Thursday, February 28, 2013

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!
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


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.

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.

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.

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).


Paris Williams said...

Nice catch with Psych Central's copying of Ron Unger's review. Very unprofesssional, eh?

I have to say, though, that as disgraceful as it to copy someone else's review, I think it's at least as disgraceful to publicly criticize a book you've never even read(!) You seriously misunderstood many of the main points and conclusions of this book, which of course is to be expected given that you're basing your entire discussion on a several paragraph review. Since you're putting yourself out there as a voice to the public (as either a blogger or a journalist), I hope that you will seriously "rethink" the responsibility and ethics that go along with this position,

Paris Williams (author of "Rethinking Madness")

Ivana Fulli MD said...

Paris Williams,

The blogger was honest about the fact that he didn't read your book and has no intention to do so in the near future.

I think that you should have to accept that he was discussing a review of your book as an introduction to his thoughts on the shortcomings of psychiatry.Of course I understand that it might seem illogical to you but your book is not really the subject of that blogpost.

In order to look at a halfull glass of the beverage of your choice , remember that even a bad publicity is a publicity and many people will want to read your book after reading that blogpost.

By the way do you agree with:
///SethF1968 on March 2, 2013 at 7:49 am said:

(...)There are about a dozen well known authors who expressed this view of madness in the 20th century including Anton Boisen who more convincingly than anyone I have read pointed out the parallels between the breakdown/breakthroughs of “religious geniuses” such as Jesus, St Paul, George Fox and others, and ordinary hospitalized schizophrenics. Laing regarded normal consciousness as insane––as out of touch with the reality of the inner world, and thus if anything merited the label of serious pathology it was the consciousness of the normal man/woman. I think I took Laing’s main ideas in The Politics of Experience ideas to their logical conclusion–from which he turned back after 1967: that the schizophrenic experience if encouraged and nurtured could lead to the birth of a messianic sensibility, and that those with this sensibility could be catalysts of a new Great Awakening, a spiritual revitalization. As we stand today on the verge of an ecological Armageddon a messianic sensibility is I argue our only hope for saving the species and enabling it to realize our highest and greatest possibilities.

This was I think the embryonic intuition upon which The Icarus Project was originally based, as I argued in my own book The Spiritual Gift of Madness. And thus I regard the leaders of TIP with ambivalence –with gratitude for their intuition and courage expressed in TIPs Mission Statement and with disappointment for their repudiation of the mad gift perspective in the ensuing years.

It is my argument that the redemption of humanity rests upon the willingness to view madness, despite its frightening aspects, as a positive good, and to nurture it so that the mad can be come the catalysts of messianic change who can lead normal people into the promised land before we plunge over the edge of the abysss upon we are are so precariously perched.

Seth Farber, Ph.D./// ?

For myself, I don't.

Ivana Fulli MD said...

To my mind and knowledge, one of the most important book written on an individual experience and management of psychosis over decades is by a law and psychiatry professor who happens to be a strong mental health advocate fighting against forced treatment for the mentally ills. Still, she believes that drugs were and are very useful to her but that psychoanalysis also helps her tremensdously (Nb: I am not a psychoanalyst myself)as well as living a healthy life according to her needs.

The Center Cannot Hold: My Journey Through Madness: Elyn R. Saks: 9781401309442

Although I believe that some people are not helped by the neuroleptics we have to offer now,I do believe with you that psychosis and schizophrenia- and indeed any psychiatric illnesses and need to be written and thought about with s like the autisms.

This might explain the miracle stories and the miracle cures in the kind of books which is the subject of the review you discussed in your post.

To my mind, it is like if I were to proclaim that lung cancer, chronic obstructive pulmonary disease, asthma, pulmonary embolism and chronic right-side heart failiure can be cured by chicken soup because chicken soup “saved” me from a very nasty episode of flu with very high fever and mostly respiratory symptoms etc...

I would sell my chicken soup recipe in books and conferences for a good price and/or for inflating my self-esteem and just ignore the persons minimaly helped by my chicken soup blaming the thoracic doctors and their drugs.

Or, if you prefer, you can remenber how bloodleting had been the physicians 's treatment of choice for centuries: it was indeed very useful in acute right-side heart failiure (when you can hear the water in the lungs) but useless or dangerous for other diseases. Idem for leeches which can still save a limb when too much oedema prevents oxygenation.

Actually, a "Layla" wrote the same idera in a better English than mine commenting an antispychiatry activist's blog about psychiatry being a cult:

Layla on February 24, 2013 at 7:46 pm said:

///Hi Laura,

I’m sorry for the struggle you describe. I don’t wish to comment on your experience, as it is yours, but I would like to caution against the use of anecdotal evidence to support a strong, broad conclusion, as you seem to be doing by tying your personal experience into the argument about psychiatry. Having read some of your other posts, I notice a tendency to use your story as an indictment against the entire field. I have had a very different experience with psychiatrists and other mental professionals. I don’t feel I’m “broken” as a person, or anything else along those lines, but I do struggle with what I believe is accurately characterized by mental illness, and I have been helped by several psychiatrists and psychologists. It seems that most of the people who leave comments have had experiences similar to yours, but it is not representative of all who have entered the mental health system.(...)"

John said...


I made it perfectly clear I had not read the book, I was prompted to write the post by the Psychcentral email containing the review. That I included the heading "The Contents of ... Review" should make it perfectly clear that I was addressing those contents, not the text itself. I had a clear purpose in doing that, the development of my thinking on this issue can be seen from other posts. Additionally where I do specifically review a book that is mentioned in the blog post title.

The reviews are not encouraging because the once again the argument is appears to be a recapitulation of anti-psychiatry themes. That's old, that's dead, it is not going to work. That you have chosen to come to little read blog to tell me I'm a bad boy rather than provide a statement like ... No John, the reviewers haven't addressed the key points of the book. These being ... in itself highlights one of my main concerns which was indicated when I wrote:

Modern psychiatry and the anti-psychiatry movement must stop being so polarised and come together for a more productive mutual interaction.

You immediately jump into a polemical stance. A little more impulse control there, if you wanted to do your book some favours you could have taken the opportunity to provide some insight into it.

Such an approach would have been far more constructive because that would have generated interest in your text. But you came here to lecture me about ethics, not psychosis. That is instructive.

If I seriously misunderstood the conclusions of the book it is because the reviewers either did so or chose not to provide a cliff notes version of those. You should take that argument up with the reviewers.

As to rethinking the responsibility and ethics ... "Seeking the truth is not seeking what is desirable". (Camus, The Myth)
"The reasonable man adapts himself to the world and the unreasonable man adapts the world to himself. Therefore all progress depends on the unreasonable man."(GB Shaw) Responsibility and ethics are janus faced issues: these can easily prevent us from speaking our minds, from telling people what we really think. While we do need to exercise appropriate restraint demanding one invoke such imperatives with respect to such a controversial subject is not about ethics but about stifling debate. Attempts to make my guilty have about as much success as prozac for mild depression.

If you are concerned about bad press don't write books. If you wish to address bad press do it by pointing out the errors of the bad press and presenting your views rather than preaching at someone.

Get over it, blogs are soap boxes on street corners.