What do you think of hallucinations? Do you wonder how they work? Recently I talked about this with a woman I know well, who was experiencing some as we spoke. Her hallucinations included ‘bugs’ – microphones that she saw scattered around the room that she assumed had been put there because she was coming in, by people who wanted to keep track of everything she said, and might hurt her at any point. She could see the bugs, but I could not.
Martha is in her mid 30s. Her bright blonde hair is natural. She sat on one side of a corner from me, her body tense and passive at once, the odd mixture one sees with people who are gripped with inner distress but whose musculature is flattened out by atypical antipsychotics. She carries the tight, extra weight that also accompanies those drugs. Her eyes are shy and furtive, checking the room, checking my face.
She is a very intelligent person and is vexed by people telling her that such things are not real. She cannot doubt her senses, and she sees them. (I say: ‘I agree. I don’t doubt my senses either.’) Same thing with the voices speaking to her on the turned-off radio. She understands that I do not see and hear these things, but she does.
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.‘
She answered thoughtfully: ‘That seems true.’
I said then: ‘I think that when we have done more work on your terrible memories and on danger and shame, and all that is more out and somewhat neutralised, you’ll have an easier time getting off of Seroquel.’ Seroquel is a cause of weight-gain, so a big priority for her.
‘Yes, probably,’ she said, then changed the subject to tell a very private story that revealed, in a new way, the dreadful danger of her parents. We talked about it in depth, then at the end of the session I thanked her for the story (which she had never told to anyone before). She thanked me for listening.
Talk of suicide, which had begun our meeting, was gone for now.
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.
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 antipsychotic 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.
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 antipsychotic 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.
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.
James Carpenter is a clinical psychologist and psychotherapist. He is an adjunct professor in the department of psychiatry at the University of North Carolina at Chapel Hill.