I went to medical school in 1977. I was still only 17 years old but it was a great relief after the horrendous years I had spent at an all-girls boarding school. My fellow students and I started our first year ‘pre-clinical’ training with 4 ½ days a week of lectures. We were expected to assimilate a massive amount of information and then to regurgitate it during the end of the year exams. Those who failed would have one chance to re-sit and if unsuccessful, they would have to leave medical school.

University students are expected to be inquisitive, to ask questions, but at medical school, it was the other way round. Medical students were expected to answer questions correctly to the lecturer or teacher’s satisfaction.

I already felt disadvantaged; one of the lecturers had broadcast that any student who did not have ‘A’ level Physics should not have been granted a place at medical school. I was one of those students. I had done Maths ‘A’ level instead. My school didn’t do physics or chemistry and I had had to cycle to a neighbouring school just to get the mandatory ‘A’ level Chemistry lessons.

I clearly remember the time when I dared to pose a question during one of our lectures: We were learning about asthma, and I asked why it was that I suffered from wheezing after a thunderstorm but at no other time.

“Impossible,” said the lecturer, “grass pollen is the wrong size and cannot provoke any kind of allergic reaction in the bronchioles (small airways in the lungs).”

I felt humiliated—he had just denied my experience in front of 80 students.

It was many years later that I discovered that doctors had observed this phenomenon on a regular basis. It is now understood that aerosolization of pollen in thunder storms can indeed provoke dangerous asthma attacks for hay fever sufferers like me.

This was just one small example of how humiliation of medical students was routine. By the time we got to our clinical studies and spent most of our time rotating around the various specialities in the local hospitals, we were well used to being subjected to belittling treatment at the hands of our superiors. The ward round was a time when the consultant showed his (rarely her in those days) colours. It was not enough to dominate their junior doctors; terrorising medical students was a daily occurrence. We would be quizzed over a patient’s condition and if we failed to give a satisfactory answer, then making personal and derogatory comments to our detriment was considered fair game.

I was not looking forward to my psychiatry rotation. The prospect of spending time in the large institution, Springfield Psychiatric Hospital in Tooting, was scary. Medical students were tasked with presenting written cases on a variety of patients, finding examples to illustrate the most common psychiatric diagnoses. I surprised myself at how much I enjoyed the experience of interviewing these interesting patients. I felt privileged to have the time to sit and listen to the reasons why they were in hospital and discover more about their background and circumstances. I did well and was awarded an ‘A’ grade for my efforts.

However, I wanted to be a surgeon, so my interests lay elsewhere. As it happened my life took an unexpected turn when I became pregnant. I had no maternity leave and had no family help. By the end of the training, when I finally qualified as a doctor, I was exhausted. I was told that my decision not to go straight into work as a junior doctor was tantamount to career suicide, but I wanted to give our little daughter the best chance in life by looking after her myself.

I didn’t start work as a junior doctor until 8 years and 3 additional children later. My husband and I role swapped to enable me to work the grueling 80-100 hours a week required to get my full registration as a doctor. My intention was to become a GP, but just before I reached that goal, I was side-lined into postgraduate training to become an A&E consultant.

At that time, there were only a few brave patients who came to A&E following overdoses, and it was very rare to see any other manifestations of self-harm. The medical profession expressed a global disdain towards these individuals; those diagnosed with a mental health condition were highly stigmatised and considered weak or defective characters.

Admittedly I was tired out. I had been present during some very distressing resuscitation attempts of young children and the memories of my awful, traumatic experience of boarding school had just surfaced. I knew the reasons why I was having an emotional crisis and I went to my GP for help. The GP left little room for discussion before telling me I was depressed. I left the GP surgery feeling utterly bewildered and wondered how on earth a pill like Prozac was going to fix my problems. But I was a doctor and conditioned to believe that the experts knew best. The GP must be right.

I took the Prozac for a while, but it just gave me side effects, so I stopped it. I had no idea that stopping antidepressants precipitously was not a good idea. I had been told they were not addictive and had very few side effects.

My circumstances didn’t change, and I was still very tired, very stressed and feeling unhappy. I became increasingly anxious about the responsibility of treating very sick patients with minimal support from more experienced doctors. When I went back to the GP, I was signed off sick and told I must take the antidepressants and the dose was increased.

At home, alone, with no-one to talk to, things went downhill rapidly. I loved my husband but genuinely didn’t want to burden him with what I felt were unreasonable concerns. After all my profession told me I should be able to cope, and the GP had assured me these pills would soon make me better. I just had to wait it out. But I just kept feeling worse. I couldn’t sleep, I felt agitated, my thoughts were going round and round and then I became suicidal. Being suicidal made no sense. I had a loving husband, four beautiful children. I had a job. There was no reason to want to die.

Nobody understood that suicidal thoughts could be caused by the very drugs which are used to treat depression. When I shared my thoughts with a doctor friend, she was alarmed. I was taken to an emergency appointment at the GP, then an emergency appointment at the department of psychiatry and my husband was told I must be admitted straight away.

That was just the start of the seven-year fiasco, where I was continuously treated with a changing cocktail of psychiatric drugs and multiple ECT treatments. I never improved, instead slowly became worse and worse, as a revolving door patient.

I was given psychotherapy all through this time, but the therapists were not impressed by my accounts of childhood trauma. Apparently, nothing I told them was sufficient to cause the state I found myself in. Nobody considered that the treatment I was having could possibly be detrimental in any way. Nobody understood that the drugs I was taking could be responsible for my deterioration. Instead, I was told that my brain was disordered, that I had a chemical imbalance, and I was seriously ill.

When I started to act out on my suicidal thoughts, self-harming to the extent that my life was in danger, I was sectioned and, in the sixth year, admitted to the secure ward and placed under continual observation. The prognosis was so grim that I was offered psychosurgery. I was desperate to get better. I wanted to be normal, live at home and be a mother to my children. I agreed to the surgery, not really knowing what else to do.

At the point of the psychosurgery, the psychiatrists reduced the cocktail of five drugs at extremely high doses down to two drugs at lesser doses. When I made a spectacular recovery, even the psychiatrists thought it was miraculous. But they could not credit the psychosurgery as responsible for what happened when the ‘light switched on in my head’, nor was the reduction in the number and doses of drugs I was taking ever considered to have any bearing on my recovery.

Eventually I was discharged from the hospital, and I started to take myself off the remaining doses of antidepressants against the wishes of the psychiatrists. When I reported brain zaps, the psychiatrist had no idea what to suggest, other than reduce the dose slowly.

But I was only drug free for a couple of years. During this time, I even managed to get back to work and I was writing my memoir, going through my medical notes to glean the necessary information. The psychiatrist was worried when I reported that I wasn’t sleeping well. He convinced me that this was a sign that the depression was returning. What he said scared me so much that I capitulated and went back on antidepressants.

When my book was published in 2006, I was doing ok, but it didn’t last long. Within a year, I was back to being depressed and suicidal. I felt a terrible fraud having told the world about my successful psychiatric treatment. Once again, I was admitted, this time given ECT. This time, when I was discharged, I was told I must take high dose antidepressants for life. I was also told that I would never fully recover and suffer recurrent relapses. I was therefore advised to avoid all stress and that meant I should never work as a doctor again.

When we moved away and my husband started his training to become a counsellor, I started to hear a different story to the one that I had been taught as a doctor and different to what had dominated my life as a psychiatric patient. I had believed the psychiatrists when they told me I had a very biological depression caused by a chemical imbalance or some kind of as-yet-unidentified brain disorder. In addition to being told that my only hope was to take antidepressants, I was also advised that having any further psychotherapy which went over the events of the past was pointless, and would only serve to further destabilise my precarious remission.

