Monday, July 15, 2019

Comments by Colin Bradley

Showing 34 of 34 comments.

  • I think you’ve got a good point there, and in some ways I agree. The existence or otherwise of ‘schizophrenia’ is a moot point really. There is a well described phenomenon of mental disturbance recognizable across different cultures and historical periods; calling it schizophrenia is really just a convention which is supposed to enable therapists and carers to have a common understanding of what it is – and just as importantly what it is not – we are talking about when we use the word.

    For example in Denmark before the coining of the word schizophrenia it used to be called “ungdoms sløvsind” which means mental lethargy or bluntness, in youth. This is very descriptive of what the problem is and why indeed it is a problem, because it provides an immediate contrast with the normal state of affairs; youth is the time of our lives when mental alertness, drive, and development of ideas and interests are at their peak. Yes, we’re all different all unique all individuals, yet certain things we all have in common enable each one of us with all our uniqueness, individuality and differences to be woven into the social fabric. To become, at this point in life, disinterested, demotivated, reclusive, anti social, and to just allow friends, family, studies, employment, pastimes, personal standards of care and hygiene to drift away and instead become completely absorbed in some inner world of experience quite impenetrable to onlookers, is abnormal and a legitimate cause for concern. Call it schizophrenia or by any other name, any person so entangled is not going to be able to live an independent life, while in the grip of the spell. I do not see it as failing to adapt so much as being maladaptive. We can quickly agree that society is ‘a mess’ but that, for me, does not make schizophrenia a ‘relevant or understandable response’.

    The point Kwame McKenzie is making about the epigenetics of the problem, if I understand it correctly, is that while we cannot simply ignore that there must be a genetic involvement in these very serious types of psychosis, the hope might be that human environmental influences (socially engineered) not only might compensate for negative effects of biological disadvantages, they may in fact hold the potential to modify the negative effects themselves at the biological level. This is for me a truly exciting prospect – one I often have tried to grapple with in abstract modes without ever having had the science to be able to articulate it in a way which could be accepted in any academic fraternity. It explains admirably for me why recovery is possible and why for example Open Dialog works.

    Which – after all – is partly what Whitaker is trying to tell us. There are in many cases alternative possibilities to medication in the treatment of schizophrenia which we – through laziness, ignorance, false economy, ideological dependence on models of treatment behind which there lie strong vested commercial interests, – are not exploiting fully. It is the other part of what he is trying to tell us – when he turns these sage observations on their head and in doing so tries to argue a ridiculous case for schizophrenia being an “epidemic” of medicine induced madness – which alienates me from his campaign, and prevents me from taking him seriously.

  • You then raise the spectre of homelessness and mental illness without mentioning the huge disparity between rich and poor . . .
    Not quite sure what point you’re making here John. Nobody is trying to say that mental illness causes homelessness other than those political parties who have made it a habit to blame the victims for so long that they take such things as self evident truths. Homelessness is created by bad and cynical governments which prioritize the cleansing of the backsides of the superstars of rapacious global capitalism, instead of raising and spending taxes on maintaining and improving social safety nets, for those in society who are not well enough equipped to compete for a decent living in the fashion most of us are expected to compete.

    I gather from some of the comments here that some people choose homelessness to escape psychiatry in the US and that is truly shocking if it is a widespresd phenomenon. This is unknown in Denmark where I live, even though community treatment orders, something I’m vehemently opposed to, were recently introduced in a restricted form for about “100 especially difficult cases nationwide” (as the political blurb phrased it in the attempt to make it palatable.) I’m pretty sure that “100” will soon become 2 or 300. But I live in hope that at some point it will become clear that it is a stupid law without any real effect, and be repealed.

    In Denmark it is illegal to live on the streets, and local authorities are bound by law to house homeless people. Being mentally ill and homeless will increase your chances of being admitted to a psychiatric ward about tenfold I’d guess. Not so in the US it seems. It was Fuller Torrey who raised the spectre of homelessness in his critique of “Anatomy of an Epidemic” and he seems to know quite a lot about the American side of things. His point was pretty clear I thought: Do you want to know about how people with an unmedicated mental illness fare? Then don’t just read about the few cases in the Harrow and Jobe study, but instead get out onto the streets in the big cities of America and talk to the vagabonds rummaging for food in the waste bins, and then come back and tell us whether schizophrenia is caused by medicine. Nobody has taken him up on it and I wonder why.

    I don’t know who would assess the quality of psychiatrists, or how it could be done fairly. I’ve met some I regarded as good and some exceptionally so, including some who would fit your definition. If patients and relatives subjective opinions are the best measure then there are endless surveys in DK which point to 60, 70, 80 and even 90% satisfaction levels with the treatment received. I’m sick to death of questionnaires and quality controls and neither take any interest in nor believe very much in them, but they are there. It’s the critical 10 – 25% who make most noise in the debate, and that’s OK of course, as long as the quiet majority don’t get forgotten.

  • @Seth

    You have no way of determining who is the “most severe.”
    No, I don’t. But that is just my point. Harrow and Jobe had no way of determining it either. Therefore the only certain conclusion to be drawn from the study is that about 25 % of people diagnosed with schizophrenia experience recovery whilst 25% remain chronic and the rest experience partial recovery. We simply cannot know if the people who took medicine and did badly would have done better if they had gone off medicine.

    @ John Hogget

    Nicely summed up. Thank you. I too think that it is a reasonable proposition that drugs can impede recovery for many.people, but I also think that it is a reasonable proposition that they can prevent catastrophe for some people. I only wish people would take care to err on the side of caution before rushing off to tell the world that ‘science has proved’ their point of view. That should apply to both sides of the debate of course. I do hope my manner has been decent and civilised. I have tried my best to argue my points in a sober and scientifically neutral mode, without insulting or speaking condescendingly to anyone.

    https://youtu.be/QxVY2Vptfwg

    This seems to me to offer a potential third way out of the impasse.

  • “There is room for you on ours.” Really? Somehow I doubt it. There’d first be room for me on the day I reformed my thoughts to fit yours. Until then MIA would prefer not to see or hear people like me on their site. Even though I’m actually not so radically removed from some of the points of view, – actually I’m pretty moderate and not at all a slave of the pharmaceutical industry. But because I’m not 100% against then as far as the extremists at MIA are concerned I’m as good as 100% sold to the APA and the Big Pharma. I don’t at all seem to be able get through with any kind of nuanced message.
    It’s not only I who is saying that there are schizophrenias that are relatively mild and others relatively severe. Regarding just the 70 people in the H&J study who had the schiz label: H&J themselves used differential prognoses because they had to try to qualify their point. And exactly therefore the tautology you’re trying to accuse me of, and which I agree 100% is a problem. enters into their analysis, and disqualifies it, from being any kind of valid proof that medication “causes schizophrenia”

  • @Seth

    I perceive that dialog doesn’t interest you very much. At least not dialog with me, as someone who potentially could be treated as one with thoughts and ideas equally worthy to your own, even if different. You work/think within an extremely narrow framework of ideas, and as long as my ideas don’t fit that framework you will patronize me if possible, instruct and teach me, help me see the error of my ways, but you will not enter into a real dialog with me. This is the impression your tone gives me.

    We would not be able to work together in any treatment/care setting, because good psychiatric care requires a robust flexibility, in order to be able to respond to sometimes very bizarre and even grotesque situations that can arise at the drop of a hat, a good sense of humour and an empathic understanding which does not preclude the responsibility for taking charge, setting limits, and imposing codes of behavioural etiquette. Intellectual rigidity and the discreet supercilious arrogance of one who ‘knows better’ does not work in these settings.

    I have not proved the APA wrong – I just haven’t taken any special interest in their dogma, because experience teaches one not to rely on dogma of any kind, if you want to be any real help to anyone. You are welcome to your interpretation of schizophrenia as spiritual crisis; I’ll continue to work with and develop my multi dimensional understanding of the illness.

