on diagnosis http://felton.org/wp-content/uploads/2016/11/Diagnosis-Early-Psychosis-UPDATED.pdf

  • I don’t have any reason to believe that the authors of the NAVIGATE Family Manual were any different than those listed, but it is always possible that ghost writing was going on.

    I do know that the whole biochemical imbalance myth is super convenient for pushing people to quit asking questions and just take their drugs, and I suspect it’s that convenience that causes this lie to still be featured within the NAVIGATE program.

  • Thanks Matt, for all the points you added.

    Regarding the “blame” thing – I guess I’m wary of bending over backwards to avoid using that word. If there’s a car wreck, we understand it makes sense to figure out who was to blame, even if we still understand it was an accident, and we aren’t condemning anyone as being a terrible person. Going too far out of our way to avoid being blaming just makes it harder to make sense of what happened and how to prevent it in the future. On the other hand I do agree it makes sense to be compassionate also toward those who made mistakes that led to problems.

    And yes, I certainly think NAVIGATE is more influenced by big pharma than by the child molesters, though on this issue, their interests line up pretty well! I did start to write a little about that, but it didn’t make it into my final draft.

  • Yes, it is discouraging. But I think it’s something we have to watch out for: there are organized forces that don’t want to hear anything new and that will pretend to be humanistic and forward thinking while hiding at their core the same old toxic slop.

    And then there are organizations that will take in some of the more progressive viewpoints but just kind of mix it in with various kinds of misinformation. For example EASA, Oregon’s early intervention program, will admit that trauma can contribute to psychosis, or that anyone can possibly experience psychosis under the right conditions, but also portrays psychosis as definitely a medical condition, suggests that “schizophrenia” can cause psychosis (rather than it just being a label used for when something causes psychosis and other problems over a certain period of time), etc. See http://www.easacommunity.org/what-is-psychosis.php

  • I think the idea that “there is no right and wrong way to perceive reality” can be sorely tested when people start taking actions based on really different views of reality. If someone decides for example that in their reality I am a demon who needs to be killed, I may have some complaints. If a bunch of people decide that that what I believe to be the greatest threat to humanity is really no threat at all, and so they take power and organize action that I believe will vastly accelerate that threat to humanity, I may see a problem with that as well.

    So I think there really are dilemmas that occur. Certainly it makes sense for professionals to be less sure of themselves than they are in the standard mental health system, and to open a space for multiple perspectives where possible. In Open Dialogue, they try to create a space where big decisions can be put off, while different ideas about what is objective and what should be done can be discussed. I’m all in favor of that, but I’m not in favor of thinking that different views of reality don’t have consequences – it seems to me instead that at times differences in views can lead to very dire consequences, which is why it is important to create a space where other views can be heard and things can be sorted out in a wise way.

  • I can simply say I have talked to young people who were depressed who didn’t seem to have a distinct pattern of emotional abuse by caretakers. That doesn’t mean of course that the caretakers were perfect, just that they seemed average, both in my estimation and in that of the young people themselves. Of course, young people can have emotional challenges created by many other kinds of misfortune, bullying at school, and all sorts of other mistreatment, as well as the fact that more sensitive young people are more deeply affected by the emotional sicknesses and abuses perpetrated by our society as a whole.

    I haven’t done any studies myself about the overall percentages who have had what kind of experiences, so I won’t try to estimate what percentage has had or not had emotional abuse by their primary caretakers. I just know I wouldn’t support the idea that it is 100%. I think people’s lives are more possibly complex than that, and we should be interested in getting people’s actual story rather than making fixed assumptions that may not be true.

  • I agree it is not always clear who is the “bully” and who the “victim” – but as a practical matter, we might have to try and decide, with the only other alternative being to let the bullying continue, throwing up our hands and saying we can’t do anything because we can’t hope to understand what is going on.

    One of the dilemmas in life is that we can’t fully understand human relations and other important matters, they are too complex (whether looking at them from the outside or the inside) – and yet we do have to make decisions about what to do, guided by the best understanding we have.

    To address this, we might act when we see an urgency to do so, but then humbly step back into something closer to what Alex is calling unconditional compassion. So one child appears to be beating up another – one might intervene to stop the beating, but then attempt to understand both children, and the situation, from that place of deeper compassion. Similarly, one might have to actively oppose a voice (with a person) or a political group (within a society) but then also turn toward that same voice or political group with compassion, an interest in getting to know other perspectives and unmet wants and needs, etc.

  • Regarding the two headed monster of the prison system and the mainstream mental health system, I would note that both are rooted in a desire to control whatever is disturbing. So when control is overemphasized, then such systems become very oppressive.

    With mental health it’s a little more complex because many people are seeking help from it not to get control of others who are disturbing them but to get help to control stuff about themselves which seems out of control. So some people come in seeking drugs or even asking to be hospitalized.

    Regarding the value of contemplation: when issues are complex, there is some danger in just jumping in with action that isn’t thought out – such action can often inadvertently feel the problem itself. So I believe there is a place for finding a spot of calm or even doing nothing for a bit, which then allows us to act from a place of clarity and thoughtfulness. But it is also important to act swiftly enough, and so the best balance of contemplation versus rushing to action varies by situation.