But each day my husband came home from his training and started to drip feed me with alternative ways of looking at things. Maybe feeling stressed and unhappy was a normal response to terrible circumstances. Maybe believing that those supposedly negative emotions were abnormal fed the downward spiral. Maybe hearing society reinforce a message that you should be happy all the time while experiencing the stigma from my profession made it all worse. When the psychiatrist told me time and time again that I was ill and would never recover, maybe it had become a self-fulfilling prophesy.

But could these experts really be wrong? After all, they were highly trained, highly skilled doctors involved in research. Surely while these eminent professors of psychiatry said that I was one of the worst cases they had ever treated, there was no way I could have just been a normal person reacting in a normal way to difficult circumstances. Could I?

When I weaned myself off the sedating antipsychotic drug which had been added to the cocktail of high-dose antidepressants, I felt a lot better. The psychiatrist was not happy. He warned me. If I was to stop any more of my drugs, I might once again find myself back in hospital with a relapse.

When I tentatively started to return to work as a doctor—very part time at first—I was fine.

By 2016, I had seriously started to doubt that suffering awful side effects from taking off-licence high doses of two antidepressants was worth my while. Slowly I started to reduce the doses and I was fine. While I became more confident in the robustness of my recovery, I still remained ignorant about withdrawal. If only I had searched online, I would have known better.

Likewise, I was ignorant that other people who had also been sent away to boarding school as young children also suffered severe consequences as adults. If only I had searched online, I would have discovered these important facts earlier in my life. As it was, left in ignorance, I believed that I was somehow uniquely weak, uniquely flawed and terribly, terribly ill just like the psychiatrists had told me.

I didn’t want to tell doctors about my symptoms during withdrawal. I had no desire to draw attention to what I was doing, and risk being re-diagnosed or medicated again. By trial and error, I discovered that reducing the dose of the psychiatric drugs had to be very, very slow. It wasn’t scientific but I found myself cutting tiny slivers off the tablets and carrying them around with me, to make sure I could take a tiny amount when the feelings like electric shocks became too much. I had to reinstate the other drug when I found the rebound insomnia, the restless legs, the cramps intolerable. But my emotions were alive. I was living in three dimensions after years of feeling like the world was unreal and that I was completely numb. I cried and cried, but I also laughed and felt joy. It was incredibly scary at times, when I felt panic stricken and afraid. Occasionally I had suicidal thoughts, but somehow, I knew they would pass.

One day, it was like the penny dropped and I laughed out loud when I realised that I had been prescribed medication to treat my psychiatrists’ anxieties. They should have been the ones taking my pills.

I found a counsellor and talked over what had happened to me as a child at boarding school. She was amazed. How on earth had nobody taken this seriously all those years ago? I had been through hell back then, and it had been re-enacted by the psychiatric system which re-traumatised me every time I was admitted to hospital. At last, I started to process memories and emotions that had remained suppressed for decades. I had to learn to recognise my survival persona, one who was easily controlled and coerced. One who knew only how to drive herself harder in response to difficulty. I had to meet my inner children and give them the love and comfort which they had been deprived of while I was growing up.

I made a grave error when I decided to go cold turkey on one of the antidepressants – within two days I had severe burning pain and to this day, I still have the symptoms of small fibre neuropathy. I haven’t slept through the night since that time and now I know that these symptoms are very likely manifestations of a protracted withdrawal syndrome.

In the last few years, I have met two educators in different parts of the country. Both were involved in teaching medical students and/or doctors. Neither of them were medical themselves but both qualified teachers and had the academic credentials to be recognised as experts in education. One of them was employed by a medical school, but suddenly their expertise was no longer required to teach ‘problem-based learning’. The other person was also ousted from their role. They are happy to speculate that this is because the students had learned how to apply their critical thinking too effectively. They were becoming bold, asking awkward questions, no longer willing to learn by rote.

Medical research is largely funded by the pharmaceutical industry, papers ghostwritten by the pharmaceutical industry and influencers paid by the pharmaceutical industry. Regulators are not independent either and so it is that most doctors have become pawns in a system, used to deliver the drugs which provide the fundholders with the maximum profit. So far, the system has failed to eliminate corruption and bias, for one reason only, that is there is no such thing as a free lunch.

Most doctors are not capable of critically appraising the research and ‘evidence’ is sold to us as ‘gospel’. Doctors lack time and training, and are part of a historical, culture which trusts in the academic expertise of influential colleagues. My own medical training had simply reinforced the myth that expert doctors knew best. I had denied my own personhood, ignored my gut instincts and succumbed to the traditional biomedical psychiatric paradigm.

There could have been a quicker route to reach the same conclusions as I have now. There was no need for me to have done this alone; there are plenty of other voices out there, plenty of people who can guide the way.

We might think we choose what we believe but it very much depends on what information is fed to us and importantly, what is withheld. We live in a culture which is heavily influenced by social media and the advertising industry. We cannot rely on the medical profession to take the lead.

While some patients may find psychiatric drugs helpful, at the very least all patients need to be fully informed of the risks of potentially dangerous side effects, and the risks of withdrawal.

I am one of the lucky ones who survived, but others have lost their lives as a direct result of psychiatric drugs. I have written a sequel to my original memoir which reflects the turnaround in my thinking. Unshackled Mind will be published in the coming year. Please join me in speaking out, so that others may be spared from unnecessary suffering and life-threatening risks, all of which may follow an innocent request for help during an emotional crisis.

The post Doctors Are Not Trained to Think Critically appeared first on Mad In America.

This continual cycle results in a vast spectrum of mental and emotional reactions ranging from ecstasy to unbearable pain, with varying levels of intensity and duration. Our understanding of, and response to, the continual contact with pleasant and unpleasant experiences either promotes emotional and mental wellness or intensifies mental and emotional suffering.

Buddhist Psychology offers an alternative lens that examines and seeks to gain insights about this human experience. The Five Hindrances framework explores understanding and recovering from mental and emotional pain by delving into the intricate interplay between mental processes, emotions, and external conditions. It empowers those suffering from mental and emotional pain by normalizing their experiences. By emphasizing the dynamic nature of mental and emotional states, Buddhist Psychology encourages individuals to explore the underlying causes of their suffering and develop strategies for coping and resilience.

Contemplative practices in Buddhist Psychology encourage observing mental and emotional processes to gain insights about them. This involves recognizing patterns that foster mental and emotional well-being while compassionately addressing those that do not. For instance, the mental process of analyzing can be beneficial when solving an algebra problem, but it may not be helpful in coping with emotional pain following the death of a loved one. Acceptance of the loss, as difficult as that might be, is a more adaptive response. Similarly, the mental process of planning helps up to set goals and prioritize. However persistent worry about future events can lead to anxiety and stress. A contemplative approach refrains from pathologizing and instead focuses on understanding and cultivating conditions that promote emotional and mental well-being. As contemplation deepens, a type of “treatment plan” often begins to emerge as we learn to distinguish between non-beneficial and beneficial mental processes, their causes, and conditions, and how to cultivate positive mental and emotional patterns and responses.