    I’ve read both Szaz and Laing. They’re both very interesting though they apparently were professionally sworn enemies. I don’t presently have time for the other works you mention, but as I said a learned dissertation on schizophrenia as spiritual crisis I’d be willing to try.

    As for prognosis – no, in psychiatry prognosis cannot be predicted without consideration of behaviour. Quite true. In general a schizophrenia which manifests early in life with overwhelming negative symptoms, with severe ambivalence, loss of drive and motivation, anhedonism, and very pronounced social withdrawal, will receive a worse prognosis than a schizophrenia which first surfaces in the late twenties and is characterised by sudden and spectacular onset of positive symptoms, and fewer negative.

    I am indeed assuming that the APA has a similar function to similar bodies in other countries. It produces guidelines and standards for diagnosis and prognosis, but does not itself diagnose and give patients their individual prognoses. If there is just one prognosis for any and every schizophrenic patient as you seem to be suggesting, and no room for independent professional interpretation by doctors at the level of the individual patient, then how on earth could Harrow and Jobe have divided their schizophrenic groups by varying prognoses?

    But these prognoses are not guarantees or something proscribed by any human or natural law. The actual progression of a patient’s condition can completely make a mockery of prognoses and frequently does. The analogy with quantum physics is lost on me I’m afraid, but I concur naturally that observation infers a degree of subjectivity. And this is why prognostic differentials cannot give a study such as Harrow and Jobe’s the authority to pronounce a verdict on the influence of medicine on outcomes adjusted for prognosis. We cannot discount a factor of human error in setting a prognosis, and therefore we cannot eliminate the risk that such a study ends up merely demonstrating that less severe cases of schizophrenia open better chances for reducing or quitting medicine than severe cases. That’s not to say necessarily that it’s untrue that longterm medication hinders recovery, it’s just saying that the H&J study is not enough to prove it. Which is about all I ever intended to communicate with my contribution to this thread.

  • @Seth

    I had an idea that I would focus my energy narrowly just on Whitaker’s liberal exploitation of the Harrow and Jobe study without taking other aspects of the general discussion of psychiatry’s failings into consideration. The remark on his claim that eugenics played a major part in the building of asylums was an afterthought. Polemical discussions have a habit of branching out and thereafter quickly losing their way; hence my avoidance of answering some of your points. But you insist and so I’ll try to reply to your latest piece point for point, without branching deeply into other areas of discussion too much.

    What strikes me from your presentation of your arguments is that you have painted yourself into a corner where nothing other than strict orthodox adherence to the pure antipsychiatry path will be tolerated. Anyone who is not 100% with you is against you. It is almost as if it’s a kind of religion. That’s a great shame because I feel that there would otherwise be a good deal of fertile common ground where we could meet. I’m not American and don’t know much about the APA and the American approach to mental health. I’m not dependent on them for my own ideas and and opinions about schizophrenia; where I work the APA party line of which you speak has long since been abandoned if it ever really took root in the first place. If you are working to overthrow this kind orthodoxy then I can only say you have my best wishes, but if it means that you just end up replacing one set of dogmas with another set, then I don’t think any real progress will have been made.

    A little like Whitaker, who in spite of the fundamentalist tendencies exhibited in his book, actually says that he can see that psychopharmacological treatment is in some cases both relevant and necessary, my position is one which espouses minimal use of medicine and especially in the long term, since it seems to me quite a reasonable proposition that long term antipsychotic use caould be harmful to the body, even though I don’t believe the H & J study can be used to prove it. Again I’d have to say that I also know of persons in long term treatment for whom the harm is not immediately apparent, and it would not be difficult to imagine that much greater harm might have occurred had they attempted to manage their illness without drugs. That does NOT mean that I subscribe to a blanket philosophy of drug treatment for anyone with the slightest hint of a schizophrenic illness for the rest of their lives. Please understand that. And please explain why that would equate with “living in a bubble” and “insulting patients.”?

    Yes, patients get better without drugs – some patients anyway. That’s old news. Side effects and possible brain damage bother me a great deal – sorry if I forgot to mention it. Whatever the ‘party line’ is, what I’m interested in is reality. The reality is that prognosis is notoriously unreliable in psychiatry. Well you know that. You miss no opportunity to remind me that patients get better without medicine, and some even get better even though they take medicine. If the APA wants to give all these people a uniformly bad prognosis without any nuance whatever then yes of course – the APA is talking out of the part of the anatomy which is highest over ground level when one is plucking strawberries. But APA doesn’t actually make prognoses; it only sets guidelines. Doctors make prognoses. We are not at all in disagreement there as far as I can see, and prognoses were variable in the H & J study and most probably wildly inaccurate. So I don’t quite see the problem with comparing setting prognoses with picking a number from a hat, although obviously I exaggerate the case for the sake of emphasis.

    Schizophrenia is not a spiritual crisis in my view. If so it would certainly be a mystery. Few of the people I know with schizophrenia would think so either. Spiritual crises do not run in families as far as I know. Just what schizophrenia is, is of course a truly fascinating question, a question many people, myself included have given many years of thought to. We cannot cover that here, but I’m not so pigheaded that I would not be willing to read a learned dissertation on the subject of schizophrenia as spiritual crisis if there is one. My antipathy to this standpoint does not of course mean that I cannot accept that it is possible for a person with schizophrenia to experience a spiritual crisis, any more or less than the next person.

    ” . . . the drugs are addictive”. Hmmm. Well, what about an experiment? Take a bottle of Risperidon or Quetiapine tablets down town. See what you can get for them on the black market. You’ll still have your bottle of tablets with you when you eventually head home. No-one will want to buy them even if you cut the price to a loss making minimum. They are apparently not so addictive that anyone ever gets desperate to get hold of them. So I think you have to qualify that word ‘addictive’.

    I know of the Wunderink study but have not studied it in enough detail to judge it. I read that Wunderink was very ethically minded so he would not allow a blind study where patients went completely off medicine without their knowledge or that of their clinicians. If they did go off medicine then it was their own choice, but does that not then mean the study was not completely blind? And also if patients who were reducing started to get psychotic symptoms then they might be increased again or reduced more slowly. I’ll get round to studying it sometime. But I cannot comment on it yet.

    “Bob concedes that there are a small subset that might require them–20%” – again old news. We have known for many decades that up to 25% of people diagnosed with schizophrenia or 20% if broader diagnostic criteria are used, develop a chronic form of the illness, whether they receive medicin or not. You may well be right in this last point – if there were sufficient resources then it may be possible to look after these people in some way without the use of medicine. Here at any rate is an incidence of one chronic patient for whom an alternative program succeeded. But he was exceptional and no – sadly even in the richest countries resources are not so abundant that such a program could be supplied for the whole chronic population.

    http://ovartaci.dk/eng/kunstnere/ovartaci_eng.htm

  • @Seth

    As I’ve mentioned elsewhere, I’m no fanatic druggist, and I’m with you all the way in advocating minimal, professionally responsible and best possibly informed administration of these medicines. I know of several who successfully quit them, and I have recommended others to try it. On the other hand I know of people I would never have recommended trying and who nevertheless do try regularly, sadly with predictable and sometimes tragic results.

    If your statement is not a tautology–meaningless–you need an operational definition of less sick–basically it comes down to appearances
    which is also my point precisely. In order to promote his wild thesis that schizophrenia in our time is really an iatrogenic epidemic of drug induced side effects, (at his most shamanistic he seems to hint that schizophrenia might not even have existed before the introduction of neuroleptic medicine) Whitaker misrepresents a sober enough study to back up a theory, which the authors themselves never intended.

