News and interesting bits

The Following is an artice from Aeon Magazine

I am an older therapist, now in my 70s. When I was trained, I was taught that in the majority of cases, an acute psychotic break with delusions, hallucinations, and odd and extreme emotions was a naturally self-limiting condition. We distinguished acute psychotic break from chronic psychosis – long-term profound withdrawal and a failure to develop psychologically, frequently linked clearly with brain dysfunction, and also from brain-destroying diseases such as syphilis or head trauma. Acute psychosis, not treated chemically, would often last no more than a year. With kind, safe, custodial care, and good psychotherapy, remission would come more rapidly and be more stable. Many studies bore this out and my own experience confirmed this point of view.

I have always had a lot of interest in psychosis, and a lot of sympathy for people gripped by it. I have worked deeply with many people who have shared their experiences with me to try to understand as much as I could about it – from the inside as well as the outside. The more I learned about the inside of it, the more it seemed clear to me that people who became that messed-up have generally been badly hurt, usually early in life, often by people upon whom they were vitally dependent.

Now young psychologists and psychiatric residents in training are taught that psychosis is no one’s fault; it is a biological defect of the brain, and it lasts a lifetime. And their subsequent experience bears this out too. When patients are given powerful brain-altering medication, their symptoms usually go away quickly. Therefore, the untreated brains must be disordered. When meds are withdrawn, the symptoms come back. This tends to happen repeatedly. Therefore, the disorder must be a lifelong fact.

How can one reconcile this modern view of psychosis with the training I received decades earlier? Can both views be true? Does acute psychosis frequently resolve on its own or is it a disorder that lasts a lifetime, requiring a lifetime of psychoactive drugs? Has madness itself changed? Well yes, it has.

What has changed madness is our treatment of it. Our powerful drugs change brains in ways that make them profoundly drug-dependent. Coming off these drugs is a very tricky business. You can quickly become crazier and/or more anxious and/or more depressed than you ever were before starting the meds. The psychiatrists I know who are currently at the top of my personal referral list are those who are not only good at treating symptoms with medications, but also skilful at helping people terminate their medications. The latter seems to be by far the more difficult problem (Martha’s psychiatrist, thankfully, is one of this skilful group).

You might think I am a bit mad here myself, since what I am saying is against what has become the culturally accepted standard of care. Yet it is supported by a great deal of good research reported in our best journals of psychiatry. For example, a long-term study conducted by the psychologist Martin Harrow of the University of Illinois at Chicago asked whether anti-psychotic drugs reduced psychotic symptoms over the long term. The findings, published in Psychological Medicine in 2014, were dramatically negative. The majority, some 72 per cent of the patients remaining consistently on medications over a 20-year period, were ‘persistently psychotic’. Only 7 per cent of those who were withdrawn from drugs after two years remained in such dire condition. Was this finding an illusion created by the possibility that healthier patients were taken off meds, while sicker ones were not? This question has been addressed by other studies that randomly assigned patients to a drug-withdrawn versus a drug-maintained regimen, and found the same pattern of results.

If you suffer a psychotic breakdown, your odds of complete, treatment-free recovery are much, much better if you are treated in a third-world country that cannot afford psychotropic medication

The devastation of drug withdrawal has been covered eloquently in Anatomy of an Epidemic (2010), Robert Whitaker’s analysis of psychiatric drugs and the disturbing rise of mental illness in America. He spells out what we know about the neurophysiological changes that underlie these profound withdrawal syndromes that my patient Martha and countless others experience. In a nutshell, to compensate for the drug’s reduction of the neurotransmitter dopamine, the brain generates many new dopamine-producing cells. When available dopamine is no longer reduced because of withdrawal of the medication, the brain is flooded with excess dopamine, leading to a heightening of psychotic experience. A brain that never truly had a ‘chemical imbalance’ now has one for sure, caused by drug withdrawal.

Among the many fascinating facts that Whitaker has gathered is that if you suffer a psychotic breakdown, your odds of complete, treatment-free recovery are much, much better if you are treated in a third-world country that cannot afford psychotropic medication. In poor countries they treat psychotic breaks with various forms of social support, and largely leave the brain alone and unaltered. This long-term superiority of non-drug treatment in ‘backward’ countries was found by a World Health Organization study in 1992 and confirmed in a follow-up study a few years later.

Is acute psychosis a brain disorder? Hypothetically yes, but no evidence exists. Of course our brains are involved in all of our experience. This is a trivial truth. But there actually are no demonstrable differences between the brains of psychotic and non-psychotic people. We might be told that there is no physical test that will discriminate these groups. But the words ‘not yet’ are always added, since psychiatry seems to have faith that such a test is around the corner. This faith is robust: in the age of psychopharmacology our humanity is reduced to our brain, and all problems can be salved if not really solved with pills.

But I have grave doubts.

I have the deepest regard for the profession of psychiatry. I am a psychotherapist because once, without clearly knowing it, I badly needed psychotherapy. I sought it, but along with that, I read about it. Almost all of the great psychotherapists have been psychiatrists. Think of Donald Winnicott, Frieda Fromm-Reichmann, and Fritz Perls. However, with the recent wholesale commitment to the ‘biological model’, psychiatry has, it seems to me, cast off its own finest achievements and grabbed a tiger by the tail. Like the Freudian patient eager to repress guilty memories, current training programmes serve psychiatry’s old inferiority complex among other medical specialties by repressing mountains of hard-earned wisdom about treating the whole complex psychological person. It is an astonishing self-abandonment.

