I’m happy to see more interest being taken in this kind of approach, and a video has just become available which, in 5 minutes, very coherently explains how a compassion focused approach can completely transform a person’s relationship with their voices and so transform the person’s life!
The video is an animation developed by Charlie Heriot-Maitland working with Eleanor Longden and Rufus May who do the voiceovers. Check it out, let me know what you think:
As we struggle to invent a humane approach to the extreme states that get called “psychosis” or “madness” or “schizophrenia,” it may be helpful to investigate some of the better approaches developed in the past.
While these approaches are not without their flaws, they are often surprisingly insightful. (It can also of course be depressing to notice how truths once more widely known were so easily “forgotten” as compassionate approaches got ditched in favor of the latest coercive innovations.)
One of the pioneers in actually listening to those in extreme states was Frieda Fromm-Reichmann. She advocated assuming that every communication from those in extreme states contains meaning, and for appreciating that there is an “ego,” however beleaguered, within even the seemingly “hopelessly deranged.” She believed that if therapists would persist in reaching out, while respecting the person and his or her struggle, then communication would gradually become clearer, and the person’s special perspectives and talents could emerge and flourish.
Fromm-Reichmann is perhaps best known as being the therapist for Joanne Greenberg, who wrote a fictionalized version of her story of psychosis and recovery in the novel “I Never Promised You a Rose Garden,” and whose story was also covered in Daniel Mackler’s documentary “Take These Broken Wings.”
One person who has extensively studied the work of Fromm-Reichmann and others like her is Ann-Louise Silver, MD. In the short clip below, taken from the “Broken Wings” documentary, she contrasts the kind of recovery that can come from psychodynamic therapy with what happens when people are offered what she calls the “scotch tape” approach of medication:
So how does this psychodynamic approach work, and what parts of Fromm-Reichmann’s approach could be helpful to us as we design alternatives for today’s world?
Ann will address that topic at an ISPS online meeting on Friday 2/13/15, at 3 PM EST. This meeting is free to ISPS members, with a donation of $5-$20 requested from others, though there is also an option to register without donating if that works better for you.
Ann was the first president of ISPS-US, an organization started by people who were mostly psychodynamic therapists. This organization has since broadened, as awareness increased about the need to collaborate with those who have lived experience, and as knowledge expanded about the effectiveness of other kinds of approaches, and of the need to have different approaches available for people who may respond better to something other than long term therapy.
It certainly isn’t too late to register for http://www.isps2015nyc.org/ where you can hear from leaders such as Mary Olson (of Open Dialogue), Aaron Beck and Tony Morrison (of CBT and CBT for psychosis), and of special importance, lots of people with both lived experience of psychosis and expertise in other areas, such as Ron Coleman, Pat Deegan, Noel Hunter, Sascha DuBrul, and Oryx Cohen among many others.
I will also have a presentation there, titled “Admitting Uncertainty about “Illness” and “Reality” is Essential for Dialogue.”
Of course, many of you aren’t going to be able to attend big conferences like this – which is why I hope to keep working with others in ISPS to make available online meetings, accessible to all, which give people a chance to hear from leaders in our field in a live format that includes interaction with the audience. Expect to hear more about these meetings on MIA, and/or you can always hear about what’s coming up by going to http://isps-us.org/blog/online-meetings/
When people are seeing the world really different than we do, it’s often reassuring to think that there must be something wrong with them – because if they are completely wrong, or ill, then we don’t have to rethink our own sense of reality, we can instead be confident about that own understandings encompass all that we need to know.
But it can be disorienting and damaging to others to have their experiences defined as “completely wrong” or “ill.” And we ourselves become more ignorant when we are too sure that there is no value in other ways of looking or experiencing.
In a practical sense, there are often many ways for example to look at a particular object – we can look at it from various angles, and through different lenses for example, and what we see will be different depending on how we look. In that sense, it’s actually ridiculous to see one way or another of looking or experiencing as “wrong” or “sick”; instead, it makes more sense to understand that different ways of looking may be useful for different purposes.
Looking at things the same way as others around us are looking at them can certainly be helpful if we want to understand what others are seeing and to coordinate with them. Looking at things in more unique ways may be more helpful though if we have other purposes: for example looking at part of a tree through a microscope may be very helpful for some purposes, even though it is unhelpful for seeing the tree in a conventional way.
