1 Boring Old Man

It seems my previous comment was not my last one as I thought it was going to be. Maybe this will be my last or maybe I will keep making comments until you cut me off. Certainly my distress has increased with the recent post you have made about the BPS report, so it is difficult for me to know whether or not you will consider my writing to be civil enough any more.

Many of the contributors of the BPS report went through ‘the stark reality of psychosis’ so it feels unbelievable to me that you would suggest that they are either romanticizing or trivializing psychosis.They are emphasizing the things that they believed helped them return from the disintegration of their lives. I feel that when you call the report ‘reductionist’ ,’too sixties’, ‘too poliltically correct’ this is similar to the type of ‘dismissiveness’ that has so angered people when they try to point out alternatives to the current treatment of psychosis.

In a previous comment I talked about how important I though clinical experience was and I think that is something you agree with. However very few professionals have in depth experience following people with severe psychosis on a daily basis for years and years -fewer yet knew the patients were prior to their disintegration.

Bernard Carroll- who you link to in this post – has described psychosis as not being his area of expertise. Many people who do have intensive and long term experience with people in psychosis have spoken very favorably about the report. Indeed there is a psychiatrist who posts here -Dr. Sandra Steingard -who has a wealth of experience, integrity and commitment in the area of psychosis and always seems to make very balanced posts and comments. I would really value her thoughts on this report. The fact that Bernard Carroll has responded to her comments in the past, in what I consider to be a rude and dismissive way, really does make me wonder about how open he is to really trying to understand the criticisms of the current treatment of psychosis that make reports such as the BPS report, invaluable..

I am someone who has had daily experience for years and my N=1 has not been spared any of the devastating symptoms described by Bernard Carroll in his post. I too wished that there was more information in the BPS report about negative symptoms, catatonia and thought disorder I think these areas have yet to be figured out in an in depth way, in the way that ‘hearing voices’ has been studied and figured out thanks to the leaders in the hearing voices movement; and that is why those areas are missing from the report., We were never given any helpful information about how to support and help people with thought disorder, etc. from `conventional literature and treatment’ either.. The comments we received from conventional treatment about these symptoms were similar to the `lack of hope’ narrative that has permeated mainstream psychiatry (e.g. people with ….have the worst prognosis etc, etc.) Where we found some answers and helpful information was from the stories of those who have worked intensively and long term with people with psychosis and from recovery stories.

I have seen first hand the progression of someone from a devastating state of psychosis go through steps of recovery. I have watched a person who had not responded to any of my comments for months give a ‘slight nod’ after I showed him the ‘Stuart and his Voices’ video (narrated by Eleonar Langdon and Rufus May), when I asked if I should play it again. I know and understand on a deep level how relationship (and time, and other things without antipsychotic medication) can lead to reconnection and to the slow releasing of the grip of psychosis. I know I am only an N=1 but my intensive study of my n=1 has likely led to much more knowledge than from someone who works with a client much less regularly. Yet I do not feel my voice about this issue is given much value – I dont feel that most psychiatrists are `itching’ to hear this information so they could figure out all the variants which would give them the deepest understanding of psychosis. No, as Bernard Carroll says in his blog, psychiatry already knows all this. He says ” All of the recommendations made in the BPS document for improvement of psychological and social services are admirable but none are really new – they all fall within the traditional biopsychosocial model of psychiatry”.

Really? Why did I find the BPS report so helpful when we had already had so much contact with the experts in conventional psychiatry. Do people really think that the research of Marius Romme and recovery stories like Eleonor Langdon etc, were not insturmental in changing how people now think about the symptom of hearing voices? I wait for other recovery stories and holistic therapists to help us understand other symptoms in a deeper way.

When psychiatrists make disparaging remarks about ‘alternative’ therapists thinking ‘all you need is love’, this shows me that those psychiatrists do not understand what people who work intensively with people with psychosis are trying to say – how crucial both ‘hope’ and ‘relationship’ are in terms of bringing someone back from disintegration.. (not to mention reduction of fear, TIME, sleep , exericise, good nutrition etc. ) .

