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Anatomy of a delusion

I just finished Whitaker’s “Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America.”  I thought I would probably take few weeks to read it, as I have so much other stuff going on, but it kind of took over my weekend.  While Whitaker can be faulted with at times making things seem simpler than they really are, I think his overall thesis, that psychiatric medications in general are on average making long term outcomes worse instead of better, is accurate and well supported (you can browse the evidence for his thesis at his website.)

What I am struck by is the similarity between the dynamics around the delusions of those who get psychiatric labels, and the delusions of the mental health system itself.

Why does the mental health system think medications are routinely helpful, when the long term data suggests they tend to be harmful?  Let me list the reasons:

  1. Medications seem to work great in the short term
  2. There is a lot of pressure to decide something quickly, to resolve a crisis, so thinking about the possibility that long term results may be the opposite of short term results doesn’t happen
  3. Choosing medication creates secondary gains for various people and groups within the mental health system, and the existence of these secondary gains leads to a distorted examination of the evidence
  4. Quitting medications very often quickly leads to problems, and these problems are seen as “proof” that the drugs are helping long term
  5. Once medications are believed in as “the way” then evidence to the contrary is discounted or not examined.  It would be too painful to even consider the possibility that so much has been invested into something that not only doesn’t help, but makes things worse.

These of course are the same reasons our clients hold on to delusions in general.  Let me again list the (pretty much the same) reasons: 

  1. The delusion “works” in the short term, to resolve some kind of dilemma or unbearable situation for the person
  2. The decision to believe in the the delusion is made during a crisis, when the person’s mind is ready to jump to any conclusion that resolves the crisis without looking at it carefully; and the possibility that believing in the delusion may lead to long term problems is not even considered
  3. There are secondary gains to various parts of the person from believing in the delusion.  These secondary gains are never looked at objectively, but their presence leads to a distorted examination of the evidence.
  4. Even starting to question the delusion is scary & upsets psychological equilibrium, as even considering that one might have been so wrong about something creates a sense of “losing one’s grip on reality.”  This loss of equilibrium when one starts to question the delusion is taken as evidence that it should not be questioned.
  5. Once the delusion has been invested in, contrary evidence is ignored, as first of all this evidence just seems wrong (since of course the delusional belief seems so obviously true) plus it would be very painful to even consider that one has been wrong about the belief for so long.

One difference of course is that with a mental health consumer, the parts gaining from the delusion, and the parts suffering from it, exist within one person, while with the mental health system many people are involved, and even if the some people such as the “patent” may be suffering from the mental health system delusion, other persons may be making large profits in both dollars and prestige.  

In cognitive therapy for psychosis, the idea is to notice the distress the person may be experiencing, and then to use the distress as a justification for reviewing the beliefs that may be distorted.  It is unlikely the parts of the system that are profiting will want to engage in such a dialog, but many parts of the system are not profiting from the current arrangements, and may be open to dialog.  This includes:

  • The mental health consumers
  • Allies of consumers
  • The public, which doesn’t want to pay money to make problems worse
  • That portion of mental health professionals that care more about helping people than they do about their own prestige or “keeping the peace” with those in power.

If we can create an effective dialog, we can eventually change the system.  But the idea that a medication that seems to “help” short term will also help long term is a very entrenched delusion, and replacing it may take a lot of work!  Still, given that it is likely that there are probably more mental health problems being created by the mental health system currently than are being resolved by it (hence the current “epidemic”) it seems unethical for any professional, such as myself, to just work in the field and not speak out about needed changes.

27 comments… add one
  • Great post!
    One thing you left out in the possible future of admitting long term chemicals for mental illness does not work, ( doctor admitting wrong?) is the probable anger of the patient when told of the mistake. Their Tardive dyskinesia was not necessary.
    The medical professionals-helpers do not want their patients to dislike them, half or more the job motivation of the mental health worker is the idea “we” are helping people who need help. An act of charity and goodness.
    Facts of harm, might shatter the ego of the professional helper.

