Dr. Carpenter’s BLOG
Things that Aren’t There
What do you think of hallucinations? How do you think they work? Is this something you ever wonder about?
Recently I talked about this with a woman I know well and long, who was experiencing some as we spoke. One thing was the “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 literally see the bugs. I could not.
Martha is in her mid-30’s. 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 very 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 puts the question to me 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 or read before, but as I heard it, it seemed to me to be true. At least true as far as I know.
“It’s not as simple a question as we usually think. We usually think that whatever we perceive is just simply what is there. Perception equals reality. However, we now know from tons of research that every perception we have is actually constructed by the unconscious mind which then instantly hands it to consciousness. What the unconscious mind largely uses to do this constructing is sensory stimulations. This sensory information is almost all of the raw material, most of the time. 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 this lamp. . . “ I point to it. “and we both see the same lamp, as far as we can ever know. It’s easy to say, this lamp is real.”
She trusts me, so she was hanging in with this.
“However, sensory information isn’t all the unconscious mind uses to create experience. It really makes reference to anything, any concern or issue that is pressing enough. If a person, like you, is dealing with a huge amount of fear and sort of meaningless agitation, the unconscious factors this into perception as well. You’re in the middle of a withdrawal syndrome from Geodon and Seroquel, and your brain is hugely agitated. You also grew up with an amazing amount of secrecy and danger and abuse.” I could see in her face that she was remembering some of the things she had told me about.
I went on, “these associations come in and get factored in too. Agitation feels like danger and danger brings up being exposed and hurt and shamed. These things get factored in too. All unconsciously. You perceive the product of all that. Same lamp and room as me, but some additional things, like the bugs and the radio talker.” The radio man is dangerous, an accusatory talker.
“So the answer to the question about is it real. . . It’s not that the lamp is real and the bug isn’t, it’s that your constructed reality has some things in it right now that my constructed reality doesn’t. 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 neutralized, you’ll have an easier time getting off of Seroquel.” Seroquel is a big weight-gainer, so a big priority for her.
“Yes, probably,” she said. Then she reflected for awhile. Then seemed to change the subject.
I won’t relate what she changed the subject to. It was a very private and difficult story. Not of childhood sexual abuse or beating or shaming, but something much more recent that also underscored the dreadful danger of her parents. We talked about it in depth, back and forth. Then at the end of the session (I felt very moved) 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 not intimately familiar with the currently-conventional treatment of psychosis, you will not understand what an odd approach I took with Martha in this interaction. I want to contrast this with the current approach, which emphasizes drug treatment almost exclusively, and dismisses the idea that such psychotic experience is a meaningful, if desperate and terrible, response to the condition of one’s life, rather than a meaningless disease. I want to draw a distinction between chronic psychotic disorder and the kind of acute aberrations experienced by Martha, which can usually be better understood as a “spiritual emergency” than the ravage wrought by an impersonal disease.
The typical script for such a situation is 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 go 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 such an illness.” This speech may be delivered more sternly or more warmly, depending upon which seems more likely to result in medication compliance.
Are there drawbacks to this script? I think there should be, because most of it isn’t true. And there clearly are drawbacks.
I am an older therapist, now in my 70’s. When I was trained I was taught that in the majority of cases, an acute psychotic break with delusions, and hallucinations, and odd and extreme emotions is a naturally self-limiting condition. It is important to distinguish acute psychotic break from chronic psychosis -- a condition characterized by long-term profound withdrawal and a failure to develop psychologically, which is frequently linked clearly with brain dysfunction – and also from the related category, which used to be called organic psychosis, which is associated with brain-destroying diseases like syphilis and encephalitis, or with toxins, or head trauma. Long term prognosis with chronic psychosis and organic psychosis tends to be poor. On the other hand, I was taught that acute psychosis, not treated chemically, will often last no longer than a year, sometimes no longer than a few weeks. With kind, safe, custodial care, and good psychotherapy, remission is on average quicker and more stable. Many studies bore this out. (for example, Davis, 1955, Harrow, 2007). And my own experience with psychotic patients in several settings bore this out.
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 by life, 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 medications, their symptoms usually go away quickly. Therefore, the brains must be disordered. And when they are taken off of meds, the symptoms come back. This tends to happen repeatedly. Therefore, the disorder must be a lifelong fact.
How can both these things be true?