When you say “And while we can all be excited with the cases that recover, there are many who have a very different trajectory.” , I think the important question there is why do people have different trajectories, and whether some of these trajectories could be improved if all those who work in the field of psychosis could really listen to each other respectfully.,

What’s really confusing about the landscape right now is that sometimes the obsessive focus on brain science is also infected by political correctness and admonitions to “be nice” — they aren’t always at opposite poles of the spectrum, as they are in the BPS / Brain Science pissing contest.

I did a DV presentation this week where I also had an opportunity to attend a presentation on Trauma-Informed Interviewing by a very experienced clinician who I respect very much who works for a very well known community mental health resource that has done outstanding work. However, I was somewhat disheartened by how many times she said, “now we know from the latest neurobiology” and repeated some fairly basic, generic stuff about the amygdala’s role in memory or oxytocin.

There was a lot of nicey-nice, too– be empathic, be kind, be respectful– that, as you say, has really been part of good practice for decades. And it also seemed oversimplified in a way that could even be dangerous– some trauma survivors may also turn out to be violent (depending on the population you’re working with) and I’m not sure it’s a good idea to teach the empathy piece without also dealing with possible containment and physical safety issues.

One of many reasons I liked Dr. Carrol’s post was the focus on negative symptoms. I was always taught to ask “which hand holds the knife?” and he really speaks to that issue with respect to schizophrenia.

Hi Sally,
I have found your posts so cogent. I have little more to add to what you have said. I do not think I romanticize psychosis – if I ever tend that way, I can guarantee that when I go to work, I will encounter some person, some intractable situation, some heartbroken family member who will get me back on track.
But I continue to fail to understand why this is an either/or discussion. I find it mind-boggling that empathy is discounted as a therapeutic tool. I find it astonishing why we would not wonder about the experiences of those who were failed by the traditional system of care and then dramatically helped by so-called alternative approaches.I find it surprising (and this draws from the next post) why a call to consider the societal contributions to/needs of the incarcerated mentally ill, would be considered radical or anti-psychiatry. If you read or listen to Eleanor Longden, it is hard to conclude that she did not suffer for years.
I just read an interesting book by Y O Alanen, “Schizophrenia, Its Origins and Needs-Adapted Treatment”. Dr. Alanen and colleagues developed Needs-Adapted Treatment whihc is the forerunner of Open Dialogue. It was developed to help the people in his region who were institutionalized and diagnoses with schizophrenia. It is hard to summarize but it starts with the premise that while there may be something of value in many of the theoretical constructs offered to explain psychosis (biological, psychoanalytic, family systems) none were “true” in an absolute sense of but all seemed to offer some helpful perspectives for some people. NAT was an approach which held all of the theories lightly and approached people in an open flexible way. Along the way, they found that bringing families in early was not only helpful but seemed to attenuate the psychosis in a good number of people. Medications were not abhorred but they held off and considered them tools rather than cures.
http://www.alibris.com/Schizophrenia-Its-Origins-and-Need-Adapted-Treatment-Yrjo-Alanen/book/5918187

Do we have enough straw men for a bonfire yet?

Sandra, thank you for the link to Alanen’s book (also available electronically from Amazon in the middle of the price range quoted on Alibris, in case you are like me and insist on carrying around your entire reference library every time you go out for coffee.)

This passage from chapter one seemed very much on point with respect to this post and the post that follows it:

“The premises of researchers considering the origin of schizophrenia continue to be highly contradictory. They are often also extremely one-sided; the relatively narrow field of study adopted in one’s own work is regarded as the only correct approach, and one’s view is restricted by blinkers that prevent one from effectively shield one from seeing any other field. The polarization of clinical practice may have diminished somewhat during the past few years. But it continues to exist and notably hamper the development of the treatment of our patients.”

I think it is THAT– that polarization, the one-sidedness, the blinders– or reducing ideas to buzzwords, easily-digestible ideas and catch-phrases– that may be what bothers Dr. Nardo about the BPS report, or one of the things, anyway. The superficially sensitive and culturally inclusive tone that disguises an often snide and abrupt dismissal of earlier theoretical frameworks.