    It will probably take the next generation of upcoming health workers to push short term medications as they have no guilty past of pushing medications-for-life.

    That is if society has enough healthy people left.

  • Great post. I would like to circulate it on my own blog. I agree with markps2 – doctors (and family for that matter) cling to the belief that the drugs are okay, because admitting that they were, in fact, harmful, used the way they were used, is too guilt inducing to entertain. Then you look at the current crop of retiring researchers, like E. Fuller Torrey. They have based their whole career on ideas that turn out to be untrue (at least for now). Why would they admit it was all for nought?

    • I agree that the guilt that would be felt is a major factor that makes it difficult for people to even consider the possibility that current treatment is more harmful than helpful.

      As for the younger generation coming along and making it better, one problem is that young psychiatrists go to medical schools where they don’t hear about possible problems with existing approaches, and then in their residencies they are expected to start drugging away and pretty soon they are the same as the older generation. We need to make sure these concerns become well heard within the culture, so that young people know there is a possible problem before they even start getting educated by institutions that too often are in bed with the pharmaceutical companies.

      As for reposting my blog posts on another blog, I’m fine with that as long as a link to my blog is included. Thanks, Rossa, for asking.

  • “We need to make sure these concerns become well heard within the culture” .
    Who is paying for this system? As long as the money keeps flowing (Vince Bloem “It has been estimated that 69 cents out of each dollar spent on antipsychotic medications in the U.S. comes from the taxpayers pocket.”) there is no problem, no motivation to change the current system.

    • I do think that if taxpayers realized how so much of what was being spent on current treatment was being wasted or even making the problem worse, they would demand change. So this is one angle to take when arguing for change.

  • Money of course is an important aspect. But I think, there’s is another one that, as far as I have heard (haven’t yet read Whitaker’s book, although I can’t wait to get my hands on it), Whitaker doesn’t take into consideration, and that, IMO, only can be underestimated: people’s fear of madness. The drugs provide a means to keep mad people under control. Or at least, this is what people imagine. If it only was about money, the idea to screen embryos for “mental illness” and consider abortion in case the test results are positive, would hardly find any supporters, as it is (a lot) less lucrative for the pharmaceutical industry. Meanwhile, both the public in general, the professionals and politicians seem to be highly supportive of the idea. Here in Denmark.

    Also, psychiatrized people have, with the exception of a short period in history (“moral treatment”), never been other than mistreated, silenced, and locked away in our culture (although we today lock them away on the fringe of society, on disability, in assisted housing settings, drop-in centers, etc., and not behind thick walls and bars anymore). This wouldn’t have been so if monetary profit was the only reason for the mistreatment to happen. Big pHARMa’s profit was no issue before the second generation of psych drugs hit the market.

  • Can never reiterate enough how offensive it is to hear the word ‘consumer’. A woman who hires a gigolo is a consumer, a woman who is raped is a rape victim and survivor of that assault. I’m not a consumer, don’t lump coercive psychiatry survivors in with ‘consumers’. It’s offensive.

  • Ron,

    The facts are pretty simple… Psychiatric drugs are not a long-term answer… they impede recovery, and cause more harm than good.

    The complex issue, as you point out is how people begin to process the facts… Psychiatric survivors have known the drugs don’t “work” for years, other than limiting symptoms… what a price to pay, huh?

    Hell, a six pack of beer will limit symptoms too, but nobody pretends it’s “medicine”, nor hangs accollades on their wall as “experts” in helping someone get drunk.

    It is what it is, Ron.
    Simple, on the one hand…
    Complex, on the other…

    Due to an industry we’ve created, a myth, and “professionals” of all sorts… the misled, misguided, along with those in complete denial, and all points in-between… a “system” that is not only broken, but shattered! One that doesn’t need to be repaird… one that needs to be replaced!