  • Thanks Steve, for your comment! I agree with you that the issue you are talking about is very important. Not every depressed teenager has been emotionally abused by caretakers, but there is some kind of story to their distress, and we certainly need to be curious about that rather than simply proclaiming they have a “depressive illness” or “biochemical imbalance!”

  • Yes, it was a great story, thanks Caleb for sharing it! Regarding the fear of another episode: I like what Ron Bassman said about vulnerability to future episodes. He said, if I remember correctly, that when people really come to understand what they went through and what it took to recover, that they often become less vulnerable to a future episode than people who have never been through one. Because they know the territory and just what to do if they start slipping into anything. So it’s good to keep that in mind as a possibility.

  • Hi Frank, I would tend to agree, most of history is full of examples of groups of humans acting in a way that is far from “sane” or especially far from “wise” – but lots of us are fearing we will soon see new lows in this country that go far below what we’ve seen in our lifetimes.

    As for what is wise, trying to describe it is itself tricky. In some ways for example tolerance seems to be a virtue, but in some cases it isn’t, as in tolerating lies and fraud, tolerating rape and child abuse, tolerating human rights violations in the mental health system, etc. So wisdom is often seen as closely related to “discernment” or knowing where to draw the line in regards to tolerance…..

  • Hi Richard,

    I think you may be reading things into my brief sketch that I didn’t intend. I don’t find myself having any sharp disagreements with your comments, so we may only differ in nuance. I like you see a need for both dialogue and confrontation. And I share your desire for a society that exists for all, not for the advantages of some over others.

    Compassion and fighting have an interesting relationship. It might be compassion for a vulnerable person for example that causes one to confront and battle with someone who threatens that vulnerable person. That’s one level of compassion. But once we are successfully defending the vulnerable person, then we might notice it might also be important to have compassion for the person who threatened the vulnerable person – what was going on with that, what were the misguided wants and needs that led to the threatening behavior, how can we make peace with that person? At least, this makes sense if the threatening person is a member of our community or even our family.

    And at some point, we do have to be one nation. So it doesn’t work to just confront, we have to also pay attention to what is going on underneath, even if that isn’t the first thing we do. Just like a person with terrible voices might have to first learn to resist having those voices take over, but later learn to also have compassion for them and relate to the underlying needs that the voices represent.

  • Oldhead, your comment only makes sense if you ignore the fact that people have lots of problems with things that might be called mental health difficulties, even before they ever encounter any “treatment” or “mistreatment” by the mental health system. Lots of people seek help, and they aren’t crazy for looking for help, because they really are having trouble. Further, they do sometimes currently even get help, for example by good counselors, or doctors that might help them with a physical health condition related to their problem, or whatever.

    We wouldn’t be talking about alternatives like Soteria and Open Dialogue if people hadn’t experimented with various kinds of incremental change. Soteria for example evolved out of alternatives that were first tried within mental hospital wards, and Open Dialogue evolved out of family therapy and psychodynamic approaches.

  • While you are correct to point out the large barriers to incremental change, the problem I see is that the barriers to revolutionary change are even bigger! So it’s easy to call for revolution, but not so easy to make it happen.

    There could though be incremental changes that then set us up for bigger, revolutionary changes. So instead of seeing it as either/or, it would be more of a both/and strategy.

    For example, we need to have smaller “alternative” programs get started within the current system, just to create the awareness of what is possible and to test out how to really make it work. And then we need to build support for such things, so people actually see the need for the revolutionary changes you talk about.

  • I think Masson’s reasoning is a good example of how one can reach an apparently hard and strong conclusion by defining the meaning of things a certain way, even though the range of possible meanings is much broader and the hard conclusion being made is not justified.

    While you report that he defines the task of therapy as being “to change people” I believe better therapists see the task more as being to help people consider where or if they want to change themselves and to help them see options for doing that.

    To do this, therapists do bring in or draw attention to other viewpoints, not just their own but also those of others. This sort of dialogue creates a sense of options about how to look at things, but it remains the individuals choice what to go with amongst those options.

    Therapists are not lawyers or cops, nor a good substitute for them. But I have found them useful for myself at a point and I often see good therapy being helpful, even though the potential for it to to practiced abusively also remains a reality.

  • Very well said, you made a lot of very important points, clearly, with few words! And you tell a compelling story.

    The sticking point though in getting action is probably is that you are asking legislators to “second guess” people seen as medical doctors, and that’s a bit taboo in our society. I wish someone could come up with a way to overcome that – the best I can think of is to gather more dissidents within the medical profession, so legislators would feel they have at least some “doctors” on their side!

  • Hmmm, I agree with the first part, that to be really healthy we do need to feel our feelings, and to really hear from all of our psyche, or in Open Dialogue terms, “let all the voices be heard.”

    And I guess I agree all 4 of the things you cite MIGHT get in the way. Psychiatry and the more oppressive forms of religion do indeed routinely get in the way. But when therapy is good, I don’t believe it gets in the way. And while bad notions of recovery can get in the way, by creating a narrow sense of what people have to “get back to,” the wider idea of recovery I think is still important and helpful – people in our current mental health system are still too likely to be seen as stuck with problems rather than able to “recover” from them.