I feel it tempting me even as I write this.

Like Sally, I find the reactions to the BPS report quite bewildering – not in the sense that it is beyond criticism but in that most of the criticism seems to be, as Dr Nardo himself admits, so emotionally charged – and as a result, often demonstrably inaccurate.

I will focus on only one point here: the accusation that the report ‘trivialises’ what is sometimes called ‘psychosis.’ Here is a selection of actual quotes from the document:

‘It’s like the whole top of your head comes off…and by that point I was completely lost because….I really believed I was going to hell. I thought I was dying.’
‘I began to think that… my blood had been poisoned by evil spirits and that I was evil and that there were spirits around me, warping my thoughts and changing my thoughts, and that was very frightening…..’
‘I believed that I was in danger of losing my ability to think freely and spontaneously, that I would become an automaton as I reached adulthood…I was in a high state of vigilance, fear and tension.’
‘I still experience paranoia. It’s the worst feeling I’ve ever felt, and it comes on during the middle of the day and lasts until I go to sleep at night…I would do anything to stop these feelings.’
‘I was constantly bombarded by terrifying voices. …one claimed he was the devil, another threw lewd insults at me…and told me he could kill anyone he wanted if I didn’t do what he said..’
‘I was regularly being sectioned by the local police force for attempting to jump from motorway bridges and in front of oncoming intercity trains.’
‘When (paranoid thoughts) are happening I go completely crazy and have even hit myself to make the thoughts go away. Sometimes I feel that I am losing my mind completely.’
‘One day… considering myself Christ-like I laid out all my possessions by the west door of a church…more recently I believed myself the cause and focus of an impending collision between the earth and the setting sun and was found mute and unmoving in the shade of a garden hedge.’

‘Trivialising’, ‘domesticating’ and ‘romanticising’ the experiences we call ‘psychosis’? I hardly think so. Please can we drop these absurd charges and have a more sensible debate about the important issues raised by the report?

As Marx–the British museum keeper, of course–said, man’s consicousness is determined by his relationship to the means of production. I think this fits here: How we tend to see “psychosis” is much determined by how it is manifested in our specific practices.
My own opinion of how to treat “psychosis” very much reflects the many referrals I now get due to my being known for doing very comprehensive evaluations of patients who themselves or their families come to me with a history full of complaints that the patients were not listened to by previous doctors, who did little else but increase or add medications with each patient contact.
Thus it has been my experience to see many individuals labled as psychotic, but who on careful evaluation are better seen as over diagnosed and over medicated. Their stories more often than not additionally involve the failure of previous psychiatists to take into account traumatic histories. The end result often has been to find that careful tapering trials of meds and working in the relationship with the patient–and often with their families–leads to the patient’s doing much better on little or no psychotropics.
So when we are talking about treating “psychosis,” it perhaps would be best to consider that we often might be talking about an “alleged psychosis.”

Here’s a quote from page one: “psychosis can be understood and treated in the same way as other psychological problems such as anxiety or shyness.”

In my opinion, yes, that statement does trivialize the experience of psychosis. Very unfortunate that the authors framed their position this way, because there’s a lot to like in the report.

I see the report as a missed opportunity.

To Another Contributor (who won’t tell us who s/he is): The BPS report’s discussion of suicide is the clearest instance of domestication, trivializing and romanticizing, as I discussed earlier on this blog. Nowhere does the report even acknowledge that 10% of patients diagnosed with schizophrenia die by suicide.