    We have known for the past two or three generations that schizophrenia remits spontaneously in some cases without help from drugs, sometimes partially sometimes completely. And we know that for some it never remits. Medicine or no medicine. The great problem is that we don’t know at the
    early stages how to identify who will experience remission and who will not. Harrow and Jobe understood that their study was potentially open to a bias in that it would be a natural tendency that anyone who could go off meds without relapsing too harshly probably would do so with time, whilst those who experienced insurmountable problems whenever they tried, would probably remain on medicine either by choice or by coercion. Under these circumstances it would be futile to postulate that medicine hinders recovery from schizophrenia, on the background of a study showing that after twenty years those still on medicine were doing worse than those who had gone off meds. Notwithstanding that we are speaking of tendencies here, to which there could, of course, be exceptions. There are simply too many possible causal unknowns to make any direct cause effect connection between medicine and poor performance. The best we can say is that we have a correlation.

    One of these unknowns is why and how schizophrenia manifests in individuals in such idiosyncratic ways, as to make most attempts at prognosis, little better than a lottery. Nevertheless the only option open to Harrow and Jobe to attempt to eliminate this unwanted potential bias, was to make use of these very uncertain prognoses (presumably authorized by a doctor) and see if prognosis made any difference in sorting medicated from non medicated outcomes. If the results show that regardless of prognosis nonmedicated outcomes are better then that would strengthen the case for saying that medicine hinders recovery, in as far as one could say prognoses are reliable. But if prognoses are not reliable then the wished for conclusion also runs the risk of ending as a tautology. ( Medicine prevents people getting better –> therefore people who give up medicine get better –> therefore medicine prevents people getting better) To their credit I think Harrow and Jobe understood the weakness of this part of the study, and confined their conclusion to pointing to the correlation and saying more research was needed.

    Not so Whitaker who uses the study as definitive proof that we are witness to a rampant epidemic of medicine induced mental illness in our society. And that, even though he himself says it is the only study of its kind, which you might think would prompt any serious researcher to take a pause for reflection, and realize that quite a few more studies of the kind would be needed to make any kind of definitive statement of the kinds he is making.

    I note however, that Whitaker turned up at a NAMI conference where he surprisingly delivered a very moderate speech acknowledging along the way that long-term use of antipsychotics is sometimes necessary and appropriate, and that open-dialogue treatment in Finland is still – for 20% of patients – supplemented by longer term psychopharmacological treatment. So maybe his position is not so far from mine.

  • @Seth

    You’re right to point out that it’s a self serving argument to say that the only scientifically reliable prognosis is one made in hindsight. Of course. But that’s the whole problem with trying to use the Harrow and Jobe study the way Whitaker does. Because every individual person is precisely an individual, with individual personality, individual neurophysiology, individual pathology if they fall ill, and individual responses to the variety of potential treatments, it is only meaningful to conclude that medicine worsens schizophrenia outcomes if you have rock solid 100% reliable prognoses for each individual, based not alone on diagnosis but also on each individual’s individuality. Because taking or not taking medicine is far from being the only factor which can influence the course of a psychotic illness. Personality for example has a huge bearing on how well a person can mobilize the resources necessary to counteract the debilitating effects of a schizophrenic relapse. Manifestation of symptoms does not necessarily always equate with “most sick.” Schizophrenia is an ego disintegrating experience; medicine can only help the re-integration process if it’s used wisely in conjunction relational based ego rebuilding therapies. And this is surely why Harrow and Jobe wisely caution that their study cannot be used for what Whitaker wants to use it for. There are too many unknowns, and because each unknown has the potential to interact with each of the other unknowns to disturb the predictive certainties which one might seek from the study, uncertainty rises exponentially in proportion with the number of unknowns.

    At the end of the day the only thing which can be concluded with certainty is that around 25% of the subjects experienced a recovery, and that of this twenty five percent (17 persons in all), 25% (4 persons) had managed it because of or in spite of the use of medicine, and 75% had managed it because of or in spite of staying off medicine. This is unfortunately simply not enough to able to conclude that more of the group which stayed on medicine would have experienced recovery if they had gone off it. They might instead simply have disappeared with the other 6 who disappeared. Who can tell? Not I and not Whitaker either. The study is therefore unremarkable other than that it does allow the general conclusion that the use of medicine statistically makes no difference to long term outcomes of schizophrenia, which remain stable at about 25%, in case there might be some drug companies that are trying to claim that drug use does make a difference to long term outcomes at the macro level. I don’t know if there are.

  • @Someone Else

    You make quite a lot of assumptions on my part, which I won’t spend a lot of time on. I don’t claim to be an expert, and I don’t believe Robert Whitaker is either. I have no delusions that neuroleptics are wonder drugs, nor am I in any way trying to agitate for any acceptance of neuroleptics as the best or only treatment of schizophrenia. These drugs are dangerous, just as many thousands of other drugs used in many other fields of medicine are, and should be used with great care. I know of no other way to explain the fact that the neuroleptic drugs can create (or mimic) the negative symptoms of ‘schizophrenia,’ other than from existing research which suggests that excess dopamine activity in the brain’s limbic system has some relation to, (but is by no means an exclusive cause of) the phenomenon of psychosis in human beings, among others the so-called positive symptoms of schizophrenia, and that a deficit of dopaminergic activity in the frontal cortical area is implicated in the so called negative symptoms of schizophrenia. A good psychiatrist is of course well aware of these pitfalls in treating psychosis with medicine, and takes suitable precautions. The bad psychiatrists must vouch for themselves.

    http://www.dialogues-cns.com/pdf/DialoguesClinNeurosci-8-137.pdf
    http://bjp.rcpsych.org/content/186/1/7

    To get back to the point – and the only point – of my comment in this thread; Robert Whitaker replies to Torrey Fuller’s very pertinent critique of Whitaker’s reading of the Harrow and Jobe longitudinal study of the progress or otherwise of 70 schizophrenia diagnosed patients over a twenty year period. Fuller claimed that Whitaker was reading conclusions into the study which the study in fact does not bear out, and which apparently Harrow and Jobe explicitly denied were to be found in the study. Whitaker’s reply is really no reply at all other than a very brief summary of the study with a link to a more or less completely uninformative slide show, and the comment “I’ll let readers of this blog decide whether such findings are—as Dr. Torrey writes— ‘completely unremarkable.’ ” As a reader of the blog my conclusion is that the findings are indeed – as Fuller says – completely unremarkable, for the reasons I wrote of in my previous comment. However good or evil anyone may want to argue psychiatry to be, the study provides no evidence one way or the other to support any conclusion of the kind. Schizophrenics continue to recover today in the days of modern psychiatry, at a rate of about 25% just as they did a hundred years ago before medicine came into the picture, and another about 25% become chronically ill. I don’t know if that part answers to a similar figure for chronicity pre 1920s. I would imagine this would be a much more difficult comparison because of differences in mortality rates and patterns. And as Fuller notes there may be up to a million unmedicated chronically mentally ill on the streets of the USA. (Strange that Whitaker has absolutely nothing to say about that.) The 6 (or 55 if we include all the other none schizophrenic patients ) who disappeared from Harrow and Jobe’s study over the twenty years, may today be among the million out there. Anyhow the part of Whitaker’s argument that recovery rates for schizophrenia have not improved despite the heralded scientific and pharmacological advances, seems to be vindicated. But his implicit and explicit conclusion to which end he is trying to misuse the Harrow and Jobe study, that schizophrenia incidence today is attaining epidemic proportions, and is doing so because of the use of antipsychotic medicine, remains the same nonsense it has been from the start.

  • Seems to me there’s at least one huge defect in the Harrow study which, for Whitakers thesis, is so axiomatic. It is this unquestioning assumption that ‘prognostic types’ are scientifically valid and reliable indicators. If we take this assumption out of the equation, then all we can conclude from the Harrow study is that severe schizophrenia and the tendency to use medicine correlate, whilst milder schizophrenia correlates with a diminished tendency to resort to medicine. That is of course exactly how it ought to be – one should only take medicine if one can’t manage without it. To assume that the poorer outcomes are actually caused by the medicine is, to put it mildly, jumping to conclusions. Because obviously, the alternative explanation is that it is the severest grade of schizophrenia which is causing the severest problems for a certain percentage of the sample, and quite naturally this subgroup is much more likely to attempt to solve the problem with medicine.

