Note: This post isn’t like most of my others. I’m not in the habit of simply saying what I think without documentation, or in areas this far outside of my area of expertise. But I’ve got a really strong feeling here. Take it for what it’s worth – just a strongly felt, definitively stated, but nonetheless speculative feeling… Maybe it’s a polemic too – my polemic… I titled and ended the last post <to be continued>… not just because I was going to have more to say on the topic, but because it’s the only thing I’m absolutely sure of – that this debate will keep on and on just like it has since the dawn of 1boringoldman time [in psychiatry] and for that matter, before…
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A controversial argument, especially one refuting or attacking a specific opinion or doctrine.
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A person engaged in or inclined to controversy, argument, or refutation.
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PLoS Blog: Mind the Brainby James CoyneFebruary 26, 2015
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The Mental Elfby Keith Laws, Alex Langford, and Samei HudaNovember 27, 2014
on medications
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Guideline Watch [APA 2009]
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Individual Resiliency Training Manual [NIMH 2014]
on the medical model and diagnosis
In storm duties… I talked about the bio·psycho·social model suggested by George Engel that, in my opinion, was never really implemented. It’s my "medical model" of choice. I would agree with the BPS that diagnosis can be stigmatizing and either used or experienced as an indictment. It can and has been used to imply an etiology when, in fact, none is known. And people can be misdiagnosed. Even worse, the categorical criteria can be intrinsically flawed [as they definitely are in the DSM-III+ with depression]. Those are all bad things to avoid or even preach against on any available pulpit. But the BPS report suggests that for those reasons, we should abandon categorization altogether, any model that underlies that categorization with it, and goes on to argue that the category doesn’t really exist, but simply represents phenomena along a spectrum with normal mental life.
I have no great love for the DSM-III+, but in this case, I think they did a decent job. First, the diagnosis was initially the gloomy Dementia Praecox popularized by Emil Kraepelin in 1893. In 1911, Eugen Bleuler re-evaluated the syndrome and coined the term Schizophrenia. He described a broad spectrum of people, presentations, and outcomes including complete recovery following a psychotic episode. With Bleuler, diagnosis was not destiny. In the 1980 DSM-III, they separated out Brief Reactive Psychosis and added duration and functional impairment to make sure that the diagnosis didn’t rest on symptoms alone, though they didn’t name a pathognomonic symptom [a symptom that is unique to a syndrome that nails the diagnosis]. I happen to think there is one – the complex described as negative symptoms [though they are inadequately described in the DSMs]. I’ve not seen a case where I was able to explore the history in depth and the negative symptoms weren’t present in some form or another long before the outbreak of frank psychosis [I’m including kids I grew up with and kids of my friends who later developed the classic disorder].
Treatment of negative symptoms begins with assessing the patient for syndromes that can cause the appearance of secondary negative symptoms. The treatment of such secondary negative symptoms consists of treating their cause, e.g., antipsychotics for primary positive symptoms, antidepressants for depression, anxiolytics for anxiety disorders, or antiparkinsonian agents or antipsychotic dose reduction for extrapyramidal side effects. If negative symptoms persist, they are presumed to be primary negative symptoms of the deficit state. There are no treatments with proven efficacy for primary negative symptoms.
At times, some people may appear inexpressive, withdrawn, listless, apathetic or unmotivated. They may find it difficult even to find the energy to prepare food or generally to look after themselves. Traditionally these difficulties have been thought of as ‘negative symptoms’: part of an illness. However, they can often be a result of feeling overwhelmed by experiences and trying to cope, or arise from feelings of helplessness and depression. They can also be unwanted effects of the drugs that people are often prescribed
Speaking of the dawn of 1boringoldman time, on the first day I was a psychiatry resident, I was assigned several patients who were already on the acute ward where we worked. The first one I met was a twenty something year old mother of three who had been brought to the hospital after drowning one of her sons to death in the lake in Atlanta’s central park. She had been stopped by bystanders during her attempt to drown the second one, directed to do so by the voice of God. By the time I met her, she had been declared NGRI [not guilty by reason of insanity] and was awaiting definitive placement. She’d been there for a while, and was an obvious favorite of the nurses – a long-stay patient on a short-stay unit. One of the nurses took me aside and asked that I have my sessions with her at times other than between 3PM and 5PM when she watched the after-school children’s programs. The nurse called it "being with her kids" – something she had done with her children daily when they got home from school. The other patients intuitively complied and left the day room to her or sometimes even watched with her.
By the time I met Gloria, she was not psychotic. She would answer questions about what happened with her kids, but didn’t really engage the topic. Her family visited often, and they didn’t talk about her son’s death either. Like the nurses, there was always a tear nearly visible as their looks conveyed both the tragedy and their love. The thing that most struck me about her was her flattened affect and her literalness. She was on a low dose of a first generation neuroleptic which might’ve explained some of the emotional flattening, but I doubted that. It seemed like part of being her. We were taught in those days to assess abstracting ability by asking the meaning of proverbs. She had no idea what they meant. I’m not even sure she got the point of my asking. And her general literalness was pervasive in all conversaton – striking even to my then untrained ear. I awkwardly asked her mother about those things. I think I was wondering if the medication was responsible. But her mother knew exactly what I was asking and said something like, "Oh no, she’s always been like that! I only wish I’d known where it was headed!" And cried painful tears.