To Ed,
I appreciate hearing of your experiences but I wonder why we would call this “alleged psychosis”. I may be misunderstanding you but this seems like a circular kind of argument. I seems as if you are saying that if an experience that appears to be psychotic can be ameliorated by listening to and understand the person’s story, then it is “alleged psychosis.”
This, I think, is one of the problems. I have met a number of people who have recovered from severe psychosis who are often told by psychiatrists something, “You weren’t really psychotic.”
To me it seems to make more sense to say that we do not fully understand all of the antecedents to psychosis and therefore it is hard to know what interventions will be of most help. For some, it may require use of drugs, for others it may require a careful understanding of their story, for some both may be needed along with other interventions. So why not start with a careful understanding of the story (while simultaneously addressing safety concerns!), and go from there? This is the essence, I think, of needs adapted treatment. (and I am sorry if I misunderstood your point).
To Catalyzt,
What I just wrote is why I do not see the problem in the statement you quote above about psychosis being understood in the same way as other psychological problems. For some people I see, psychosis appears to be an extreme form of anxiety. This does not rule out the use of neuroleptic drugs, but at least in my experience, acknowledging that anxiety and its antecedents, appears to be helpful for some. I do not think this closes any doors for treatment options but I have found it helps for a person to feel that you are aligned with his plight. As I said before, this does not need to be framed as either/or. But connecting to a person who is experiencing psychosis is so challenging. Emphasizing ways to connect is so important. I think we can all agree that there is much to be said about trying as hard as can we can to avoid ending up at an impasse where forced treatment appears to be the only option.

I appreciated hearing Catalyst’s specific example of why he or she feels that the BPS report trivializes psychosis. It was eye opening for me to realize that that comment could be seen in that way, but now reading that comment again I can see how the comment doesn’t express the ‘extremeness’ of psychosis. For myself, however, that same comment was one of the comments that gave me such hope. The comment reminds me of Eleanor Longden’s story and how essential she felt it was to her recovery to realize that her ‘voices’ or ‘hallucinations’ were not completely ‘meaningless’ and divorced from being a ‘psychological’ problem but rather could be traced back eventually to experiences in her life. So now I find myself wondering is there a ‘rewrite’ of this portion of the report which could express both the `extremeness’ of psychosis as well as the ‘distorted meaningfulness’ of psychosis that would satisfy people on both sides of this issue? (This reminds me of Dr. Steingard’s position of “both/and’ rather than “either/or”) .
In my story, there was a long period of time where issues of ‘safety’ and ‘containment’ were paramount, and if we had not already been extremely vigilant about safety and containment, then certainly reading in a report that `10% of people dx with schizophrenia die by suicide’ would have helped to make us so. But even during that time our beloved psychiatrist, (yes, we have one), helped us realize that there was a ‘person’ inside the psychosis and that ‘being with’ that person during that chaotic time, or ‘terror state’ and persistently trying to forge a relationship, was an essential ingredient to ‘bringing him back’. What helped me believe in the power of this type of approach for our situation, was thinking that if ‘fear’, ‘intense anxiety’ etc. can produce psychosis in susceptible persons, (certainly people accept that this happens for ptsd) , then why couldn’t things that make people feel ‘safe’ (like ‘relationship’ and ‘hope’ ) work to calm the nervous system, or reduce the ‘inflammation’ or whatever the heck is going on. Our psychiatrist believes in the ‘essential meaningfulness’ of my loved one’s experience and seeks to understand his underlying distress, without letting us get sidetracked by ‘the smoke and mirrors’ nature of some of his behaviours and responses.

Sally,
One of my early teachers and later colleagues had done a stint at the NIMH on a unit where acutely psychotic patients were treated without medications. They noted that the patients who wanted to explore the meanings of their psychotic experiences were more likely to have a robust recovery than people who wanted to “cover it over” and “put it behind them.” That was certainly true in my subsequent experience. Often those meanings came some time later. As I recall, Eleanor Langdon also dates her recovery from that suggestion being offered.

Thanks to all for such a nuanced, thoughtful discussion. Yes, I do wish there was a way to capture the “extremeness” of psychosis as well as the importance of connecting with the symbolic meaning of someone’s psychotic symptoms with warmth and familiarity.

I guess I was just thinking that a first year intern might treat anxiety or shyness successfully, but probably not psychosis, and perhaps I am imposing my own bias based on admittedly very little experience.

I treated my first client with really florid psychotic symptoms after about three years and 2,500 hours, and I was very, very closely supervised.

My client’s hallucinations had at least five separate layers. The first was actually someone talking within earshot, the second was a language barrier, which made it easier for the client to mistranslate the words that he/she heard, the third was severe complex trauma that twisted the mistranslation into a recapitulation of horrific events, and I believed the fourth– though it was beyond my scope and I could never prove it– was an environmental toxic exposure that added paranoia which had a signature remarkably similar to crystal meth.