    Peer suppport, survival groups, freedom to opt for safer and more effective options of all kinds…

    And some justice as well… Not for the county workers who are doing their job as best they’ve been taught, not for the recent college grads in marketing psychiatric drugs… not for the doctors who read the propaganda, and believe it, because of what they’ve been taught… No, justice needs to come with those at the top… Top management with Pharma who have known better, and continue to market these drugs, managment teams with “advocacy” groups who have done nothing short of perpetuating a myth… one that has caused injury and death to children, traumatized adults, seniors, and military service members/veterans….

    Those at the top with Pharma and with non-profit groups need to be held accountable, Ron… To include Michael Fitzpatrick, Executive Director of NAMI… When the top people are put under oath, and given some fair trials – and then placed in prison… then, and only then will this stuff come to an end….

    It’s simple.
    It’s complex.

    But it will become much clearer, and much easier for many people who have been injured by “hospitalizations” and “medications” when a few key people go to jail… It will all begin to make sense then…

    And the “recovery” and “thriving” movements will really begin to take hold, with or without “professionals.”

    That’s my call.

  • One last comment….

    In a sane world, we would see that Medicaid Fraud has become prevalent, and hold people accountable…

    You rightly point out that if people knew the price of these drugs to the taxpayer, they would take notice….

    The problem of course, is that the feds and Pharma are joined at the hip… Prescription drug use is most prevalent in Medicaid programs…. These account for half of some states’s budgets!

    Again, it seems pretty simple, and it is… stop paying for drugs for kids that haven’t been approved for them, and start using other approaches….

    But it ain’t that simple.
    Because in this case, it isn’t denial that’s getting in the way…..
    It’s a “health care” bill that was signed and passed into law… Drafted, lobbied, and promoted by PhRMA… the ads on the television paid for by PhRMA… politicians paid-off, both sides of the aisle, both houses of Congress…. So, they haven’t the political and moral will to change it….

    The health care bill needs to be repealed…. Period.
    If not, PhRMA will target children, and the drugging will continue.
    A wake up call…
    Congress didn’t pass “health care reform”, nor did the President sign “health care reform”…

    It passed drug-care, and at the top of the list is children and the “mentally ill”… make no mistake!

    In the 1960’s and 1970’s, Robert Whitaker points out the “social services” were available to the “mentally ill” as long as they took their medication…
    I have long-feared that we will re-instate this measure… In other words, once a person has been “hospitalized” and/or “medicated” into oblivion, and becomes disabled – due to the treatment!… they will then have to stay on psychiatric drugs to continue to recieve SSI/Medicaid, and/or SSDI/Medicare….

    Could it really happen here?
    It already has in our history, and my best-guess is that’s precisely where PhRMA and Congress will try to take this thing….. more mandatory screening, more mandatory drugging….

    “The problem with capitalism is capitalists.”
    “The problem with socialism is socialism.”
    Kinda says it all for me….

    We have introduced a socialist agenda into mental health care… We’ve always had some of it, but not to this level… We either repeal the “health care bill” and allow for more freedom, or do nothing and watch people lose their lives with “treatment” – drugs that don’t work, that cause more harm than good.


  • OK, I’m not doing a great job of keeping up with all the comments……

    I agree with Marian that “fear of madness” is a huge factor in sustaining inappropriate treatment. Actually it’s not just people other than the “mad” person who fear madness, it’s often the “mad” person as well. Fear of madness plays a huge role in creating madness, and both the individual at the center (the so-called “mentally ill person” or “consumer” and everyone around it, gets caught up in creating the very thing they fear.

    And I understand Jenny’s problems with the term “consumer.” I do wish there was a universally recognized word that everyone would accept – “survivor” is good for some who felt victimized by psychiatry, but others who voluntarily use services (called “users” in the UK) don’t identify with the term “survivor.” I’ve seen some use the term CSX (for consumer/survivor/ex mental patient) but only some seem to know what that means.

