Recovery from "schizophrenia" and other "psychotic disorders"

I found a link to a very interesting article on the Beyond Meds site.  The article is called The Creativity Crisis and it documents how creativity is key to a society’s success, and yet it has been in a decline in the US since about 1990.  The article finds various reasons for this, but one reason it doesn’t mention is the dramatic escalation of use of psychiatric drugs for kids since that time.  Even Ritalin and other stimulants used for “ADHD” is known to reduce creativity, but the antipsychotics, also increasingly used for kids, are even more dramatic in their ability to inhibit original thinking.

It’s interesting that our society tends to view “living in your own world” or even “attending to internal stimuli” as the hallmark of mental illness, yet as this article points out, it is also key to creative development.  There’s even a word for the “imaginary worlds” that creative people often develop in childhood and then take with them into adulthood:  they are called  “paracosms.”  Really creative kids can see and hear stuff they make up.  But what happens to kids like these when they annoy someone and come to the attention of a psychiatrist?

This article actually downplays the connection between creativity and mental and emotional problems – calling it a myth, for example, that creative people tend to be anxious or depressed, and stating that such traits tend to shut down creativity.  But when researchers have actually look at people who have had creative achievment as a group, they do find higher than average levels of “mental disorders.”  It may be true that anxiety and depression get in the way of creativity, but it also seems true that creative people are prone to struggling with such things. 

At one point in the article, it is suggested that people get suicidal because they aren’t creative enough, and points to people who think of all the ways things can go wrong, but not to possible solutions, as being the one’s prone to depression and suicide.  But this could also be seen as misguided creativity – the creativity is all going into seeing how things could go wrong, and not into possible solutions.  So I think it makes more sense to see mental and emotional problems as often related to misguided creativity, and to see the solution as helping people learn to use their creativity in more constructive ways.

One interesting part of the article is the distinction made between divergent and convergent thinking, and how both play a key role in successful creativity.  In psychiatry, both these forms of thinking are well known – but there they get labels like “positive symptoms” for thinking that diverges from “normal,” and “negative symptoms” for thinking that seems too convergent, when too many possibilities have been eliminated and the person seems to be missing something normally present.  I think it is true that many people get carried away by both divergent and convergent thinking in ways that are not helpful to them, but I think it is also helpful to know that these forms of thinking have important uses, and that if they are better directed, they can be part of a healthy creative life. 

Our society tends to want to produce kids as a sort of standardized product:  they should succeed in some simple linear way, shouldn’t cause trouble, shouldn’t do anything freaky, etc.  But that isn’t how kids work.  We as a society need to be less controlling, and re-envision childhood as a time to explore imaginary worlds.  And when young people get lost in their imagination, we need to see that as a sign of potential talent as well as trouble, and help these people learn to put it to constructive use.

I spent some time down by the river today, alternating between reading and swimming, and learned a new concept (and a term to go with it) that I thought I would share with you.  I was reading “Cognitive perspectives on dissociation and psychosis: Differences in the processing of threat?”  by Dorahy & Green, from the book Psychosis, Trauma & Dissociation.

This chapter discusses an odd finding where people who tend to be paranoid were found to spend less time than normal looking at threatening stimuli, but then when they looked away at relatively non-threatening stimuli, they tended to see more threat in that non-threatening stimuli.  This pattern was called a “vigilance-avoidance” method of threat processing, and it was hypothesized that the paranoid people were attempting to avoid the unpleasant feelings resulting from observing the threatening stimuli by looking away, but then since their more automatic perception of threat had been “set off” they then tended to see more threat in the non-threatening stimuli.

In cognitive therapy we call this sort of thing a dysfunctional experience control strategy.  The person is trying to perceive less threat, but ends up feeling threatened by stuff that really is relatively safe, which of course makes everyone else think the person is crazy, and of course one can do oneself much good by taking action to protect against threats that aren’t there.

In its more extreme forms, a person may withdraw attention from most of the external world which seems threatening, but then since the automatic aspects of threat perception have already been activated, even the formerly safe internal world begins to be perceived as threatening, and there is no escape.

Lots of fictional tales start with the hero being threatened in some way in a real-world kind of way, then the person journeys into a kind of fantastic land where threat follows them, though in a new and more fantastic form.  In stories, the hero often first learns to do something to handle the threat in the fantastic world, then emerges with a new strength that allows him or her to handle the real-world kind of threat. 

The key thing is that the person needs to learn how to take a stand and start looking at threats in the eye, not turning away to try to feel better.  Unfortunately, most mental health treatment currently is based on helping people avoid having the experience of facing their demons, using everything from drugs to distraction.  So it is hard for heroes to emerge from that.

