Recovery from "schizophrenia" and other "psychotic disorders"

“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 »

 Many of you have probably been aware of two prior World Health Organization (WHO) studies that showed almost twice the recovery rates from “schizophrenia” in developing countries as in developed countries.  While critics of current psychiatric practice attributed the better outcome in developing countries to the fact that most were not on medication, others suggested that cultural factors were mostly responsible for the better outcomes.

A new study though, that looked only at people on medication in a wide variety of countries, found little difference in outcome between developing and developed countries.  While not noted in the article, this apparently provides new backing for those who would maintain that it was the greater use of antipsychotic medication in developed countries that resulted in the greatly reduced recovery rates in those first two studies. 

For those who want to know more about the assertion that long term use of antipsychotics is highly detrimental to real recovery and contributes to long term disability, this issue is covered in depth in Robert Whitaker’s new book, Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America

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.

As I pointed out at a recent mental health system meeting in my county, people with mental health problems face two kinds of risks. 

The first sort of risk is from the mental health problem itself.  Unless the person finds effective treatment, mental health problems can often cause high distress, disability, and even result in death, such as from suicide.

The second sort of risk, however, is the possibility that the person may receive an unnecessarily hazardous treatment.  For example, some people recover from psychosis without antipsychotics, and some people aren’t helped by antipsychotics, and some are helped but not enough to justify the hazards, and some could be better helped by less hazardous methods if such methods were made available.  So when antipsychotics are used routinely for everyone with psychosis, it follows that many people will be exposed to a treatment which will be unnecessarily hazardous to them.  This treatment itself can often cause high distress, disability, and even result in death.

(Some argue that most psychiatric treatment offers more risk than help:  for a good summary of those arguments, see Robert Whitaker’s new book, Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America  If you click this link you can both find out more about the book as well as get many of the main points and the supporting data on the website.)

The mental health system is organized to prevent the first kind of risk, the risk from the mental problem itself.   Billions are spent to address this risk.

Strangely enough though, the second kind of risk is usually not even discussed within a mental health system.  At the meeting in which I was talking, we wanted a document on guidelines for treatment to mention this sort of risk, but our attempt to get it simply mentioned was labeled as “inflammatory” and was being denied.  Why? More »

Richard Bentall, in his book Doctoring the Mind: Is our current treatment of mental illness really any good? describes how researchers first noticed and tested the properties of the medications that later became known as “antipsychotic.”  The procedure was fairly simple.  They first exposed rats to an electric shock applied to the floor of their cage, accompanied by a sound.  The rats quickly learned to climb a rope to get away from the floor of the cage whenever they heard the sound:  this is what is called “conditioned avoidance.”  Then they gave the rats the new medications, and noticed that the medicated rats no longer showed the conditioned avoidance – that is, they no longer climbed the rope in response to the sound.

That this effect exists is not surprising given what we now know about the function of dopamine in the brain, and the role of antipsychotic medication in blocking dopamine.  Dopamine nerve cells are involved in anticipating threats, and that animals that have been repeatedly exposed to threats show increased sensitization of their dopamine system (in other words, their dopamine system is more reactive).  And since antipsychotic medications block dopamine, it follows that they reduce threat anticipation.

People who are diagnosed with psychosis are often misperceiving people or events as threatening when they are not.  Often, such misperceptions cause chaos in a person’s life (especially if the person takes action to fight off threats that are unreal, actions which may create real threats.)  So, medications that reduce “conditioned avoidance” reduce reactivity to perceived threats, and this is helpful at least some of the time.  But isn’t it also possible that such reduced anticipation of threat can go too far, and result in people on medication being less likely to protect themselves from many real threats that may exist? More »

[Note:  The document below is just a part of the proposed consumer empowerment guidelines for Lane County.  I'm posting this separately here, because it is the part of the document that would be of most general interest.]

Recovery from many kinds of problems is affected by beliefs about the possibility of recovery.  Consider a hypothetical example of a person who has received an injury which affects the person’s ability to walk, but which is not necessarily permanently disabling if strong efforts are made to recover.  If the person is led by medical authorities to believe that the disability is permanent, efforts at rehabilitation will probably not be made, and the prediction may become a self fulfilling prophecy.  Since the disability at that point is a result of the inaccurate prediction rather than the injury itself, the disability becomes a medical system induced condition.

The mental health system faces the same kinds of issues.  In fact, none of the major mental health disorders have been shown to be reliably permanent, and no studies have shown mental health professionals being able to determine who will definitely have the disorder for the rest of their lives.[i]  For each disorder, at least a sizable minority are found to fully recover, without need of further medication or other mental health treatment.[ii]  Consumers who do recover typically credit others who helped them believe they could recover, and their own efforts at recovery, as essential parts of that recovery.[iii]

And yet, many consumers have been led to believe by the mental health system that they will always be “mentally ill” and that their need for treatment, in particular treatment by medication, will inevitably be lifelong as well.[iv]  More »

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 »

A lot of efforts to transform an often oppressive mental health have focused on “recovery” and making the mental health system more “recovery focused.” Many agencies have integrated the notion of recovery into their practice, and if the use of this word were a measure of progress, we would be well on our way to system transformation! Unfortunately, what seems to be happening is that as the word “recovery” is used more and more, it seems to mean less and less. I know someone for example who is on heavy doses of an antipsychotic as well as other medications, lives in a foster care home, and spends most of his daytime hours in a mental health day treatment program, yet is assured by his case managers that he is “recovered.”

More at this recovery page.

(Note, this is a very old post, and at least many of the problems reported with the EAST program no longer exist, as they have been open to making some changes.  This post however does still describe problems that exist with many suppposedly “progressive” programs which really still follow an excessively narrow and inaccurate “medical model.”)

The following exerpt is part of an email I wrote to Kathy Savicki, the director of an early intervention in psychosis program in Oregon called EAST.  (You can find out more about EAST by checking out www.eastcommunity.org.)  While this program can be praised for at least bringing up the issue of recovery, it also apparently suffers from very serious flaws due to the way it pushed a biological explanation for psychosis – both common sense and research tell us that when people believe their mental problems are biological, they feel less able to do anything about them.  Since empowerment is a key factor in recovery, and since biological theories are highly speculative, then biological theories should never be presented as fact.  ”I found some things about your program that I liked very much, but also some apparent problems which I would like to discuss with you.  Since you have taken a forward looking approach in being involved in new programs, I am hoping you are open to hearing different and probably controversial ideas, even if critical of some aspects of your program!