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Rethinking “Delusions”: Envisioning a Humanistic Approach to Troublesome Beliefs

When people are told they have “psychosis,” it’s usually because they are experiencing one or both of the following:

  • “hallucinations,” defined as sensations that don’t seem to have any physical cause, and
  • “delusions,” defined as beliefs that don’t agree with others in one’s culture and/or with physical reality.

Thanks to the revolutionary impact of the Hearing Voices Movement, many people around the world are now able to think of the experience of  the first phenomena, “hallucinations,” as something much broader than just as part of a “psychosis.”  In fact, even the term “hallucination” has been questioned, with less medicalized terms like “hearing voices” and “seeing visions” proposed instead.  And it has been asserted that hearing voices itself should never be defined as an illness.  Instead, hearing voices is conceptualized as a human variation, like being left handed or gay.  It is understood that people may have problems with the voices and may need help figuring out how to relate to them, but once the relationship has been improved, the experience may change to something that is overall benign or even beneficial to the person.

Unfortunately, less attention has been brought to that other key component of psychosis, the “delusions.”  And yet, the need for a revolution in how they are approached may be just as intense.

Sometimes, revolutions start with changes in understanding.  One area to begin with might be the notion of a firm distinction between hallucinations and delusions.  Hallucinations are understood as disorders of perception, while delusions are understood as disorders of conception: but in practice conception plays a big role in perception, and vice versa.  For example, consider the difference between thinking that an external force is controlling one’s thoughts (classified as a delusion) and “hearing” thoughts that seem to be coming from outside one’s mind (classified as a hallucination.)  Are these two really that different?  Or are they better thought of as on a continuum, with some experiences in the middle and not easily classified as one or the other?

The history of the distinction between hallucinations and delusions is explored in the article Voices, Visions and ‘Persons Under the Floor’: ‘Delusions’ and ‘Hallucinations’ in Nineteenth-Century Psychiatry.  It notes that the belief in a clear distinction between the two was not always present, and that our imagining that there is a clear distinction can make us insensitive to the lived reality of people’s experience.

In hearing voices groups, the lack of a clear distinction between perceiving a different reality, and conceptualizing or believing in a different reality, is often understood, and so alternative ways of relating to “unshared beliefs” have been developed alongside alternative ways of relating to voices.    But these alternative approaches to working with troublesome beliefs have not received as much publicity as have approaches to hearing voices.

One example of a person working to change that is Rufus May.  At age 18, Rufus became convinced that he was a spy and that a device had been planted in his chest.  His beliefs were treated in the conventional way by the mental health system:  he was diagnosed with “schizophrenia,” hospitalized, and drugged.  But Rufus decided not to believe in the diagnosis and the drugs, and he eventually found his own way to regain control of his life.  Then, using undercover skills which he had previously just fantasized, he infiltrated the mental health system, keeping his psychiatric history secret as he completed his training as a psychologist.

With his training complete, Rufus shifted to being open about his history, and became an effective advocate and educator for alternative approaches.  And while some of his efforts have been around alternative approaches to hearing voices, he has also written very coherently about alternative approaches to working with difficult beliefs. for example in his article Accepting Alternative Realities.  He also explored that topic in a recent webinar, Believe It or Not! Ways of Working with “Delusions” or “Unusual Beliefs”  (See the link at the end of this post.)

One reason I believe Rufus is a great teacher on this topic is due to the degree of flexibility, creativity, and respect for people that he brings to the work.

A key issue with “delusions” is that people are often holding beliefs in a rigid manner:  this tends to prompt those around the person to become unhelpfully rigid in return.  In conventional mental health treatment, this rigidity involves insisting that the person “get insight” into the “fact” that their belief is a delusion and is a sign of the presence of a “mental illness” like “schizophrenia.”  This rigidity is maintained despite evidence that many ideas about “schizophrenia” may be as untrue as any “delusion,” and despite extensive evidence that confronting any strongly held belief in a rigid way tends to make the person holding the belief dig in and defend it more.

I’ve been practicing CBT for psychosis for many years, and CBT does have some ways to approach “unshared beliefs” in a less rigid way.  But there is still a tendency in much CBT literature to emphasize attempting to change the belief seen as troublesome.  That is sometimes possible, and work around reconsidering beliefs can be important, but it is also sometimes not possible or not the most helpful approach.

In many cases, it can be more helpful to work on things like understanding the life experience that led to the belief, exploring the possibility of living successfully even while continuing to have the belief, and/or looking at the belief as a possibly metaphorical message about something that needs attention, and then shifting the focus to that area.

A couple years ago I had a chance to hear Aaron Beck, a key founder of CBT, speak about his understanding of how to approach apparent “delusions.”  It may be common for older people to be rigid in their views, but I was pleased to find that Beck, then age 97, was advocating for a more creative direction.  He was asked for example how he might respond to a man who was claiming to have been roasted in an oven.  Beck said first he would acknowledge the man’s story, and be curious about what that experience was like, how it felt etc.  Then he would ask about other times in the man’s life when he may have felt that way, and then inquire about whether anything currently was making him feel something similar.  In other words, he was saying it might make more sense to follow the vein of emotional content to where it might connect with the man’s past or current issues and distress, which then could be addressed directly.  That could be way more effective than simply trying to change beliefs.