    In Law’s story, he himself first identified himself as having mental problems, and sought help with them. He didn’t of course seek to be locked up, not talked to, and injected with mind numbing drugs, but he did have a problem and was seeking help. That’s pretty common for people. The key thing is that we learn how to provide help that is really helpful, that leads to people “recovering” on their own terms, as Law was able to do. Anyway, that’s what I’m working for.

    Thanks for commenting, and thanks to all the others who have expressed appreciation for this post!

  • It is indeed “maddening” to have the system label as “delusion” thoughts which are actually quite “evidence based” such as the notion that neuroleptics are, at least to some extent, poisons, and can lead to death.

    But, to keep on the “high ground” I do think we need to avoid making claims we can’t really back up. So whenever someone on MIA says that the drugs are what’s responsible for people in the public mental health system living on average 25 years less, I think it’s worth reminding everyone that the drugs are not the only cause of the early deaths, even though it appears likely they play a huge role. (Poor people who have extensive trauma histories tend to die earlier even when not exposed to these drugs!)

    We sound more dramatic when we claim the drugs are entirely responsible for the problem of early death, but we also risk sounding biased and unscientific, out of touch with what is actually happening. Let’s just keep the attention on the fact that the drugs do shorten many lives while on average reducing chances for recovery – that is damming evidence enough.

  • Hi Richard,

    It seems we are on the same page with this one!

    One flaw I would see with “coping mechanisms” is just the “mechanical” emphasis. But that term also has some advantages as you suggest. Whatever term we use, the key thing is to recognize the way the same sort of response can help up to some point or in some situation but then not when things are different.

  • Hi Ragnarok,

    I think your point about how people can develop coping mechanisms for their own coping mechanisms that they are having trouble with, is very important! It suggests something which I think is true, which is that we can develop layers of such problems. None of it is well described as “illness” but it can be a mess. Still, it’s discerning what is what, and what is truly helpful in what situation, that helps sort it out.

  • Certainly it makes sense to focus on prevention – but it also makes sense to help those who have already been hurt etc. For example it makes sense to try to prevent kids getting broken bones, but you don’t put all the dollars into prevention and neglect the kids who have the broken bones already.

    And even if we make our families and schools and society more functional, I think some people will still have problems. Life is tricky, for example some kids get hurt even when they play on reasonably safe playgrounds. We are somewhat chaotic systems, breakdowns can happen, but we put ourselves together better when we can see purpose in all the different parts of ourselves.

  • My rough definition for “psychosis” is that it means being out of touch with what others call reality, and/or disorganized, in a way that causes serious problems. Of course we are all somewhat out of touch with what others see as reality, and somewhat disorganized, so none of this is black and white. And a person can be out of touch with what others see as reality, but more in touch than many others with something that may be very important: so it’s sometimes complex.

    I hear your argument that we should just give up the word psychosis, but those of us who are trying to be helpful to people with such issues need some way of talking about these kind of problems. Some use the term “extreme states” or “madness” but those don’t have super precise definitions either. In a way I think it’s good the term isn’t very precise, because in reality each person’s experience and problems are unique, there’s always a lot to explore.

  • Hi oldhead,

    In my line of work – as an “outpatient” mental health counselor, I tend to see people who voluntarily seek out psychiatric approaches because that’s the only way they know to deal with what seem to be the “symptoms” that disturb them. I try to show them that a different way is possible. I do think the problem starts with the way people are taught to understand what is disturbing them, though there’s all the misinformation, and lack of information, that they get about the drugs on top of that.

  • Hi Naas,

    Thanks for sharing your experience!

    I think change is most likely to happen if we both notice good behavior, and good approaches, while we also criticize bad. One problem with just being a fundamentalist “anti-psychiatrist” is that then it’s impossible to recognize and support good psychiatric behavior (at least not without contradicting one’s anti-psychiatric principles!) As I’ve said elsewhere, I think it makes much more sense to be just opposed to bad and oppressive psychiatric practices, then there’s no contradiction in supporting good psychiatric practice.

    It’s just not true that all psychiatrists think they are treating “diseases.” Some of them are aware that much of what they see are just human reactions to life difficulty that are complex, and they see psychiatric drugs as a tool that might be useful in a sparing way to help people deal with these difficulties. And fortunately, those who practice well also learn how to help people get off the drugs when they aren’t needed anymore.

  • Hi Oldhead,

    I really out to get my photo for MIA updated, it is certainly misleading – still it shows me in my 50’s, and I’m 60 now, so not so young!

    My history opposing most of what we call psychiatry goes back to the 70’s. But I was inspired in that mostly by psychiatrists, especially Ronnie Laing, also Szasz to some extent, and older figures like Jung. And also my sense that standard psychiatry was the very opposite of what I needed when I was in crisis.

    I met David Oaks in the early 80’s, and we’ve collaborated on and off ever since. My only involvement in the mental health field until the later 90’s was as an activist protesting the system. But I decided to become a mental health worker so I could help develop alternatives instead of just talking about how they should exist.

    So my sense of resisting psychiatric oppression probably comes out of that history – I never saw the criticism of psychiatry offered by people like Laing as separate from the survivor movement, they were just different points of resistance against what was wrong.