I didn’t know it then, but Gloria was the nidus for what I now think about this affliction. As dramatic and disruptive as the psychosis of Schizophrenia can be, I no longer think of it as primary, though it can certainly be an overwhelming and sometimes insurmountable problem. I see the baseline state as the primary affliction – what people call "negative symptoms" or Eugen Bleuler called "Anhedonia." It’s what I was trying to get at in birdman…. To Gloria’s literalness [living in a world without abstract meanings] and her difficulty experiencing or accessing an emotional compass, I would now add a confusion in reading and understanding the subtle but ubiquitous metacommunications in interpersonal experience. Those things contribute to the oft-expressed sense of non-being, of identity diffusion, of confusion, of deadness, or the many other ways people try to explain something that others rarely ever even think about because for them, it is intuitively present and operating automatically. I tried to talk about this in 1. from n equals one…, 2. from n equals one…, 3. from n equals one…, etc. with another example. I know that if a person showed up seeking psychotherapy with just those complaints without psychosis in the story, I’d still be likely to give it my best shot. Those things alone are heavy burdens to carry into a life, particularly a life among people.
I’m not trying to mount an antecdote war here, just trying to give an example. Effective psychotherapy requires a shared view of what the problem is, and is informed by the nature of the problem. Patients can learn how to identify, live with, compensate for, or even change what happens in these states of confusion if that’s the focus of the work. I’ve never seen a patient who came for a therapy who was hurt or demeaned by talking about negative symptoms [again the never word]. They already know about them – every day. And I worry that any approach that doesn’t take them on as a central focus will flounder much in the same way as relying only on medications does. In fact, some of the examples in their own report address these very problems and I was glad to see that. End of sermon.
on rights and laws
on etiology
Their traumatic theory is as speculative as some of the biological theories. I personally doubt its primacy, but how about some proof before NICE buys into the radical change in mental health policy suggested. Chasing trauma has had a powerful pull throughout history [and brought down some of the best of us], but only really worked in patients with clear PTSD as specifically defined. Having spent a career treating a lot of traumatic illness, I don’t personally think that Schizophrenia is primarily a post-traumatic syndrome – certainly not without some solid consistent evidence.
I have 1 question specific to schizophrenia and the constellation of “negative symptoms”.
(1.) You describe patients whose non-psychotic thinking is very concrete and literal. Have you ever had the opposite experience? I don’t know if this would be more common with a bipolar type schizoaffective disorder, but this is what I’m thinking of: Highly intelligent, creative/poet, history of psychosis, poor social skills and occupational functioning–but with thinking that is too abstract, not concretely grounded in reality. Someone who could probably run circles round the person asking the proverb questions.
I have two questions about the meaning of the term “medical model” which gets thrown around a lot. It’s not clear to me that this is what a non-psychiatrist physician would call medical.
(2.) I once heard a psychiatrist a few years younger than you refer to the “so-called medical model.” (He’d trained years ago and worked with patients who had complicated medical illnesses in addition to their psychiatric symptoms.) It seems to me that good primary care doctors do consider psycho-social factors. Would the bio-medical model cut it in the rest of medicine or is everyone outside of psychiatry implementing the bio-psycho-social model?
(3.) What is the medical model in psychiatry? (Aren’t both recovery paradigms and psychoanalysis outside of it?) And (see above) is the medical model of psychiatry truly medical?
1. The striking thing in what I have always called Schizophrenia is that there is a problem with abstraction, I think originall described by Bleuler. It’s the thing that one is looking for in asking about proverbs. They just don’t get what “If a fish didn’t open it’s mouth, it wouldn’t get caught” means in the abstract. It’s apparent in their everyday speech as well – taking things literally or concretely, without extrapolating other meanings. On the other hand, they can create elaborate, fantastic delusions that seem to be beyond abstract – but they are meaningless. It is likely that the case you describe with “thinking that is too abstract, not concretely grounded in reality” would flunk the real meaning of proverbs. My point in this blog is that without being able to understand abstract meaning, the world is a very confusing place to live in…
2. I never even heard the term “medical model of disease” until I arrived in psychiatry, and it was in a negative context. It was interesting how it came up back then. A radical behaviorist was ranting about psychoanalysis – and Freud’s adhering to the “medical model of disease.” What he meant was that Freud saw symptoms but was focusing on causes behind the symptoms. He was railing about causal thinking. Instead of focusing on the symptom as an object of change itself [with behavior modification]. Nowadays, “medical model” thinking is still a bad thing when it’s used in something like the BPS Report. But here, they’re talking about assuming that there’s some causal disease entity underlying the symptoms collected as a diagnostic entity like Schizophrenia. They contend that it’s not a “disease” – an entity.
Outside of psychiatry, this isn’t much of a topic. Medical diseases have biosignatures proving their existence. Since we don’t have actual markers like an abnormal x-ray or a bloodtest, psychiatrists are criticized for assuming an underlying cause. Thomas Szasz particularly popularized this criticism in his book The Myth of Mental Illness.