We used everything from very exotic psychodynamic interventions to really basic behavioral ones. Transference and noise-cancelling headphones. We didn’t try to kill off the hallucinations so much as capture them– corner them someplace they couldn’t do any damage.

I guess that’s the “not either or” part– depathologizing a symptom at the same time you’re respecting how serious it is.

Another tricky bit is the reality testing. That I needed a lot of help with– from two different supervisors and the staff psychiatrist– how you explore someone’s experience in a genuine way without colluding with it.

To Sandra:
Thank you for you comment, and you are entirely right. Instead of “alledged psychosis” I should have said, “alleged schizophrenia [or bipolar or schizoaffective or another such Dx]. I choose to declare these and many other Dx’s that have come my way with patients as “alleged” perhaps because I was too inhibited to simply say that many of the patients had been sadly wrongly diagnosed.
It has also been my experience that some of the patients I have seen have been psychotic, but not in the hopeless and fixed way so many of our colleagues understand psychosis to be. I once had a patient who could be in and out of a psychotic reaction–well, maybe a powerful dissociative reaction which looked compelling psychotic–at least twice in one hour. Being with her without my getting too anxious and reaching for a prescription pad was what seemed most helpful.

Thank you all for the comments. It is so valuable to hear of your work and experiences. I appreciate that we have tried to hear each other out.
In terms of the diagnostic labels, what Courtenay Harding and so many others would say is that this notion of hopelessness that we have decided is intrinsic to the “schizophrenia” label is our construct. The long term outcomes in her study and others were much better than what so many us are taught. But then one someone gets better, we say, the diagnosis was wrong.
The more fundamental issue is the entire diagnosis is a construct. Now, this is not to minimize the impact or complexity of psychosis! It is just to say that we are not good at applying diagnostic labels that tell as much about outcome as we think they do. I am not sure we are as good as we think we are at distinguishing between what many of us would consider a dissociative reaction and what we would call psychosis. I am not sure that we can’t see both of these things (whatever they are) in one individual. Given that and given that is seems extremely likely that what we tell people about their outcome has an influence on what the outcome will be, let’s err on the side of hope.
I am beginning to have experiences when getting in with someone and the family early and having these kinds of open conversations seems to create a shift in a helpful way from a concretized delusion to a more metaphorical way of thinking. And this is not about blaming families! It is just about trying to understand the person’s perspective and being open to trying to make sense of it in the context of the person’s life. It is about having a deep concern about considering the impact of drugs – both prescribed and not prescribed – that might have triggered the problem (let’s stop a drug before adding a new label and a new drug).
Of course, in any given person, I have no idea what would have happened with a different approach but I know how the system would most likely have responded – offering medications, not taking the time to try to understand the person’s perspective, educating the parents about the illness model, and, if the person declined – which happens often, walking away and telling the family they can call if he becomes a danger to himself or others(this has some relevance to the next post).
Catalyzt gives some clue to why this kind of approach was largely abandoned. It takes time. If it is true that over the long run a good number of people will have better outcomes, the savings are potentially huge.

Thanks for these constructive contributions, Sandra, Sally, Ed and Catalyzt. This is the kind of debate the BPS report can contribute to, if we can avoid lapsing into misrepresentation and defensiveness.

I am uncomfortable with the situation in which service users who have survived and documented the worst excesses of ‘psychosis’, and who have contributed to and endorsed the BPS report (Eleanor Longden, Rufus May, Rai Waddingham, Jacqui Dillon etc) are repeatedly being told by a group of high-prestige, professional men (Coyne, Pierre, Nardo, Carroll) with (as far as I know) no personal experience of psychosis, that they are WRONG; that the report does NOT represent their lived experience.