    So I don’t think my perspective is naive – I’ve been doing this for a long time, I just think that positioning myself as opposed to bad and unhelpful psychiatric practice is a much stronger position than being “anti-psychiatry” in general.

  • Hi Steve, I think all the steps you suggest, including “revolution” of a sort makes sense – but your idea that incremental change is impossible is proven wrong by the fact that some psychiatrists are already changing their practice. That is incremental change in action. I’m not saying I think it will be enough, though, which is why I also like your other ideas.

  • I agree there are more unknowns than knowns, but still a lot to know. And these drugs don’t just affect the brain, they do a lot to other parts of the body. And a big part in being expert in prescribing the drugs would be knowing how to talk to people about them, especially how to talk to people who are in various kinds of crisis or extreme states. So there’s lots that your average MD would probably not be great at.

  • Did you see me somewhere generally recommend neuroleptics for “psychosis”? I think not, I would prefer to see something like the practice of Open Dialogue, where most people can be helped without any use of those drugs. But not every experience of psychosis or extreme states is the same, not all cases respond to even highly skilled help, and sometimes a bit of emotional deadening or drug induced indifference can help people come out of some horrible places even when nothing else is working. It would be best of course if the drugs can be used only very short term, and even better if we get improved ways of helping so we never need the drugs at all, but we aren’t there yet.

  • It’s true that someone who isn’t medically trained can know a lot about the drugs and possibly offer helpful advice, but things do get weird in the way these drugs affect people sometimes, it still would be great to have people who had full medical training and could understand some of the complexities. Again, not that most of our current psychiatrists do, just that they should.

  • I think the complexity of the way particular psychiatric drugs affect particular individuals is actually a good argument for having people who really study that and specialize in understanding what is possible and how to work with it – I’m not suggesting your average modern psychiatrist does anything like that, only that there is reason to have medical specialists who do try to figure all that out. Your street dealers or witch doctors (who may have their own area of expertise, not to knock them) are not going to have that expertise about psychiatric drugs.

    And yes, I do agree with Gotszsche, that we would easily be better off with no psychiatric drugs at all, than with them being used the way they are. But I’m not proposing we continue to use them as we are: I’m proposing we have some kind of medical specialty that uses them very sparingly and “slowly,” only when there is a strong need and when other things aren’t working.

  • There was a day when most doctors delivered babies without washing their hands in between, and many fatalities resulted. One guy bucked the trend and noticed hand washing worked better (they ignored him and he ended up in an insane asylum!) But his bucking the trend didn’t mean that “real doctors” were people who failed to wash their hands in between deliveries: instead the exception became the rule as the importance of hand washing was eventually recognized.

    See http://www.npr.org/sections/health-shots/2015/01/12/375663920/the-doctor-who-championed-hand-washing-and-saved-women-s-lives

    So that’s my argument for paying attention to exceptions, and then teaching others the better ways, I suspect that will be more effective than just condemning everyone, including those who are doing a good job or might do so in the future.

  • Oldhead, you seem to be stuck in believing that all psychiatrists believe or propose that they are always treating diseases, even when they have no real evidence of that. But that’s not true: some of them know they are often just offering some medical interventions into what are actually very thorny problems people experience which have social, personal, and existential or personal dimensions, and which can be disabling or overwhelming. These problems do exist and offering to help with them is not fraud. Nor is it fraudulent to notice when physical health conditions seem to be leading to mental and emotional difficulties, or vice versa, and to have ideas about what to do about that.

    Actually it just takes one exception to show that a rule is not an absolute. What would be good to do is to make what is now exceptional into something common, and to define much of what is now common as malpractice.

  • I think we have to get beyond overly simplified statements such as “in today’s world Psychiatry does in fact equal multiple forms of oppression then “slowing down” psychiatry is still means preserving oppression.” Actually any number of things go on under the heading “psychiatry” in today’s world, much of it quite bad and oppressive, and some of it quite helpful. Many of our movement’s heroes have been psychiatrists, and they continued to practice psychiatry as they critiqued the bad psychiatry they say going on all around them.

    In general, being against bad psychiatry makes way more sense than simply being “against psychiatry” in my opinion. I think taking a sledgehammer approach makes our whole movement look uninformed, uncritical and insensitive – really the reason I argue this point is I want to see us coming from a sounder position.

    It’s easy to say one doesn’t need a psychiatrist to prescribe drugs for a limited period of time – but to find a medical person who say can really talk to and understand someone in an extreme state, who knows not just the drugs but also a lot about the alternatives that might work, who can resist the panicked relatives and maybe the panic of the patient who wants more drugs right now enough to move with caution, while still making wise choices to prescribe when that makes sense – that isn’t going to be your run of the mill doctor.

    Sure, it makes sense for all doctors to know something about this, there’s all kinds of things doctors should know something about. But we have specialists for a reason, and its because when problems become complex and the simple stuff isn’t working, it helps to meet with someone who knows a bit more.

    I know today’s psychiatrists usually aren’t the sort of specialist I’m talking about, but some of them are, and we do have reason to have a specialty like that.

  • Hi Richard,

    I think you are mistakenly concluding from my failure to list all the forms of psychiatric oppression, that I am unfamiliar with them. I’m pretty familiar.