The Five Hindrances contain alternative concepts for understanding mental health and well-being as well the causes and conditions which create mental and emotional distress. The Five Hindrances include:

Sensual Desire. This hindrance refers to the almost constant drive to seek pleasure and comfort while avoiding pain and discomfort. Pleasure-seeking varies in intensity, from slight cravings to irrational obsessions and compulsions. We often believe that obtaining a particular object (girlfriend, new car, new figure, recognition, fame, etc.) will bring contentment. However, once we obtain the object, contentment is fleeting, and dissatisfaction soon returns. Hyper-consumerism, coupled with hyper-competitiveness, clouds our ability to see what truly brings us peace, joy, and contentment. It is easy to lose sight of what brings stillness and joy when we are bombarded by enticing advertisements defining that for us. This constant cycle of craving and dissatisfaction can lead to significant emotional and mental distress.

A basic mindfulness strategy is to recognize the hindrance as it arises. Sometimes desires are apparent, such as intense cravings for a particular food; others are subtle and experienced as a slight irritation. The constant cycle of wanting and dissatisfaction can undermine our mental and emotional well-being. If you look at this hindrance carefully, you might find that in every moment, there is a desire arising. The present moment contains X, but you don’t want X; you want Y. We are either grasping for a completely different condition other than the one that ‘IS,’ or the present moment might be generally pleasant, but we can think of one or two things we might like to change.

Mindfulness of desire may also reveal cravings that are healthy, such as for nutritious food or exercise. However, even healthy cravings may disrupt our focus on the present moment, causing frustration if unfulfilled.

Ill Will and Aversion. This hindrance encompasses a vast array of experiences that range from finding something slightly distasteful, or off-putting, to intense hatred. Ill will and aversion can be seen as the opposite of sensual desire. While sensual desire pursues, ill will and aversion pushes away. Ill will and aversion can be directed internally (negative self-talk, self-harm) or externally (hurtful words, violence). During high intensity levels of ill will and aversion, the potential for impulsive, irrational, or illogical thought and emotional patterns emerge. Like the previous hindrance, ill will and aversion are pervasive experiences of the human condition. Therefore, mindful awareness when faced with challenging conditions—those we dislike or even hate—is a powerful coping skill to regulate and cope with distressing thoughts and emotions.

The practice of mindfulness, particularly attention regulation, helps us recognize when ill will and aversion arise. Understanding that the aversive mind is not the rational mind allows us to detach from these thoughts. This recognition supports the ‘mindfulness pause,’ which encourages postponing impulsive actions driven by ill will and aversion. For example, if someone feels intense anger towards a colleague, mindfulness can help them acknowledge this anger without immediately reacting. This pause allows for a more measured and rational response, reducing the potential for conflict.

While ill will and aversion can be seen as the opposite of sensual desire, they share a significant similarity: both are persistent and experienced almost constantly. In varying levels of intensity, the present moment is either lacking something we crave, or contains something we don’t like. The lens of Buddhist Psychology offers invaluable insights into recognizing and understanding conditions, objects, or phenomena that we find disagreeable. However, through contemplative practices like mindfulness and meditation, we can illuminate our awareness. By doing so, we gain a deeper understanding of when ill will and aversion arise, allowing us to restore equanimity in both body and mind.

Sloth and Torpor. Sloth and torpor refer to the hindrance of physical laziness and mental laziness respectively. Like all the hindrances, sloth and torpor manifest in various levels of intensity. When sloth arises, contemplative practices encourage recognizing the conditions that give rise to it, as well as noticing its qualities such as duration and triggers. For instance, when feel lazy and don’t want to exercise, I’ve noticed making a small effort, like putting on my tennis shoes often dissipates the feeling of sloth. Torpor, or mental laziness, manifests as an aversion to mental activities perceived as challenging or uninteresting. While lack of interest can reach pathological levels, it’s not always harmful.  Buddhist Psychology urges us to turn our awareness to the conditions giving rise to these hindrances and to cultivate healthy responses. Sloth might dissipate with proper nutrition, rest, or exercise, while torpor may fade by engaging in novel experiences, finding purpose, or enhancing concentration. Overcoming sloth and torpor requires the right effort and pushing through discomfort, forming a foundation for overcoming all hindrances.

Restlessness and Worry. This hindrance consists of both physical and mental aspects. The physical aspect of restlessness presents on a spectrum ranging from slight unease or fidgeting to hyperactivity, tenseness, and nervousness. The mental aspect is worry, which results in mental processes such as rumination and negative thinking. Both restlessness and worry can vary in intensity, from mild unease to overwhelming distress.

Buddhist Psychology recognizes restlessness and worry as normal biological responses to danger or uncertainty. When restlessness or worry arise, examining the previous hindrances can be helpful. The present moment, as we currently perceive it, contains conditions we don’t want (aversion), is lacking something we want (desire), or is without passion or purpose (sloth and torpor). Awareness of this and all hindrances also reveals their transitional nature. Hindrances appear, gain intensity, peak, and then gradually fade away. They are not gone permanently, as they can arise again when the conditions are right.

Awareness and contemplation of this hindrance reveal how it can precede positive mental states, such as when mild worry results in problem-solving. However, it is generally necessary to recognize the hindrance at low intensity levels to take advantage of the beneficial motivation and redirection it may provide.

Doubt. This hindrance reflects not knowing or knowing wrongly. Not recognizing the full scope, characteristics, causes, and conditions of reality results in doubt or knowing wrongly. For example, while my senses tell me I am sitting in a chair, this perception does not recognize the full scope of reality, which includes the fact that I am moving around the sun at 67,000 MPH. Most of what we “know” comes from input derived from our sense organs. The reality derived from our limited sense perception is vastly incomplete.

In Buddhist Psychology, the brain is considered a sense organ. If the eye provides sensory information about color and form, the sensory input derived from the brain includes thoughts, memories, perceptions, predictions, and more. If our eyes, nose, mouth, ears, and skin provide limited data about reality, the sensory input of the mind is similarly limited. Of the approximate 60,000 thoughts I have every day, I wonder if any of them are completely accurate.

Examination of doubt in psychotherapy presents notions of sensory input of the brain—thoughts, perceptions, memories—and casts suspicion on their validity. It then becomes much easier to challenge firmly held beliefs. This dialogue can proceed to include discussions of a new reality, hopes, and possibilities.

Buddhist Psychology presents a simple yet profound template for recognizing the biological, emotional, and mental reactions that result in mental and emotional pain. This pain exists on the spectrum, from slightly noticeable to intense and overwhelming. Contemplative and awareness practices encourage a disciplines examination of the hindrances, exploring their presence, absence, the conditions that make them arise and dissipate, and the adaptive levels of their intensity. The Five Hindrances add additional depth to our understanding of experiences that create emotional pain. This approach to recognizing the human experiences that lead to mental and emotional suffering feels kinder and may promote a less stigmatizing identity than one arising from an official diagnosis.

The post Reframing Mental and Emotional Pain from a Buddhist Psychology Perspective appeared first on Mad In America.

While one explanation for top psychiatrists’ exuberance unchecked by reality is their financial conflicts of interest with Big Pharma, historically, not all leading psychiatrists have been drug-company shills. So, what are other explanations for this phenomenon? Before examining these other reasons, a look at two high-profile examples of this exuberance.

In the twenty-first century, there has been no higher-level psychiatrist then Thomas Insel, director of the National Institute of Mental Health (NIMH) from 2002-2015. Insel left NIMH to lead the mental health team at Verily (formerly Google Life Sciences); then in 2017, co-founded Mindstrong Health, where he promoted digital phenotyping (which, for example, includes the monitoring of patient smartphone text messages to gauge mental illness).

Insel is a prime example of a top psychiatrist with exuberance about psychiatry regardless of his awareness of the reality of its repeated failures.