In a fascinating recording titled OF MADNESS AND MAGIC: SHIFTING THE LENS TO UNDERSTAND THE MIND, Mischa Shoni shares both her own journey and also some great insights into how discovering new ways of looking at the world, or new “lenses” to look at it through, can be both disorienting and disabling, and then eventually enriching once one learns how to use those lenses in a good way.
Here’s the written description of her talk:
What differentiates what is labeled as mental dysfunction—mania, psychosis, seizures—from what is magic, spirit, or simply … beyond the scientific method? Mischa Shoni embarks on a journey to understand her own brain. On the path, she meets dragons, gryphons, crystal-eyed snakes … and some extraordinary people who see the mind beyond the limited lens of psychiatry.
What would happen if a team of highly qualified psychologists joined up with a team of people who knew psychosis from the inside, from their own journey into madness and then recovery – and if they collaborated in writing a guide to understanding the difficult states that get names like “psychosis” and schizophrenia”?
A fundamental point made by the report is that “‘psychotic’ experiences are understandable in the same ways as ‘normal’ experiences, and can be approached in the same way.”
I believe this report will be useful to a great many people, because of the way it combines a thorough knowledge of the science with common sense and perspectives drawn from actually listening to people who have had these experiences and then have made sense of them for themselves. The knowledge in this report will likely both change the perspective of many professionals, as well as be of assistance to many individuals and families who want a deep understanding of the subject that is also very accessible and easy to read.
It includes a list of resources at the end which many people may also find helpful.
Jacqui Dillon, Chair of the UK Hearing Voices Network, was quoted as saying:
This report is an example of the amazing things that are possible when professionals and people with personal experience work together. Both the report’s content and the collaborative process by which it has been written are wonderful examples of the importance and power of moving beyond ‘them and us’ thinking in mental health.
This conference promises to stand out in terms of the variety of voices, perspectives, approaches and traditions that it will bring together to focus on the deeper issue of how helpers can best understand and interact with those experiencing what is called psychosis.
I’ve been a member of ISPS (The International Society for Psychological and Social Approaches for Psychosis) for many years now; I currently serve as chair of the education committee for the US branch of ISPS and I’m the lead moderator for its US list serve. What keeps me interested in this group and its discussions is the focus on understanding psychosis in depth, the willingness to look at it from a lot of angles, and the interest in service models that address the true complexity of the issues people face while maintaining hope for understanding and integration, not just the suppression of unwanted experiences.
In some important ways, the subject of how to make sense of psychosis cannot be separated from the subject of how we make sense of our own existence at its deepest levels. Often it seems there are a wide variety of possible ways to make sense of things, but then there is the challenge of how to make sense of all these possible explanations and perspectives, and how to talk to each other so that we can share our experience and work together in various ways. This problem can exist at various levels: within and between the “parts” of an individual mind, between an individual in crisis and someone trying to help that individual, and between and amongst all those who together form a mental health system or even a culture, etc.
The best approach to these potentially bewildering and overwhelming issues seems to be dialogue, a dialogue which doesn’t determine any final answers, but does improve relationships at various levels, and encourages multiple approaches to understanding.
I value the dialogues I have found within ISPS: these dialogues have allowed me to improve my understanding of madness and to increase my ability to communicate what I understand to diverse individuals and audiences. I think if we are ever going to shift society and the mental health system into a wiser approach to extreme experiences, we all need to find such opportunities for dialogue so we can hone our ability to connect with people coming from a variety of different backgrounds and levels of understanding.
The international conference in NYC aims to compress a lot of such dialogues into just a few days! This conference will bring together not just people from all over the world but also people holding a wide variety of perspectives: psychiatrists, other mental health professionals, people with lived experience, family members; and people from schools of thought as varied as psychodynamic, CBT, Open Dialogue, Art Therapy, the Hearing Voices Movement, and biomedical perspectives.
If human beings were meant to be entirely stable entities, then “stabilizing” them would be an entirely good thing, a target for mental health treatment that all could agree on. But it’s way more complex than that: healthy humans are constantly moving and changing, they have a complex mix of stability and instability that is hard to pin down.