    Harrow tries to correct for this ambiguity by dividing his sample into good and bad prognosis, and weighing the relative merits of medicated and non medicated in each of these groups. But there is absolutely no guarantee whatever that these group matchings are reliable. Prognosis in physical health is often inaccurate – in mental health inaccuracy is notorious. Bleuler was already aware of this a hundred years ago and warned that his categories of schizophrenia only gave very approximate prognostic guidelines.

    Whitaker’s summary of the Harrow study is not consistent either as far as i can see. In 2. (Spectrum of outcomes in the schizophrenia group) he says that 39 of the 64 shizophrenic patients who remained had been continuously on medication whilst 25 stopped taking medicine. (We don’t get to know at what point.) In 7. (Sustained periods of recovery in the schizophrenia-spectrum group.) he writes that only 24 of the 64 patients continously took medicine. The difference could perhaps be explained by the first figures being the 15 year follow up and the second the twenty year follow up. Perhaps. If so then a reasonable conclusion would be that after twenty years the 24 most chronically ill were still taking medicine and, regardless of whatever prognosis they were given at the start, with hindsight it should have been these 24 who received the poorest prognosis.

    Again Whitaker is very unclear when in 7. he writes “In contrast, there were 15 in the group of 70 who were off antipsychotics by the two-year follow-up . . .”. Which group of seventy is that? The remaining group was 64, so does that mean we lost 6 along the way? What happened to those 6 could be statistically very significant in such a small sample as this.

    All in all, as far as I can make out from Whitaker’s incomplete summary, at least 17 of these schizophrenics could be counted ‘recovered’ at some point in the twenty years. 17 of 70 is . . . well . . . 25%. I have to agree with Torrey Fuller that this study does no more than confirm what has already been known for 80 years, and certainly does not succeed in shedding any light on the perplexing issue of whether chronicity in schizophrenia follows the course of taking medication or whether taking medication follows the course of chronicity.

    And talking of dishonesty I have to say that I suspect Whitaker’s account of the role of eugenics in getting people committed to psychiatric asylums in the mid to late 1800s to be largely a product of his own fantasy. I’ve never read this elsewhere, and in spite of Darwin’s genius, neither the scientific community nor the population at large had, at this point in history, any clear idea of the biological workings of inheritance. Horrific as the asylums no doubt were in many cases, they were nevertheless from a humanitarian point of view, a huge improvement on what went before them, and the building and direction of them was motivated by Victorian ideals of morality; indeed what we now call schizophrenia was widely thought to be a condition of moral inadequacy, which could and should be corrected by the careful application of moral treatments in a protected environment. Few, if any scientific or political administrators would have cherished any notion of this moral inadequacy being biologically inheritable, and we can be reasonably certain that the huge amounts of money spent in building and running these institutions was not motivated by the need to ” . . keep them from breeding.” as Whitaker so charmingly phrases it. The notion is reprehensible and dishonest.

  • Seems that neo-con/lib (for us in Europe a Liberal is just another kind of Conservative – we
    still have (nominally at least) a third alternative we call socialism, which I understand is an
    expletive close to being banned as politically incorrect language use almost on a par with racism in the US) strategies have some almost mythical / magical power to talk the most horrific things into existence and finally into passive acceptance. The makers of this pill have surely considered the outrage and sheer horror it will provoke, but they nevertheless campaign steadily on apparently confident that they will overcome the resistance. What’s going on? They will of course demonstrate that they understand and accept the outrage, and then wait a little, wait til a newer outrage
    captures attention, quietly produce some sort of ‘study’ showing that most opposition is based
    on ‘irrational’ and incorrect assessments of the dangers and highlight the great benefits to
    health professionals and patients through increased compliance and press on with getting it
    authorized, crossing a few palms with silver on the way no doubt.

    I believe it’s called repressive desublimation. I’ll have to dig out my old copy of Marcuse again.

  • The direct cause of violence of every kind is of course in every case people, who are by their
    nature, and not necessarily because they are unbalanced mentally, subject to the irrationality
    of the emotional life. Emotions such as greed, fear, envy, jealousy or anger are a fundamental
    condition of being human.

    The major indirect cause of gun violence in the USA is the easy availability of guns. Period.
    This is so easy to prove it takes just a couple of seconds; one simply has to compare incidence
    of gun violence in the USA with the incidence of gun violence in countries where there is a
    sensible control of guns. In practice of course it would be a nightmare to clean up this mess
    and impound the probably hundreds of millions of guns which are in private possession in the
    US, but in principle the USA could reduce the rates of gun violence to match those of Europe
    by amending the constitutional amendment, so that the same legal controls on guns could be
    excerised. Indeed that is the only way the US could ever reduce gun violence.

    Which brings us to the other indirect cause of gun violence which is the obstinate Admiral
    Nelson-like blindness to the sheer obviousness of the just stated conclusion; it is much more
    difficult to perpetrate gun violence if you don’t have a gun. It’s amazing to see how people
    twist themselves inside out in an effort to avoid confronting the argument which is staring
    them in the face. And finally of course you have the pernicious, blood-letting, profit-trawling
    gun lobby with their vile propaganda which both feeds and feeds off this sad self imposed
    ignorance.

    It’s not something that fell down from heaven on Mt. Sinai. The eighteenth amendment was repealed and the second can be too.

  • Hi Sinead
    Ah! Well perhaps after all your assumptions about me and my practice and motivations, I daresay I still owe you one or two. Yes, I see from your misreading of my comments that you are unfamiliar with the Scandinavian school of psychiatric nursing care, perhaps even with the general concept of ego supporting and ego rebuilding nursing care. What a pity the excellent work by the Norwegian nurse Liv Strand Fra kaos mod samling, mestring og helhed (From chaos toward containment (or collectedness), competence(coping) and wholeness ) is not available in English. I would certainly be looking for a nurse of this calibre of professionalism and depth of understanding, if ever I became mentally ill.

    all the best
    Colin

  • Stephen – your choice would not disappoint or offend me. Absolutely OK. In DK nurses learn that the various ego supporting techniques can be seen as lying on a continuum where the two poles can be thought of as representing paternal and maternal principles. The maternal tend to be nurturing and protective and are most valuable usually at the beginning of an admission, whilst the paternal typically come into play later where there is a need to find suitable challenging tasks which will help the ego recover the strength and elasticity it will need when the patient returns to society at large.

    A good nurse needs to be conversant with both principles and able to move between them as necessary, but individuals have their preferences naturally and – not surprisingly – male nurses often gravitate towards the paternal end while female gravitate towards the maternal. Classically, Sinead is obviously more comfortable with the maternal, whilst I tend to gravitate towards the paternal.

  • Colin-
    Thank you for reading my blog. I understand what you are saying. I wanted you to know that there were quite a few people at the conference from Denmark. Perhaps you can connect with them. The meeting is scheduled to be held there in 2014.

    All being well I’ll be there. Look forward to seeing you – Colin

  • Hi Sinead
    I think it’s time to wrap this up since I’m beginning to feel a little impolite about hijacking Sandras blog, and there’s a risk from now on that we’ll just start circling around the same themes in a futile way.

    Yes I went straight into psych. It’s what interested me from the start, general nursing did not. But I spent several years as more or less untrained nursing assistent looking after the physically handicapped so I understand what you’re talking about.

    “you equate connecting with and respecting the individual who has lost all rights to his/her autonomy (my practice) as a non-therapeutic relationship due to its being on “the patient’s own terms”? “

    is not what I said Sinead. In DK people are fairly passionate about equality and they naturally extend this passion to the workplace where status is often hard to discern because they work hard to flatten out hierarchy, and make it possible for the employee to chat with his boss on very level terms. It’s not that people forget that status exists, but they insist on the distinction between equality in status and equality in rights and dignity. The same is true in the nurse patient relationship. These two parties cannot be equal in status and it would be false to pretend they can. A patient’s terms might begin as an insistence on equal status. The nurses job is then tactfully and humanely to maintain the difference in status (reality orientation) whilst simultaneously supporting the process towards equality in self esteem, which is what will most benefit the patient and realise the goal of winning back his autonomy. IMO this is the most professional way of handling things and the way that brings best results.