“I spent 13 years at NIMH really pushing on the neuroscience and genetics of mental disorders, and when I look back on that I realize that while I think I succeeded at getting lots of really cool papers published by cool scientists at fairly large costs—I think $20 billion—I don’t think we moved the needle in reducing suicide, reducing hospitalizations, improving recovery for the tens of millions of people who have mental illness.”—Thomas Insel, quoted in 2017.

“To be clear, I have no regrets about NIMH funding for genomics and neuroscience.” —Thomas Insel, in Insel’s 2022 book Healing, xxvi.

“Whatever we’ve been doing for five decades, it ain’t working . . . . When I look at the numbers—the number of suicides, the number of disabilities, the mortality data—it’s abysmal, and it’s not getting any better.” —Thomas Insel, quoted in 2013.

“The scientific progress in our field was stunning, but while we studied the risk factors for suicide, the death rate had climbed 33 percent.” —Thomas Insel, Healing, xvii.

“. . . current treatments are as effective as some of the most widely used medications in medicine.” —Thomas Insel, Healing, xxiv.

The history of psychiatry is replete with ultimately discarded psycho-babble, bio-babble, and techno-babble. The discarding of the DSM, psychiatry’s diagnostic manual, was actually called for by Insel in 2013, and in his 2022 book Healing, he acknowledged that the chemical imbalance theory of mental illness has now been discarded. Today, he is techno-exuberant not only for digital phenotyping but for brain-circuit explanations of mental illness and for more electroconvulsive therapy (ECT), commonly called electroshock:

“The idea of mental illness as a ‘chemical imbalance’ has now given way to mental illnesses as ‘connectional’ or brain circuit disorders.” —Thomas Insel, Healing, 138.

“The approach [ECT], which induces a seizure across the full cortex in an anesthetized patient, might be akin to rebooting a computer. . . Simply zapping the cortex with electricity may seem like a Hail Mary pass, and yet it actually is effective. . . .” —Thomas Insel, Healing, 55.

Dr. Strangelove or: How I Learned to Stop Worrying and Love the Bomb, Stanley Kubrick’s 1964 satirical film, ridicules nuclear war planning and the Cold War ideology of “mutually assured destruction.” The film also mocks nuclear war expert Dr. Strangelove, who is unfazed by the horrific consequences of nuclear weapons.

Analogous to the fictional Dr. Strangelove, Insel is aware of the adverse effects of ECT, noting that “there are serious adverse effects, including headache and memory loss” (Healing, 55); however, he is unfazed by these adverse effects. Rather, Insel is upset that “only 0.25 percent of people with depression [are] treated with ECT,” telling us that the stigma of ECT has occurred because “antipsychiatry groups have demonized it” (Healing, 146-147).

The scientific reality of ECT? As is the case historically with every psychiatric treatment, including bloodletting, there are positive anecdotal testimonials for ECT, however, ECT has not met the scientific criteria for effectiveness. A 2019 review of the research on ECT effectiveness for depression reported that there have been no randomized placebo-controlled studies since 1985, and those studies that were done prior to 1985 are of such poor quality that conclusions about efficacy are not possible. Moreover, it has been consistently shown that ECT results in serious adverse effects such as “persistent or permanent gaps in life memories, including of weddings and birthdays, somewhere between 12 and 55 per cent,” as reported by psychologist John Read in 2021, who also reported that “one in 50 patients experience ‘major adverse cardiac events.’”

When I think of Insel’s exuberance for psychiatry undaunted by abysmal outcomes and horrific adverse effects, I think of Major Kong (Slim Pickens) riding the bomb in Dr. Strangelove.

High-profile psychiatrists’ exuberance over psychiatric treatments regardless of scientific realities is not new.

In the late-eighteenth and early-nineteenth century, the most well-known American physician who treated the “mad” was Benjamin Rush, a signer of the Declaration of Independence. Rush is often referred to as “the father of American psychiatry,” and his image long adorned the seal of the American Psychiatric Association (APA), the guild of American psychiatrists. Rush proclaimed himself a slave abolitionist though he had owned a slave, and his views on race included the idea that blackness in skin color was caused by leprosy, and so he advocated “curing” skin color.

Based on an earlier bio-babble theory that irregular convulsive action of the blood vessels was the cause of madness (and other diseases), Rush was an enthusiastic proponent of what was called “depletion therapy,” which included aggressive bloodletting, notes Gerry Greenstone in “The History of Bloodletting” (BC Medical Journal, 2010). Greenstone tells us: “Dr. Benjamin Rush (1745–1813) was one of the most controversial phy­sicians in his time. He was arrogant and paternalistic . . . and devoted much time to the problem of mental illness.” Greenstone reports that Rush removed “extraordinary amounts of blood and often bled patients several times,” and he maintained his exuberance about bloodletting even when other physicians were beginning to doubt its wisdom. “Some doctors,” Greenstone notes, “referred to his practices as ‘murderous.’”

How to Explain Top Psychiatrists’ Exuberance Unchecked by Reality

In “What Can Physicians Learn from Benjamin Rush, Blood, and the Red Cross?” (Hektoen International: A Journal of Medical Humanities, 2020), Ryan Hill notes, “Despite the adamant opposition he encountered from many of his contemporaries, Dr. Benjamin Rush was undeterred.” Hill points out, “During Rush’s day . . . many began to look at the practice with great skepticism, if not rejecting it outright . . . . It was obvious to many of Rush’s contemporaries, who took a much more objective view of bloodletting, that the practice was doing more harm than good.”

Hill then asks and attempts to answer two questions that are highly relevant to contemporary psychiatry:

“So, given this shift in thinking, why did Dr. Rush, one of the most brilliant and educated men of his day, hold on to this near-obsolete practice so unswervingly, even in the face of opposing evidence? Taking the question a bit further, is there anything physicians can learn from his apparent intransigence today?”

One answer, Hill tells us, is provided by Thomas Kuhn’s The Structure of Scientific Revolutions (1962), which explains why many scientists do not abandon their current paradigm even in the face of data showing the paradigm is incorrect. Hill concludes, “Perhaps Rush was stubborn, and maybe even self-righteous, but it was likely his inability to comprehend the shifting paradigm, rather than sheer stubbornness that tethered him so closely to the age-old belief in depletion therapy.”

Another explanation offered by Hill is that overconfidence is a “common human bias” against questioning outdated techniques. In the history of psychiatry, from Rush to Insel, psychiatrists who can project extreme confidence are more likely to move into leadership roles. This phenomenon exists in other areas of life, including the military leaders and political advisors satirized in Dr. Strangelove, and it also exists in business, as described by Susan Cain in Quiet (2012). Cain reports how the Harvard Business School information session on how to be a good class participant instructs: “Speak with conviction. Even if you believe something only fifty-five percent, say it as if you believe it a hundred percent.” Projecting confidence that is unjustified by reality can make one a leader in many areas of US society.

Hill also offers the explanation of confirmation bias for why Rush would not let go of bloodletting. Hill defines confirmation bias as: “when people form a hypothesis and then gather information to support it, rather than looking at data objectively before forming a conclusion.” Specifically, Rush was animated by those patients who survived and somehow improved after bloodletting, stating, “Never before did I experience such a sublime joy as I now felt in contemplating the success of my remedies.” Owing to confirmation bias, Hill notes, “Despite the fact that he had seen countless deaths, he claimed that he had never lost a patient he had bled. . . . His confirmation bias, a natural human tendency, clouded his views, creating an affirming interpretation of the evidence.” Confirmation bias is a major explanation for why contemporary psychiatrists won’t let go of their treatments despite evidence of ineffectiveness and troubling adverse effects.