Some reflection and humility required here, gentlemen?

i don’t question their experience. I wish it were universal, but, unfortunately, it isn’t…

Another Contributor (who still won’t tell us who s/he is) must be a troll planted by the British Psychological Society. Her last comment just adds to the growing pile of straw man arguments in this thread. Dr. Mickey’s response to her is on target: it is unwise to generalize from an Eleanor Longden. The BPS folks want to have it both ways – they decry the low reliability of diagnoses on the one hand, then they insist that EL’s initial diagnosis must not be revised in light of her course, because that would upset their narrative.

Bernard Carroll
I am honestly curious. Do you mind listing what the straw man arguments are that you are referring to? You often use that term and I find I really do not understand what you mean by that. Also wouldn’t calling someone a ‘troll’ planted by the BPS be considered a ‘straw man’ argument?

The other thing I am curious about is what makes you think EL’s intial dx hadn’t changed? It sounded like during the year and a half that she was at home she was full of negative symptoms. Her sister described her as being truly [‘gone’. Is it because she recovered that you would say she no longer has the dx of sz or is it for other reasons?

I wonder if Bernard recognises the irony of trying to dismiss an opposing discussant as a troll because they’ve chosen a pseudonym, when the blog author has done exactly the same. Who is 1boringoldman?

And Another contributor is absolutely right: the Understanding Psychosis report was co-written by people with extensive experience not just of psychosis or schizophrenia, but of working with, listening to, and helping many many others. In my view they’re not just experts by experience; they’re experts (with experience). Critics dismissing those authors’ collective, substantial contribution to the report by singling out one or other individual as unrepresentative is a pretty shocking, shallow, and completely telling sign of their times.

I agree with Sandra above: “given that it seems extremely likely that what we tell people about their outcome has an influence on what the outcome will be, let’s err on the side of hope”.

Rory Byrne,

“Who is 1boringoldman?” Mickey Nardo, retired psychiatrist and psychoanalyst. Most readers know that. I certainly don’t make any attempt to hide it. The blog title came from my daughter when I first started blogging – her editorial when she set up the blog for me.

As to the BPS Report. I’ve sort of stopped responding to comments myself because they focus on anything I say as evidence of my being some insensitive psychiatrist who holds people back and snows them with medication. I’m not that. The complaint about the BPS report is not about Eleanor Langdon. I teared up the first time I saw that Ted Talk. Likewise, the cases of psychotic illness I followed in my practice were treated much in the same way as the BPS Report suggests, though my attitude about medications changed over time because of frequent relapses.

But I don’t think the responders want to know what my objections really are, and would prefer to keep me in the bad guy role. I’m not interested in being defensive. If my writings about this aren’t clear, ask me a question. If you prefer to see me as some doom-sayer, that’s your call…

Rory Byrne wanders angrily from comment thread to comment thread with a lot of emotion, but an inability to sustain an argument. I had to block him at my blog after he and one of his coauthors extensively spammed it. Here we go again.

^ ‘Quoth the pot…’ It’s an odd thing to read a blatant lie about yourself. Odder when it’s from a senior professor, but fascinating. I’ve never posted on a blog James has written.

Thanks Mickey, I think the point is still fair; criticising one discussant in particular for using a pseudonym is a deflection.

I don’t see anything above focusing on you as an insensitive psychiatrist, or at all. I do see a succession of direct responses to your and other critics’ arguments being ignored or dismissed as ‘straw men’.

Your criticisms suggest the report trivialises psychosis by describing it as similar to anxiety or depression. Biomedical science supports the report: there is no strong biomedical evidence for any of them being distinct psychological illnesses. The most reliable genetic evidence points to non-specific risk factors; much stronger evidence points to a wide range of psychosocial influences which can each contribute in as-yet unclear combinations to depression, anxiety, and psychosis.

Your criticisms suggest the report is most flawed where it neglects discussion of the most troubled people. I don’t agree; I think the report touches on the most serious issues in appropriate ways given it’s broad intended readership. I don’t remember reading anything in it that would dissuade someone from seeking more info about specific serious or long-term difficulties if they needed it, but much that aptly reflects the broad diversity of experience among people who experience psychosis or are given schizophrenia diagnoses. “Many people with schizophrenia now never have to go into hospital and are able to settle down, work and have lasting relationships. For every 5 people with schizophrenia: 1 will get better within five years of their first obvious symptoms; 3 will get better, but will have times when they get worse again; 1 will have troublesome symptoms for long periods of time.” (Royal College of Psychiatrists http://www.rcpsych.ac.uk/healthadvice/problemsdisorders/schizophrenia.aspx ).