I tried to at least make the distinction clear in to be continued…
The first time I heard about this inability to comprehend abstract, proverbial or metaphorical terms was in a Robert Sapolsky lecture on epigenetics, in which he talked about it as a central feature of schizophrenia. Interesting that I have barely come across it anywhere since. Is it something people still speak a lot about (but I just happened to have missed) or is it a feature that is no longer seen as emblematic of schizophrenia?
While I’d agree from my own observations that people displaying negative symptoms are able to respond to only the most literal and direct language, is this really the result of some particular dysfunction, or is their lack of response merely the result of overwhelming emotional and cognitive disruption associated with the experiences of psychosis?
I ask because many clinicians see people with schizophrenia at their worst, during their most acute episodes, and not in those intervals when their patients are at their best. It is hardly surprising that they have developed a rather negative and artificial clinical steretpye from this state of affairs. In my non-clinical experience, the communicative and linguistic abilities which are so strikingly absent in both negative and positive psychotic episodes (and which include the absence of any semblance of humour) return during periods of wellness. This suggests to me that dissociation, pain, fear, arousal, paranoia and so forth are responsible for those deficits and not some yet to be discovered permanent global dysfunction or deficit which is often seen as emblematic of those people in some essential permanent sense.
But then I have little issue with the BPS statement, which is based on many years of research by Boyle, Pilgrim, Read, Bentall suggesting much the same thing, research which considers things in a dimensional approach that continues to be ignored by mainstream psychiatry.
Mickey, I wonder if you would consider taking another look at your interpretation of the following passage of the BPS report:
“At times, some people may appear inexpressive, withdrawn, listless, apathetic or unmotivated. They may find it difficult even to find the energy to prepare food or generally to look after themselves. Traditionally these difficulties have been thought of as ‘negative symptoms’: part of an illness. However, they can often be a result of feeling overwhelmed by experiences and trying to cope, or arise from feelings of helplessness and depression. They can also be unwanted effects of the drugs that people are often prescribed.”
In response, you wrote, “So negative symptoms are either an untreatable indictment [‘primary negative symptoms of the deficit state’] or not even there at all – just an illusion or artifact of other processes. Among the many “normalizing” assertions in the report, this one stands out to me as frivolous and potentially counter-productive or even harmful – as harmful as the gloomy APA interpretation. Whether one thinks as I do that the negative symptoms are the primary problem, or have some other way of understanding them, simply whisking them away is an abandoning intervention.
I don’t read the cited passage as the BPS claiming negative symptoms are “not even there” or “whisking them away.” The statement is quite clear and explicit that difficulties commonly described as negative symptoms exist. I don’t see how it’s possible to read this section and conclude otherwise. Where this section breaks with traditional thinking is in the putative causes of such symptoms. The BPS suggests that in contrast to the presumption of illness, they can often be a product of feeling overwhelmed, helpless, and depressed; or can be adverse drug effects. Mickey, do you think your interpretation of this passage as the BPS literally denying the existence of negative symptoms is accurate, or might instead be a reaction to the BPS questioning the cause of such symptoms as not the product of an illness?
Food for thought, as usual. Thank you. I’ll need more than a morning session of reading to try and understand some more of the complexities of difficult lives in complex families and even more complicated societies. There is only little we (can?) know. So much is hidden. To be certain may feel good, but life has taught me, I hope, to live with riddles for which I only have tentative answers, except the one I got from Gaetano Benedetti: “Only with love can we understand the suffering human.”
Your Gloria made me wonder whether the mother’s assertion, always been like that, might hide darkly feared secrets, worst when involving respected male, family members, for instance a grandfather abusing his daughter, then a granddaughter, all under the wraps of respectability, as I’ve experienced here, a possibility that made Freud retract his early theory of female hysteria…
My Gloria had a baby attributed to the son of her very rich boss. She had to resign from her post as his secretary. The son’s mother first tried to lure/pressure her to have an abortion. Later the wife applied pressure to have the baby adopted to foreigners. My Gloria’s mental state gradually deteriorated, she was committed, diagnosed with schizophrenia, and has been on medication ever since, 40 plus years, impacting her negativly psychologically and physically. Once she told me that she’d been raped. I suspected the boss. The child, now a woman, is the spitting image of him. Then it transpired that both son and father could have fathered the baby. My Gloria was very feminine, pretty, deeply religious. The shadows remain, and no script catches it all. Only art, at its best, can, I think, perhaps Birdman?…
Overwhelmed by experiences, yes. Sorrow, anger, dejection, hopes of a future crashed, while still young, unprepared, few defenses ready to cope with harsh realities, sadly even more of the same can be experienced at the hands of helpers… To listen respectfully and honour the many different voices of experience may lead us to greater understanding, better practices, less suffering…?
Brett,
I take your point. I’m aware that my idea that the negative symptoms are the central issue is idiosyncratic and started to just keep my mouth shut. I’m not even fighting for the medical model. The point they were trying to make was that we should listen to these patents, talk with them not at them, take them as seriously as anyone else. I agree with that and have made the same speech myself. And they were saying that there’s a lot more to helping these patients than encouraging them to take medications. Another good point. But I just wore out with them trying to say that the single most devastating mental illness that human beings face is “normal” [what Dr. Carroll called “domesticating”]. Actually, if I “self criticize,” my use of the term negative symptoms may be idiosyncratic too in that I think the “listlessness,” “lack of motivation,” and “Anhedonia” are because of the confusion of living in a world where the abstract coloring of life is dampened, including the abstract coloring of self and the experience of others.