Why Psychiatrists Not in Denial Stay Quiet

Why don’t more psychiatrists who are aware of scientific realities call out those exuberant top psychiatrists who continue to be unchecked by reality?

One explanation is the culture of psychiatry. This is evidenced by the 2010 article “Bloodletting 1854,” published by the American Journal of Psychiatry (AJP), the official journal of the APA. Authored by psychiatrist Marshall Garrick, this article provides a window to the cultural values of psychiatry, and how self-serving rationalizations are considered artful diplomacy.

Specifically, Garrick tells us, “I came across an April 1854 article in the American Journal of Insanity (forerunner of AJP) that made me feel much pride as a psychiatrist.” This 1854 article, “Bloodletting in Mental Disorders” was authored by Pliny Earle, one of the founders of the group that would become the APA. In 2010, Garrick explains why this article provided him with pride as a psychiatrist:

“It is striking how delicate and diplomatic Dr. Earle was in showing respect for the memory of Benjamin Rush while expressing disagreement with Dr. Rush’s advocacy of bloodletting. Dr. Earle artfully allowed that maybe the causes of some mental disorders were different during Dr. Rush’s era, compared with the mid-19th century, and that that had led to different treatment practices. Dr. Earle, I believe, demonstrated skill as a leader trying to improve the treatment of mental health disorders while avoiding unnecessarily tarnishing the memory of Benjamin Rush, a founding father of the country and an esteemed physician who published the first textbook on mental illness in the United States.”

This begs the following question: Was Pliny Earle’s excuse for Rush—“the causes of some mental disorders were different during Dr. Rush’s era, compared with the mid-19th century”—admirably “delicate and diplomatic,” or was it self-serving bullshit? In other words, Pliny Earle, Marshall Garrick, and all politically astute psychiatrists are concerned about tarnishing the memory of the father of American psychiatry because that tarnishes their profession of psychiatry.

Finally, how much progress has psychiatry made since Rush’s era? Rush actually invented two mechanical devices to treat madness: a “tranquilizing chair” to slow down the fluid movement of agitated patients, and a “gyrator” in which patients were strapped down, immobilized, and spun to stimulate blood circulation. While Rush’s exuberant attachment to bloodletting resulted in the unnecessary deaths of many patients, Rush’s own inventions to treat mental illness, though barbaric, likely resulted in less long-term physical damage than psychiatry’s treatments, not only in the late twentieth century but today.

Specifically, while no doubt Rush’s devices were physically unpleasant and psychologically traumatizing for many patients, these treatments likely resulted in far less irreversible physical damage than the twentieth century treatments of insulin coma therapy and lobotomy. Furthermore, in contrast to twenty-first century ECT and selective serotonin reuptake inhibitors (SSRIs), it is likely that after patients were freed from Rush’s tranquilizing chair and gyrator, they could still, unlike many ECT patients, remember their birthday, and unlike many former SSRI patients, they did not suffer from iatrogenic permanent sexual dysfunction, today called post-SSRI sexual dysfunction (PSSD).

Leading psychiatrists appear to be unfazed that their mental illness theories and treatments are repeatedly proven to be scientifically invalid and discarded. However, politically astute psychiatrists will forever be concerned that the general public will finally catch on that their claim that “psychiatry is a young science making great progress” is nothing more than exuberance unchecked by reality.

The post How to Explain Top Psychiatrists’ “Dr. Strangelove Exuberance” Unchecked by Reality appeared first on Mad In America.

Buck, who lived to the age of 102, fought throughout her life for psychiatric reform. She created her own form of mind care, which she called “trialogue.” Buck refused to dismiss the meaning of her psychotic visions or reduce any neurodivergent state to “biological brain disease.” In trialogue, psychosis experiencers, family, and clinicians worked as equals, with respect for the value and knowledge of both experiencer and experience. Buck also demanded recognition of the Nazi murders of the disabled and the mentally ill. Many of these victims were psychiatric patients gassed between 1939 and 1941 in chambers built into German asylums.

I first encountered Dorothea Buck in 2019. Buck died that fall, at the age of one hundred and two, as I was having a psychotic episode. I learned of Buck’s life and her book through an obituary in The New York Times. I found her memoir, On the Trail of the Morning Star: Psychosis as Self-Discovery, and had it translated by the wonderful Eva Lipton. Buck wrote her story at the urging of journalist Hans Krieger, and the book appeared in German under the pseudonym “Sophie Zerchin”—an anagram for the German schizophrenie—in 1990. I encountered a thinker who captured not only the buffeting of neurodivergent experience, but its corollary: the mind engaged in a process of world-making, a making that functions through its own channels. Buck taught me a new respect for the wildly creative work of consciousness.

On the Trail of the Morning Star, from which these two excerpts are taken, appeared in English in May of 2024. It’s available at punctum books, as a physical book or a free download. Buck would have wanted that. Both excerpts describe places where, as Buck acerbically put it, “I had sworn to myself that I’d rather stay mentally ill than ever take part in having the ‘mental health’ being demonstrated here.”

****

Excerpts from On the Trail of the Morning Star: Psychosis as Self-Discovery

The first excerpt describes Buck’s experiences in Bethel during her 1936 hospitalization, including her sterilization. Buck was shocked to find inner experiences she found deeply meaningful dismissed as meaningless physical disease. Ignored, tormented by treatments like wet wraps, witness to the brutalization of other patients, Buck later called the Protestant institution of Bethel a “hell amidst Bible quotes.”

A human being can hardly be degraded more. The doctors and nurses who know nothing and want to know nothing about the history and the contextual meaning of the psychosis and think everything is just a meaningless side effect of a physical disease, probably never think about how they degrade and devalue us. As long as they don’t talk to us, they cannot know anything about us.

Was I supposed to recant what I had experienced? Is that what they wanted? Did the old authoritarian demand of the church to recognize only what fit their ideas of God’s path for humans, and keep people from questioning their role as mediators, present itself in a new form of resistance, one that was more contemporary than medieval methods? I swore that I would never exchange what I had experienced as God’s guidance for the “true Christianity” that was being modeled here. Following each narcotic injection and each little glass of paraldehyde [a powerful sedative] I was given, I insisted to Nurse Y. that none of this would ever change my mind, and I repeated this until I passed out.

On the green wall across from me painted in large letters was Jesus’s quote: “Come unto me, all ye that labor and are heavy laden, and I will give you rest [with the sense of ‘refreshment’ in German].” Refresh—with long baths and wet wraps, with cold water showers on the head, with narcotic injections and paraldehyde. That was absurd and incomprehensible. I had to think of God calling the devil “the father of lies.” And then something happened that made an indelible impression on me. Frau Pastor H. was cleaning the hall dressed in the blue-striped ward uniform and talking to herself. Maybe the tone was aggressive and maybe she looked at Nurse Y. Regardless, [nurse Y] suddenly grabbed the Frau Pastor’s long hair, pulled her down to the ground, and dragged her across the floor by her hair. She passed the Bible quote going into the bathroom. Like a strong field horse in front of the plow she looked at us—an unforgettable image of brutal violence and unprotected impotence.

Decades have passed since then and still that image is embedded in my mind’s eye as if it happened yesterday. And that is probably how all of us affected ones feel who have had the most harrowing experiences in our asylums—possibly in Christian asylums with Bible quotes on the walls. If that is supposed to be spiritual health—it could not convince us. We learned to fear this type of “spiritual health.”