Too often in conventional mental health treatment, once people express a belief that seems “insane,” there is just an effort to suppress the belief, rather than to really understand where the person might be coming from, and what their most important concerns might be.

Another example Beck gave involved a man who told hospital staff that his psychiatrist was a threat, and revealed that he wanted to shoot the psychiatrist.  In a conventional setting, this would be seen as a sign of the worsening of a dangerous psychosis, and an increase in antipsychotic drugs, by force if necessary, would have been seen as the solution.  But in this case, the psychiatrist had been trained to proceed with more sensitivity and flexibility, so instead of treating it as a symptom, he asked the patient, “why do you want to shoot me?”  The patient responded, “because you are planning to shoot me!”  “But,” the doctor explained, “I don’t even own a gun!”  “Well,” said the patient, “you use your drugs like a gun.”  The doctor thought about it and said, “I wonder if you are feeling you have very little control?  That must be frustrating.  But I know you must have lots you want to do outside of here and I want to help you get out so you can do that!”  This made sense to the person and they started to work together.

In the hearing voices movement, it is often pointed out that the voices may be “poor communicators” and that working things out with them may require considering alternative interpretations of what they are saying, until a more constructive meaning emerges.  For example, a voice that tells someone “you need to die” may be better understood as a part of the person saying that “something is wrong, you need to change something” or “you need to let something about you die.”  Once the message is properly understood, it becomes something helpful rather than destructive.  The voice hearer can learn to be like the parent who hears the child say “I hate you” but is able to infer that the child needs some love and a nap, rather than taking the statement literally.

One interesting thing about “delusions” is that people can be disturbed by their own beliefs:  that is, they can find themselves falling into a belief, but sense there is something wrong with the it at the same time.  At that point, they are like the voice hearer who hears a message that seems disturbing, but which they are also starting to believe.

A key skill people need to learn is discernment:  sorting out what might be a valid message in the belief or in what the voice is saying, while dismissing what might be exaggeration or a too literal interpretation.  This allows them to resolve the situation by believing the helpful part of the message, while disregarding the rest.

At other times people are not at all disturbed by their belief, but their having the belief does become disturbing to others.  At that point, the person with the belief is, in relation to us, like the voice is in relation to the voice hearer.  The person is saying something, and we must decide how to respond to it.  Do we see them as the enemy, and someone whose views simply need to be suppressed?  Or do we consider the possibility that while the person may be a poor communicator, there may be some valid message in what they are trying to communicate, even if we can’t agree with all of it?

To develop an adequate approach to difficult beliefs, it is also important to think more broadly about the nature and function of beliefs in general, and to understand how all humans tend to “behave irrationally” around their beliefs when those beliefs become important to their world view and their identity.

Beliefs are often a tribal kind of thing:  people may believe something to fit in with others, not because of logic.  Having a tendency to do so may benefit individuals in an evolutionary sense, because it makes the individual more likely to get along with others in their social group.  (This works, of course, only when the belief is not so destructive as to lead to the extinction of the entire group:  it remains to be seen for example how the “tribal belief” in the non-existence of the climate crisis, popular in many quarters, will affect the evolutionary viability of humanity.)

Curiously, psychiatry identifies only untrue beliefs held by one or at most a few people who are at odds with their culture as having mental health problems, and doesn’t consider the possibility that beliefs held by larger groups or even entire cultures may be even more of a problem – even though the dangerousness of a belief tends to increase the more people endorse it!

(If psychiatry were more able to recognize the “pathology” of widely held beliefs, it might for example be more able to reflect on the damage done by beliefs it has itself promoted, such as the one about how “mental disorders” are caused by “biochemical imbalances.”)

But, one might ask, if people often hold beliefs just to fit in with their group or tribe, why do some individuals seem to go their own way and choose beliefs that put them at odds with their community?

One answer may be that when a person’s life does not seem to them to be working out, they may be motivated to try on different beliefs, sometimes desperately grabbing on to whatever seems to offer some chance at inner coherence amid chaos and disruption.  Once a belief that seem to help restore internal order is found, the person may be reluctant to let go of it, even when that puts them at odds with their culture and gets them labeled “psychotic.”

It is also true that evolution would never work if there were not genetic variations, and cultural beliefs can never evolve unless we have people trying on different perspectives.  Much variation in belief may be just a part of human diversity, and not a problem that needs to be solved.  A skilled approach to working with beliefs involves both toleration of differences in perspective, with an awareness of a variety of possible things that can be tried when a belief is causing problems that do not seem to be tolerable, either to the person or to others with whom they must interact.

There’s a lot more that could be said about this topic:  this post just scratches the surface.  To go a little deeper into it, consider viewing the “Believe It or Not” webinar:

Topics covered include

  • understanding the protective function of beliefs,
  • understanding how they may be linked to past life events,
  • ways to be with someone with different beliefs, and
  • if someone is motivated to hold their beliefs more lightly how we might help them with this.