On a somewhat OT note, there are other conditions like autism and related disorders in which people can have problems with abstraction. Something to keep in mind.
Adam
“is this really the result of some particular dysfunction, or is their lack of response merely the result of overwhelming emotional and cognitive disruption associated with the experiences of psychosis?”
I don’t like “normalizing” the problems with abstraction, but I don’t like the APA “they are presumed to be primary negative symptoms of the deficit state” either. My reading of things is that these patients have a relative problem with the these things even when they’re not psychotic, not in the throes of being overwhelmed – “To Gloria’s literalness [living in a world without abstract meanings] and her difficulty experiencing or accessing an emotional compass, I would now add a confusion in reading and understanding the subtle but ubiquitous metacommunications in interpersonal experience.” It’s not a deficit, but it’s there nevertheless. I say “relative” because if you can engage them in being vigilant about the things they get confused about, you can help them clear things up. Something a coworker said. Something that happened to them. You can help them learn to actively try to clarify what they’re feeling. I guess I think of it as a “learning” process. I sure don’t think this “not some yet to be discovered permanent global dysfunction or deficit which is often seen as emblematic of those people in some essential permanent sense.” I have no idea why they have a hard time “intuiting” meanings, but I know that focusing on how to access feelings, or even simple things like asking people to clarify what they mean if they feel confused, can be very helpful. I guess I think they flee reality because they don’t understand its subtilties – but they can with help.
That something didn’t “feel right” in group and the later “that doesn’t feel right to me” may sound trivial, but they were breakthrough comments for her. There had been a time when a situation like that would’ve precipitated a psychosis for sure. She was accessing how she felt and using it as a compass for direction in her life rather than getting lost in a ruminating fog that lead her nowhere worth being. And this time, she knew how she felt with no help from me.
Re:”So while the contention of the British Psychological Society and Robert Whitaker’s Mad in America group that the official channels of psychiatry recommend ongoing maintenance medication as a first-line treatment is correct, it just doesn’t happen. ”
I think that in CATIE it was all cause discontinuation but nevertheless, I am not clear on your point. I think there is a big difference in telling people they need these drugs for life and hoping for the best vs. trying to understand what is most important to a person and tailoring what you do as much as possible to that person’s needs. In my experience, relapse is truly a disaster for some but not all and I have learned that I am not good a predicting so this is what I tell people. When people stop the drugs on their own, they often do it abruptly and that may be more risky. In addition, one loses the opportunity to engage and try to work together to figure out an optimal plan.
You said in an earlier post that you do not know what psychosis is. Neither do I. Your observations on this lack of abstraction may be true for some but not for all. A commenter, Nev, aptly pointed out here (and elsewhere) that there is remarkable heterogeneity among those who meet diagnostic criteria for schizophrenia. I would think that if we could accept how much we do not know and how varied these states are, we would be a better point for moving ahead.
Not a proverb test:
But I think there used to be a reasoning test which asked what you would do with a stamped envelope you found on the street. The “correct” answer is to put it in a mailbox. But most of the people I know in NYC would just “mind their own business” and leave it, and then there was the anthrax scare when people didn’t want to touch mail.
Sandy,
My point is that those APA guidelines are words on a web site. Patients don’t either read them or follow them. I’m not even sure they matter and Lieberman ought to know that. I’ve never been a medication for life person. I usually take your cautioning me not to be too medical or bio, because I’m not. And I know you don’t care for the term “Schizophrenia” and caution me to have an open mind. That’s fine with me. I kind of think it’s open already, and I don’t know if Schizophrenia is a thing or some things. But in this case, I’m put off by the straw man arguments on MIA or in this BPS Report. Just because the APA has some aging [2004] guidelines doesn’t mean “psychiatry” or “psychiatrists” think those things or even read them. Just because J. Lieberman and I have the same Board affiliation sure doesn’t mean I think his thoughts. I don’t. You don’t. My friends don’t. I’m still not sure why this particular Report got to me when I can usually turn the other cheek. But it really did. I’m not defending any position real or imagined that I know of.
Lieberman’s self righteous rant certainly got to me, but so did this Report. I’ll get back to you if I figure out exactly why it was this time. One thing I know. I feel the same kind of labeled that the patients feel if diagnosis is misused to simplify. I’m in a pretty heterogeneous group and I’d appreciate some open-mindedness myself…
I think it is galling because in rejecting the ignorance of modern organizational biopsychiatry, the BPS has chosen to embrace the knowledge deficit of sixties relativistic psychiatry and ignore everything we’ve learned since.
It’s not either-or and I would like to think we could discuss light as both a particle and a wave.
James,
Great analogy…
Thank you. BTW, speaking of that:
http://gizmodo.com/first-image-to-show-light-as-a-wave-and-a-particle-at-t-1689042556
Yet somehow we didn’t need this image to understand it as both although the confirmation is nice. We have to deal with reality of schizophrenia on reality’s terms until the future brings us a micro-fMRI or polyfactorial SNP analysis or whatever test (which will likely be completely unrelated to either of the former) that confirms paranoid schizophrenia.