    While I don’t plan to weigh in on how health care reform will affect anything – I don’t pretend to know – I do agree with Duane that radical reform is needed. Just getting a discussion going about that would be a good start. Here in Eugene Oregon, we are challenging the mental health system to come up with somone willing to debate Robert Whitaker when he comes here in August. I doubt they will dare to try, but just the absence of a voice on their side will speak volumes to anyone who is listening.

  • Ron: I agree that mad people themselves often are frightened by their experiences. I know that I was. At least in the beginning, until I got used to it 😀 , and until my therapist had pointed out the “normality” of my experiences to me (“Did you know that about 10% of the population hear voices?” “There was this psychiatrist at Skt.Hans [largest Danish psych prison, okay, “hospital”, where she used to work] who sat and waggled his foot incessantly during meetings. He drove everybody crazy with it.”). Usually, the system does everything else but pointing out the “normality” of extreme experiences. Or actually more like the fact that these experiences are perfectly natural, and not “weird”, “crazy”, and a sign of some sort of biological defect to be present that makes the person sort of an alien, not quite a human being.

    I see a qualitative difference in the initial fear, or fright actually, in someone who is overwhelmed experiencing extreme states of mind themselves, and the, true, fear of the surroundings, that seems to me to be a lot more vague, not made conscious, and demonizing the experience, and that then often is internalized by the mad person herself, turning her fright into fear (of this unknown and almost almighty demon called “mental illness”).

  • Hi Marian, The way I teach it in my seminars is that the usual psychiatric language “abnormalizes” experience, by putting it in completely unique categories, rather than helping people see that their experience is just an extreme version of the everyday stuf that people experience. “Normalizing” is a key part of the type of therapy I practice and it sounds like it was for your therapist as well.

    This whole process, where fear experienced by the person themselves and by the people around them, which then gets hardened into definintions about “mental illness”, is essentially an interpersonal process, not one that resides within the supposedly “sick” “mad” person themselves.

  • Marian,

    I like what John Breeding has to say about some of this…

    We all “hear voices”… all of us… “voices” of our own conscience, “voices” of our own thoughts/experiences, “voices” of the past, as we flash back through them in our mind, in our dreams, etc…


    I really like what you have to say about “normalizing” these experiences… It’s refreshing to know that there are a few good therapists out there.

    Be well,


  • Duane: I couldn’t agree more with what John Breeding says about voices. And you say something when you use the verb flash back. Because, what are “hallucinations” other than what in PTSD would be called flash backs. “Hallucination” IMO is a misleading term (while I imagine, it’s actually meant to mislead).

  • Marian,

    “Halluciations” and/or “delusions”….
    Could these be dreams, with the eyes wide-open?

    Can dreams be somwhate frightening, difficult to understand, upsetting, unerving? Not if you happen to wake up from a nightmare with a spouse or other who helps you talk about it, listens, and a person has a chance to share the dream…. and begin to understand it….

    Then, the dream begins to make sense…

    Many of the people I’ve come to know have experienced sleep-deprivation prior to a “breakdown” (I like that older term… and in my mind, it simply means an opportunity to get back up… stronger than before)…. Anyway, sleep-deprivation is so often part of the mix….. and rarely addressed…. Why do some people go for days without sleep? I think it just depends, it could be stress, stimulant use, trauma, all kinds of things… Ironically, read the back of some of the packaging on over-the-counter meds, mixed with alcholol, and/or psychiatric drugs…

    Getting on antidepressants, gettting off them… all kinds of things can cause sleep deprivation…. and I just gotta wonder, if all these frightening (and they can be frightening) “hallucinations” and “delusions” are caused by the body/brain/mind’s brilliant design…. and the effort to keep someone alive who is doing the best they can to survive…

    On the other side of that frightening experience, is opporunity…. to understand the self at a level few ever have a chance to… to grow to higher dimensions than one might have ever expected…

    We have to begin to see these things in a different light… as both natural, along with room for the supernatural, the Spirit’s involvement… the opportunity for discovery, and re-connection to self/others/nature/Spirit….

    Can dreams help a person heal?