It Should Not Be a Secret: The Connection Between Trauma and Psychosis

According to fact sheets published by the US National Institute of Mental Health (NIMH) psychosis is caused either by a “mental illness” or by the current impacts of drug use, sleep deprivation, or a medical condition.  If other factors are ruled out, then a mental illness like schizophrenia or bipolar disorder can be identified as the cause.

But there is something quite important hidden by the language used by the NIMH.  When people are told that their disturbance is caused by their “illness” they naturally think of the problem as something inside of themselves, some brain defect or chemical problem.  But what if the real cause was something that happened to them, and what if their current problems are an understandable reaction to that?  Something, for example, like child abuse?    

While the NIMH often declines to mention trauma as a possible cause of psychosis, and even funds programs that explicitly deny that people can play a role in causing psychosis in others, research increasingly shows that trauma, such as various forms of child abuse, can be a major factor in making psychosis more likely.  In fact, the connection between experiencing multiple forms of trauma and then psychosis appears comparable to the link between smoking and lung cancer.

And while people are told that the brain differences that are commonly (but not always) found in people diagnosed with schizophrenia is proof that schizophrenia is a “brain disease,” a nasty but lesser known fact is that the brains of those traumatized as children show the same brain differences.    

Here’s a video summary of the evidence that trauma can be a cause for psychosis:

It is true that not everyone who experiences psychosis has been a victim of major traumas or abuse.  But we might best think of psychosis as something like taking a “fall” from stability.  Not everyone who falls was pushed, some fall for other reasons.  But telling people they fell because they have a “falling illness,” and distracting attention away from the impact of the push, is not a helpful way to help people understand themselves or figure out how to do better in the future.

That is, when people are told that an “illness” is causing the psychosis, attention is turned away from what might have happened to the person, and from how the person’s current behavior might be an understandable reaction to those events, even if a severely troubled one.  This makes it harder for people to understand themselves, which in turn gets in the way of recovery.

It’s also true that when kids are abused, they tend to blame themselves for what happened.  When the long-term consequences of the abuse are defined by mental health professionals as being caused by a “mental illness” within the person, the result is that people once again are likely to blame their troubles exclusively on something being wrong inside themselves.  This tends to deepen a sense of personal inadequacy and self-blame; there is a kind of piling on to the damage and distortions created by the original abuse.

What would work better?  That’s a subject I explore in an online course, “Working with Trauma, Dissociation, and Psychosis, CBT and Other Approaches to Understanding and Recovery.”  This course offers 6 CE to most US mental health professionals. You can find out more about it, check out some free preview videos, and register, at this link.

The experiences we call “psychosis” can be incredibly confusing, not just to the experiencer but to those who may be trying to help.  And trauma is only one possible cause of psychosis, so many other factors may also need to be addressed.  But at the very least, let’s quit telling people that their experiences are caused by some “mental illness” which is really just a label invented by a committee.  People who are suffering deserve at least our honest efforts to understand them, and that includes addressing the possible role of trauma in creating their current confusion.

“There’s Someone in My Head, and It’s Not Me” – Pink Floyd

Since the beginning of recorded history, humans have reported having experiences in their minds (not tied to sensory perception of what others see as physical reality) that seem to be coming from somewhere other than their own mind. 

How people conceptualize these experiences has varied over time.  Such “visitors” within one’s own mind or personal sense of reality might be understood as spirits, ancestors, gods, demons, or in more modern times, the government intruding via technology.

Psychiatrists of course are not fond of any of these explanations.  They insist that people interpret everything they experience in their mind that is not based on physical sensation as being their own mind, as being sourced in themselves.  When people report experiencing things otherwise, they are routinely diagnosed with a psychotic disorder.  As psychiatric critic Thomas Szaz pointed out, what is asserted by psychiatry seems to be that “If you talk to God, you are praying; If God talks to you, you have schizophrenia.”

I recently started reflecting more on this subject when I encountered a recent article by Eric Coates, The Day I Became Schizophrenic.  In the article, Eric explains that he understands the word “schizophrenia” to indicate that one has ”a mind that you share with some sort of outside presence.”  He relates many of his experiences he has with such presences, such as voices that dictate to him poems and a novel that, it seems to him, he has no role in composing.  He also reports finding a lot of value in this experience.

Anyway, that got me thinking. For example, I reflected that we tend to recognize what is our own mind or our “self” by noticing the familiar patterns of thinking and feeling that we identify as ourselves. 

But this creates an interesting situation.  If we do suddenly find a new way of thinking or feeling, some really new perspective, it is not going to feel like “us.”  In fact this new way of thinking or feeling may feel alien to us, or even, perhaps, actively opposed to the patterns that we have identified with. 

But any kind of creativity requires stretching in some sense beyond what we previously have known as our self – because what we previously thought of as our self hadn’t previously done or said what is now being created.

That’s why I think many writers find the process of writing is often more like being dictated to, by some kind of awareness or entity that is other than their self, at least at times. Eric’s process seems especially that way, but creativity in general seems to have this aspect.