Later a young aristocratic woman joined, Fräulein von W. She had been operated on recently. She kept getting up from bed. What were those peculiar scars that she and little R and little P had above their vaginas? I asked Nurse Y. “Appendix scars,” she explained. Earlier on I’d learned that the appendix was located on the side. Had we been lied to about that as well?

In the institution we were robbed of our dignity; we were reduced to being objects to be kept and observed. We were objects to whom it was not worth talking, and who were not worthy of occupation or else considered incapable of being occupied. And to be unable to talk to anyone about it was the same as total inner isolation. As much as Bethel tried to fight my experiences as the expression of “mental illness”—for me they remained something very essential.

In the meantime, I knew we were being kept here because we were “mentally ill.” And I had sworn to myself that I’d rather stay mentally ill than ever take part in having the “mental health” being demonstrated here; it seemed to me not worth aspiring to.

One evening—it was September 17—the friendly ward nurse M. shaved my pubic hair after my bath. Why? I wanted to know. “For a necessary little procedure.” It was obvious that she didn’t want to provide a more detailed explanation and I didn’t ask any further. I had no idea about a sterilization. That is why I hadn’t had any doubts when Nurse Y. referred to my co-patient’s scars as “appendix scars”; many, after all, had their appendices operated on. And I never would have thought it possible such a serious procedure could be done without first talking about it to the concerned party.

Early in the morning, Nurse M. took me to the Gilead hospital. I felt no fear at all as I stood alone in the antechamber of the operating room in my white cotton socks and short shirt. For the first time in more than five months I was able to open a window all the way, and I felt such happiness about this wide open window on a bright morning with the sun rising. I still had no idea what they planned to do with me.

Nurse M. entered and was visibly startled to see me standing at an open window. The thought of jumping out of it had never crossed my mind. She quickly closed the window, and I got on the gurney that was rolled into the antechamber. The anesthesiology nurse—I still see her face—injected my arm and I sank into the unconsciousness I was already so familiar with, though it was faster. than I was used to. This injection worked much faster than the ones that Nurse Y. jabbed into my thigh, once with such force that the discoloration of the skin can still be seen today.

I woke up out of anesthesia in the little four-bedroom area in the ward for the depressed. Now as well, nobody informed me what kind of procedure had been performed.

Another patient, a deaconess who had been living here a long time following an auto accident, explained to me that the operation was a sterilization. She had brought flower garlands she made herself to my sickbed. Without her I would probably not have found out anything in this house.

I was in despair. I had my hair cut, because I at least wanted to watch my hair grow if everything else in my development was to stop.

****

This second excerpt describes Buck’s fifth hospitalization in 1959. The relatively new emphasis on psychoactive drugs rendered Buck semi-conscious and she spat out her pills. Though thirty years had passed since Buck’s first hospitalization and National Socialism was over, little had fundamentally changed—care remained negligent, dehumanizing, aimed at suppressing patients’ inner experiences rather than exploring them. Buck and her fellow patients began to speak to each other about their inner lives, and their conversations and mutual support became the roots of Buck’s later psychosis seminars.

I lay in the large admission hall with a number of rows of beds. The female patients lay next to each other one bed after the other, only separated by a nightstand. All of them were sedated with injections. I hadn’t experienced that yet: that we should be incapacitated with psychotropic drugs right after being admitted and then kept sedated. In a brief time, we were also so physically weakened that I stumbled to the bathroom on unstable legs. I had to hold onto the edge of the bed in order not to fall. My hand trembled so much that I could hardly hold the cup and spilled my coffee.

“Don’t carry on so!” the young nurse barked at a female patient who buckled on her way to the bathroom. That was the most eerie part of what I experienced in the institution: a large hall full of intentionally weakened, half- or fully sedated patients. The doctors barely knew what was going on, what they were experiencing, but they had the authority to take our last bit of freedom in a locked house: the freedom of our thoughts, our consciousness, and our bodies.

Even if we were put into duration baths in Bethel in 1936, or got sedative injections, once we woke, we were fully present again and not weakened physically. We didn’t have to swallow our fear and our resistance but could express them anew. Is this forced silence really progress from the “restless wards,” with their justified resistance against psychiatric methods, which fight and devalue the patient and their experiences?

I protested against the forced injections, I tried to explain that my previous break had receded on its own without medication and had actually led to a break-free period of thirteen years. The medication-induced interruption of the psychosis had led to new outbreaks after just five and three years. None of it helped. “Just leave it to us,” one of the doctors in the admission ward said. “We can already see what is going on with you.” The experience of the patient and the meaning it has for them didn’t interest our psychiatrists. They were only interested in the symptoms and behavior that deviated from the NORM. The power of these psychiatrists to force their limited viewpoint on us with medication is frightening for us.

Luckily, I got a rash after three days, so the injections had to be stopped. Instead, the nurse now stuffed pills in my mouth. I had to suffer it, but she didn’t force me to swallow them, as is done nowadays. I kept them under my tongue and waited for an opportunity to flush them down the toilet when nobody was looking. None of the doctors noticed that from that time, until about eight weeks later when I was discharged, I had not been medicated. Prior to being discharged I told the ward doctor that I had never swallowed pills. “We have to treat with medication,” he noted, “insurance demands it of us.”

For the first time, however, we tried to help ourselves on this ward. The summer of 1959 was very hot, so we were allowed to stay in the little ward garden most of the time. A group of about eight female patients sat on recliners that were shoved together and talked about what had struck us most during our psychosis experiences. This way we could give one another confirmation of the meaning of our experience and separate ourselves from the devaluing psychiatric evaluation that undermined our confidence. These hot summer days, above us the crowns of the pines in whose shadows we discussed our psychosis and dreams in a relaxed way, and thought about them, belong to my good memories of my time in institutions. It is the fellow patients through whom institutional time becomes rewarding, because they have known what psychosis is and know more about it than specialists. The specialists neither have the experiences themselves, nor are willing to learn about them by talking to their patients.

For a female patient in her first break who only heard individual sentences, it was still impossible to see a meaning in them; she couldn’t understand the context and connection. Those of us who had experienced a number of breaks and thus had more comprehensive psychosis experiences found it easier to recognize the meaning.

This patient told me about experiences of everything unifying. She much later read about similar events in the biography of an East Indian. She was a woman with a simple background, and she could hardly have known about the book. Aside from such happy experiences, she had a compulsion to add up people’s value by the numerical value of the letters of their names. Where nothing could exist without meaning, even names had to have a secret meaning. In the book Mysticism and Magic of Numbers by F.C. Endres I later read, as I found out about psychoanalysis, that this same transformation of letters into number values and vice-versa had occurred two hundred years earlier among Kabbalistic scholars. That it is much older may be indicated by Roman letters that represent number values. If this patient could have seen such parallels, then she could have understood her compulsive behavior better: a breaking open of “archaic idea possibilities,” as happens in schizophrenia according to C.G. Jung. Perhaps they would then have lost their compulsiveness for her. What one understands affords one more freedom.

Our psychoses had receded. My fellow patients had been suppressed with psychotropic drugs, in my case, the break had receded without medication. We had grown our thick skin back, the close community began to disintegrate. I felt again the slow abatement of the strong impulses of the acute break into just a quiet instinct, as with the previous break, which had also not been interrupted with medication.

We were close to being discharged.

The post Dorothea Buck’s Memoir Tells of the Horrors of Twentieth Century Psychiatry: A “Hell Amidst Bible Quotes” appeared first on Mad In America.