Does acute psychosis frequently tend to remit or does it last a lifetime? Has madness 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 of these drugs is 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 skillful 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 skillful group).
You may think I am a bit mad here myself, since what I am saying is so counter to what has become culturally accepted. Yet it is supported by a great deal of good research reported in our best journals of psychiatry. For example, a long-term study by Harrow (Harrow, 2014), focused on the question of whether anti-psychotic drugs reduced psychotic symptoms over the long term. The findings were dramatically negative. The majority (72 percent) of the patients who remained consistently on medications over a 20 year period were “persistently psychotic.” Only 7 percent of those who were withdrawn from drugs after 2 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, rather than evidence that continued drug use made the condition worse? This question has been addressed by other studies that randomly assigned patients to a drug-withdrawn vs. a drug-maintained regimen, and found the same pattern of results (e.g. Wunderlink, 2013)
For a summary of these and related problems see the very disturbing book by Robert Whitaker, called Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing 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, it appears that the brain, in attempting to compensate for the reduction of the neurotransmitter dopamine, generates many new dopamine-producing cells. When dopamine is no longer reduced because of withdrawal of the medication, the brain is flooded with an excess of the protein, leading to a heightening of psychotic experience. A brain that never truly had a “chemical imbalance” (this powerful marketing metaphor, never a genuine phenomenon, has been widely disavowed by psychiatrists), now has one for sure, caused by drug-withdrawal. (Gøtzsche, P., 2014. Accessed at http://davidhealy.org/psychiatry-gone-astray/on6/17/2014).
I have searched for solid, scientific information contrary to Whitaker’s points, but have not been able to find it, although there is certainly controversy (Torrey, 2012, Whitaker, 2012). 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 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 (Jablensky, 1992), and confirmed in a follow-up study a few years later. (Hopper, 2000).
Is acute psychosis a brain disorder? Hypothetically yes, but as far as we can tell, actually no. 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 may be told that there is no physical test that will discriminate these groups. But if we are told that, the words “not yet” are always added, since there is complete faith that such a test is just around the corner. This faith is very robust. It fits our favorite filters for reality. The rebellious psychiatrist R. D. Laing somewhere quipped 40-plus years ago that people were always finding something in the urine of schizophrenics. We could now say that people are always finding something in the MRIs of bipolars. The problem is, these “imminent breakthrough” never hold up. With more and careful research, they evaporate. If acute psychosis were a brain disease we should be able to find it in brains, but we cannot.
What we have instead of a brain disease is a handful of metaphors that can be bundled together into a simple narrative that feels very sensible in an age in which all of our humanity is reduced to our brains, and all problems can be salved if not really solved with pills.
I have the deepest regard for the profession of psychiatry. I am a psychotherapist because once, without really 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, a tiger by the tail. Like the Freudian patient eager to repress guilty memories, current training programs 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, randomized, double-blind trial. In six weeks, antipsychotic drugs, both the older and the newer, 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. Long-term follow up is more rarely assessed, and when it is, it is almost entirely in terms of the re-occurrence of psychotic symptoms. There is some evidence that continued use of anti-psychotics often continues to suppress symptoms – although this is far from always true. In fact, one large NIMH study found a higher incidence of new breakdowns in the drug-treated than in those treated with placebo, and the greater the drug dose administered, the higher the rate of relapse (Burt, 1977). Not only that, but when relapse occurred, the symptoms tended to be worse than ever before (Gardos & Cole, 1977). Even when drug therapy is maintained, the narrative that the medication is curing the “disease” of psychosis was deeply amiss. Since this research was done, many more anti-psychotic medications have become available, and the problem of relapse is typically treated by switching to a different medication, which may then succeed in suppressing symptoms for awhile. This often goes on for a lifetime. Does this look to you like a solution, or more like a frantic holding pattern?
It is another question – and surely the most important question -- to investigate outcome in terms of a functional life drug-free. This kind of outcome data is quite discouraging. A rather early study set a pattern which, to my knowledge, has never been empirically contradicted. Maurice Rapaport 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% relapse, vs. 62% for the drug-treated (Rapaport, 1978). I could cite other studies, many much more recent, with similar findings. This is why we may be holding the tail of a tiger. We may 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 transpersonal psychiatrist, Stan Grof: spiritual emergency, (Grof, 1989, 2012). Acute psychosis is certainly terrible and dangerous. It can feel unbelievably awful, and 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 unlivable. 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, and the self and those sources of guidance and grace beyond the self that we refer to nowadays 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.