    And I made no reference to simply “slowing down” oppression. Instead, the reference was to slowing down and being more cautious with things like the use of drugs, or concluding that some medical problem was/is contributing to some mental and emotional difficulties.

    Do you really think that all use of drugs for mental and emotional difficulties, at any point, is a mistake? Or that it is always a mistake to conclude that medical problems can be causing or contributing to mental and emotional problems? If these sorts of things sometimes are not mistakes, then it makes sense to slow down in the way I’m talking about.

    I don’t agree that advocating that some doctors be trained in how to work well with people in extreme mental and emotional states is the same as attempting to legitimize the ultimate scientific separation of “mind and body.” Sure it would be nice to think that all doctors could be trained to work well with these issues, but I don’t think that’s very possible or practical.

    I agree that there are so many ways the “train” of psychiatry needs to be reversed, but I’m also trying to notice the positive tasks which are medical in nature that some individuals are trying to carry out. I think these issues are worth talking about, even if I have to go against the MIA mainstream in order to assert that!

    I’ve never been very good at sticking to the mainstream……..

  • I’m not so convinced that the government is always unhelpful. After all, Soteria was a government sponsored intervention, Open Dialogue is government sponsored in Finland, and here in Oregon where I live, the government pays for people to go see counselors who are often helpful, no drugging or belief in “mental illness” required.
    When people get in big trouble and can’t take care of themselves, the government does often get involved. I’d just like to see that happen in a good way, not that it’s easy to make that happen.

  • Uprising, if you knew me very well, I doubt you would accuse me of “trying to preserve psychiatry at all costs!” Most of my comments on psychiatric practices are extremely critical, and I have no problem saying that I believe psychiatry as it exists is doing more harm than good. But if we are to be effective as critics, we need to come across as thoughtful, not simplistic and dismissive, so that means also being willing to consider where something like psychiatry might possibly do some good.

    And as I said in my blog post, I would be fine with eliminating psychiatry, and then starting over with something new. But I do think we would need some kind of medical specialty to accomplish the objectives I outlined. General M.D.s cannot be expected to know enough to carry out those objectives well in complex cases. I think anyone, including Hickey or Burstow, who might want to argue that we don’t need such a medical specialty, to be convincing would have to show a better way of accomplishing all those objectives – something I haven’t yet seen in all the comments so far.

  • Hi Oldhead,

    I hear your contention that psychiatry as a whole is necessarily built on fraud: I just disagree with you.

    I would agree that mainstream psychiatrists base what they do on beliefs that are really delusional or fraudulent: the whole notion that problematic reactions to life events are “illnesses” or “brain disease” and that psychiatric drugs correct “chemical imbalances” is wrong, and harmful to believe.

    But psychiatrists like Sandra Steingard don’t subscribe to those beliefs, so there’s no need to follow such beliefs or anything fraudulent in order to be a psychiatrist.

  • I agree that more tolerance of human differences would be helpful, but again that is an issue that goes way beyond psychiatry. Sure, psychiatrists have been the agents of a society that didn’t want to or know how to tolerate differences, but if that same society didn’t have psychiatrists to turn to, then they would turn to someone else to handle the “problem.” Of course, prisons are sometimes turned to now for that reason, they aren’t so great either.

  • I think most or all of the psychiatric drugs can create “paradoxical reactions” which are the opposite of the intended effect. So it’s not as though the average non-psychotic person becomes psychotic in response to them, usually they become just more passive and tranquilized, but yet it is possible that psychosis is the result. Obviously, being aware of such possibilities and watching out for them is something we should expect from anyone prescribing such drugs, even if that is currently rare.

  • Hi Frank,

    I didn’t much into the use of force in this article, but I think the force question goes way beyond psychiatry itself. If we decided psychiatrists shouldn’t be in charge of mental health, which I think would be a good idea, there would still be the social/legal question of what to do when people seem due to their “extreme states” that they are a danger to themselves or others.

    Regarding your assertion that we would be better off with nothing like “slow psychiatry” – I wonder what you would propose instead, to address the issues I identified that “slow psychiatry” could help with?

  • I hadn’t heard of this BCAA approach before, it sounds intriguing. I agree it’s a problem that money doesn’t go into investigating stuff like this. One thing I would like to see is a tax put on the sale of Big Pharma drugs, that would then go to pay for research into stuff that can’t be patented, and that is more likely to actually lead to health.

  • Hi Someone else,

    I agree with you that mainstream psychiatrists are oh so far from being wise in the use of drugs! But I don’t think that’s because they want to make people more mad – rather the problem is more that they just believe what the greedy drug companies tell them, and they focus on the way that drugs seem to help people in the short term, without ever asking about what happens down the road.

  • I agree, resorting to drugs should best be seen an admission of the failure at this point of other strategies, and we should always be looking for ways to come up with better alternatives that won’t fail, so drug use can be minimized, since there is no evidence it is a good long term strategy and even using them short term creates a risk of long term dependence.

  • I think a good “slow psychiatrist” would themselves be a great ally in helping people escape from any need for psychiatric intervention! Trying to prescribe the minimum dose, or no dose when appropriate, and guiding people in looking for alternatives first or switching to alternatives even if/when drugs are used at some point, would all be tasks taken on by someone who was truly slow and cautious about psychiatric intervention.