In no way would I be offended or angry if you use the term therapist for me. I just think that it is your expression of a misunderstood, imprecise and outdated definition of what mental health work entails.

If you struggle mentally, it does not mean that you are ill. It is not you, your personality, your demeanor, your thoughts or your feelings that is wrong with you. It is an expression that you have encountered loads or challenges in the encounter with your surroundings, which have become too demanding for the psychological mechanisms that the same surroundings have equipped you with in the past.

It is psychiatry’s view of what mental problems are and how they arise which in itself is pathological.

Searching for a way through

It is not treatment in the medical sense that I practice or have practiced in my work as a psychologist. I do not carry out any form of intervention, neither surgical nor chemical. Everything I do happens in dialogue. I don’t manipulate thoughts. I don’t change the way you think. But I give you access to my professional perspectives and reflections, in the hope and belief that you will be able to use them for increased self-awareness and personal growth.

I am not seeking a cure for cognitive or emotional disorders. I am looking for a real understanding and effective problem solving strategies for the individual. I have conversation tools that give you good prerequisites to get to know yourself better and what works for you.

But I’m not a therapist. I am only an interlocutor with certain, specific knowledge that can sometimes be very useful. Conversations can be encouraging, give hope and motivation, increased acceptance or possible alternatives for action. The most important thing that happens in the conversations, however, is finding security for shared wonder and the search for new insights. The collaboration to look for a good and passable road.

I cure nothing

It is not particularly controversial to say that I personally am not your doctor or healthcare provider. But it immediately becomes more difficult for many to swallow when I claim that talk therapy is a contrived appropriation, and that no psychologists actually provide health care.

Psychologists cure nothing. They lay the foundation for personal development that can lead to improvements in mental flexibility, adaptation and functional level.

Psychology as a field of knowledge is closer to philosophy than medicine, and is far from being a precise, scientific discipline. Descriptions of causal relationships and selection of “evidence-based” approaches are little more than qualified guesswork with a certain statistical probability of hitting the target. Qualities and characteristics of individual stories cannot be operationalized and quantified with any form of precision or objective neutrality. The psychiatric diagnosis is a medical theoretical construct with limited epistemic validity. Psychiatric diagnoses are hypotheses and not proof of the existence of real diseases.

Diagnosis as a pivot point for investigation and selection of treatment methodology is a biomedical paradigm, which is not automatically transferable to the psychosocial part of the human mind. Nevertheless, standardized investigation with differential diagnosis as the objective and allocation of the “best available” treatment resource as the endpoint has become the only goal for how we meet people who are weighed down by the burdens from their difficult encounters with a society and a reality that constantly puts more pressure on the individual.

The power of diagnosis

The diagnostic doctrine leads to it being considered irresponsible health care to deviate even the slightest from the Health Directorate’s guidelines, symptom checklists and NOUs on therapeutic procedures and recommendations. Emphasis on the individual’s developmental history, individual characteristics and preferences must be justified by measurable figures, instead of by an absolute minimum of trust in the shared, relationally developed understanding that good conversations provide.

I have chosen to say “take from me the authority of a psychologist and health care professional” as a protest against a Norwegian healthcare system that, under the heavy influence of an industrial efficiency mindset (New Public Management), has moved from having the optimal health condition of individual patients as the main goal setting, to using the least possible resources for the highest possible average health benefit as a guiding principle.

The introduction of the health enterprise model in 2001 gave economists and bureaucrats the mandate to override health professionals’ arguments from a cost/benefit perspective, which effectively transforms health personnel from professional service actors to gatekeepers for resources and rights.

Diagnosis is your power, with all the associated risk of abuse of power that it entails. The power of definition and the prestige that lies in being able to categorize people as either healthy and useful to society, or as sick, requiring treatment and a potential burden on society, will be difficult for those who manage it to convey. Be it politicians, hospital managers, welfare bureaucrats, supervisory bodies, children’s services, psychiatrists, doctors or psychologists.

I waive the statutory duty to follow guidelines taken from a knowledge base I can no longer trust. To paraphrase the “Iron Chancellor” Otto von Bismarck’s statement about lovers and sausages: Anyone who knows how statistics and diagnoses are designed will never again have a good night’s sleep. I know the diagnostic system. That’s why I choose not to use it. Descriptive statistics cannot function as a pillar for mental health care.

Facing a paradigm shift

You do not need treatment. You don’t need a full-blooded psychologist with a bland, public approval and a body of law and a disease terminology best suited to lead vulnerable people behind the scenes. What you need is a conversational partner who is able to reflect, explore, illuminate and wonder, together with you, on your terms.

You need a relationship that provides fertile ground for growth and development. Such relationships do not grow out of the health authorities’ organization of services. They come from knowledge acquired through education and experience, personal aptitude, relational skills and a genuine desire to contribute constructively to the individual.

We must stop pushing ready-made investigation and treatment procedures linked to diagnostic assessments. We must start taking people’s own experiences seriously. I have no doubt that we are facing a shift in the approach to mental health, forced by the inefficiency and inadequacy of the current paradigm. Eventually, there will be too many stories about misinterpretations and misdiagnoses, failed treatments and harmful, conscious and unconscious abuse of power and stigmatization.

Angry, impatient patients, who want to come to the conclusion that they are the experts in their own lives, no longer want to accept the above and the restraint that diagnostic categorization represents.

Anecdotes become empirical evidence, if there are enough of them. Not that those in power will ever care about the evidence, but loud protests and a disaffected electorate are something they don’t like. In any case, mental healthcare must, in one way or another, move away from the biomedical disease model, and into a more humanistic, relational approach.

I know what psychology and psychologists as a professional group are good for, but I also recognize the limitations. The subject and the knowledge will persist and develop further. But the management and application of knowledge and human resources must change.

I start by jumping off the high horse that is the title of psychologist, and move on a level that allows me to look people in the eye. I don’t know more about you than what you tell me, and I feel privileged if you choose to share your story with me. Then, and only then, can we figure things out. Together.

And be so kind: Don’t call me therapist.

The post Don’t Call Me a Therapist appeared first on Mad In America.

And such is how I think of Bhargavi Davar, who passed away from lung cancer on May 22, at age 61. She is survived by her daughter, Netra Prabha Davar.

I first met Bhargavi in the summer of 2015, when she was a speaker at the World Hearing Voices Conference in Spain. At first, in my own my myopic way, I saw her—and admired her—through the lens of psychiatric survivor activist. She identified as a childhood survivor of psychiatric institutions in India, and in 1999 founded the Bapu Trust for Research on Mind and Discourse in Pune, India. She named the trust after her mother Bapu, who had experienced the horrors—and violence—of psychiatric institutionalization as a person with psychosocial disabilities.

She was a vocal critic of the “medical model” and described the system of care that ensued as “violent,” and spoke about how this western model was a type of colonization that had supplanted traditional healing practices in India and the Global South. The Bapu Trust sought to promote user/survivor mental health advocacy, rights-based services, and peer-support within the community, while also studying traditional healing systems in India and the Global South.

While personal experience may have been the driver of this work, she brought scholarship and great skill as a writer to her work. She trained as a philosopher and social science researcher at the Indian Institute of Technology in Bombay, and published and co-edited several books, including Psychoanalysis as a Human Science (1994), Mental Health of Indian Women (1999), Mental Health from a Gender Perspective (edited, 2001), and Gendering Mental Health (co-edited, 2015.) She also published collections of poems and short stories, and papers in research journals.