I’m surprised the BPS didn’t bring up Lidz and schizophrenogenic mothers…
Thanks, Mickey. I guess we can all feel labeled (as in the “Robert Whitaker Mad In America group”). The problem of lumping vs. splitting, the (false?)appeal of categorization vs. the risk of an uncategorized chaos. What attracts me about Open Dialogue and related approaches is that at a fundamental level, they embrace uncertainty or at least they offer a framework of working that allows one to embrace uncertainty and humility, if that makes any sense.
Dr. O’Brien’s comments about light being both a wave and a particle are well put.
Sandy,
No problem there. I always described psychiatry as the medical specialty that dealt with ambiguity and skepticism. I expect a recent non-public exchange I had with someone on MIA had something to do with my spitting.
In my preferred branch, embraced uncertainty is all we have. I still think the reason for my particular reaction to that Report is in that particular Report itself, not my personality or professional identity. But I’ll try to keep an open mind about that…
Talking about these illnesses as brain diseases as though all mental phenomena are not embodied in the brain. Schizophrenia is a severe illness, but so is borderline personality disorder. Is borderline personality disorder not biologically-based. Everything is, in varying proportions, is the interaction of our genes and the environment. Everything–all of our experiences–are biological, because we are biological creatures.
It just seems like almost everyone is asking the wrong questions, and they need to define the terms better.
Dr O’Brian’s comment, and link, thank you, on light as waves and particles, is fascinating and a good analogy. I did not get the one about German Shepherds and a lap creature called Pugs. It’s not a matter of life and death if they are categorized as dogs or whatever. Being labelled as schizophrenia patients has been and still is. That is one reason the term is falling out of favour in several Asian locations – Japan is one – some are in Europe and even in the USA. Another reason is its lack of validity and reliability, and the fact that people with the same diagnosis may not share diagnostic criteria. It’s dangerous. It’s fraught with speculation, bias, dogma, vested interests.
In the words of the great Richard Feynman, quantum mechanics deals with Nature as She is – absurd. For example, the uncertainty principle of quantum mechanics means that the more closely one pins down one measurement (such as the position of a particle) the less precise another measurement pertaining to the same particle (such as its momentum) must become. From Wikipedia. So many reasons to be cautious, uncertain, openminded, and expect to find neither certainty nor The muchsoughtafter schizoprenia genes.
Ultimately everything is biologically based including love and free will which do not exist without functioning neurocircuitry. The issue is what explanation at this point in time has the greatest versimilitude (“truth-likeness”) and clinical utility. As Dr. Carolll pointed out, there call be no rational discussion of schizophrenia treatment in 2015 without a mentioning the D2 receptor or twin studies. As I have pointed out in other comments, often “psycho” and “social” are more useful than “bio” but we don’t ignore bio either. Particle and wave….
James, your points are well taken. All psychological phenomena have a biological basis, and the key issue is which level of analysis is the most valid and useful. I’m confident the authors of the BPS statement would agree with both of these points. I further suspect they would argue that a focus on things like D2 receptors and twin studies has generally not been useful in the clinical management of schizophrenia. I don’t think the BPS folks deny the bio part of the biopsychosocial model, but rather believe focusing on the psychosocial level is more likely to be clinically useful. In my area of specialization – anxiety disorders – this seems to be the case. Given lousy societal mental health outcomes in a decades-long era characterized by a focus on “bio” to the exclusion of “psychosocial,” and the promising albeit preliminary data from treatment approaches that prioritize “psychosocial” over “bio” (like Finland’s Open Dialogue), I welcome this serious discussion about alternatives to the dominant biomedical paradigm.
Don’t sociopaths also not get those old saws?
Hi
Have u read any of Parnas or Sass on disorders of self being the core deficit
Of schizophrenia? It’s very interesting
More on http://www.easenet.dk
If u can find the time to go on the course in Copenhagen
It’s fantastic. Best course on psychosis
I’ve ever been on
To answer your question about pugs and German Shepherds:
https://books.google.com/books?id=gVhgEMyIDUAC&pg=PA138&lpg=PA138&dq=operationalism+meehl&source=bl&ots=mA5ldUqjKD&sig=aH9d6pWKyDadB8U-MeCNd2u10Jw&hl=en&sa=X&ei=K2b2VK6ZEpG0oQT61IKIDw&ved=0CCQQ6AEwAQ#v=onepage&q=operationalism%20meehl&f=false
http://en.wikipedia.org/wiki/Operationalization
The authors of ‘Understanding Psychosis’ welcome debate and feedback. Sandra and Brett have helpfully clarified some of our arguments.
I’d like to make some general points which are not aimed at this specific post. Rather, I want to take the opportunity to nail some general misconceptions that have appeared in various other places, including those you have linked to. The report was written by the DCP (subdivision of the BPS) but it is important to note that over 25% of the authors were people with lived experience of ‘psychosis.’ A number of them have described their journeys through madness – which were as desperate and severe as anyone who has ever used services (see for example http://www.ted.com/speakers/eleanor_longden) So, it is not accurate to depict the report as either speaking on behalf of service user voices, or ‘domesticating’ psychosis by drawing only from a ‘mild’ end of the spectrum. I think our survivor co-authors would be insulted by those suggestions.