My favorite songwriter, the late Leonard Cohen, has written about the sense of not being the writer of his own work, for example as in the following lyrics from “Going Home”:

“I love to speak with Leonard
He’s a sportsman and a shepherd
He’s a lazy bastard
Living in a suit

“But he does say what I tell him
Even though it isn’t welcome
He just doesn’t have the freedom
To refuse

“He will speak these words of wisdom
Like a sage, a man of vision
Though he knows he’s really nothing
But the brief elaboration of a tube”

We often think of creativity as a conscious achievement, but really much creativity comes from “somewhere else.”  For example, I know nothing about making music, yet in my dreams I have sometimes heard very impressive music that did not seem to be anything I have heard while awake.  Something or someone composed this music, but it certainly wasn’t anything in my mind of which I am consciously aware!

Getting back to Eric’s assertion that schizophrenia means having a mind that one shares with others:  I don’t quite agree.  Instead, I agree with psychiatrist Russel Razzique when he says the function of the mental health system should be to help people with any distress they may be having while also recognizing and helping them make use of anything that might be of spiritual or creative value in that experience.  If they find a way to do this, then it no longer makes sense to consider them as a person with a mental health problem.

That is, our job should be helping people navigate the rocky parts of experiences of outside presences in our mind, without framing everything about those experiences as pathology.

Last year I put together an online course “Addressing Spiritual Issues within Treatment for Psychosis and Bipolar” https://www.udemy.com/course/spiritual-issues-psychosis-and-bipolar/ which is my attempt to convey this kind of message to the mental health field….

Amazing Absence of Scientific Support for Recommending “Antipsychotic” Drugs

When a young person or the family of a young person just diagnosed with psychosis is considering whether or not to try antipsychotic drugs, it makes sense they might want to know the results of randomized controlled trials of these drugs compared to placebo in people who have never taken the drugs.

It would be important to see this comparison with placebo in people who have never taken the drugs, since placebo could be expected to work more poorly in people undergoing drug withdrawal.

So what can we tell people about such trials?

According to a recent systematic review, what we can say is that…..well, that we don’t actually have any good studies of this nature!  The reviewers found just one study that met this criteria, but it was a flawed study done in China, with ambiguous results. 

This means that the push to get young people diagnosed with psychosis on antipsychotic drugs has no basis in science. 

That is, there are lots of studies with no placebo comparison at all, and there are lots of studies of people already on antipsychotics that compare something like taking a new antipsychotic with getting placebo while withdrawing from previously taken drugs, but no good studies comparing drugs to placebo for people diagnosed with psychosis who have never before taken antipsychotics.

If we take the concept of “informed consent” seriously, then it seems this is something we have to disclose. 

And if we disclose this, then we might find ourselves also pushed to offer treatment alternatives, since many people will not choose a drug known to have substantial risks when that drug has never been shown to outperform placebo for people with their condition.

The review article is “Benefits and harms of antipsychotic drugs in drug-naïve patients with psychosis: A systematic review” which is available in full at https://content.iospress.com/articles/international-journal-of-risk-and-safety-in-medicine/jrs195063

Finding Meaning in States Some Call “Mad”

When we relate with each other, a key thing we long for is to have the other see meaning in our experience, while we notice and reflect on the meaning in theirs.

But when people are seen to be “mad” or “psychotic” or “crazy,” they are typically told that their experience makes no sense, and their best option is to take pills in an attempt to make that experience stop.

When people’s experience seems extreme, it may be difficult to find meaning in it even when people around the person do make an effort. One reason for that may be the shallowness of our culture, which has difficulty connecting to anything too far from the “norm.”

Spiritual traditions, though, do contain clues about how to understand extreme experiences and extreme states of consciousness.

That’s a subject Caroline Maze-Carlton explores in a recorded webinar “Messages, Meaning and Ancestral Maps: Spiritual Frameworks for Extreme States.” See the link below!

Assimilation, genocide, and systems of oppression such as anti-Semitism and Islamophobia have left many disconnected from ancestral traditions, spiritual tools and texts.  When encountering extreme states of being such as Voices and Visions, the pharmaceutical model of chemical imbalance often steps into claim space in this cultural vacuum.  However, for many, Western medicalized approaches are neither sufficient nor culturally competent.  This Webinar will explore ways in which we can re-claim spiritual tools and wisdom traditions and be in open dialogue with our ancestors as we navigate extreme states of being.  Caroline will draw on over a decade of direct experience supporting others with altered states of consciousness in diverse settings from peer respites to forensic psychiatric units, as well as her personal lived experience as both psychiatric patient and student of Abrahamic traditions and Buddhist sutras.

About the presenter:

Caroline Mazel-Carlton is a ritual-weaver and sacred space holder in the Jewish Renewal lineage of Rabbi Zalman Schachter-Shalomi.  She is a student of the ALEPH Jewish seminary and recently completed the Yad B’Yad program in Muslim-Jewish collaboration and leadership.  She has traveled the globe in her role of Director of Training for the Wildflower Alliance (home of the Western Mass Recovery Learning Community) supporting systems change and alternatives to the conventional mental health system.  Her passion for re-claiming Jewish identity and tradition through a feminist lens extends to the roller derby community where she is known as Mazel Tov Cocktail (#18).

What Would Real “Informed Consent” Look Like?