For more information about this alternative view of psychosis, I recommend that the reader scout out books, not only by Stanislaus Grof, but also John Weir Perry (1974) and Paris Williams (2012). Perry ran a wonderful treatment program for psychosis that did not emphasize drugs. Williams speaks as a survivor both of psychosis and treatment.
Unfortunately, in developed countries, there are precious few resources to support people struggling with psychosis that are grounded on such an understanding. Almost all of the ones that used to exist in the United States shut their doors long ago in favor of the universal reliance upon antipsychotic medication, with very minimal psychosocial support. This form of treatment suppresses symptoms but long-term use unfortunately hinders the real process of new self-construction. At the same time, antipsychotics are helpful in relieving acute psychotic symptoms, which relieves the great distress of both the person who has broken down and of the people in his or her life. In any case, their use is deeply entrenched and we have no real alternative. It seems to me that 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 superficial “counseling” about “how to live with your illness.”) 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 not used for so long that they rewire the brain to the point that reintegration is much more difficult.
In my session with Martha, I acted on the belief that she and I are basically the same kind of person, neither 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. I don’t believe they are true.
Martha and I have an alliance between two equally honorable people, although one carries oceans of secret shame that the other does not so much. We remove pieces of emotional shrapnel as they rise to the surface. At moments we appreciate the unbidden powers, from wherever, that guide us to the next step as our work unfolds.
Burt, D. (1977). Antischizophrenic drugs: chronic treatment elevzates dopamine receptors in schizophrenia. Science, 326-327.
Davis, D. L. (1955). Reserpine in the treatment of anxious and depressed patients. The Lancet, 117-120.
Gardos, G., & Cole, J. (1977). Maintenance antipsychotic therapy: is the cure worse than the disease? American Journal of Psychiatry, 32-36.
Gøtzsche, P. (2014). Psychiatry Gone Astray.
Grof, S. (1989). Spiritual Emergency: When Personal Transformation Becomes a Crisis. New York: Tarcher.
Grof, S. (2012). Healing our Deepest Wounds: The Holotropic Paradigm Shift. Newcastle, WA: Stream of Experience Publications.
Harrow, M. (2007). Factors involved in outcome and recovery in schizophrenia patients not on antipsychotic medication. Journal of Nervous and Mental Disease, 406-414.
Harrow, M. (2014). Does treatment of schizophrenia with antipsychotic medication eliminate or reduce psychosis? Psychological Medicine, DOI:10.1017/S0033291714000610.
Hopper, K. (2000). Revisiting the developed veresus developing country distinction in course and outcome in schizophrenia. Schizophrenia Bulletin, 835-836.
Jablensky, A. (1992). Schizophrenia: manifestations, incidence and coure in different cultures. Psychological Medicine 20, 1-95.
Perry, J. W. (1974). Far Side of Madness. Upper Saddle River, NJ: Prentice Hall.
Rapaport, M. (1978). Are there schizophrenics for whom drugs may be unnecessary or contraindicated? International Pharmacopsychiatry, 100-111.
Torrey, E. F. (2012). Anatomy of a non-Epidemic: A review by Dr. Torrey. Retrieved from Treatment Advocacy Center: http://www.treatmentadvocacycenter.org/component/content/article/2085-anatomy-of-a-non-epidemic-a-review-by-dr-torrey
Whitaker, R. (2011). Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America. New York, NY: Broadway Books.
Whitaker, R. (2012, May 16). E. Fuller Torrey’s Review of Anatomy of an Epidemic: What Does It Reveal About the Rationale for Forced Treatment? Retrieved from Mad in America: E. Fuller Torrey’s Review of Anatomy of an Epidemic: What Does It Reveal About the Rationale for Forced Treatment?
Williams, P. (2012). Rethinking Madness: Towards a Paradigm Shift in our Understanding of Psychosis. Cleveland, OH: Sky's Edge Publishing.
Wunderlink, L. (2013). Recovery in remitted first-episode psychosis at 7 years of follow-up of an early dose reduction/discontinuation of maintenancy treatment strategy. JAMA Psychiatry, 913-20.
A different version of this essay has appeared in Aeon.