    You better believe they can!


  • Marian,

    I hope you’re doing well, and enjoying your horse!


  • Duane: I would even go further than to say that dreams can help the person heal, and say that healing in terms of coming to an understanding (of oneself and the world) is the purpose of dreams. Just as it is the purpose of “psychosis”, seen as an extreme form of dreaming, 24/7, and with the eyes wide-open, because it’s too intense, the message too important to let you sleep. And, btw, I think most people have experienced to wake up from a dream, and to have some difficulty “getting out of” the dream, and into the here and now = a few seconds of “psychosis” on occasional mornings (Oh boy! Everybody obviously is severly mentally ill. Maybe they should add antipsychotics to our drinking water?!). It happens to us while we are kids. Growing up, we learn to say “ah, it was just a dream, forget it“. But some things are simply too important to be forgotten.

    Enjoying my horses (you won’t believe it, but my boss gave me a horse, so now they’re two), and all the others, yup. Hope you’re doing well too!

    • I wrote earlier about dreams and psychosis, and linked to a very interesting webpage on the subject, in this post.

      Usually we dream while we are asleep, when are muscles are paralyzed so we don’t get into any trouble by flailing about, and then we promptly forget the dreams when we wake up. Dreaming while awake is much more hazardous, but also has some possible benefits as Marian suggests, which are linked with creativity. I do think it is possible to help people get some of those benefits while avoiding some of the risks – that’s what shamans did for centuries.

  • Marian,

    Congrats on the second horse! How cool is that!
    Our youngest knows a girl who lives on a ranch nearby, so he may be riding again soon… He’s like you, he loves horses!

    Ron and Marian,

    Thank you both for you thoughts… There’s a lot to learn, and each time I hear from people who have really looked at this stuff, I learn something new… I sent an email to someone the other day, explaining that so much of this is a mystery to me… I suppose it will always be, but I certainly enjoy learning about things from other people’s perspective and experience.

    My best to you both,

  • Ron: Something struck me when I looked at the Kaufman-paper: this is (and I don’t say it’s not interesting!!) scientific research about the probably most “unscientific” phenomenon you could imagine, the unconscious. It’s a result of our constant struggle to grasp the irrational per se with rational thought, or to define with words (scientific terms) what cannot be said with words. How idle!

    We possess in our intuition a kind of knowledge that is potentially unlimited, boundless, and in its way so much more true than all the statistics and randomized double blind studies in the whole wide world together ever could be. Rational thought, and science with it, will always have its limitations. Nevertheless, if we can’t squeeze it into bars and lines in a diagram, it can’t be true. Like when I say, I know that crisis won’t happen to me again. I would have to come up with what is called scientific evidence to be believed.

    What the Kaufman-paper (among all the other, similar ones) shows is just a fraction of the knowledge we hold without knowing (acknowledging) it. And I’m completely baffled, time and again, by how dismissive our culture is of this knowledge.

  • Marian: I think the problem with intuition is that while we can know a lot that way, it isn’t clear exactly how we know it, so that raises doubts about whether or not it is true. And it isn’t uncommon for people to think they intuitively know something, and it turns out to be untrue. (Of course, we also commonly think we scientifically know something and it turns out to be untrue, but at least we have a story about how the error happened, since we can track where the misinformation came from. So science allows us a systematic way to have disputes with each other about what is true, while when people have different ideas based in different intuitions, there is no way to have a systematic discussion about it.)

