Rethinking Madness(Again?)

What is that old saying: that if you keep doing the same thing over and over and expect a different result then you are insane? Why do we need to keep rethinking madness? If we're going to do that then do it properly rather than using polemical literature which so often leads to polarised views.

As some of my recent posts indicate I am more than willing to criticize modern psychiatry for some of its excesses. The problems of modern psychiatry are not just within the domain of psychiatry. The situation is very complex and I cannot do full justice to that issue here. Nonetheless I do feel that modern psychiatry lacks sufficient numbers of iconoclasts, that psychiatrists, generally speaking, are too willing to adopt the medical model of mental illness in spite of a dearth of evidence supporting those models.


Be advised, I have not read this text nor have any intention of reading it. I came across it because I receive emails from Psychcentral and the latest contained a review of this book. Talking of madness when checking other reviews I noticed these similiarities between their review and this one from Mad in America.

Psychcentral guilty of plagiarism?

Mad in America

If madness, or psychosis, is just a result of a physical defect in the brain, then it makes sense to devote little effort to understanding the experiences of mad people, and to focus instead on suppressing such experiences as much as possible. That’s what our vast “mental health” industry has been doing for decades, without success.  In this book, Williams outlines a very different approach, one that prioritizes understanding and valuing personal experiences.

Psychcentral Review

If madness, or psychosis, is just a result of a physical defect in the brain, then it makes sense to devote little effort to understanding the experiences of mad people, and to focus instead on suppressing such experiences as much as possible. That’s what our vast “mental health” industry has been doing for decades, without success. In his book, Rethinking Madness: Towards a Paradigm Shift In Our Understanding and Treatment of Psychosis, psychologist Paris Williams outlines a very different approach — one that prioritizes understanding and the valuing of personal experiences.

Mad in America

Before writing this book, Williams spent time as a hang glider pilot, winning one world championship and several national awards.  He then experienced a mental crisis that could have been labeled psychosis, but he avoided getting diagnosed or “helped” by psychiatry, and instead worked through his experiences on his own.

Psychcentral Review

Before writing this book, Williams spent time as a hang glider pilot, winning one world championship and several national awards. Then, he tells us, he experienced a mental crisis that could have been labeled psychosis, but avoided getting diagnosed or “helped” by psychiatry. 

Mad in America

Williams is arguing that psychotic experiences typically occur as part of a process of experimentation at a deep level of the mind, a risky process of profound disorganization and then reorganization. 

Psychcentral Review

The author argues that psychotic experiences typically occur as part of a process of experimentation at a deep level of the mind, a risky process of profound disorganization and then reorganization

Disgraceful plagiarism. Psychcentral then has the audacity to assert that theirs was a "scientific review" and reserved all rights!
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The Contents of the Psychcentral Review

If madness, or psychosis, is just a result of a physical defect in the brain, then it makes sense to devote little effort to understanding the experiences of mad people, and to focus instead on suppressing such experiences as much as possible. That’s what our vast “mental health” industry has been doing for decades, without success.

True and not true. It is true that the main therapeutic aim is to suppress the positive symptoms of psychosis. Why? Because for many patients the positive symptoms are terrifying and disabling, failure to immediately suppress these symptoms can have disastrous consequences for the patient and society. The problem is not in the suppression of positive symptoms but in the failure to help the patient develop strategies to deal with these positive symptoms rather than continually seeking to suppress them forever and a day. Antipsychotics are invaluable in suppressing positive symptoms. "Without success" is a blatant lie. 

Before writing this book, Williams spent time as a hang glider pilot, winning one world championship and several national awards. Then, he tells us, he experienced a mental crisis that could have been labeled psychosis, but avoided getting diagnosed or “helped” by psychiatry. Instead, he says, he worked through his experiences on his own.

That's instructive. There is psychosis and there is psychosis. There is schizophrenia from a very early age, schizophrenia from heavy teenage use of modern marijuana strains, and latter onset psychosis that may or may not be schizophrenia. These are all different entities. Psychosis is not just a continuum(if at all, not sure), it is categorical in nature. That is, it is a cardinal error to think of psychosis as a single distinct entity. Yet nothing I have read in the reviews indicates that this cardinal, fundamental, absolutely essential distinction must be made in relation to both the etiology and phenomenology of psychosis. That's a fatal flaw and sufficient warrant for me to discard this text as a serious examination of psychosis.