When people are fully informed about a proposed mental health treatment, they should be familiar with three things:

  • What are the likely benefits of the treatment
  • What are the risks, and how likely are they to be a problem
  • What are the possible alternative treatments, and what are the benefits and risks of those

As part of a Mad in America continuing education course, I recently moderated a panel discussion about informed consent (and too often the lack of) informed consent in mental health care. 

Those on the panel had lots of “expertise by experience” as well as experience working within different facets of the mental health system.  We were also reflecting on a number of presentations on informed consent that had preceded within the course.  It made for some good discussion!

 Bob Nikkel, chair of the MIA continuing education project, said “I think it was one of our most powerful presentations.”

The course as a whole does cost a little, but you can watch this panel discussion for free, at this link:

Don’t React – Choose How to Relate to Distressing Voices!

“Don’t React – Choose How to Relate to Distressing Voices!”  is the subject of a webinar that was presented by Dr. Mark Hayward on 6/20/19. (See the link to the complete recording below.)

This webinar presents a very practical way to help people start experimenting with different ways of relating to voices they might be having trouble with. I encourage people to check it out!

“There has recently been a shift from conceptualizing a voice as a sensory stimulus that the hearer holds beliefs about, to a voice as a person-like stimulus which the hearer has a relationship with. Understanding voice hearing experiences within relational frameworks has resulted in the development of psychological therapies that focus upon the experience of relating to and with distressing voices. This webinar explores lessons learnt from the development, experience and evaluation of one of these therapies – Relating Therapy. These lessons are located within the broader context of other relationally-based therapies that seek to support recovery through the use of digital enhancement (Avatar Therapy) and dynamic interaction with voices (Talking With Voices).”

About the presenter:  Mark Hayward has worked as a Clinical Psychologist within NHS mental health services for the past 20 years. His roles combine clinical (Lead for the Sussex Voices Clinic), research (Director of Research for Sussex Partnership NHS Foundation Trust) and teaching (Honorary Senior Research Fellow at the University of Sussex).

His research activities have focused primarily on the exploration of voice hearing within relational frameworks – acknowledging the voice as an interpersonal ‘other’ and researching differing aspects of the relationships that people can develop with their voices. These relationships have been central to the development and evaluation of new forms of individual and group therapy that can facilitate acceptance of self and voices through the use of assertiveness and mindfulness training. His books include the CBT self-help book ‘Overcoming Distressing Voices’, and the research monograph ‘Psychological Approaches to Understanding and Treating Auditory Hallucinations’.

Mark is committed to increasing access to effective psychological therapies for people distressed by hearing voices.

You can download the PowerPoint slides associated with this presentation at https://tinyurl.com/yxbonc3g

Recovery Versus Mad Pride: Exploring the Contradictions

I’ve been intrigued by the way the battle against mental health system oppression has drawn on two important and powerful ideas – which happen to contradict each other!

One is the idea that people can “recover” from mental health problems.  Asserting the possibility of recovery has been key to fighting back against the oppressive belief that certain people will always be “mentally ill” and will need to resign themselves to a limited life as a mental patient, etc.

The second idea is that people may not have to change to be OK and valuable – that people can even be proud of what has been called madness!  Mad pride helps people fight back against the oppressive notion that one has to be “normal” to be acceptable, and that mental diversity means illness.

But, if one is perfectly OK as one is, then there is no need for recovery.  In fact, if one is already quite OK,  then the suggestion that one should work on recovery can itself be oppressive – like offering “reparative therapy” for gay people.

On the other hand, if one’s mental state and current beliefs are causing lots of problems that are keeping one stuck, then being encouraged to be proud of that mental state can become a barrier to changing or recovering and so can deepen or prolong problems and oppression. 

Contradictions like those outlined above can lead to battles between activists about how to move forward.  They can also lead to battles, and confusion, within people who are trying to find the best way to deal with their own “mad” states. 

What I want to show is that it’s possible to embrace both “recovery” and “mad pride” despite the contradictions.  But to do so, we need to be aware of both the advantages, and of the “down” or “shadow” side of each of these notions.

Let’s start by looking at the concept of recovery.

Compared to mad pride, recovery has been much more widely embraced.  It has even been embraced by much or most of the mental health system – though often what is embraced is just the word itself, and not the possible reality!  But because of its popularity, it has also been more widely critiqued, and some have even advocated that we stop using the word altogether.   

One common critique is that the word “recovery” implies that one must have been ill in the first place, and so this word should not be used when the problem never was an “illness.”  However, people do “recover” from many things that aren’t an illness:  we recover our balance, we recover from injuries, we even recover from the down side of events that were overall positive, as in “I’ve finally recovered from that wild party I attended last night!”  Krista Mackinnon, in her “Recovering Our Families” course, emphasizes that all humans are constantly recovering from all sorts of things, and so “recovery” is not something unique to those who have been psychiatrically labeled.

A stronger critique of the notion of recovery points out that recovery involves going back to something, while many prefer to see their life as going forward.  John Herold for example talks about wanting to move toward “discovery” and not “recovery.”  I agree with that up to a point, but I also notice that we often have to go back to something we had possessed previously in order to move forward overall.  For example, if I used to know how to face people and maintain friendships, but then I seemed to have lost that ability during an emotional crisis, I may want to recover the skills and habits I had before so that I can then get on with my life and move into that wider process of discovery.