“Schizophrenia” can be seen as revolving around having difficulty in containing opposites, such as love and aggression.  In normal everyday culture, opposites are often contained simply by pretending they aren’t there and aren’t supposed to be there, while “under the table” they are allowed to coexist.  In other words, hypocrisy is the rule.  Those who end up defined as “schizophrenic” are often those who actually attempt to do what the culture says it does, which is to get rid of one opposite in favor of another.  This sets off an internal war, as other parts of the self rise up to prevent any such elimination, since in reality both opposites are necessary to life.

At the same time, when people who are caught up in “schizophrenia” manage to recover, they do a huge service for the culture, because they find ways to accomplish the reconciliation of opposites in new ways, and often ways that are much less hypocritical than those common in the culture beforehand.

Of course, problems with opposites manifest as other disorders as well.  More »

My county, Lane County, Oregon, is one of a number of places around the country just starting to participate in a new “early intervention” program sponsored by NIMH, called RAISE, that says it aims to help people soon after they begin experiencing their first psychotic episode.  While there are some good reasons to offer help to young people as soon as they start having problems that might be labeled psychosis, I have serious doubts about the program here being offered.

For one thing, the very name of the program (RAISE stands for “Recovery After an Initial Schizophrenic Episode”) suggests the program will be reckless in applying labels and stigma.  Even the DSM cautions against calling a psychotic episode “schizophrenia” unless the mental health condition has lasted at least 6 months, but people will be recruited into the RAISE program as soon as possible after their problems with psychosis begin, a much shorter time period.  Nevertheless, just due to the name of the program, they will feel defined  as having had a “schizophrenic” episode. 

Second, the NIMH website advertises that the program involves “intense and sustained pharmacological intervention.”  This implies a reckless use of medication as well as of labeling.  (Of course, the two go together – the sooner a person is labeled with “schizophrenia” the more justification can be made for “intense and sustained” drugging.) 

Early intervention programs that really aim to help are very cautious about the use of both labels and drugs.  The lack of caution in the design of this program suggests that the true purpose of the program is the early recruitment of young people into a life as labeled consumers of psychiatric medication.  Tobacco companies have to recruit their own customers, but pharmaceutical companies have government assistance in capturing their market.

It’s interesting that an old friend of mine, John Bola, did a review of all the studies that ever compared programs that started people out on drugs immediately, with programs that didn’t, and where the comparison period was at least a year.  You can read his paper here.  What he found was that in each case, the program that didn’t rush people into drugs did better – and that was before taking into account the fact that the people not on drugs didn’t have to deal with drug side effects.  And of course the best effects reported for an early intervention program are those of the Open Dialogue program, which also avoids using drugs wherever possible.

I wait for the day when we will treat young people with “psychosis” based on the evidence, and not based on the wishes of those more interested in profit.

A great deal of research shows that one of the more common effects of child sexual abuse is “auditory hallucinations” or hearing voices and other experiences which tend to get diagnosed as “schizophrenia.  Yet, the US federal government, on an official website, assists mental health workers in telling people diagnosed with schizophrenia that nothing anyone did (and so this would include nothing a child molester did) had anything to do with the person’s later mental health problems.

So first kids get molested, then the mental health system, collaborating with the federal government, comes along and tells them that their “biochemical imbalance” is what caused the problem, and that the sexual abuse had nothing to do with it!  Excuse me if I think that is disgusting…..

The exact language on the SAMHSA National Mental Health Informtion Center website  includes the following:

“What causes schizophrenia?

“Schizophrenia is nobody’s fault. This means that you did not cause the disorder, and neither did your family members or anyone else. Scientists believe that the symptoms of schizophrenia are caused by a chemical imbalance in the brain. Chemicals called “neurotransmitters” send messages in the brain. When they are out of balance, they can cause the brain to send messages that contain wrong information.

“Scientists do not know what causes this chemical imbalance, but they believe that whatever causes it happens before birth….”

Is it too much to ask that the federal government, and the mental health system, quit collaborating with child molesters to blame the brains of victims for problems that are actually caused by abuse?

Not everyone who is diagnosed with schizophrenia was molested or otherwise abused in childhood.  There are a variety of ways people end up with the troubles that get this diagnosis, and it probably is true that some are born with increased vulnerability (just as some are born with increased vulnerability to sunburn.)  But it’s an atrocity when people paid to “help” instead provide gross misinformation, and attempt to convince people who often were victims of abuse that this abuse has nothing to do with their current mental and emotional difficulties.

In an article titled “ Effects of Culture on Recovery From Transient Psychosis” the author asks why premodern cultures studied by the World Health Organization had 10 times the rate of acute onset psychosis followed by full recovery as that found in more modern cultures.