One of the key ideas Williams sets forth is that psychosis, in the presence of the right conditions, can be expected to most commonly result in a positive outcome: an outcome that is better than the state that existed before the psychosis. This assertion flies in the face of most of what our culture thinks it “knows” about psychosis, but the author documents the argument well.

My emphasis

In an ideal world! What right conditions for varying psychosis types? There is abundant evidence to demonstrate a wide variety of factors can contribute to psychosis onset. The problem for many patients is that they are too often in a life where they are bombarded with potential drivers of psychosis, from shoddy parenting to poor nutrition to lousy living conditions. Psychiatrists can't do anything about these things, it is a societal problem not a medical problem so why are psychiatrists being blamed for this state of affairs?

Another major point Williams makes is that the core issues in madness are not a struggle with an “illness” experienced only by some, but rather a struggle with the existential issues that we all face, such as being caught between a fear of being separate and a fear of being overwhelmed or engulfed by connection.

Fear of being separate? Do people really fear identifying themselves as separate from other people? No, of course not, what they fear is being alienated from other people. But hey, as this freak well knows, you get used to that; sort of. Life wasn't meant to be easy but it shouldn't be so damn hard either! If anyone has a rational reason for suicide, I AM. I'm not going anywhere, I have too many butts to kick. Then I'll go.

Overwhelmed or engulfed by connection? Oh please, just what does this mean? Are all those so called "enlightened ones" overwhelmed by their sense of connection? Even Zen Buddhists long ago knew that there are those few people who come to them seeking enlightenment who should not meditate because they will experience the enlightenment of insanity. These troubled souls went in search of an answer but searched in the wrong place. It reminds me of two separate stories, both by neuropsychologists. Elkhonen Goldberg makes reference to how when accepting people into post grad psychology at Moscow the examiners would use a big red tick to indicate that while the student has the right academic qualifications they are trying to sit on the wrong side of the desk. I mentioned this to a friend of mine who is a neuropsychologist in New York and he told me how an New York post grad school did exactly the same thing.

As William James once commented, early life cognition is a blooming, buzzing confusion. So are all babies psychotic? Hmmm, there may be some truth in that but last time I checked babies were not living in terror of imaginary friends. I recall studies on how some intelligent children have "imaginary friends" and this is often a good sign of their future mental health.

The author argues that psychotic experiences typically occur as part of a process of experimentation at a deep level of the mind, a risky process of profound disorganization and then reorganization.

Typically occur? How often, how much, and when? Again, lumping all discussion of psychosis under one category is a category mistake of cosmic proportions. I wish it were that easy to think about psychosis. If I were to rethink madness the very first thing I would do is develop very clear delineations between psychoses. Psychiatry does do this, I can't find any evidence this text does that.

 He illustrates how the current mental-healthcare system interferes with rather than safely facilitates this process, and how recovery seems to only be possible when people manage to break away from the system to at least some degree.

Not true. Plenty of people have gone on to live happy lives by relying on that dreadful biomedical model to manage their psychoses. The drugs work. There are problems for sure, like we don't have a clue as to why the drugs work but they do work. The side effects can be horrendous. So can the side effects of untreated psychosis. Choose your poison.

Recent personal encounters have illustrated to me how woeful the treatment of those with mental health problems can be. Too ready to prescribe drugs in the hope that some good will come out of it, too quick to diagnose rather than investigate, too quick think about psychosis as "all in the head" and a serious failure to under estimate how environmental contingencies can play a big role in driving mental illness. That is where the biomedical model is seriously flawed and represents a common error in thinking about human behavior. We too often under estimate how our behavior is modified and shaped by our environment. We too often think we are the masters of our cognition, a concept that many accept as a given but one I continually struggle with. I cannot understand how I can be in control of myself. I'm overwhelmed by the connectivity I tell ya! Get me outta here!

 
So how do we rethink madness?

1. Analysis

Identify "madness" in all its manifestations. Don't be so lazy as to decide madness can understood from any single perspective or is a specific entity. Gather the data, categorize, synthesize, examine the purported etiology for the specific categories, and then the real work begins. Too many examinations of psychosis start out from the exclamation: They are not really mad just different! or They are really mad and will never recover! The first step in analysis is get your definitions straight and your data clear. Neither modern psychiatry or those opposed to it have adequately addressed this requirement.