Secondly, this report is not, as has been claimed elsewhere, the minority viewpoint of a small group of UK clinical psychologists. The situation may be different in the US, but we are nearer to achieving a cross-professional consensus position in the UK (albeit not without dissenters.) Among the report’s strongest supporters are psychiatrist Dr Geraldine Strathdee National Clinical Director for Mental Health (‘Ground-breaking and momentous’), and Professor Sir Robin Murray from the Institute of Psychiatry, who said he wished his own profession had written it. Voluntary organisations Rethink and MIND are promoting it, and it has garnered extremely positive responses from a whole range of professionals, voluntary workers, service users and carers. The links below make my point. That doesn’t mean it is beyond criticism, of course, but it makes the picture rather more complicated than ‘This is just a group of psychologists and their self-interested views.’
Thirdly, it is very hard to see how the report can be described as Szaszian, reverting to 1960s theories and so on, when the strong message throughout is about pluralism of models and interventions, including what we might call ‘medical model’ ones. It is concerning if the very idea of offering people choices which work best for them gets re-cast as imposing controversial views from decades ago.
The most interesting part of your commentary, for me, was your honest admission: ‘I’m still not sure why this particular Report got to me when I can usually turn the other cheek. But it really did.’ Certainly the report has aroused strong reactions, some of which have very little to do with its actual content, and I do think this merits further reflection and debate. I would urge people to read the actual report at http://www.understandingpsychosis.net before coming to premature conclusions.
Daniel Freeman’s piece in the Guardian Science:
‘How far we’ve come …may be gauged by the arrival of Understanding Psychosis and Schizophrenia’
http://www.theguardian.com/science/blog/2014/nov/27/delusions-hallucinations-psychosis-schizophrenia
Clare Allan’s piece in the Guardian Society:
‘There is something of a sea change in the way we understand experiences that have traditionally been labelled as psychotic’
http://www.theguardian.com/society/2014/dec/02/psychosis-rational-talk-therapy
Jay Watts’ piece in the UK Huffington Post ‘Making Space for the Meaning in Madness’
http://www.huffingtonpost.co.uk/dr-jay-watts/understanding-psychosis-and-schizophrenia-_b_6221996.html
Long piece by Art Levine in the US Huffington Post:
‘What’s striking is how positively this radical new British Psychological Society report — certainly compared to the perspective of mainstream psychiatry in the U.S. — has been received by Britain’s health establishment’
http://www.huffingtonpost.com/art-levine/abilify-is-top-selling-us_b_6282684.html
Angela Gilchrist’s piece in the Psychologist (also on Discursive of Tunbridge Wells):
‘This is a critical moment in mental health history’, according to the National Clinical Director for Mental Health, Dr Geraldine Strathdee’. ‘Ground-breaking and momentous’
https://thepsychologist.bps.org.uk/we-need-brave-people-speak-out
Vanessa Pinfold’s piece on the McPin Foundation website:
‘I found myself nodding at the computer screen in agreement – upbeat and inspiring’
http://mcpin.org/understanding-psychosis-and-schizophrenia-new-report-from-the-british-psychology-society/
Graham Davey’s piece on ‘Psychology Today’:
‘Conceptualizing schizophrenia as an ‘illness’ …misleadingly implies that the best way of understanding psychotic symptoms is through medical and biological research, to the detriment of psychological research and psychological understanding of the individual.’
http://www.psychologytoday.com/blog/why-we-worry/201411/understanding-psychosis-and-schizophrenia
Thank you, dr O’Brien! Operationalism is a familiar concept in political science and in practical politics. Military action is spreading democracy, social democracy is what the parties’ leaders do and so on. Power always involved. I do not trust any science as wholly disinterested, objective, but individual scientists maybe, I hope…I’ve ordered the book you linked, by Millon, Krueger and Simonsen, from the library, after reading a concluding, very diplomatic remark by Millon:
“We have argued that conceptualizing scientific classification as an attempt to “carve Nature at its joints” helps the field to aspire to classify the world objectively, but also makes diagnostic literalism and reification of classifications harder to avoid.” …and then the turf wars
Lucy Johnstone is one of the authors of the BPS report Understanding Psychosis and Schizophrenia. Her comment above displays zero understanding of my judgment that the BPS report domesticates psychosis and schizophrenia. In my initial critique I stated “…The BPS dumbs down psychosis and schizophrenia to an ‘alternative adaptation’ condition, attributed without compelling evidence to childhood trauma and abuse. Hallucinations become the experience of hearing voices; delusions become the experience of unusual beliefs; paranoid thinking becomes the experience of anxiety – never mind that the great majority of patients with clinical anxiety disorders are not at all paranoid in the way that psychotic patients are. They also make much of the fact that milder forms of these “experiences” are common in the general population – as are milder forms of many clearly medical symptoms. In short, they fail to acknowledge the state transition that demarcates mild or prodromal symptoms from outright psychotic illness.
This approach is what I call domesticating psychosis. The BPS document fails adequately to convey the range of symptoms and associated behaviors in psychosis/schizophrenia. Even when these are mentioned, they are not addressed in a way that matches their clinical salience. Thus, decompensating psychotic crises are discussed unhelpfully in the framework of poor sleep habits. Acute inpatient psychiatric units are discussed in a patronizing way and are faulted as being unhelpful for some patients – never mind their rescue function. Catatonia as a common feature is not acknowledged. Psychotic terror and panic are not acknowledged. Formal thought disorder with truly crazy speech is not acknowledged. The 10% lifetime incidence of suicide among schizophrenic patients is not acknowledged. Core negative symptoms are brushed away as demoralization or as neuroleptic drug side effects…” None of these issues is addressed by Dr. Johnstone.