  • I agree it what I am proposing would stretch a bit the common definition of what is medical. But it is medical in that medical training would be helpful in doing things like understanding the effects of drugs and their potential toxicities etc. Certainly they should be able to suggest any substance that was likely to help with particular issues, as you say with no illusion that the substance directly treats the illness, but with the notion it creates a drugged state of some kind that may be strategically helpful in coping at least for a while.

  • I should mention that I don’t think neuroleptics correct “psychosis” in any direct way: rather they usually induce a state of relative indifference, which then has the effect for many people of making them experience the world, and act, in a less “psychotic” way. Breggin I think is basically right in saying that all psychiatric drugs are disabling in some way: but sometimes temporarily disabling some function or other can be strategic when things are going very wrong and nothing else is working.

  • Thanks Nancy, for sharing these thoughts. The bit about meditation, the default network, and dementia is quite interesting!

    I would disagree though on the bit about all psychiatric drugs being equal to placebo. That’s pretty true of the so called antidpressants, but neuroleptics for psychosis, or stimulants to help kids pay attention to boring tasks (in the short term) do beat placebos most of the time I believe, even if they are also destructive in many ways and unwise in the long term (and stimulants for kids should probably be illegal.)

  • Hi Oldhead, in the blog post itself I said one option was completely eliminating psychiatry and replacing it with a new medical specialty, while the other option was reforming it. I didn’t take a position on which was the best approach. Like you I can see a lot of sense in just eliminating psychiatry since it has so many bad practices entrenched within it, but on the other hand it’s very difficult to just wipe out one medical specialty and replace it with another. Getting more psychiatrists to practice in better and slower ways, and then pointing out the problems with the more arrogant and corrupt ways of practicing, can lead to gradual change that we can get started in right now.

  • I agree it’s going to be hard for the slow psychiatry movement to get established, for the reasons you mentioned. But why do you think it will somehow be easier to just eliminate psychiatry completely? That seems even harder, the profession would fight back, and people who want some kind of medical help and their families would be their strong allies. If on the other hand we establish something like slow psychiatry, then we can use increased awareness of the problems with traditional psychiatry and the existence of an alternative to push for change, with the support of people and families who want medical help at times but in a form that is not arrogant and corrupt.

  • Hi Alex, I agree with you it usually doesn’t make much sense, and can even be quite dangerous, to look for help from modern “psychiatry” in general. But that isn’t what I’m proposing. I’m suggesting we think about how medical people might learn to specialize in actually being helpful instead of harmful, and I’m proposing there is a role for people who want to do that, at least when other things aren’t working.

  • Mania has various degrees of intensity, and then there are complicating factors, like what kind of supports are available, the person’s willingness or ability to engage those supports, etc. I think a variety of things might work, but for all of them, sometimes they might not work. So having a “slow” cautious and informed medical person might provide another option when other things don’t seem to be working.

  • Hi Kim,

    I know reforming psychiatry or replacing it with a wiser medical specialty sounds difficult, but I believe it’s probably way more practical than attempts to completely eliminate it with nothing to replace it! It’s not like we have an “Eliminate Psychiatry” button we can just push! I believe we are more likely to succeed in persuading the public and policy makers if we can show we have a better approach that covers all the bases, with one of those being the sorts of things I’ve been writing about.

  • Hi jimg,

    It’s good to hear about your recovery! And I agree with you that we should have hospitals or other respite centers that know how to offer people an alternative to just taking drugs right away. Even if the drugs seem to help, they then create a dependency that can be hard to get away from – and of course it’s even harder when all the professionals are insisting one should never stop taking the drugs!

  • Hi Steve,

    I agree with you about how mainstream psychiatry often does little of what I talk about (though I see psychiatrists who don’t seem that far from the mainstream do a little of it.) But my point is just to identify what should be happening, and to get people talking about it. It seems likely, that unless we have some kind of huge change in the mental health field that is hard to anticipate, most psychiatrists may continue to be corrupt for awhile – but why not help some envision a way to practice that would be truly helpful?

    You mentioned that you “don’t see how the profession will ever garner the humility to admit it has misled us and choose another path. ” One possibility might be that the better psychiatrists will create their own standards of practice, and once the public becomes aware of them, a good portion of the people will want what they have to offer and so some good things will happen, even as what is now mainstream psychiatry gradually loses credibility. I don’t know how long that will take, but even some movement in that direction will be helpful to those who get better care as a result of some medical professionals starting to practice in a more thoughtful and cautious way.

  • Hi madmom,

    You make lots of good points. I do think it would help to have medical experts who really understood how to support withdrawal. Uprising is correct to point out that many current psychiatrists are more causes of the problem and know next to nothing about how to solve it, but that doesn’t mean we couldn’t use people who really did understand the issues and who knew a lot more about how to support psychiatric drug withdrawal than the average GP.

  • Hi John, I definitely agree that psychiatrists should not dominate in treatment. I meant to make that part of my post, thanks for making that point now. Psychiatry’s claim to dominating treatment has been that the whole issue is really one of medical illness, when in fact the issues are often much broader than that, ranging from social problems to the very deepest questions about human meaning and existence.