    Many thanks for your engagement in this discussion with me. I hope others got something out of it. – Colin

  • “Yet you don’t seem to address me at all, as you project this emotional association?” (apropos blaming and shaming)

    You’re right David it was an egotistical little sidekick on my part where I engrossed myself in one little aspect of your post, without really stopping to consider whether it might be something which interested you too, quite blithely skipping over the issue you wanted to talk about. The blaming and shaming of me is quite appropriate.

    And I hope you won’t take it personally but I won’t pick up the cue on this one since in times past I’ve had my fill of discussions on Freudian guilt, and it’s role in the formation and extension of social repression and status formation. It’s great stuff, and I adhere to the Marcusian school of thought 99%, but I can’t manage any more of it.

    Cheers Colin

  • “Not one single person in the 72 hours I was there had the inclination to offer that kindness. They had time for coercion. They had time to force horrific amounts of medications down my throat, they did not have even 30 minutes for kindness. ”

    Sheesh! OK Malene that makes me angry too. I’m stumped. Don’t know what to say other than that I don’t believe it would have happened to you in DK. If it did I’d have been there protesting with you. I apologize on behalf of my profession.

    I think the risk of diabetes with taking 4 -500 mg Seroquel over three days is effectively zero, but in any case as I say, no-one here would have forced you to take it anyway.

    “If you truly want to learn something better then I suggest you work hard to learn non-violent ways to interact with your patients, instead of defending the violence. ”

    I couldn’t agree more and of course I already have worked hard at learning non confrontational conflict management. 99 times out of a hundred I succeed too, there’s just the odd occasion when no-one seems to have the skill to solve a problem without the use of force. When I mention that coercion is a daily affair on my department I don’t mean that there are violent episodes every day, where we force medicin down people’s throats and strap them to beds. I just mean that the door is locked for a proportion of the patients who have been sectioned under psykiatriloven and this is something we always have to keep in mind even though everything is peaceful on the department. Sometimes six months goes by without a single case of belt restraint, and the average number of days in total annually, adding together all days for all patients using this form of restraint is about 25. Every kind of coercion used is registered and submitted to a national board for review and statistical analysis. This year for some reason has been a bit of a freak year where the number of belt days already is up over 80. But our ambition is always to reduce this number.

  • Sinead – yes I think you’re right that psychiatric nursing is not “real” nursing á la Florence. It’s more of an art really, and being artful probably isn’t too wild an exaggeration, which isn’t to say it’s about being dishonest. You certainly have to give a lot of yourself IMO to do it well, but in an artful way where humour, compassion and empathy aren’t necessarily worn on the sleeve and trumpeted about, but nevetheless are in place, and allowed to shine through naturally in whatever way the developing relation between nurse and patient allows, to lighten burdens and lend authenticity, without compromising professionalism. As you yourself have discovered connecting with patients is what it’s all about, but if the connection occurs completely on the patient’s terms then you really haven’t done him any good as a rule and may even have done harm.

    Maslow and basic needs are all given proper attention in my experience. Perhaps I’m just lucky to be on an excellent department. In DK psychiatric nurses learn to equate the psychodynamics of relations with treatment possibilities, and use the relationship to confer ego support. For me the great attraction and why I love psychiatric nursing is the paradoxes it throws up, and that I have to relearn my psychical juggling skills every day, because there’s always something new. So in that way yes, I do truly get a lot of personal satisfaction out of it, and it’s not as if I “take something” from the patients in doing so. On the contrary I would say it’s greatly to the benefit of my patients that I take something from the relationship too, because that gives authenticity, and offers precisely the opportunity to prepare oneself for the real world of real relations.

    I daresay you could relieve me and my colleagues. It wouldn’t be too difficult. The thing is the first day when you unlocked the door you would lose the first six patients and the next six would soon apply for discharge or transfer when they found out they weren’t going to get any medicine. So I guess the remaining four wouldn’t be too much of a handful. I don’t know what you’d do when an alarm sounded for aid on another department, (we don’t have any ‘security’ we manage these things ourselves) but as you say that wouldn’t be for me to interfere with.

  • Malene – it’s a distorted mirror you hold up. I neither like nor am proud of having to use restraint, and usually feel that I’m lacking something when my communication skills fail to resolve a situation in a more professionally satisfactory way. But coercion is there on a daily basis in lieu of the fact that the door is nearly always locked, and sometimes it’s locked because a judge has ordered it to be locked, so it’s not as if I have any influence whatever over the situation. The only thing I can do is quit the job, (which I’m not going to do) but if I and all my colleagues did that, where would the patients be then? Are you and all your likeminded ready and willing with your alternative to take over and assume responsibility? I seriously doubt you have anything near the competence needed.

    I can reassure you that had you been in DK when you were in distress, and admitted to my department it would have been on a voluntary basis only, if indeed you had been admitted at all. At most you would have been offered (not forced to take) an Oxapax (benzo) and 100 – 200 mg Seroquel, daily within the first 72 hours. Unless your condition deteriorated you would almost certainly have been quickly discharged, perhaps even the next day. Grade 3 close observation probably would not have been instigated at all and grade 2 would most likely have been concluded within the first four hours. We would have taken contact to and consulted your relatives only to the extent you yourself gave consent. Only in the event that you attacked a member of staff or another patient, started vandalizing the surroundings, set fire to something, abused the telephone to ring false alarms or terrorize persons known or otherwise, repeatedly ignored the smoking restrictions, or seriously threatened to harm yourself would you have been subject to any restraint, and the restraint employed would be considered and measured to meet just the need and avoid excess. (It would by no means automatically involve harnesses and syringes, but but even minor restrictions would give you the right to consult a patient counsellor and lodge an appeal to the patient complaints body.) The door to the outside world would be opened to you as soon as we could ascertain the risk of doing so was defendably low. At any time we would attempt to meet your needs for contact and communication, although we might discourage long drawn out nocturnal discussions which could mean you were deprived of sleep, which we regard as an important healing factor.

    That’s how the Danish common sense would have reacted to a case like yours; like you I’m a subscriber and find it hard to see how it could be much more reasonable. You might find this hard to believe but sometimes we have to use coercion to get people out of the place, who no longer really need us, but would prefer to stay longer.

  • Sinead – I hold no assumptions about you just as I hold none about anyone else I don’t know personally, except for the one assumption I did mention in my last post. Perhaps I ought to revise that one however.

    Once again I do appreciate your thoughts even if they can seem a little abstruse for me, and rather seem to – in a slightly arrogant holier than thou attitude – only draw esoteric circles around the concrete issues I’ve been bringing up instead of addressing them head on.

    People on this site on the other hand are certainly not withholden when it comes to flaunting their prejudices about me; for one who has only just recently discovered the site and been commenting – I think in a decent, sober and respectful way – just a short while, I have to admit I find the vitriol pretty overwhelming and distasteful already, although of course I can only blame myself. I knew full well what I was letting myself in for when I stuck my head into the lion’s den. I’m chastized for abusing my patients, although none her really know anything about that, and the abuse I’ve already received here certainly isn’t going to convince me that the ideas being promoted by the site are worth considering in any depth. So perhaps it is already time for me to be on my way.

    That’s a great pity really because even though I don’t and will never buy the lock stock and barrell hopelessly unnuanced “Psychiatry is all wrong – dismantle it now” slogan, I am dissatisfied with psychiatry as it is and am on the lookout for credible ideas for reform and alternatives. But I don’t think any longer I’m going to find any here, though actually the reason this blog did interest me (we’ve strayed far from the subject – a bit disrespecfully of the author perhaps?) – was that it was about Open Dialogue, which seems to me to be one of the most promising projects launched in the last quarter century. I have for many years now had a fruitful working co-operation with the Fountain House movement which pre-dates Open Dialogue by more than half a century, and like Open Dialogue has stood the test of time and achieved impressive results. It is not however and never could be a replacement for mainstream psychiatry, nor has it ever promoted itself as such.