The author contends that “Traditional treatment in a premodern society usually consists of a prescribed period of rest; sympathy; heightened social support; alleviation of underlying social stresses; exploration of alternative coping
strategies; and various types of traditional healing rituals, sometimes lasting days or weeks, and frequently resulting in the full recovery of the patient.”  

While “modern medical experts” make fun of “primitive” perspectives about spirits and the use of “witch doctors” to address them, it seems that any truly “evidence based” approach to understanding psychosis would be more interested in figuring out how and why they were so effective.

Contrast the “primitive” approach with the relative isolation and drugging imposed on the newly diagnosed psychotic person in in a modern culture.  The person is identified as “biochemically imbalanced” rather than overcome by stressful life events, no attempts are made to really understand him or her, the experience is identified as an illness with no spiritual consequences, and no coping tools are suggested beyond taking pills as prescribed.

I am reminded of an early drug trial on antipsychotics.  They had 4 groups, three groups were each on a different antipsychotic, while the fourth group was a placebo.  After about 6 weeks, each of the drug groups was doing better than the placebo group. But when they came back and checked on how everybody was doing after a year, they found that the group that had been started on placebo was doing better than any of the three groups started on drugs.  Instead of concluding that there was something wrong with rushing people into drugs however, the experimenters hypothesized that the group initially started on placebo was only doing better because they had been noticed by others to be doing worse because of not being on drugs, and this had elicited sympathy and concern from the people who noticed, and it was the extra care that they received that resulted in them doing better when measured a year later.  Of course, it never occurred to the experimenters that giving a drug to people that made them seem like they didn’t need extra support, resulting in them not getting the support they really needed, so that they would be doing worse later, may not have been a good idea.  (Not to mention that more drugs meant more risk of nasty side effects as well.)  And so the modern era of drugging and lack of empathy was begun. More »

I have written elsewhere about links between creativity and psychosis.  In a recent blog entry, Gianna Kali of “BeyondMeds” links to an article describing how teachers in schools all say they seek to encourage creativity, yet their favorite students all tend to be those who show traits incompatible with creativity – those who are good at agreeing, following rules, etc.  Why the discrepancy?  And what does it mean for mental health?

Creativity is extremely valuable, but it can also have high costs.  One of the costs is that people who are attempting to be creative will sometimes make errors, and their attempted improvements will sometimes make things worse.  But if we are to become a society that truly values creativity, we need to recognize that we benefit from those who live more “on the edge” and who sometimes fall off the edge:  instead of stigmatizing them or labeling them as forever ill, we might better collaborate with them in helping them figure out where they might have gone wrong while also staying open to the possibility they have a lot to teach us.

I really wonder how much creative talent is currently buried under high doses of antipsychotic medications……

In the mental health field currently, when people experience intense anxiety and depression, and when they experience mania and/or psychosis, the experience is understood to be a “disorder” or a “biological dysfunction” that is of no use and should “corrected” by any means that might be effective in doing so.  The most straightforward way of doing this is conceived to be a drug that might directly reverse the theorized “biochemical imbalance” though other methods are tried, particularly when drugs don’t work.

The primary opposition to this point of view in our culture comes from those who deny the existence of mental disorders at all:  they see “diagnosis” in the mental health field as being an illegitimate enterprise, and the DSM as a work of quackery designed to make money for drug companies and for “mental health professionals.”  It is noted that there is no physical test for any sort of “mental disorder” and no objective way of determining what should be called a disorder.  It is then imagined that people would do fine if saved from those in the mental health field who attempt to diagnose and then “help” them.

A middle ground between these two extreme views is however emerging.  In this view, the mental states that get diagnosed as “disorders” tend to be specialized states of mind which do tend to cause trouble for people, but which can also be seen as part of an evolved, problem solving strategy used by the mind.  That is, while these mental states may not be consciously chosen by the person and may cause problems, they also may solve important problems, and so in any given case it may be unclear whether they are doing more harm than good.

An example of a “biological” evolved problem solving strategy that both causes problems but also potentially solves problems is that of a fever.  Fevers cause many problems, and if quite high may cause brain damage or even death, yet we have evolved to have fevers because they often help solve the problem of infections. More »

In the attempt to convince people to take medications, the hazards of such medications are often minimized or overlooked. While many people may truly be better off taking some medications, at least for awhile, the danger in hiding the hazards of the drugs is that rational decisions about how long to stay on medications, at what dosage, and how hard to try to find alternatives, become impossible. Instead, an illusion is created that the only rational approach is to stay on medications indefinitely, because only an irrational person would risk the return of a destructive psychosis.