I called attention as well to the highly problematic language in the BPS report concerning suicide: “Some people in acute distress harm or even try to kill themselves. There is a debate within services about the best way to respond. Traditionally both self-harm and suicide attempts have been seen as ‘symptoms’ and services have used coercive measures to prevent them. Most of us agree that services need to protect people from taking their own lives when they are confused and not in their normal frame of mind. However, in most other circumstances there is acceptance of the need for ‘positive risk taking’ – people who use services have a right to take risks, make their own choices and learn from mistakes just like anyone else. Indeed taking away people’s liberty and right to make their own choices risks making them feel even more hopeless.”
Dr. Johnstone chose not to confront or even acknowledge this appalling passage, which she herself authored! Instead, her comment resorted to a transparent appeal to popularity, along with mostly irrelevant discussion of concerns about the process followed in producing the report. She studiously evaded the substantive issues. So much for the empty words about welcoming debate and feedback.
Bernard, there is a large and growing literature on the association between abuse, trauma, invasive parenting, family crisis and etc. and psychosis.
I’m not sure if it’s appropriate to put such a list here [perhaps Mickey could give me a “yay” or “nay” on that]. If you email me at adam.dickes@gmail.com I’d be happy to send what I consider to be convincing evidence of this association, which is more reasonably explained in developmental or psychosocial terms than in genetic or biological ones.
The DCP statement shares much with the earlier DCP critique of DSM 5, both are critical of making pseudo-biological categorical diagnoses based on behavioural symptoms alone. Inevitably, this leads to a stigmatising essentialism that is counter to psychological and social well being of our clients.
Rather than ‘domesticating psychosis’ the paper uses the points above to argue that psychosis is best seen as a (often dysfunctional and problematic) response to environmental stressors, rather than an innate biological disease. Suxh a model reduces the stigma and sense of permanence which has become entrenched by psychiatry over the past 50 years.
I’m interested that you chose the word ‘domesticating’ to disparagingly refer to the DCP paper. ‘Domestication’ of serious mental illness was first attempted (and disparaged) in the late 18th century, when the Quakers in Britain turned towards humane treatments and away from Bedlamite humiliation meted out to them at the time.
I would also add that the notion that rather than taking over control for everyone who has thoughts of self harm but rather helping people to understand those thoughts and feelings, learn ways to manage them, and in fact come to an understanding that ultimately that it is within the realm of personal choice has been embedded implicitly and explicitly in my psychiatric training since I was in medical school. As noted in the quote above, there are times when we do take control and these kinds of decision are complex and fraught. But there are many other times when the work has much more to do with helping people understand that we in fact can not ultimately protect them, that they do have a part of themselves that wants to live, that we can help make their own ambivalence explicit so that they are able to feel more in control. I am trying to keep this brief but I think this is embedded in well respected approaches such as DBT but more to the point, it is has been part of clinical practice for a long time.
http://psychcentral.com/news/2006/06/13/child-abuse-can-cause-schizophrenia/18.html
The problem with such as study is obvious to anyone who understands the difference between prospective and retrospective analysis of historical causation.
It should surprise no one that a psychotic patient would recall more trauma in their past than normals. First of all, they are psychotic, secondly, they are suggestible. The work of Loftus and others has shown that suggestion is highly influential in memory recall. So if you have an examiner who wants to prove a trauma link the subject will pick up on that and you have a negative Hawthorne effect.
To study this correctly you need to start with a database of thousands of kids who have been traumatized (police, DCS records), follow them into adulthood and see what happens, correcting for factors such as drug abuse and family history of schizophrenia.
http://schizophreniabulletin.oxfordjournals.org/content/34/3/568.abstract?ijkey=40209d8b050c4b739a838df77a4b875e4a8f15d4&keytype2=tf_ipsecsha
There’s a lot of bad research out there
To Adam Dickes: Your comments about trauma and psychosis are unnecessary – we already went around that tree with Brett Deacon here. George Dawkins also has some cogent observations on this and related aspects of the BPS report.
In your second and third paragraphs you repeat the destructive theme of the BPS report – attaching moral judgments to scientific positions. Can we not please have a discussion of essentialism, say, without injecting moralistic slogans about stigma and patient harm? There is no necessary link between making a diagnosis and stigma. When we manage a patient in the biopsychosocial model we aim to cover all the bases.
And please do not give us yet another tired refrain about DSM “making pseudo-biological categorical diagnoses based on symptoms alone.” DSM is explicitly atheoretical – to a fault, as some of us think. It would be nice to move finally beyond the straw man posturing.
To Sandra Steingard: what you say is unexceptionable standard practice, but it is not what the BPS document said. It does not reflect the permissive and laissez-faire tone of the BPS document on suicide risk. See my earlier comment.
In some of these retrospective studies, I’d like to see the examiners ask some other questions like have you ever been visited by a monster as a child…but instead of making the conclusion that sensible people would make they would argue that more research needs to expose these monsters and that looking under the bed and in the closet every night could save your child from schizophrenia.