Then there’s the problem of the word being co-opted to mean something much less than real recovery.  Lots of mental health programs use the recovery word, but their practices remain targeted towards lifelong drugging and containment of the person, with “recovery” apparently meaning only getting to where the person won’t be in crisis so much.  I understand why that sort of use of the word “recovery” makes people want to vomit, but I would rather work on reclaiming the word, rather than giving it up.  The US government can call a nuclear missile a “Peacekeeper” but that doesn’t mean we need to quit using the word “peace.”  I think our best strategy is to continue to emphasize the true meaning of recovery and to contrast truly recovery-oriented treatment with that which is not.

Adding complexity to discussions of recovery is the distinction between “clinical recovery,” or no longer experiencing “symptoms,” versus “personal recovery” which has been defined as “recovering a life worth living.” 

Interestingly, within standard care, “personal recovery” is often framed as the proper goal because of a belief that “clinical recovery” is not possible.  In other words, it is believed that the person will always have symptoms and will always be less than healthy than others because of that, but they may still learn to “recover a life worth living” despite continuing to be ill.  (Of course, this notion that they are still ill can be used to convince people to stay on their drugs, which makes this interpretation popular amongst those who embrace the medical model but who still want to offer some appearance of hope.)

But there is a deeper and more valid reason to focus on personal recovery rather than clinical.  That’s because the experiences that the mental health system called “symptoms” may not be a problem at all once the person learns to live with them.  Hearing voices for example may be benign or even helpful once the person learns to relate to them differently.  And once experiences no longer cause problems, there is no longer a need for drugs or any kind of treatment to manage them.    

Of course, it’s the idea that people don’t need to change, and that their differences may be OK or even something quite valuable, that is basic to that idea that sometimes seems in opposition to recovery:  mad pride. 

“You are only given a little spark of madness.  You mustn’t lose it.” Robin Williams

From a radical mad pride perspective, there is only mental diversity, and not any mental problems, disorders, or illnesses.  People do best when they accept and become proud of themselves as they are rather than try to change.  If people have problems, or seem to be disabled in some way, it’s just because society has failed to accommodate their differences, and so it’s society that needs to change.

But what are the problems with this kind of radical mad pride perspective? 

One issue is that if I am suffering in some way, while believing that there is nothing wrong with me but only problems with others, and if it’s also true that I don’t have the power to make others change, then I am stuck with my suffering.  Working on recovery from a problem may not require accepting that one is ill, but it at least requires accepting that something needs to be changed; but pride is the opposite of believing in a need for change.

Another problem is the adversarial relationships that a radical mad pride perspective can create with others.  If I for example demand that others change their attitudes and start accepting me just as I am and if I demand that they change in other ways to accommodate my differentness, while I insist that I am perfectly fine as I am and don’t need to change anything, I may just piss people off.  I’m certainly not likely to be effective at winning friends and forming peaceful relationships, since good relationships tend to be built when people are willing to change at least some to accommodate each other, at least when they are able to do so.

On the other hand, the notion of radically accepting ourselves just as we are can often seem to be the very core of peace of mind and mental healing.  So it can all seem quite complex.

How can all this be best resolved?  Or, how can we take what is best about mad pride, and what is best about recovery, without getting caught up in the shadow side of each?

I think it may help to take a step back, and look in more general terms at how we can resolve other kinds of contradictions.

It’s not uncommon that things are opposites, but we find ourselves needing both.  Breathing in for example is a good thing, but so is breathing out, even though that’s the opposite.  Our ability to open up to people and trust is a good thing, but so at certain times is our ability to close up and distrust. 

Mental health issues can be notoriously complex.  People can go through terrifying, bewildering experiences that may also have a very important positive side.  Or, experiences may seem to be quite positive, but then lead to something very detrimental. 

It’s also possible that an experience we want to recover from at one point may be something that later we wish to regain.  In my own life I can identify times I have worked to recover from “madness” and to regain my ability to integrate with normality, and then also times when it seemed more important to turn around and work to recover from that normality trance, so I could reclaim what I had discovered when I first went “out of my mind.” 

One metaphor for madness is that of revolution.  Revolution overthrows the existing order – then anything is possible, which is both great, and terrible.  Revolution is both something to be proud of, when it is necessary and when it works out well, and it is something to recover from, so that order can be restored. 

When we over-value sanity, we stick with an existing order in rigid ways that can be oppressive.  When we over-value madness, or revolts against sanity, we can get lost in disorder.  Life though works best at the edge of chaos and order, so it may require both rebellion against order and efforts to recover order.

One way to map relations between polarities, where neither polar opposite provides a full answer, is to use what is called a polarity management map.  These maps make overt what is positive and negative about each polarity, and suggest that each polarity is the solution for the problems caused by the other.    

Below is a polarity management map about recovery versus mad pride.  It suggests that there is no final answer to resolving the tensions between mad pride and recovery, or between madness and sanity generally.  Rather, whenever we emphasize the positive of one side, we will also sooner or later encounter its negative, and then may have to shift to the opposite side. 