    If psychiatry is going to change then people like you and I have to meet somewhere neutral where we can exchange ideas in a slander free zone, and accept that we won’t always agree on everything. You have criticized but not slandered me and I appreciate that. I am pragmatic and doubt if I ever will be absolutist like you, but I imagine we can agree that reducing coercion in psychiatry to the absolute minimum must be a goal we should wholeheartedly commit ourselves to. (which I am already)

    Best wishes Colin

  • Sure David. It was reaction. Well considered reaction nonetheless and maybe not a reaction to what you might be thinking it was. I happen to have an interest in ancient Welsh and Celtic legends and poetry, and couldn’t help noticing the the format of Bradshaw and Booth’s poem – it’s Cad Goddeu (The Battle of the Trees) and Hanes Taliesin but with a different and very Freudian content. I’ve no idea why Bradshaw and Booth might try to synthesize these two things since there’s no obvious connection. But then again the Battle of the Trees is very mystical and open to just about any interpretation. The best I know of is found in the remarkable work by Robert Graves “The White Goddess”.

    I am by the way a closet admirer of Freud, but please don’t tell anyone.

    Cheers – Colin

  • Sinead – thanks for your very illuminating reply. I should like to work with you sometime. I suppose that your colleagues sometimes feel you get a free ride when it comes to what they see as the necessary dirty work. I assume nevertheless they could depend on you in a truly critical situation, (a colleague or another patient was getting strangled or threatened with a knife for example). I hate using coercion but I do it nonetheless, and I’d be out of a job in no time if I tried to do what you do, and nor would I accept that one of my colleagues opted out except on the grounds of their own injuries or frailty. But unwillingness to lose my job isn’t the only reason of course, I do accept that it is necessary sometimes. I think I can deduce from your insert that your clientele are kids and young adults only. These can of course be pretty hefty, but there may be some difference when it comes to adults, which is my clientele. And because we’re a combined acute/assessment/treatment department many with unknown histories and backgrounds get admitted, not even necessarily mentally ill, perhaps with long criminal records, coming sometimes directly from prison, or the street, sometimes they are foreigners with no command of either English or Danish, sometimes they are in a state of delirium and therefore totally uncommunicable with. They may be people with a history of intellectualis inferioritas or control problems because of previous head injury and at the same time intoxicated to the eyeballs and thus completely out of control. You don’t know what they may have in their pockets of weapons, drugs, syringes or alcohol. If there’s good reason to suspect they might have such things, and they won’t surrender them voluntarily, then force may be the only option.

    I should of course qualify the use of the word coercion which I know conjures up any number of terrible scenarios in people’s imaginations, but when a coercion situation goes after the book which it does in the majority of cases, it’s usually pretty undramatic. Personnel assemble in a number which signifies clearly to the patient that the situation is unwinnable for him through the use of force, a doctor then states the requirements and informs the patient of his rights to contest the decision legally afterwards, and he is given a couple of minutes to digest this and decide what to do. If he decides to use violence he will be quickly overpowered, and with minimun risk of injury. But usually the explosiveness of the situation fizzles out, the patient aquiesces (not consents obviously) and tensions subside.

    This won’t happen with someone who is violently delirious, and unaware of what’s around him and simply lashes out at anything that moves within the periphery of his vision, as well of course at things that are not there. This is a medical emergency which strictly speaking ought not really have anything to do with psychiatry, and the only thing to do is use physical restraint so that tranquillizers can be administered as quickly as possible. I know you know all this Sinead, but I include it for the sake of readers who might not know it. The point is that in DK at least, these patients get admitted to psychiatric departments because these are the only departments authorized to use restraint.

    I recall once a patient who I had a good rapport with (so I thought) who suddenly attacked me after we had been singing together in the common room. He told me at the time that it was a particular Donovan song he couldn’t accept me singing, but later he told me that he periodically had a need to rediscover the boundaries of his own being, and getting himself into these physical constraint situations was the only way he knew how to do this, and indeed it turned out he had done this several times before. I was amazed to say the least. Had I but known this beforehand and had you availalable with your massge therapy perhaps this episode could have been pre-empted? Then again perhaps not – who knows. Our physiotherapists specialize in helping people in psychosis to ‘ground’ through use of massage, but it’s not a cure-all unfortunately.

  • Well – like it or not coercion is a fact of life. We meet it both in psychiatry and in a thousand other situations in life having nothing whatever to do with psychiatry. So NEVER is a very unrealistically categorical stance to take if left unqualified.

    I’m not quite sure what you mean by “due process” but something along the lines of the protocols required to be adhered to by a police officer making an arrest is my guess.

    Life and liberty I go along with as inherent human rights but property? That’s a weird assertion I’ve never read in any book on philosophy, and sounds especially weird in the world’s most supreme capitalist state where the doctrine that rights to property are not inherent but have to be earned is almost religion.

    Anyhow whatever the case what has it to do with psychiatry? Are psychiatrists now beginning to take people’s property as well as their lives and liberty over there?

  • “Given this, I don’t see why it’s far fetched to say that withdrawal from antipsychotics can cause a temporary increase in psychotic symptoms, even if you do believe the dopamine theory.”

    Well, you can’t both have your cake and eat it. If you’re saying that it’s true that antipsychotic medication causes increase in D2 receptors and this accounts for the return of even stronger psychotic symptoms on withdrawal, then you’re also saying that excess dopamine activity in some part of the brain is intrinsically bound up with psychotic symptoms, which in essence is what the original dopamine hypothesis says. “Things just aren’t that simple” is an excellent starting point, since the brain IS complex, but I know of nobody who can think without one, so it’s a fair guess that seriously disturbed thought processes might be a manifestation of ‘faulty wiring’ in the brain. What constitutes ‘seriously disturbed thought processes’ and who has the authority to define which thought processes are and which are not ‘seriously disturbed’ is of course another matter, as is the question of whether the ‘faulty wiring’ is caused exclusively by genetic factors, exclusively by environmental factors, or a combination of the two, or indeed some as yet unknown third and fourth factors.

    The addictive properties of benzodiazepines are of course well known, and they are on their way out in mainstream psychiatry. But that’s a completely different discussion.

  • Hi Malene . . . “did I notice misspellings” . . Well observed . . indeed you did although I have to say to my shame that I am English! Du har sikkert også danske rødder med et navn som Malene.
    “the use of coercion is always . . .wrong. [but] there might be some extreme examples of when it is necessary” Need any more be said? War is wrong but can be unavoidable.
    That said is it then necessarily true that use of coercion “has to be seen as an inherent failure of the care takers “? Naturally none of us are perfect nor would we want to be, so of course a basic and vital component of any suitable training for this kind of work, has to be development of an acute awareness of the meanings, uses and effects of the interpersonal psychodynamics which inevitably attain to this work, the most important part of which is communication under sometimes very bizarre or difficult circumstances, where the patient experiences those who try to help as enemies and torturers. Our ‘soul-searching’ is therefore done on a systematic and regular basis with both group and individual supervision and counselling, and when finances permit it subscription to courses aimed at upgrading our skills and knowledge. I doubt if we ever find ourselves in a situation where we think that what we have done couldn’t have been done better in some way, big or small.
    When I mention that most professionals are used to being demonized I was thinking more of the times when I’ve been accused of being in league with Satan, being a mass rapist who every time he is on night duty has his way with all the women patients, of working for Mossad and so on and so on. It is not in my opinion inherently disrespectful to shrug one’s shoulders and accept that this is part of the job
    You are undoubtedly on to something when you begin to talk of fear as a background for abuse of power, but this is a huge and complex subject and to be able to talk authoritatively about it you need to have insight both into individual human psychology in extremely stressful situations, and a comprehensive understanding of the bigger picture in which large organisations operate, including the very real dangers inherent in the work. I have been battered several times but thankfully not as seriously as one or two of my colleagues who came close to losing their lives and were forced to retire with PTSD. Here the tendency is anything but to shrug one’s shoulders and accept it as part of the job. One makes individual decisions to err on the side of safety, and sharing these decisions leads to policy and finally a culture which puts safety first above all else. This can unfortunately lead to a quite restrictive environment which a psychotic but non dangerous patient with no insigt into the background for the culture, will inevitably find both absurd, demoralizing and intrusive.