All this relates to one of my favorite subjects, the intersection of creativity and madness.
It is a curious fact that people seen as “psychotic” or “schizophrenic” may show sometimes more creativity, and sometimes less creativity, than “normals.”
A good example of this was a test done to see how
people “guess” which of two alternatives (e.g., “left” or “right”) will occur next, when in fact the order of outcomes is random. We can analyze the sequence of guesses and quantify their entropy (unpredictability). Healthy people tend to have a Gaussian distribution of sequential guesses, with most responses at intermediate levels of entropy, and fewer very redundant or very entropic responses. In contrast, people with schizophrenia tended to show both more redundant (predictable) and more entropic (unpredictable) responses; longer periods of predictable behavior were interrupted by very unpredictable behavior.
What the guessing game test, and other research tends to show, is that people diagnosed with psychosis are often both too “unstable” at times, but also overly stable at other times (actually more of the time.) This corresponds to the way people experiencing “psychosis” can be both very flexible and innovative in the way they understand things, and also often very rigid and uncreative in other ways or at other times.
When I was a young guy going through a somewhat “mad” period, I identified as being very creative, while I saw “normals” as being more like robots or insects or something. The truth at the time was that I myself was often too much like the robot or whatever – I would fall into ruts or various sorts of “false selves” that weren’t very connected with anything alive within me, and then here and there I would be very weird or random in efforts to break free of those ruts. [click to continue…]
This sounds like a weird question – everyone knows that psychosis is often very disabling, and antipsychotic drugs are widely recognized for their effects in reducing psychosis in at least most people, and most often taking effect in just a few days. And when people become psychotic again, it’s often understood that it’s because they “weren’t taking their meds.”
But what if it’s trickier than that? What if “antipsychotic” drugs make things better in the short term, but make long term problems worse? How would we even know?
In a recent letter to the Psychiatric Times, psychiatrist Sandy Steingard outlined some of the ways we can know that there definitely is a problem with the long term use of antipsychotics. (Note that while she addressed a limited number of studies, that’s just because there actually are very few studies which look at really long term outcomes.)
She started her letter by writing about the Wunderink study, which found dramatically higher rates of recovery among the group that had been randomly selected 7 years earlier to receive a trial in getting off antipsychotic drugs, compared to those maintained on the drugs as usual.
It should be stated that the results of the Wunderink study are not perfectly clear in all respects. For example, of the members of the group that guided discontinuation of the drugs, most had resumed taking at least some drugs over time, though the dosages on average were much smaller than those of the “treatment as usual” group. So some have argued that the positive effects might have come from lower than average doses, and they argue that the study should not be taken to indicate that any use of drugs is detrimental long term.
But Sandy brought up more evidence, and the case against long term use of antipsychotics became more convincing as she continued. [click to continue…]
The kinds of experience we call psychotic are often incredibly scary: people feel they are being persecuted by strange forces, or that their brains have been invaded by demons or riddled with implants from the CIA….. the list of possible fears is endless, and often horrifying.
While standard mental health approaches counter many of these fears, they often create new fears of a different variety. People diagnosed with schizophrenia for example may be led to believe that they will definitely be mentally ill for life, that this illness controls what happens in their brain and not themselves, and that there are few or even no alternatives if drugs don’t work for them.
This can be extremely demoralizing. Oryx Cohen graphically described his own reaction to the standard mental health psychoeducation he received after his first psychotic experience: he reported it made him feel he had lost his membership in the human race! As a result of it, he felt caught up in a pathologized understanding of himself, he lost his expectation of being capable of learning from experience and shaping his future, and he now felt defined by his abnormality rather than by his humanity.
Despite rather than because of what the mental health system taught him to believe, Oryx later discovered other ways of understanding his experience, and he made a full recovery. But wouldn’t it be better if people like Oryx were helped to find a more humanistic understanding of themselves within the mental health system and from the very beginning of treatment?
Wouldn’t it be helpful if professionals were trained in an approach that could help people shift away from both dangerous psychotic ways of thinking and also away from the sometimes equally terrifying explanations which emphasize pathology?
Further, what if such an approach could also build a foundation for learning effective coping skills, and also help a person build hope and a road map toward a possible full recovery?