I don’t think the report trivialises or romanticises psychosis or schizophrenia, I think it does a good job of humanising them.

To Sally: a straw man argument is raised when one interlocutor refutes a position that the other never did espouse. I won’t try to be exhaustive here but a good example on this thread is from Sandra Steingard: “I find it mind-boggling that empathy is discounted as a therapeutic tool. I find it astonishing why we would not wonder about the experiences of those who were failed by the traditional system of care and then dramatically helped by so-called alternative approaches. I find it surprising… why a call to consider the societal contributions to/needs of the incarcerated mentally ill, would be considered radical or anti-psychiatry.” Those don’t sound like Dr. Mickey’s positions and they surely are not mine. Another example is from you: “When psychiatrists make disparaging remarks about ‘alternative’ therapists thinking ‘all you need is love’, this shows me that those psychiatrists do not understand what people who work intensively with people with psychosis are trying to say – how crucial both ‘hope’ and ‘relationship’ are in terms of bringing someone back from disintegration.” Did I ever say that? Did Dr. Mickey ever say that?

A third straw-man example is from the BPS troll: “I am uncomfortable with the situation in which service users who have survived and documented the worst excesses of ‘psychosis’, and who have contributed to and endorsed the BPS report (Eleanor Longden, Rufus May, Rai Waddingham, Jacqui Dillon etc) are repeatedly being told by a group of high-prestige, professional men (Coyne, Pierre, Nardo, Carroll) with (as far as I know) no personal experience of psychosis, that they are WRONG; that the report does NOT represent their lived experience.” None of us said they are WRONG and none of us denied their lived experience. But we do warn against over-generalizing from these fortunate cases.

My reference to the BPS troll would not qualify as a straw man argument. It is very likely that this troll is one of the authors of the BPS report, in fact, and I have a sense of who she is. She should come out of hiding and identify herself. To not do so would signal a lack of professional candor and would further taint the BPS effort. The giveaway is the style and the content of her comments. She is obviously intimately familiar with the “service user” contributions to the BPS report and her comments echo assertions you can find on other blogs in closely similar language.

Rory, just a quick reply. I’m in the middle of something and when things calm down, I’ll give a more complete response. But for now, we’ve been here before.In the late 1960s, this same kind of rhetoric was in vogue. Some from psychiatrists, more from other mental health people, most from administrators and hospital administrators. The lectures and articles were upbeat. Szasz was prominently mentioned. But there was a tragedy afoot. As services were cut, the patients that needed protective hospitalization lobbied to get in the front door and were quickly ushered out the back door. Social services that worked were overwhelmed and the dedicated people that worked in them burned out and ultimately bailed out. Any system that was put in place to help went through that same process. Community outreach people with a reasonable case load suddenly found themselves with a telephone book full of people they had no time to call, much less visit. And worst of all, the cops and judges got fed up and started sending people to jails and prison – people who had been “manageable” before. It was sad to watch and that’s all we could do. As a Training Director, I had to pull residents from various places because they wouldn’t participate, and, to be honest, I didn’t want them to. Of course hope springs eternal for the patients we see. But some of us have lived through a time when this very Mantra had a very dark side. The rosy rhetoric never changed, but the plight of our patients definitely did – many became a new brand of homeless or inmates. Maybe things are different in the UK. We tend to do chaotic systems on this side of the pond more than in the Social Democracies. I’ll give you another shot at this when my time frees up. For the moment, I’d appreciate your holding it for a later time. We get your point…

Bernard Carroll
Thank you for clarifying this for me. I actually wasn’t directing that remark at either of you (that is why I said ‘psychiatrists’ rather than using your names like I did when I was directing remarks at you) However I can see how that could be confusing so I will be more careful about proper referencing of my comments in the future. . (They are comments that I have heard made by psychiatrists when discussing ‘alternative’ treatments.)