  • Yes Fiachra, I definitely think most people can get better without drugs. I really hate the drugs in general, I think hating them is a good basis for a careful practice! But sometimes people face really tough problems, therapists etc. don’t always help, even in Open Dialogue where they are really skeptical of the drugs they sometimes turn toward using them. All I’m suggesting is that it does make sense we have people who use care and develop some expertise with the drugs – very different than the approach of modern psychiatry.

  • Hi BPDTransformation,

    I would certainly agree that psychiatry as it exists is largely corrupt, and as such it is often dangerous, and people often do well to get away from it if they can. What I focused on in my post though was what psychiatry might be like if it wasn’t corrupt.

    There already are psychiatrists like Sandra Steingard who can see the corruption that exists and are blazing a trail toward practices that really try to be helpful. And they can be at times: no, a “medical specialty focused on mental and emotional problems” is not like “a trash-removal company focused on skyscraper building.” People with severe mental and emotional problems often face situations where things are spiraling out of control, and medical tools, drugs, can sometimes cool things off for a bit in a very helpful way. Finding something to support sleep when a person is manic and most drugs aren’t working is a good example.

    I agree that only a very small bit of our approach to helping with mental and emotional problems should be drugs – but we would still need people wise in how to apply drugs. Ideally, medical specialists trying to be truly helpful would know a lot about how to hold off on prescribing in most situations, or until lots of other things had been tried.

    As for whether I think mental and emotional problems not caused by medical conditions are common – I did explicitly state that “I believe they more commonly are simply reactions to difficult events or environments….” But there is stuff in the DSM that is explicitly medical, such as dementia. And many other problems described in there can have biological contributions, like lead poisoning adding to attention and behavioral problems, thyroid problems contribution to depression, inflammation with its multiple causes playing a role in depression and anxiety, etc.

    Anyway those are my thoughts in response to your post…..

  • Hi Oldhead,

    I very much agree with you that the imagined “illnesses” of the DSM are no justification for a medical specialty such as psychiatry. But I’m asserting something different, which is that there might be value in a medical specialty that doesn’t imagine illnesses, but does things like become really familiar with how drugs might or might not help with mental and emotional problems, and that also has deeper knowledge of how some physical health issues might aggravate mental and emotional problems, or on the other hand how physical health issues might result from those problems. Sure one could go to a generalist MD for such issues, but just as in any other medical area, it might make more sense at times to have someone involved who has deeper expertise in a particular area.

  • Hi Someone Else,

    Thanks for your comments. Your story is an example of how each story is unique, and real help requires tuning in to what is going on for the specific person. People get blinded by their hopes that everything will be explained by using some fixed categories! Of course, we all try to fit things into categories to make sense of them, but the more we can do so in a tentative and humble way, also noticing when our categories don’t really fit, the more we have at least a chance at those mutually respectful and understandable conversations that can be healing.

  • Thanks Alex for sharing your thoughts.

    You wrote that the mental health system perpetuates and embeds distress and suffering, by creating an appearance of having a solution but not actually having one. I think that point is spot on. Professionals often feel better when they can assure themselves and others that they are doing the right thing and offering the best services possible, but in fact, there are so many unknowns in dealing with individuals that it is impossible to be sure of this. And being “sure of oneself” when one is headed in the wrong direction does not have a good prognosis.

    People who work dialogically on the other hand don’t pretend to know, instead they engage in discussions that explore what might be happening and what the different views about it are, and if that doesn’t work, they are willing to consider they might have gone about things in a way that was wrong for that person. It’s a much more humble approach, but ultimately I believe more effective on average.

  • Yes, I didn’t get into the problems with existing “treatment” approaches in this post, I figure there’s lots of other coverage on that!

    Though I think you (and some others) exaggerate when you blame the mental health system for all of the disparity we see in lifespan outcomes for the diagnosed versus not diagnosed. For one thing we know that people who’ve been traumatized, and who are poor and disenfranchised, are already likely to have shortened lives: see http://www.scientificamerican.com/article/childhood-adverse-event-life-expectancy-abuse-mortality/ and http://www.nytimes.com/2014/03/16/business/income-gap-meet-the-longevity-gap.html?_r=0
    So even before the mental health system gets to many, they already have a few strikes against their longevity. Of course better forms of treatment might reverse some of those effects and help people live longer instead of add on things like metabolic disorders and heart irregularities from drugs, along with reinforced hopelessness from excessively biological theories about what the trouble is……

    I think we are in agreement though about the central role dialogical approaches could make in moving toward a better system.

  • It sounds like an important study, but it’s kind of scary to see it set up to look at a period of only 2 years. As I recall in the Wunderink study, after just 2 years it looked like the maintenance group might have been better off, with significantly fewer relapses. And it might be even more important to have more than two years to show positive results of guided discontinuation for a group that had multiple psychotic episodes in the past. So I really hope the study is extended past 2 years, or else I fear it may possibly become a study that could be used to support maintenance treatment…..

  • Hi Someone Else,

    I do agree with you about the point that when people make believe people have an “illness” called “schizophrenia” that has little or nothing to do with what happened to them, that they are often participating in covering up what happened.

    It’s sort of as though someone came in with broken bones, and we identified them as having some kind of broken bone illness, probably caused by genes for bad bones. If they person had just been beaten by a gang, it would turn all the attention away from the gang. (Of course, we also couldn’t conclude that the presence of broken bones meant someone had just been assaulted, as broken bones can have other causes, and sometimes biological factors do play a role in creating vulnerability to broken bones – just ask David Oaks!)