    Thanks for reminding me not to let my humanity be trained out of me. I certainly won’t let that happen; if there’s any one thing I am a little bit proud of it is my humanity which I guard jealously! As for yourself well it’s shame you lost your job at the halfway house. I mean if I’m trained wrongly, and I’m doing the wrong things and harming the people I’m trying to help, and need the right training to do it properly, then who is going to help me? I need a demonstration of someone who is doing it right. Who is it who is in possession of the truth and can show all of us in the dark the light? When are they coming my way, and where are the successful cures of people I once regarded as hopeless? So I hope you’ll get back on the right track again soon and perhaps be my beacon of light.
    ps I have no problem with people making mincemeat of me. It happens every day. If someone’s got something concrete to offer me which will help me help my patients then my arms are wide open. If they’re just intellectually huffing and puffing, but in reality have no credible alternatives to offer then I pass them by, because I know they’re not the ones I can depend on to come and relieve me on the front line when the going gets tough, and I need a bit of support.

  • Sinead – I guess you are – like me – a psychiatric nurse and therefore, like me, have inside knowledge of cases so grotesque they defy belief. What baffles me is that you can work on a locked unit where it’s patently obvious that coercion is used, perhaps even on a daily basis, and yet be exempted from taking part in the execution of decisions to employ coercion.
    But let that be. This discussion has brought up very many very interesting points, some of which I feel a need to contest, some of which I’d like to endorse or simply ask for more elaboration thereof. I’m not aquainted with American practice but I assure you that in the civilized countries of Europe, involuntary commitment is not first line treatment for people presenting with psychosis. The majority of people presenting with mild symptoms of psychosis would not be able to get admitted even if they wanted to – and often they do want to. The countries I know of have strict guidelines for the use of involuntary commitment, which always entail a requirement to document that stringent efforts have been made to secure the patients’ compliance, before any form of compulsion is considered.
    Likewise with medication. Although it is true that medication is the first choice treatment for psychoses deemed severe enough to warrant admission, there is generally only one exception to the rule that coercion can only be considered after all other avenues have been exhausted. The exception is where a patient is already under a court order to receive medical treatment for his condition.
    And medical screening processes for physiological causes certainly do precede any treatment in Europe, at least inasfar as it is possible to gain the patient’s consent to these processes. (In the case of ‘swingdoor patients’ a recent screening process from an earlier admission might be considered up to date enough. )
    I would also contest that it necessarily is a simple matter in every case to rule out organic/toxicologisk causes as the primary ætiology. It is very common to see a developing schizophrenia masked by a chronic use of cannabis, where many years may go by before it is possible with any confidence to reach a diagnosis.
    As to the question of whether coercion is intrinsically bad, I do have to admit that after 25 years in the service I no longer (it would be an emotionally impossible thing to do) ask this question every time I make use of it. I only ask if it is the least evil of the available alternatives. As recently as today I have used coercion – it was a very quick and undramatic process where as much dignity and respect as such a situation allows was preserved, the goal being simply to ensure the patient was not suffering certain kinds of side effects as a result of his treatment. Contrary to what some believe using coercion is never pleasant for the staff, nor does it satisfy power lusts or any other kinds of deviant psychological or physical needs. True professional satisfaction comes alone from using ones skills to garner trust and form therapeutic alliances with one’s patients.
    Most professionals are used to being demonized of course, and don’t last long in the profession if they can’t take it with a smile. What really left a lasting impression on me as a newly educated nurse, determined to be the best and wisest, with a real commitment to listen to patients needs, and act solely in their interests, was a psychotic man who resisted all my attempts to reach out to him and refused both general care and dialogue as well as the offered medical treatment, and who by utilizing all his patient rights to have the proposed treatment reviewed by the independent patient counselling body, managed to delay the start of treatment by four weeks, in which time he became more and more chaotic, but finally after being treated coercively, recovered his composure and was able and willing to enter into dialogue again, and showed a personality and humour which before had been completely absent. This man then suddenly said to me one day in the course of breakfast: “What the hell took you so long getting round to getting me medicated?” It turned out that this was all he’d been waitng for; he both expected and wanted it, but in his psychosis, whether by command of voices, or by dint of some delusional system, he was committed to strive in the very opposite direction. The decision to treat had to be ours, and had we not taken that responsibility upon us we would have seriously let him down.
    So even though the principle of the least invasive intervention for me is sacred, I now know that the field I am in is a field of the most amazing paradoxes, where weak or no intervention actually can be less respectful and in a sense more invasive than intervention where coercion is necessary, and it can certainly be more negligent.
    I think the comments and questions I have about Open Dialogue (the subject of this blog after all) I’ll make in a new reply, to avoid this already long piece getting even longer. But I’d like to say one last thing about science concerning knowledge and hypothesis. The dopamine hypothesis remains that. It is not knowledge and professionals with respect for their science and profession do not pretend it is. The same applies to the much more popular ‘knowledge’ which is getting bandied about everywhere; I’m referring to the discovery, some believe, that the brain reacts to treatment with dopamine blocking neuroleptic medicine, by sprouting more D2 receptors in an attempt to compensate, and this is what acounts for people becoming psychotic when they come off the meds (in contrast to the much more simple and obvious explanation which is that it was the medicine which was holding psychosis at bay.) This new ‘dopamine theory’ interesting as it is, is by no means established fact. It is, just as the old dopamine theory only a hypothesis. Please remember this.

  • I lovd this article, and especially the satirical reference to the sky being ill. This is definitely not trivial semantics, because it’s important to be as clear as possible about what we mean when say someone is “mentally ill”. The concept of “Mind” is truly but metaphorical/theoretical/philosophical, as you wisely allude to. Frustratingly it’s hardly a metaphor we can dispense with, just as we hardly can dispense with at least some sort of idea of mental illness. But therefore it’s all the more important to keep the concept bracketted within a placeholder until such time as we can say with reasonable assurance what it actually is.
    I live in a Danish city where the population in the 30’s was between a third and a half of what it is today. At that time (before the advent of psychiatric meds) the city supported an “Asylum for the Insane” which housed up to 2000 inmates, most of them more or less permanently. Around that time the asylum idea gradually became abandoned and the place was transformed to a hospital. By today’s standards of course asylum conditions would be regarded as horrific, but actually the asylum idea was grounded in surprisingly humane ideas and philosophies. You’d only have to compare it with what went before to see that.
    Today only about 220 beds are left and the average admission period is around 3 weeks. There is no doubt that the advent of psychiatric meds was an important factor in making this possible, although of course the asylum idea has to a certain extent been preserved in the post hospitalization social-psychiatric lodging facilities to be found, of which there are possibly 200 permanent places and 7-800 temporary or semi permanent places. So something in psychiatry has changed for the better because now with a population of 2 -3 times that of the thirties, institutional requirement has dropped by at least 50% (80% adjusted for population increase) or if you only think of lifelong institutionalization then it’s well over 90% adjusted for population increase. None of this however necessarily means that the extant concept of mental illness is unassailably correct in its assumptions.
    So from this historical perspective it will be enthralling to see how Vermont manages to get by without a state hospital at all. Even with Denmark’s very good and comprehensive social welfare system, and with all the social-psychiatric centres available it would be hard for me to envisage anything other than complete breakdown in mental health services if the hospital suddenly was not there any longer. Not least because it houses nearly 50 forensic psychiatric patients who, presumably would have to be transferred to ordinary prisons if the hospital was not there. But certainly also because it is there where the clinical expertise is found (could of course be re-allocated) and the facilities for clinical observation exist which enable systematic evaluation of the hundreds of different kinds of psychiatric crises known to psychology and medicine. I mean it’s no use trying to talk someone through a psychotic crisis if the real root of the problem is a slowly developing demential condition brought on by a lack of thiamine, or a rare genetic disorder such as Huntingdons breaking out for the first time. Whatever system is in place has to be able to disclose, diagnose and refer or treat such things, as well as have clear well drilled procedures to cope with the rare occasions where a psychotic or otherwise mentally disturbed person actually becomes dangerous. (These procedures have proved inadequate on at least two occasions in DK this year where one worker was raped and killed and a doctor and two nurses stabbed and severely wounded.)
    This is probably why, however peremptory it may seem to be, we won’t be able to dispense with the concept of mental illness in any near future. A professional system has to be able to respond, communicate, dispense, sort through, evaluate, co-ordinate and act on the basis of commonly understood and accepted categories, in order to discharge its duties in a systematically transparent and effective manner, and be thereby accountable to the public. A system will not be able to marry its resources to the perceived needs if there is not some kind of objective referential framework to define and grade these needs. As a professional myself I would automatically ask, (not unreasonably I think) if I heard that there is no such thing as mental illness, why society then should spend money and resources on either traditional or alternative therapies and treatments for people who are not ill, but have some needs which they alone have the privilege of defining.
    I thought it interesting that you chose to illustrate your point by referring to homosexuality as an example of a condition once described as a psychiatric disorder, now abandoned due to cultural change. The inference obviously being that one day we could come to accept psychosis as a variant of normality, so we no longer would be frightened to have psychotic persons as neighbours or workmates. Hmmm. Have to think carefully about that one. Meanwhile it could be instructive to bear in mind that it is homosexuals themselves who are in the forefront when comes to campaigning for the view that their sexuality is something they are born with and thereby biologically predetermined! It’s not that their brains are diseased or even different in any anatomically detectable way, but some genetic difference apparently causes the brain to function in a different way, at least if the emotional life has anything to do with brain functioning, and it’s difficult to imagine that it doesn’t.

