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Fixing Psychiatry

Men in strait jackets on an old psychiatry ward looking profoundly unhappy

 

Recently I participated in a discussion about the Hearing Voices Movement with another consumer/survivor and two psychiatry residents. The discussion was part of a program to help psychiatrists understand the concept of recovery in mental health. Neither of the doctors had seen Eleanor Longden’s TED talks (here are the shorter and longer versions) so I, along with the second consumer/survivor, described to the doctors key concepts that Longden raises in the videos.

Longden started to hear voices at the beginning of her second term at University (exactly the same point at which my psychological unraveling began). Central to Longden’s story is the observation, in hindsight, that the more engaged she became with the psychiatric system, in an effort to cope with her voices, the more problematic and malicious the voices became.

Longden ultimately recovered remarkably; not from hearing voices but rather from her terrible experiences of psychiatric care. The voices continue to be a part of her life, but their impact is no longer negative. An idea that Longden stresses is that voice-hearing is not intrinsically pathological, and should be seen instead as a complex psychological phenomenon, often (but not always) in response to stress. She takes the position that hearing voices can be a manifestation of past trauma or current emotional upset that is not otherwise being expressed, and recommends approaches to the experience of hearing voices informed by this perspective.

When we shared these points with the doctors, both found them interesting. One suggested that there were two types of voice-hearing experiences (Oliver Sacks suggests that there are many). Her observations were that the type of voice hearing that Longden describes is dissociative, and much less responsive to the neuroleptic medications used to treat schizophrenia. However the psychiatry resident also suggested that there was another type of voice-hearing that was much more clearly a pathological symptom of a physiologically diseased brain, and these individuals usually saw their symptoms diminish considerably when on medication.

Despite having had some awful experiences taking these drugs, I believe that they, and other medication, can be an important and powerful tool in coping with the overwhelming challenges that arise when our minds are not responding in constructive ways to the circumstances around us. Neither I, nor my consumer/survivor partner in the discussion, were promoting an anti-medication agenda. Instead what we were trying to communicate was the idea that the psychiatric establishment plays a powerful normative role in shaping the experience of hearing voices (and indeed of all forms of “mental illness”), and that, regardless of the varied origins of voice-hearing, seeing the experiences as intrinsically pathological is a self-limiting approach to recovery.

This is one of the fundamental challenges in mental health. Our mind is the seat of our consciousness, our sense of self, and our sense of our place in the world. A diagnosis of mental illness is thus an indictment of the self. A diagnosis can sometimes help to situate frightening and dangerous experiences in a framework that helps us to feel that we are not alone in our experience. However medicine also sees a diagnosis as a disease. This can quickly become corrosive to a healthy sense of self. Longden’s case is a clear example of just how harmful this can be.

In the days following the half-hour discussion I was struck by the fact that the doctor’s observation was, no doubt unintentionally, a manifestation of psychiatry’s resistance to shifting the paradigm in mental health from treating disease to enabling wellness. Although I am aware of other doctors who apparently, based on this article, disagree with the resident’s observations, I don’t have the experience necessary to assert that the resident is wrong. I do know of research that challenges her observations. I could not help but think that even if the resident’s observations are correct, Longden’s alternative perspective is fundamentally important in how we go about improving mental health as it is understood in medicine.

William James was one of the first psychologists to  prominently espouse the idea that how we see the relationship between mind and body can have significant impact on our mental health (this article includes a succinct, less academic, description of one of James’ ideas). Just prior to the discussion above I was having a conversation with another consumer/survivor who was passionately making the point that how we think, how we feel, how we act, and how our bodies respond, are bound up intricately and inseparably. This means that changing any of those things has an impact on the others.

This interconnectedness is a foundation of mental health. There is considerable evidence that pre-natal experiences of stress, poverty and famine by mothers can increase the risk of schizophrenia for their offspring decades later. Psychiatry is becoming ever more focused on the structures of the brain and the chemical reactions within them. However this approach is marginalizing wellness strategies, like talk therapy, whose first line of approach is our thinking, our feelings, and our actions. There is a growing body of research suggesting that even adult brains show neuroplasticity— the ability to change physiologically in response to circumstances. When medicine frames unusual experiences of the mind as symptoms of a diseased brain, little room is left to explore circumstances under which our minds, and perhaps our brains, can change so as to make these unusual experiences less problematic and perhaps, at times, even constructive.

There is no escaping the fact that our minds can behave in extremely dangerous ways and that as a society we must cope with these circumstances. However healing those of us who have had such experiences involves situating even these extreme experiences within a larger psychological and wellness framework rather than treating them in ways that condemn us to the realm of the chronically diseased.

Health care is trying to achieve a shift in emphasis from disease treatment to disease prevention. For the reasons above psychiatry needs to be at the forefront of this trend, and perhaps may well need to situate itself beyond it. This means starting to see people and our unusual psychological experiences in terms of neurodiversity, rather than condemning our minds entirely to the realm of disease. That is not about ignoring the fact that extremely dangerous situations can arise when our mental health is neglected. It is about recognizing that the only real path out of these situations lies in approaching treatment with the fundamental belief that wellness is founded on being able to see ourselves and our experiences holistically, not divisively. Pathologizing unusual, even harmful, experiences of the mind as symptoms of an intractable physiology can only ensure that they remain pathological and intractable.

For those living with a major psychiatric diagnosis, wellness involves managing potentially harmful psychic experiences that often never completely go away. If mental health treatment is to improve, psychiatry must constantly rescue what it sees as symptoms of mental illness from a disease mindset that requires us to “defeat” our illness. Otherwise this mindset can easily put us at war with ourselves. It is a very difficult, even paradoxical, challenge for a doctor. However it is only in rising to that challenge that psychiatrists can help us to manage potentially harmful experiences in ways that enable our well-being.

(This piece was originally posted on Medium in February of 2015)

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