    To stretch the analogy further, even though in the case of the gang assault, the real problem is with the gang, once the bones have been broken, the victim of the assault is in need of assistance, they do now have something wrong inside themselves. So then we need a kind of intervention that will promote long term healing, not just short term suppression of symptoms at the expense of making the long term worse. That’s a tricky area in many fields, and I don’t think the problem is just that psychiatry is sometimes corrupt, it’s also that it can be quite difficult to take the “long view” when immediate distress and confusion is intense.

  • Thanks Noel, for your excellent response to the hype around that study. Your thinking seems very clear, and it’s so sad to say that this sort of thinking is still rare!

    I had been working on a post about this same subject, I won’t post it to MIA because I think it mostly just covers the same ground in a less thorough fashion, but some of you might want to check it out, it’s “”Schizophrenia Breakthrough” – Or a Case of Ignoring the Most Important Evidence?” at
    http://isps-us.org/blog/

    One thing I touch on in that article is to point out that the NIMH is still pretending it is “unknown” what kind of psychosocial events might contribute to a later schizophrenia diagnosis – despite everything we know about childhood adversity and psychosis! It’s a scandal on the scale of the Catholic church hiding the facts about sexual abuse by priests!

  • One article on families you all might want to check out is THE REHABILITATION OF PSYCHOANALYSIS AND THE FAMILY IN PSYCHOSIS: RECOVERING FROM BLAMING by Brian Martinadale. It’s available at http://tinyurl.com/j3kd58h

    I like for example the distinction he makes between punitive guilt, which is not to be encouraged, and reparative guilt which can be constructive. Then there’s also a bit about projected guilt…..

  • Hi Someone Else,

    I agree that much of the current mental health system is the opposite of what is needed. But I think you paint an exaggerated picture, especially when you suggest that it’s obvious that the drugs are making things worse. Actually it takes a bit of detective work to see how they often make things worse – on the face of it people are more likely to notice ways the drugs seem to help, to calm down people who otherwise seem at extreme risk because of their agitation for example. And when people stop the drugs, that’s often when really severe problems pop up. Noticing that the drugs can make things worse over time (and that for some people, they make things worse even in the short term) takes some more attentiveness to detail, and noticing how things can be tricky.

  • Hi Alex,

    I would agree with you that most of the dominant practices in the mental health field are about as sick as you describe. But I do work in the system and I see good things and practices and people here and there as well, so it isn’t monolithic.

    so I am all in favor of condemning what’s wrong with the system, and I think it’s great when people tell the stories of what went wrong (and even better when people really listen, which isn’t often enough.) But I’m not in favor of just condemning everything about it, because there are those bits of it that involve people actually being helpful, here and there.

  • I don’t think anyone recovers just thanks to any system, because a lot of the work is done by the person and also people get help from families, friends and other kinds of allies.

    But I have heard stories where people did credit the mental health treatment they received as being pretty appropriate – and they were people now off drugs and in control of their lives. Of course, they had also encountered somewhat better practitioners, who didn’t peddle lifetime dependence on drugs and treatment.

  • Hi John, I noticed you said you were finding something “odd” about this discussion – I hope you didn’t think anyone was trying to minimize abuse when it happens or fail to acknowledge that it frequently is involved in causing later mental disturbance.

    I am a big fan of the work of John Read and others who have done research clearly showing that abuse, and especially extreme abuse, puts people at high risk of later having problems such as “psychosis.” Once course I teach is on trauma, dissociation and psychosis, and I’m currently working on making that available online.

    But I think what people are saying is that we can’t just assume that parents or other family members have been abusive. There are other kinds of events that can lead to “madness.” So it’s all about getting the actual story as best we can, and then figuring out what people can do starting from now to possibly make things better, including dealing with past traumas if that’s part of what happened.

  • Thanks Sa, for your kind words about this post!

    As for whether helpers can go wrong if they approach people with compassion, humility and an open mind, and then really listening to what they are saying – well I think these issues are so tricky that it is still possible to go wrong even with that approach, but at least if one has that attitude one is more likely to notice when one goes wrong, to apologize and then be willing to try something else!

  • I agree with you, Someone Else, that we need to talk about and understand the way the mental health system and other helpers can put “mad” people into binds and double binds, often without realizing they are doing so.

    But I think it’s also worth recognizing that it often isn’t easy for helpers, and they experience their own binds and double binds. For example, a helper may want to support autonomy in someone, but notice that everything they do to help the person get more freedom is used by the person to harm themselves, say by street drug use or moving toward suicide or other destructive things.

    I also think to work with these issues it’s important to appreciate nuance, and to notice when people and systems may not be all good or all bad. So while I think our current system is very flawed, and further flawed by the way it often avoids any discussion of those flaws, I also know many people who find various parts of what it offers helpful at various points, so I think it’s best not to paint with too broad a brush.

    Of course, I understand there are also individuals who have received nothing but harm from the system, I’m not arguing with those stories and I think we need to learn from them, it’s just that I also don’t want to assume that everyone’s story follows that trajectory.