    We are wandering into theory of knowledge” stuff. By the way, when I was young I wrote a (kind of long) paper about how all knowledge is uncertain: it’s pretty radical, some might see it as “psychotic” but I still like it and find it informative. (I question all forms of knowing, and examine questions such as “Is the madman God? Is God mad?”) If you are curious, check out

  • Ron: I think that whenever something we thought we knew intuitively turns out to be untrue, it wasn’t intuition to start with, but probably the ego, engaging in some kind of wishful thinking or so. The difficulty then of course is to know whether it is intuition, or something else. Maybe it is my ego’s wishful thinking that makes me believe I won’t ever experience crisis anymore. Who knows. But, on the other hand, if I can’t know, who else can? The system of course would point to its scientific knowledge – which is based on a set of premises that can’t ultimately be proven to be objectively true, but may well be another form of the ego’s (the system’s ego’s) wishful thinking… (One of these premises that I see often go completely unquestioned is that crisis would be a “bad” thing to happen. Almost all scientific research in the field is based on this premise. But is it true?) And the question is then, if anyone has the right to tell me that I’m wrong – as the system certainly would do.

    Reading your paper, I was reminded of the (quite heated) discussions I used to have with a friend who believes in an objective reality, an absolute truth, absolute knowledge, etc., while I don’t. Needless to say that our discussions in a way were idle too, as it is rather impossible to discuss objective vs. subjective, true vs. untrue, right vs. wrong, if only one part in the discussion questions the very validity of these concepts in the almost nihilistic way I do. While at the same time me too, I keep looking for the “magic word”, the ultimate truth, the Holy Grail. Or I would stop communicating.

  • The notion that intuition is always correct (but that sometimes we mistake something for intuition that really isn’t) is very much like the notion that God speaks to us and always tells the truth, but that sometimes we might think a voice is God when it really isn’t. The bottom line is that whatever we hear or feel, we still have to wonder if it is really correct or not.

    As to whether crisis is “bad” or not – science can’t make statements directly about value, though it can provide clues about whether something such as a crisis helps or hinders people from getting to places that we have decided are valuable. Most writers of mental health “scientific” papers I’m sure don’t even ask that question, but just assume that crisis is bad and then look at how to prevent it.

    It’s interesting that people in psychotic states, that psychiatry defines as meaningless, are actually often wrestling with the ultimate questions about what is meaningful at the very deepest levels. Of course, like I pointed out in my paper, paradox is very active at those levels, so often the distinction between the deepest level of meaning, and meaninglessness, breaks down.

  • What we call science may also be predicated upon false beliefs. A fundamental problem with science today is it fails in defining a universal view. It approaches problems symptomatically and directs treatment at symtpms rather than universal systems. The complexity of a human being extends beyond that which can be measured with a thermometer or an image.

    As humanity’s knowledge increases we will begin to understand that our comprehension of the whole person or the whole universe is really not much more complex than that of the barber surgeons of a century or two ago.

    If we can get that life has no meaning and no purpose and that it’s purpose and meaning is that which we have defined it as we can begin to understand that we are the masters of our own destiny. We are responsible and we are in the driver’s seat. Those consumed by the quest for universal meaning and purpose more often than not cannot reconcile their own insecurity with the insignificance they believe they represent in the universe confined by the human fabrications of space and time.

    It is the “stories” be they scientific or intuitive that serve to validate our limiting and false beliefs.

  • Bringing the obvious back into discussion, physically we humans are a form of animal similar to the other apes. Our long distant ancestors probably lived in a green forest. Today we live in boxs and in noisy, stinky and cruel cities. Put a monkey in a box and what happens to the mind of the monkey?
    BBC news
    There is more evidence that living near a ‘green space’ has health benefits.

    Research in the Journal of Epidemiology and Community Health says the impact is particularly noticeable in reducing rates of mental ill health.

    The annual rates of 15 out of 24 major physical diseases were also significantly lower among those living closer to green spaces.

  • I hope that someday the system changes. What I envision is a person who would have a crisis would have a review for possible causes and that traumatic experiences would be taken into account. That even if a person is really unable to think at all, the medication would still be short-term. Once the person is grounded back in reality, therapy and then getting off medication. Is it so hard? We need a new attitude. Especially towards schizophrenia. In fact, I don’t think it should be called schizophrenia, other than it does seem to define how a crisis can split someone apart inside. Sometimes I wish I had been my own doctor, you rely on these people to take care of you and they just mess it up.