If we really allowed ourselves to face all the facts however, we would see that these decisions are much more complex. For example, while the effects of being caught up in psychosis can be terrible, the effects of the antipsychotic medications can be terrible as well. These medications significantly increase the risk of death, due to causing things like heart problems, metabolic syndrome, obesity, diabetes etc. And, while most of psychiatry is still in denial about it, it appears that antipsychotic medications have a tendency to shrink brains. (For those of you unfamiliar with the evidence for this effect, I include some references and other information at the end of this post.)

Some people might think that if antipsychotic medications will shrink the consumer’s brain and then possibly kill them, then the obvious decision is to just get off the medications as quickly as possible. However, the problem is that it appears that uncontrolled psychosis, and its associated distress, will also shrink a person’s brain and very possibly kill them (besides making a total mess of their life in other ways.) More »

Earlier today I was informed by the director of our county mental health agency, where I work only a few hours per week, that I am now officially banned from sending emails to the psychiatrists, unless it concerns a particular client. The reason for this ban? I sent them a list of suggestions about how the agency might work to reduce the high death rate among the mentally ill (see below for the text of the email I sent.) Apparently, the new chief psychiatrist was offended, and decided I was simply too radical to be allowed to speak to the medical staff. So much for willingness to hear different points of view…..

There are some advantages to being censored however, as anyone knows who has ever had a book or movie banned. People start wondering, why did that happen? So the next step (after talking personally to the director about it) will be for me to go public, and question why my suggestions were seen as so radical as to require censorship, and why the county refuses to even allow discussion of alternatives to current forms of treatment, even as people are dying. I’m sure the local newspapers will be open to a column in the editorial section on the subject……

Here’s the text of my email, sent to all the county mental health workers:

LCMH’s program to integrate primary care with mental health care is great as one angle to take on reducing death rates in our clients, and there also has been some focus on shifting to neuroleptics with somewhat less hazardous known side effect profiles for clients who do OK on those other neuroleptics, but I think we need to address much more than that if we are to really have a sufficient impact on minimizing deaths.

A few thoughts on what LCMH might additionally do to reduce deaths caused or partly caused by neuroleptics:

Let consumers know that we want to collaborate with them in safely minimizing the use of neuroleptics. Let them know that our success in this will partly depend on their willingness to use alternatives and to learn more about other ways of managing their issues.

Make sure consumers are fully informed about the risks to their health from taking neuroleptics, so they are more likely to be interested in working to reduce their use, and so they don’t end up being exposed to risks from neuroleptics without informed consent. (This means not just telling them once, but making sure they really “get it” about the risks.)

Provide groups to educate consumers in how to shift to relying more on alternatives to medications, so they will experience less need for medications.

Provide written material that educates consumers on how to shift to relying more on alternatives to medications.

Attempt to identify types of clients who are currently getting started on neuroleptics, but where alternative approaches that are available in the community might work if tried. Figure out how to encourage trying these alternatives and giving them a reasonable chance to work before neuroleptics are tried.

Identify clients who may have needed a certain level of neuroleptics in the past, but who now might possibly do well with less or no neuroleptics. Work out with them a process of weaning off, which would include assistance in handling withdrawal reactions and with gradually shifting to alternate forms of coping. Have a good relapse plan in place which includes the possibility of resuming higher levels of medication as one option, if necessary.

Specifically avoid using forms of psychoeducation that imply that certain forms of mental problems can only be handled by medication, as these discourage attempts to handle the problems in other ways. Instead, always frame medication as a possibly temporary measure, which could become unnecessary in the future if other forms of coping become more successful.

Make sure consumers are informed about the likelihood of withdrawal effects when neuroleptics are discontinued abrubtly (the fact that relapse is 3-5 times more likely in abrubt withdrawal.) This will help consumers avoid mistaking withdrawal effects for a need to constantly maintain medication.

Make sure alternative treatments are as available in the community as possible. For example, make sure that clinicians are available who are trained in psychological approaches to psychosis, so they don’t just see “more medication” as the only option when a client experiences a psychotic symptom.

Rather than just focus on the risk to clients of reducing or getting off neuroleptic medications, acknowledge that risks of reducing or getting off must be weighed against the possibly life threatening consequences of staying on the medications, and acknowledge that the balance of risk is different for each person, and varies as well over time. For example, trying a reduction may be too risky at one point in time, but may make good sense later.

All of these steps could be done without really adding new programs, though adding new programs, such as an early intervention program for psychosis that prioritized a non-medication approach, could also be an important part of the solution.

I’d be curious to hear your thoughts about these options and their potential role in reducing death rates…….

Ron Unger