  • “. . . in certain cases, [the loosening of our cognitive constructs] . . . . can lead to the potential benefit of having a more open mind (less rigid belief systems) and the richness of experiencing a greater sense of interconnectedness with all . . . . . but on the other hand . . . .can also lead to the potential terror of experiencing just how precarious and ungrounded our existence and self really are . . ”

    the “loosening of our cognitive constructs” can be achieved artificially by the use of psychotrpic drugs, but it is important to realise that states of mind so induced only mimic, and cannot be equated with, psychosis. Furthermore it is important to understand that the term “schizophrenia” was coined by the German psychiatric tradition over a century ago in an attempt to delineate what the tradition’s practitioners, through very painstaking observation and listening to the subjective experiences of many hundreds of patients, (remember there were no antipsychotic medicines then) saw as one particular and relatively rare, but very personal-independence-crushing and chronic type of psychosis. So “schizophrenia” as such has only been with us for little more than a century, but madness, which the term schizophrenia was an attempt to understand a little more systematically, has always been with us. The German tradition regarded schizophrenia as pathologically understandable and conceptually separable from the vast majority of other forms of psychosis, many of which undoubtedly can be understood in terms of life crises and stresses.

    Mr Williams now asks us to reconsider these attempts to delineate madness along psychopathological lines, and instead in some ways return to a more amorphous pre-nineteenth century madness concept, and then understand it, not in the light of any kind of pathology, but instead in the light of what he calls the “existential dilemmas” of being a human being in the world.

    Now I’m not sure that the first of the two dilemmas he outlines really qualifies as an existential dilemma, but let that be; it’s the second which is altogether more interesting, and more probably would, in Sartres understanding of the word, qualify as an existential dilemma. This, as I understand it, (and I have worked full-time for over 25 years with hundreds if not thousands of the very most chronically disabled schizophrenia-afflicted persons) pertains to the very core of the schizophrenic experience. These people generally cannot pull themselves up by their own bootstraps from the swamp of psychotic chaos and confusion, as has Mr Paris Williams and thousands of others who, like him have experienced Recovery with the big R, because if they could then they surely would have done so.

    And, I’m sorry to say, it very rarely is a help to these people to take the position that they simply are overwhelmed in a wrestling match with this existential dilemma, and just need to be shown the deeper meaning of their psychosis, in order to be able to “live it through” so as to come out the other side a stronger and richer human being. (Sigh!) It’s a lovely idealism – if only it had anything to do with the terrible reality of this disability.

    Paris Williams defines (rather weakly in my opinion) the dilemma thus:
    “The need to maintain a relatively secure and stable sense of self when the very fabric of one’s being and indeed of the entire universe is profoundly groundless, impermanent, and interconnected.”

    This definition seems to say everything and nothing all at once, but if we fillet out the two key elements, “stable sense of self” and “fabric of one’s being ” then we can immediately relate this to what seems give the schizophrenic such extraordinary difficulty in navigating the relational aspects of what should be (and indeed are for most of us) the most simple social interactions. It is perhaps not so much that the sense of self is lacking but more that the sense of self in a profoundly solipsistic way permeates everything within the schizophrenic’s range of sensory and intellectual input. A schizophrenic man with quite marked ideas of omnipotence I once went out for a walk with, replied to my comment about it being a fine day, “Thanks.” He took my comment as a compliment since it was implicitly understood that he was responsible for the fine weather.
    In some quirky way you might almost say that a more stable sense of self you could not wish for, and as for the fabric of his being it was as if he felt that the fabric of the world was the fabric of his being. And it does seem that this is the core of the schizophrenic subjective psychotic experience. The schizophrenic is not in and of this world, but almost the other way about – the objectivity of the world is somehow irrelevant to the schizophrenic, because it is the subjective experience alone which has any meaning. Thus anyone at any time can get some fleeting idea about “being watched” but we almost immediately and without thinking refer such ideas to our inbuilt reality testing apparatus, and quickly dismiss them if there is nothing real to build them on. But to a schizophrenic just the fact that such an idea could arise in consciousness is in itself profound and therefore meaningful, and he will therefore build freely upon it without any concern about reality, until he becomes fully blown paranoiac.

    I would say that Paris Williams little diagram (figure 1) is very misleading, because not since Emil Kraepelin’s preliminary description of schizophrenia as “dementia praecox” back in the nineteenth century, has mainstream psychiatry regarded schizophrenia as a dementia or progressive degenerative brain disease. Indeed it is well known that schizophrenics as well as anyone retain cognitive function into advanced age; it is just the ability to put these functions to use in any socially cohesive context which is lost.

    To his credit Paris Williams does ask the pertinent question:
    “So, if these existential dilemmas are universal, then why do some individuals become more overwhelmed by them than others, and go on to develop psychosis?”
    Yet part of the answer he comes up with –
    “it appears that . . . . .some individuals may even have some genetic or developmental predisposition for such experiences. ”
    . . seems more or less precisely to abrogate his very own argument for a biologically free understanding of the phenomenon generally known as psychosis, and in particular that specific form of psychosis known as schizophrenia. For I would definitely argue that it is precisely this “genetic or developmental predisposition” (notwithstanding the fact that scientific investigation into this complex area is far from complete) which accounts for why it is that only “some individuals” and not every individual who grapples with the existential dilemmas Williams outlines, “go on to develop psychosis (more precisely schizophrenia)”.

    Big Pharma has undoubtedly much on it’s conscience, but one of the things it does not have on it’s conscience is the invention of the schizophrenia diagnosis. This took place in an era before Big Pharma even existed. And even if it is true (and I believe it is so) that science has no incontrovertible evidence to back up the thesis that schizophrenia is solely down to dysfunction in the brain’s biochemical signal system, then it is equally true that there is just as little evidence to back up the thesis that schizophrenia is nothing other than the “manifestation of a mind deeply entangled within the fundamental dilemmas of existence.”