Do you mind answering my other question? I was wondering why you thought EL dx had changed from being sz? Is it because she had such a robust recovery or was it for other reasons?

Sally, I don’t have an opinion about EL’s diagnosis and I don’t believe in making long distance diagnoses on a person I have never met. My earlier point about her reflected the well-known unreliability and the consequent instability of initial diagnoses. A good clinical rule of thumb is that diagnoses become clearer with the passage of time – and that is true across the board in clinical medicine. It is also the case that many conditions have a list of differential diagnoses or look-alike conditions with a great deal of superficial overlap. Psychotic disorders are in that category. So, when the course of a psychotic illness proves to be unexpected or atypical it is appropriate to question the initial diagnosis. In the case of EL and the others, any suggestion for diagnostic revision is met with great resistance by the BPS folks – their narrative has by now become almost hagiographic, and any questioning is viewed like blasphemy. Those are not the values of clinical science.

Mickey, if it’s all the same I’ll reply now. I appreciate you’re busy, but you could have responded to my comment in the time it took to write your reply. Interestingly, you didn’t.

I respect your substantial experience in this area, but yes things are different in the UK, and they’re different now compared to then. The development of Early Intervention approaches have significantly improved the landscape and rightly shifted our focus in a much more optimistic direction. Of course those with the most serious difficulties will often continue to suffer without adequate help, and much better support is needed, but the BPS report doesn’t prevent us recognising that, it just doesn’t focus on the most serious cases as ‘the norm’ as you seem to, because they’re not.

It’s funny to see Bernard repeatedly describe someone as a troll while ignoring actual textbook trolling from James (completely ad hom, dishonest, intentionally inflammatory). Any comment on that?

“…but you could have responded to my comment in the time it took to write your reply. Interestingly, you didn’t.”

I’m not sure what you’re implying here, but if you think it’s avoidance or defensive, it’s not. This is a topic I’m interested in, and would like to think through. I’m aware also that this report is something you have a primary interest in, have strong feelings about, and that you would very much like to debate with critics. I am a critic, and I said I’m game, but I’m wary. I have no interest in standing in for the group that is the central object of the BPS criticism, and I’m identified with that very group throughout this thread and elsewhere. Frankly, I’m weary of being cast into that role. Similarly, Dr. Carroll is a respected colleague, but I’m not interested in speaking for him. He does that quite well all by himself. Likewise, James Coyne is someone that I’m impressed can and will speak for himself.

Also be aware that my first response to this report was to go after Jeffrey Lieberman for his silly little snit-fit on Medscape [which side of the street?…]. And also be aware that when I say I’m busy, I’m not deflecting anything. This is where my head is right now: A Milestone in the Battle for Truth in Drug Safety, and where it will likely stay for a while.

I’m primarily focused on cleaning up psychiatry’s side of the street. Thus my involvement in Data Transparency in Clinical Trials, the invasion of the psychiatric literature by the pharmaceutical industry, the overuse of medication in Medicine in general. Those are my central reasons for being here in the blogosphere, and after two long years, our group’s project in that regard is finally coming to fruition. So that’s the “busy” I want to be right this minute. I’ll return to the BPS Report when I can give it the thought your questions deserve. You can count on that…

I guess that is what I implied Mickey. I may be unfair here but hope you’ll forgive me for saying your second reply gives the same impression as your first. I honestly wouldn’t have thought it’d take much more thought to respond to the points I made if the criticisms you’ve voiced had been well-considered originally. Having said that, again I respect your position and wish you well addressing the issues you’re working on.

I wasn’t asking for you to speak for either Bernard or James, but perhaps to comment on what we see above. Your blog, your rules: “this is not the place for contentious interpersonal dialog. Your opinions are welcomed, but categorical or ad hominem comments to or about each other are not.” James’ only comment, for example, couldn’t be a clearer example of that but there it is, unchallenged. Oh well, I’m familiar with his MO and will take it in stride. I take it as a positive if anything: when someone needs to lie to attack you they’ve shown their hand, and it’s empty.