“She frames a question that carries deep implications of challenge and shame: ‘Do you think they are real?’
An answer came out of my mouth that I had never quite thought before, but as I heard the words, they seemed true: ‘It’s not as simple a question as we usually think. We usually think that whatever we perceive is what is there. Perception equals reality. But research shows that every perception we have is actually constructed by the unconscious mind, which then instantly hands it to consciousness. What the unconscious mind uses to do this constructing is largely sensory stimulations. We grasp this information with our senses, we process it with our brains unconsciously, and the product enters our consciousness. Because we all share this sensory world, we do very similar unconscious constructing. We can both look at a lamp like this one and see the same lamp, as far as we can ever know. It’s easy to say, this lamp is real.’
Martha trusts me. She is hanging in with this.
‘However, sensory information isn’t all the unconscious mind uses to create experience. If a concern or issue is pressing enough, that becomes raw material, too. If a person, like you, is dealing with a huge amount of fear, if you are in the middle of a withdrawal syndrome from Geodon and Seroquel, your brain is hugely agitated. What if you also grew up with an amazing amount of secrecy and danger and abuse?’
I could see in Martha’s face that she was remembering some of the things she had told me.
‘Agitation feels like danger and danger brings up hurt and shame. These things get factored in too. All unconsciously. You perceive the same lamp and room as me, but some additional things, like the bugs. It’s not that the lamp is real and the bugs aren’t, it’s that your constructed reality has some things in it right now that my constructed reality does not. It’s not that my version is real and yours isn’t. They’re both real, but both constructed, only out of somewhat different materials.’”
“If you are unfamiliar with the standard treatment of psychosis – drug treatment, almost exclusively – you won’t understand what an odd approach I took with Martha in this interaction. Most of modern psychiatry dismisses the idea that psychotic experience is a meaningful response to the condition of one’s life in favour of the view that the voices, the visions, come from meaningless disease. By contrast I’ve learned to distinguish between the ravages of chronic psychotic disorder in the long and persistently afflicted, and the kind of acute aberrations experienced by Martha, which can usually be better understood as a ‘spiritual emergency’ instead of an impersonal state of disease.”
“The medical script for such a situation is usually something like this: ‘Of course the bugs and the man on the radio are not real. However, you shouldn’t feel responsible for this. No one else is to blame either. You have a serious mental illness. You were born with it, but sometimes it takes decades to develop, as it did with you. You are experiencing these delusional and hallucinatory symptoms because you have tried to get off of some of your medication, and this relapse is proof again that your illness is still there and must continue to be treated. Unfortunately, this will probably always happen, so you must try to live as normally as you can with these medications for the rest of your life. It’s like the diabetic who must always take insulin. Like any medications, these have some difficult side-effects, but these can often be treated with other medications and kept to a minimum. They are the price a person has to pay for the bad luck of being born with this disease.’
This speech can be delivered more sternly or more warmly, depending upon which seems more likely to result in medication compliance.”
“Yet as far as I’m concerned, this script is mostly untrue and clinically wrong-headed.”
“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).”
“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.”
“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.”
“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.”