We are told that it is an astonishing success story. This is partly because success is judged by the quick alleviation of symptoms, and this alleviation is measured by the gold standard of a six-week, randomised, double-blind trial. In six weeks, antipsychotic drugs, both the older and the newer varieties, look very good. Crazy thoughts and experiences and emotions quieten down enormously. Acutely psychotic people make others around them feel intensely uncomfortable, and after six weeks on the meds they often become much easier to be around.

Fewer patients have been followed over the long-term, but one large study from the United States National Institute of Mental Health found a higher incidence of new breakdowns in the drug-treated than in those treated with placebo; the greater the drug dose administered, the higher the rate of relapse. Not only that, but when relapse occurred, the symptoms tended to be worse than ever before. Even when drug therapy is maintained, the narrative that the medication is curing the ‘disease’ of psychosis is deeply amiss. With so many more anti-psychotic medications available today than in years past, the problem of relapse is typically treated by switching to a different medication, which can then succeed in suppressing symptoms for a while. This often goes on for a lifetime. Does this look to you like a solution, or more like a frantic holding pattern?

Surely, the ultimate goal would be a functional life, drug-free. But the data here are discouraging. A rather early study in 1978 set a pattern which, to my knowledge, has never been empirically contradicted. Maurice Rappaport, a psychiatrist at the University of California in San Francisco, randomly placed 80 newly diagnosed schizophrenics into drug and placebo groups and followed their course over time. The drug-treated group showed somewhat faster alleviation of symptoms, although both groups stayed in the hospital about the same length of time. Over three years, those never treated with antipsychotics had much better outcomes – 8 per cent relapse versus 62 per cent for the drug-treated. I could cite other, more recent studies with similar findings. This is why we might be holding the tail of a tiger. We could be unwittingly turning an acute and generally time-limited condition into a chronic disability.

Healing must involve a new integration of deep, inner parts of the person and deep, transpersonal forces beyond the person

Should we even think of acute psychosis as a disorder? Actually, I no longer think so. I like the term used by the transpersonal psychiatrist Stan Grof: spiritual emergency. Acute psychosis is certainly terrible and dangerous. It can feel unbelievably awful; some people kill themselves when gripped by it, and a very few kill others, too.

Grof’s term implies that this kind of radical breakdown is a terrible bid for self-healing by a person whose life has come to be completely unliveable. It often erupts when some unbearable catastrophe unhinges a person (in Martha’s case, it was the death of her eldest child, in about the most horrible way that one could imagine).

Grof thinks that the healing must involve a new integration of deep, inner parts of the person and deep, transpersonal forces beyond the person. It involves new connections between the secret self and others – between the conscious self and the self beyond consciousness nowadays referred to as ‘spiritual’. When this new integration happens, it is pale and misleading to call it a ‘remission’. It is a remarkable achievement. Like the sobriety of a recovering alcoholic, it is always a work in progress. A post-psychotic man told me recently, looking back on himself before his madness: ‘It had to break down. I was too arrogant. I couldn’t see it, but it wasn’t working, it all had to change.’ At present this man is a successful artist and a leader in a vital artistic community.

Unfortunately, in developed countries, where psychopharmacology is the coin of the realm, there are few resources grounded in alternative views. Current, medical treatments suppress symptoms but long-term use hinders the process of new self-construction. But research tells us that we should use our medications carefully, sparingly, and temporarily. We should always use them in conjunction with serious psychotherapy that aims to help personal reintegration (not just superficial ‘counselling’ about ‘how to live with your illness’). Antipsychotic drugs should play a role, of course: just as it is helpful and humane to use painkillers until surgery can be performed, these symptom-relieving drugs can be a great mercy until reintegration can be achieved. But they should not be used for so long that they extensively rewire the brain, making reintegration far more difficult to achieve.

In my session with Martha, I acted on the belief that she and I are basically the same kind of person, neither one more biologically normal than the other. I went to some pains to find a way to say that her experience is as real as mine, and explain why I think that is a reasonable conclusion. It helped a lot that I actually believed what I was saying. Besides wanting to tell the truth, I did not want to add to her shame. It is very difficult for us, in the best of circumstances with the most apparently secure people, not to add to one another’s shame. We keep these secret currents invisible for good reasons. Is there anything more shaming than telling someone that he is the product of his brain, and his brain is defective? We should not make such statements unless we have very good reason to know that they are true, and I don’t believe that they are.

Random acts of kindness:

Im sure a lot of us can identify with the following if we are feeling low or suffer with depression or low self esteem. At times we just want to be left alone. May sound good but it is not always good for a healthy mind. we need others, we need to be loved and show love. Next time you feel down try the following- you may have to force yourself but trust me it will be worth it:

Do something nice for someone, pay their bill at Mc Donalds etc.

Smile at people, its infectious, you will be surprised at how many smiles you get back

Buy an extra news paper and give it to someone you dont know

Get my drift, try it. It makes you feel good and I personally get a kick from being nice to people.

Competition winners:

Congratulations to N.W and P.C both from Tamworth who both win a free session and a relaxation CD

well I’m off to Cardiff for a wedding next weekend and also celebrating my 51st birthday with family. Carry on enjoying August and please continue to support and comment on our face book page:

Till next time. Warmest Regards

Mario Gauci DHP Acc HYP PHPA