If we follow this line of thinking, it follows that there are no final answers as to when a focus on change and recovery is best, versus when it might be better to instead be proud of one’s current state and perspective, even if it is somewhat “mad.”  Instead, we will be more open to exploring what might fit or seem healthy, or not, in any given situation.  And we will be open to the possibility that whatever we choose now, we will later be called upon to choose the opposite.

When we are too sure that our side is right, that “God is on our side,” we end up at war with our opposite.  People who are too sure that their current mental view or version of sanity is correct will go to war against that which opposes it, be they voices or other people who are seen mentally wrong  But going to war just makes everything more extreme, and prevents the “peaceful revolutions” that are possible when people realize that their current polarity is just one side of a more complex picture.

Modern humans are not, of course, the first to struggle with these issues.  Spiritual traditions going back to ancient times wrestle with how to relate to the limits of any existing order, and how to find value in what is outside of that order, or “outside of our minds.”  While these traditions are not perfect, and have too many times been bent to completely corrupt and oppressive purposes, they also contain reminders that we humans do our best not when we stay confined within a mundane “sanity” but rather when we allow ourselves, at least at times, to open up to what goes beyond.

What would mental health treatment look like if it balanced an awareness of the need for “recovery” with an awareness that people also sometimes need to go “out of their minds” to resolve problems that they haven’t been able to solve otherwise, or maybe that their entire culture has not been able to face and resolve?

To explore some possible answers to that question, I recently put together a new online course, “Addressing Spiritual Issues Within Treatment for Psychosis and Bipolar.”  This course outlines some radically different ways of conceptualizing the mental states that get called “psychosis” and “bipolar” and reviews ways professionals can shift from pretending to “know it all” to being helpful to people as they face some of the bigger mysteries together.  In the course, I try to strike a balanced position that avoids both “romanticizing” extreme states and the more common mistake of “awfulizing” or “pathologizing” them. 

This course comes with 6 CE for most US professionals. Use this link to get more information, or to register.

A few more thoughts:

One other possibly helpful metaphor for madness is that of wilderness.

It can be disturbing when young people wander off into the wilderness.  What if they become lost, and need to be rescued?  Sometimes people do need to be rescued.  But a society too sure that the wilderness is nothing but bad will seek to prevent young people from ever wandering off, won’t recognize when people are doing OK in their explorations and don’t need to be rescued, and/or will even seek to destroy the wilderness so that everything can be “civilized” – aka, sane.

But any society cuts itself off from the wilderness, and/or declares war on what is wild, only at its own peril.  Certainly, modern civilization or “normality” has declared war on the wild, and it does often seem that it is winning.  But that “winning” is a most terrible thing, and puts us all in danger!

Rather than winning, we need to focus more on finding a dynamic balance, or peaceful coexistence.  The peaceful coexistence between recovery and mad pride that I have proposed is just one example of that. 

Emerson said that “People wish to be settled; only as far as they are unsettled is there any hope for them.”  It’s time that we define mental health not as some settled “sanity” but as the unsettled and possibly playful dialogue that results when we value both madness and sanity, and when we explore together with those whom we wish to help rather than impose our own version of some settled, and dead, “correct answer.”

Helping People To Constructively Engage With Voices

When people have problems with voices, the most common recommendation they are given is to try to avoid them – to take drugs to make them stop, to simply ignore them, to use distraction, or similar approaches.

But these strategies often don’t work. Or even if they do seem to work, they may themselves cause other kinds of problems that may not be acceptable. So what else can people try?

One possibility is to try the opposite of avoidance: to deliberately engage with the voices!

But this sounds scary or wrong to some people. Won’t engaging with the voices make people take them too seriously or see them as more real than they are? Might that lead to people getting even more lost in the world of voices, and so more distressed?

While the mind is tricky and things can always go wrong, we now know that it is possible for people to engage with voices in ways that make things better. Specifically, when the engagement is done with creativity and compassion, the result can be a positive change in the relationship with voices, leading to much greater peace of mind.

But how can people learn how to facilitate this sort of constructive engagement?

Fortunately, Charlie Heriot-Maitland (known for producing the Compassion for Voices video), Rufus May, and Elisabeth Svanholmer have just made available a free series of videos, in which they offer practical ideas about how to do just that. These videos cover topics such as how to:

  • Prepare to engage with voices
  • Identify and nurture the compassionate self and engage with voices from that perspective
  • Change the power balance with voices
  • Identify the function of voices
  • Work with voices that don’t seem to want to engage
  • Map out voices
  • Engage constructively with voices that sound like an abusive person from the past
  • Marital arts exercises that can help in work with voices

This is the first video in the series:

You can access the rest of the series at https://openmindedonline.com/portfolio/engaging-with-voices-videos/

I spoke to Rufus May, one of those involved in making these videos, and asked him what inspired he and his colleagues to do this. He answered that:

“We know there is a growing interest in this approach and we wanted to make some accessible resources. In the Bradford Hearing Voices group I volunteer with, I might facilitate a dialogue with a group member’s voice and then encourage them to regularly engage with their voice or voices. In this way group members have found they have been able to improve the relationship they have with their voices.