We’ve been down this road with recovered memories in the eighties…
The only thing missing are anatomically correct puppets..
As others have pointed out “psychosis” is overly broad and kills any point to this research out of the gate. It only makes sense that someone suffering from amphetamine psychosis or any long term drug related psychotic syndrome probably was more likely to have a screwed up childhood and possibly parents who were addicts or mentally ill.
You could completely eliminate pharm from psychological and psychiatric research departments today and most of their product would still be a waste of time and money. Bad methodology is a bigger curse than pharma.
Bernard, to your second paragraph, research reliably shows that biomedical causal explanations of psychological problems and labeling them as illnesses worsen important aspects of public stigma for certain problems (e.g., perceptions of danger and desire for social distance related to schizophrenia) in a manner consistent with essentialist theory (http://www.ncbi.nlm.nih.gov/pubmed/21859181). A rapidly growing body of literature (reviewed here: http://onlinelibrary.wiley.com/doi/10.1111/cpsp.12056/abstract) is showing that biomedical explanations cause symptomatic individuals to have more prognostic pessimism, less agency, and to perceive medication as more credible and effective than psychotherapy (even in contexts where it is not). I’m not sure I would agree with Adam that stigma is exacerbated by diagnosis per se as much as it is by biomedical explanations that often accompany it, nor would I suggest that stigmatizing essentialism is “inevitable.” But I think it’s hard to argue with the claim that in real-world practice biological explanations typically accompany diagnostic labels (arguably implicitly but often explicitly), and that the literature reliably suggests the outcome of this process does not reduce stigma and likely worsens it in some contexts.
What I find truly disturbing is that this body of research is simply ignored by high-profile entities and individuals – including the usual suspects Mickey discusses in his blog – who claim to care about reducing stigma. Although you chide Adam for “attaching moral judgments to scientific positions,” I see this as a transparently moral issue. The status quo is for biomedical explanations to be provided to psychiatric patients, and to be disseminated to society by NAMI/NIMH/the APA/etc., and there is good reason to believe this practice is actually doing more harm than good on critically important outcomes. Again, I’m speaking more about biomedical causal explanations than diagnosis per se, but in the standard practice of psychiatry (as opposed to your respectable but unfortunately rare biopsychosocial model) these two have long since merged. I also think it unwise to ignore the lived experience of so many people who report being harmed in predictable yet tragic ways by the effects of receiving a diagnostic label couched in biomedical terms. I give the BPS credit for acknowledging the existence of such people and consulting them in their statement, as opposed to dismissing them as crazy, dangerous, and unworthy of a moment’s consideration.
Illnesses and diseases are not the same thing. Illness incorporates and acknowledges psychosocial influences. I don’t think any of the BPS critics have used the term disease.
You’re falling into the trap that light can’t be a wave because it is a particle.
By the way, you’re “pessimism” argument assumes a process is more reversible if it is traumatically induced than biologically based. If you compare TCAs for melancholia or lithium for bipolar vs. psychotherapy for trauma related severe personality disorders, you will notice that is not the case.
Brett:
Re:I give the BPS credit for acknowledging the existence of such people and consulting them in their statement, as opposed to dismissing them as crazy, dangerous, and unworthy of a moment’s consideration.
There is another way this group is dismissed and that is to say that because they now appear to be recovered, that they were never as symptomatic as they say they were. They are not the ones who were ever “truly ill”.
It always helps to maintain a focus in a discussion. This conversation, however, is getting to feel like a game of Whack-a-Mole. As soon as one of our interlocutors’ gambits fails they change the subject, as Sandra and Brett did here: “Brett: Re:I give the BPS credit for acknowledging the existence of such people and consulting them in their statement, as opposed to dismissing them as crazy, dangerous, and unworthy of a moment’s consideration.
There is another way this group is dismissed and that is to say that because they now appear to be recovered, that they were never as symptomatic as they say they were. They are not the ones who were ever “truly ill.”” None of us said or believes in such a caricature, so why continue to drag up these prepackaged BPS/MIA talking points?
Notice that nobody has stepped up to the plate to address the substantive critiques I presented. Nobody has defended the appalling section about suicide risk in the BPS report.
James, I said that research suggests labeling psychological problems as illnesses worsens aspects of stigma and related phenomena. I didn’t say illness and disease are the same thing; their distinction is interesting but tangential to my observation about research findings. My comments about prognostic pessimism are not an “argument” but an observation – research reliably shows that biomedical causal explanations of psychological problems engender prognostic pessimism. You could argue that this should not be the case because of the issues you raised, but as they say, the data are the data.
Bernard, people who comment here are under no obligation to maintain a focus on the issues you wish to discuss. What you describe as my “changing the subject” was me directly respond to your most recent post. I critiqued your comments about dismissing “moralistic slogans about stigma and harm” in light of literature indicating this is a topic to be taken seriously. I noticed you ignored the substance of my comments in your response above, which given the context is ironic.
I wrote, “I give the BPS credit for acknowledging the existence of such people and consulting them in their statement, as opposed to dismissing them as crazy, dangerous, and unworthy of a moment’s consideration.” This is not a caricature; as you know, Jeffrey Lieberman repeatedly does just that.