 
2. Recovery is possible but how often and under what conditions?

He has come to a surprising conclusion: full recoveryfrom schizophrenia and other related psychotic disorders is surprisingly common; furthermore, the mainstream treatment of these disorders may be seriously reducing the likelihood of such recovery. He explains, “It is really quite tragic that the myth of no recovery continues essentially unimpeded, since there is a path to recovery available.”

I don't know why this is surprising because it has been in the literature for years. I do accept that psychiatry writ large could well be guilty of not recognising this in the literature. However I would challenge the view that recovery can be the normal state of affairs. Again though there is the category problem, I doubt that many with early onset schizophrenia will fully recover. Here's one reason why. In my archives is a beautiful study of neuro-imaging in early onset schizophrenia. The patients demonstrate remarkably elevated apoptosis(programmed cell death) during puberty than the controls. All of us lose many brain cells during puberty but in early onset schizophrenia the loss is much larger. This raises serious doubts that in such individuals full recovery will be possible. A big tick for the biomedical model.

Another big tick for the biomedical model is the paradoxical finding that schizophrenics who smoke marijuana often demonstrate preserved if not enhanced cognition from the smoking of marijuana. The paradox is resolved when one considers that the onset of schizophrenia from marijuana smoking is not the same as other forms of schizophrenia. Again, categories! This invites me into another little fascinating exploration in the biomedical realm which relates to the very tentative ideas that some forms of schizophrenia having a significant immunological etiology with implications of a subtle autoimmunity and recent findings indicating that cannabidiol has anti-autoimmunity properties. Sadly though the modern strains of marijuana contain far larger THC\CBD ratio, the former driving psychosis, the latter inhibiting or at least being neutral(there is a great study on that). So the emergence of the cannabis-schizophrenia linkage reflects the change in cultivation over the last few decades, a change driven by the Drug War. That is, the Drug War is creating more schizophrenics than old style cannabis could ever hope to achieve.

3. Complexity. 

It is true of schizophrenia that the literature provides a bewildering array of contradictory findings. Schizophrenia is very difficult to diagnose because its manifestation is so varied. We should not be surprised at this difficulty because we can't even define normal behavior which makes defining abnormal behavior somewhat problematic.

Behavior is not just a function of the brain. It includes the whole body and the environment. The complexity is such that even when we identify specific features of the brain we should not expect that to correlate with specific behaviors because the brain is not the sole driver of behavior. So it doesn't surprise that the literature contains these paradoxical findings, it is exactly what someone like myself expects to be found. To then argue, as the author of this text and many others do, that there is no scientific consensus regarding the physiological correlates, is both true and not true. That is, it betrays a fundamental misunderstanding of the drivers of behavior. Moreover it presumes, with great hubris, that we have a clear understanding of the relationship between brain and behavior.

This is potentially an intractable problem. Too many variables. That does not mean there is no hope of any understanding but we must accept the possibility of a limited understanding.

What Needs to be Done

1. 

Modern psychiatry has a serious drug addiction problem and engages in too much magical thinking. The profession is under siege and there is justification for society at large to demand that psychiatry crawl out of a 19th century mindset and recognise the enormous complexity of behavior. It needs to be much more honest with the general public and acknowledge that our understanding of these issues is very immature and it will take decades of hard work to make progress in the field.
2. 

Modern psychiatry and the anti-psychiatry movement must stop being so polarised and come together for a more productive mutual interaction. Both need to stop attacking each other and get back to the business of developing a more mature and disciplined approach to the reality of psychoses. As I have argued in relation to cancer, we should never use the singular tense, it should always be cancerS and psychoseS.
3.

Cure is possible. That has been seriously neglected. I have deep concerns that the use of antipsychotics can impede recovery because the drugs impede cognition to such an extent that instantiating new behaviors can be very difficult. There must be a much more aggressive research agenda in seeking cures that can be achieved by through the drugs and preferably by eventually discarding the drugs.
4. 

We need to be realistic about the adaptive potential of human beings. While advanced societies promote individual freedom these societies are also creating conditions which limit the expression of that freedom. We are required to study much longer, work much harder, be bombarded with stimuli from multiple directions simultaneously, are surrounded by modern media that titillates before it informs, that scares us rather than giving us hope, that continually sends us the message that you are quite right if you don't dress right, or look right, or conform in certain ways. We are losing our sense of community, we no longer trust each other as we once did, we are more fearful because so often that is the message that we receive. We are creating a society that at once promotes freedom and makes it harder to achieve. We are living in an increasingly mad society. Something must break, this world isn't mine(apologies to Ian Curtis, Joy Division).