And wouldn’t it be nice if this approach was already proven to be “evidence based” so that both people learning the methods and their supervisors and colleagues could have confidence in its effectiveness and safety?
Fortunately, at least one such an approach exists, and it is called CBT for psychosis. This method allows professionals to collaborate with people in developing understandings of their psychotic experiences that neither minimize problems nor emphasize pathology, but instead help make sense of extreme human experiences in a way that is grounded in more everyday human experience and issues.
And better yet, those of you who are interested don’t need to go out and buy something, or travel to a seminar somewhere, in order to learn this method: instead, an online training module on normalizing is now being made available, for free!*
To access this training, I’m asking that you first register with my email list at this link, then you will be instructed how to sign up for the training module itself.
Here’s an outline of what you can learn from participating in this training module: [click to continue…]
When Doug Turkington, a UK psychiatrist, first announced to his colleagues that he wanted to help people with psychotic experiences by talking to them, he was told by some that this would just make them worse, and by others that this would be a risk to his own mental health, and would probably cause him to become psychotic! Fortunately, he didn’t believe either group, and in the following decades he went on to be a leading researcher and educator about talking to people within the method called CBT for psychosis.
I’m writing about Turkington because I just spent a week learning more about CBT from him at a training in California. This training was part of a bigger effort to bring this psychological approach into wider use in the western US. Attending this training and seeing the interest and passion in those who attended got me reflecting on what the role of CBT might be in changing our mental health system overall. A key question related to that, it seems to me, is the question of how CBT can improve its relationship to another key change effort in the field of psychosis, that of the Hearing Voices Movement (HVN).
I have a lot of interest in the possible improvement in that relationship between CBT and HVN, because for quite a while I have had my “feet in both worlds.” My first involvement with the mental health system was as an activist for change and increased choice, then I became a mental health professional so I could work to provide some of the alternatives I believed should exist. The first alternative approach to voices I heard about was the CBT approach of Paul Chadwick, so I started with that, and went on to become a CBT practitioner and educator. Then, when I heard about the HVN, I adopted many of its ideas as well, arranged for Ron Coleman to come to my town of Eugene Oregon to do some trainings, and got an HVN group going here.
While I have always interpreted CBT for psychosis in a flexible way, integrating it with HVN ideas, I have sometimes been unsure how well that would fit with the approach of the CBT for psychosis establishment. So it was really interesting to spend a week with Turkington, and to have a chance to explore his views in depth.
According to Turkington, the very most important part of cognitive therapy for psychosis is “normalizing” which means framing psychotic experiences as understandable and as just a fairly common variation of normal human experience and issues. This includes talking with people about how to get past fearing or “catastrophizing” such experiences, and even how to see them as possibly valuable, for example by seeing how such experiences can be part of a creative process or of a shamanic journey, etc. I have always been open to talking about this positive, somewhat shamanic side of psychotic experiences, and discussion of such views is common within HVN, but it was nice to see Turkington teaching this approach as part of standard CBT for psychosis! [click to continue…]
As we develop critical awareness about the mental health “treatments” that don’t work and that often make things much worse, the question inevitably comes up, what can those who want to be helpful be doing instead?
I believe that one key to successful change is going to be making effective training in alternatives widely available, so that those working in the field who hear our protests and criticisms with an open mind will be able to get support in then transitioning to doing things differently.
I’m hoping that in a few years, it will be possible for people all over the US to easily learn ways of helping that are both respectful and likely to lead to long term improvement. Such forms of helping may include everything from setting up peer self help such as that provided by hearing voices groups, to one on one support such as the better forms of therapy, to more systematic/team approaches like Open Dialogue and Soteria houses. Only when we have lots of people thoroughly educated in what to do differently will we be able to “take over” the mental health system and then more consistently provide real help instead of oppression to those who are distressed! [click to continue…]
Use the link above to signup to get access to a free online training in how to talk to people with psychotic experience in a way that allows them to calm down, feel more grounded, access coping skills, and increase hope for recovery.
By signing up here, you will also be added to an email list to be notified about upcoming events like the release of the complete online training in CBT for Psychosis, which will include CE credits for US professionals. You can unsubscribe from this list at any time.