“People ask me, how can you talk with someone’s voice? I sometimes joke ‘I‘ve got a special microphone!’ But the truth is we ask someone to ask their voice questions and then report the answers the voice is giving them. We have found if we use good communication skills such as empathy and non-judgemental questions the voice sometimes begins to respond in a different way.”

I asked Rufus for an example of this:

“Through a facilitated dialogue with a person’s voice that was being quite harsh and critical towards the person, we established the voice wanted the person to be more assertive with people in their social network. The person went on to consult with the voice on who to be more assertive with and when she became more assertive the voice seemed to relax and become more constructive.

“We have also found if people compromise with their voices the voices often behave in a less controlling way. So finding out if the voices like certain types of music or food or drink and listening to the music the voice likes or consuming the food the voice likes can role model to the voices a more respectful collaborative relationship.”

I asked Rufus where these engaging approaches have come from:

“In many traditional cultures consulting with voices is something that has been done for 100s of years. The original Hearing Voices research carried out by Romme and Escher in the 80s in Holland found many voice hearers who had never used mental health services negotiated and engaged with their voices.

“The challenge is how to talk with voices that are hostile and controlling. This means we as communities need to support voice hearers to become more confident in being assertive with their voices and then learning how to engage in a power with style of relationship, rather than power over.

“Hearing Voices groups can be good spaces to learn this ‘living with voices’ approach. We have also found tools like Nonviolent communication and mindfulness and compassionate mind exercises helpful in supporting this process.

We have tried to make short films that demonstrate how you can engage voices and find ways to learn from them. The three of us myself, Elisabeth and Charlie have used both role-play and some demonstrations of mapping out and talking with Elisabeth’s voices.

“We don’t want engaging with voices to become a therapy that only highly trained professionals can used. While we welcome therapists using these approaches, we also want people who hear voices, and their friends and family to know about dialoguing and creative ways to understand and engage with voices.”

I think that last point Rufus makes is really important! It’s helpful when mental health professionals can offer certain kinds of assistance, but it can be even better when people learn how to help themselves and each other. That’s what really creates a healthy society. So I hope lots of you take an interest in this approach and do check out the video series, which again is available at https://openmindedonline.com/portfolio/engaging-with-voices-videos/

Treatment Focused on Immediate Experience, Not Diagnosis: A Video Presentation by Isabel Clarke

” The approach is not so much trans-diagnostic as dismantling of diagnosis, and includes a perspective on psychosis that sees it as part of a wider potential of human experiencing that includes valued aspects such as spirituality and creativity.”

What would it look like if mental health providers were trained to be both deeply humanistic, AND very efficient at helping people identify and cope with the issues at the core of whatever their difficulties might be, including psychosis?

It might look like the approach developed by Isabel Clarke and Hazel Nicholls, which they call “Comprehend, Cope and Connect (CCC).”   CCC starts from the perspective of the immediate experience of the individual -‘what it feels like to be me, now’. This approach to mental health difficulties brings together the impact of past trauma and adversity on present coping (comprehend), and utilizes the latest in mindfulness and compassion-focused approaches to manage change (cope and connect).

In the presentation linked to below, Isabel Clarke focuses on using this approach with people whose experiences might be described as “psychosis.”  Isabel brings a uniquely deep and yet practical understanding to this topic.  On the one hand, she has thought deeply about the nature of psychosis, and she has written several inspiring and insightful books and articles on the intersection of spirituality and psychosis.  On the other hand, she has extensive experience working in acute care settings where making a direct an immediate impact is essential, and this has pushed her to develop an approach capable of accomplishing that objective.

“Simple and yet powerful, this impressive body of work has transformed practice wherever it has been introduced. Mental health practitioners should all be aware of it.” said Dr Lucy Johnstone, consultant clinical psychologist and author of ‘Formulation in psychology and psychotherapy’.


Comprehend, Cope, Connect: An Experience Based Approach to Psychosis & Other Mental Health Challenges

About the presenter:

Isabel Clarke’s work spans two areas: psychosis and spirituality, and clinical psychology. Both draw on the research based Interacting Cognitive Subsystems model of cognition, and both seek to bring spirituality into center stage, founding it in cognitive and other research and theory, and regarding it as a central part of what it means to be human.

Recently Isabel has been developing Comprehend, Cope and Connect (CCC –  previously known as Emotion Focused Formulation Approach, EFFA) in the diverse contexts of Acute, Primary Care and Culture Free Adaptation.  See  “ICS Underpinning 3rd Wave CBT”  and the following book for more details:

Clarke, I. & Nicholls, H. (2018) Third Wave CBT Integration for Individuals and Teams: Comprehend, Cope and Connect.  London & NY: Routledge.

Other books by Isabel Clarke:

Clarke, I. (2013) Spirituality: a new way into understanding psychosis. In E.M.J. Morris, L.C.Johns & J.E.Oliver Eds. Acceptance and Commitment Therapy and Mindfulness for Psychosis. Chichester: Wiley-Blackwell.P.160-171.

Clarke, I. ( 2008) Madness, Mystery and the Survival of God. Winchester:’O’Books.

Clarke, I. (Ed.)  (2010) Psychosis and Spirituality:  consolidating the new paradigm.  Chichester: Wiley

More information about Isabel’s work at http://www.isabelclarke.org/

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