In 2004, she became a board member of the World Network of Users and Psychiatric Survivors, which established a task force that helped prompt the 2008 United Nations Convention on the Rights of Persons with Disabilities (CRPD). This groundbreaking document declared that people with disabilities should enjoy the same rights and fundamental freedoms as everyone else, and, in essence, declared that forced treatment and forced hospitalization should end.

Bhargavi then became one of the first CRPD trainers in India and soon throughout Asia, as she travelled to the Philippines, Nepal, Hong Kong, Fiji, Kingdom of Tonga, South Korea, Thailand, Sri Lanka, Indonesia, and China. The Indian government invited her to participate in the drafting of a CRPD compliant disability law, with the Bapu Trust putting CRPD compliance at the top of its agenda. The Trust, under her leadership, conducted CRPD trainings for legal professionals, social workers, and other professional groups—as well as for disability organizations—throughout Asia and the Pacific.

In 2014, the Bapu Trust created Transforming Communities for Inclusion, Asia Pacific (now TCI Global) to further this work to “ensure the full inclusion of persons with psychosocial disabilities,” as set forth in the CRPD.

In short, Bhargavi saw psychiatric users/survivors as part of a larger group of people with psychosocial disabilities who regularly suffered a loss of human rights and fundamental freedoms, with the CRPD a mandate from the UN for countries to protect those rights.

In 2016, the Bapu Trust hosted a meeting of the International Network Towards Alternatives and Rights-Based Supports (INTAR), and as Bhargavi wrote in 2017, in a post on the meeting for Mad in America, it did so in the spirit of “inclusion.”

It was at that meeting that I came to see—and admire—Bhargavi and her work through the broader lens of a global leader for human rights, with her work as a psychiatric survivor activist simply one aspect of that work. I also believe that INTAR India in 2016 has had the most profound impact of any conference that I know of on the global mental health discourse. There were representatives from the World Health Organization and the UN at the meeting (including members of the UN’s CRPD committee), and in the wake of that meeting, both the World Health Organization, under the leadership of Michelle Funk, and the UN Special Rapporteur for Health, Dainius Pūras, issued calls for radical change in psychiatric care, with a de-emphasis on drugs and the biological model, and a focus instead on the social determinants of health, and the provision of services grounded in a human rights approach.

For Mad in America, the INTAR conference led to the creation in 2018 of Mad in Asia, which was founded with support by TCI Asia and  the International Disability Alliance. Bhargavi, in concert with the founding editors Jayasree Kalathil and Jhilmil Breckenridge, envisioned this MIA affiliate as an e-zine, with the stated goal of setting forth a narrative that focuses on the “human rights and community inclusion of persons with psychosocial disabilities.” Mad in Asia, under their leadership, remained an active webzine for four years. (Jhilmil and Bhargavi spoke about their views on a MIA podcast in 2018.)

Here are remembrances of Bhargavi Davar from those who had the good fortune, in one arena or another, to engage with her in this effort for radical change, both within the world of psychiatry and beyond.

Jayasree Kalathil

Remembering is honouring.

I remember. The first time we met in 1996 at Anveshi Research Centre for Women’s Studies in Hyderabad. Your big, beautiful eyes that held an ocean of sorrow, and also the passion and confidence that foretold the force of nature you would become in the world where we fought, together with many others from around the globe, for self-determination as psychiatric survivors and persons with psychosocial disabilities.

I remember. All that I learned from you. The political conviction that you nurtured that led me away from a life in literature and into mad activism and research for over two decades. The clarity you brought, over the years, to my fledgling thoughts about madness in a mad-making world. The many discussions about women’s rage and how it could be channelled, without having to let go of it, into something useful to connect with others. The inspiration you gave to advocate, to organize, to write about the non-consensus realities some of us live in.

I remember. Your home that became my refuge through the turbulent years of my life even as you were yourself riding rough waves. Our shared love of nature, and of growing things which you took to a whole other level through AhamSetu Sustainable Lives in Cities. The way you were a compassionate, liberating mother to your daughter.

I remember. Moving to Pune to work with you, my first ‘proper’ job, at Bapu Trust for Research on Mind and Discourse, the organization you set up in memory of your mother to fight against the violence and discrimination ingrained into the institutions that were supposed to care for those with psychosocial disabilities. The days in the office in Fathima Nagar and nights on the small balcony of my one-room home, listening to you as you analyzed patriarchy and the collusion of psychiatry in disempowering women who deviated from the roles expected of us by diagnosing us with mental illness. Learning from you about the continued harm caused by the colonial notion of ‘unsoundness of mind’ that still exists in our legal frameworks and our institutions of care. Watching you lay the foundations for all that you would accomplish in your life.

I remember. Watching, now from the periphery of your life, as you went on to spread your passion and your light, through your work on the UN Convention on the Rights of Persons with Disabilities (CRPD), collaborating with global disability organisations in training disability rights advocates and their groups to strengthen their advocacy for inclusion and rights; through campaigns to end coercion in all its forms, especially in the form of the Mental Health Act; through Transforming Communities for Inclusion (TCI Asia Pacific and TCI Global); through your writing; through Seher Urban Community Mental Health and Inclusion programme; through your work in arts-based therapy.

I remember. Our first collaboration creating a mental health advocacy platform in the form of the print newsletter, aaina, and our last, this time online, the platform Mad in Asia Pacific.

I remember. The differences of opinions, and oh, the irritations and arguments stemming from our stubbornness that was well-matched in intensity. The long, sullen silences that ended with even longer chats and emails, the catchups in London, in Pune, in Leicester, in Galway, in Paris.

Most of all, I remember your unwavering belief in the idea of interconnectedness which was rooted in your deep faith in Buddhist principles. And how you went about pouring everything you were, everything you had, into making the world a kinder, more compassionate place. A whole lifetime of work dedicated to decolonising the mind.

Rest now, my friend, my love, as we, all of us who were fortunate to have known you, continue to remember.

Ayurdhi Dhar

I first read Bhargavi’s work as a young doctoral student. Over years I have gone back to her writings which have become even more pertinent with time. They taught me to not accept partial solutions and to bluntly call out falsehoods when I see it. She fought against the witch hunt of indigenous healing systems and wrote about the social nature of human emotionality. Her unwavering rights-based approach and her unrelenting criticism for Psychiatry’s many abuses are well-known, but her academic contributions are just as important as we try to decolonize Psychology in South Asia. Her voice fighting for service-user rights will be missed.

Kimberly Lacroix

One of the foremost voices representing and amplifying the experiences of persons with psychosocial disabilities from Asia has left us just a day before Buddha Poornima. The significance of this is left open to interpretation to each of us who have known her in the varied roles she held in our lives. A fierce advocate of the rights of persons with psychosocial disabilities and alternative healing traditions, she did not just challenge the mental health discourse but turned it in a way that allowed us, those of us within the closed confines of the mental health framework, to see experiences of persons across disabilities.

Today as she passes on, we carry with us the flame she ignited in us and hope we can carry her conviction and dedication through our work.

Prateeksha Sharma

Life is not fair to many, but we have a choice how to respond. Bhargavi’s choices at every stage, her progressive unfoldment, which I witnessed for a short time merit a bigger canvas. It is my hope many children whose mothers suffer thus will tune into Bhargavi’s story and see what someone can make of their life. Our choices are our destiny, after all.

If someone’s life could have been decimated by the toll schizophrenia can take it could have been Bhargavi’s. Yet, if there was someone who did exemplary work in mental health in India it was her. No doubt her work does not evoke the kind of recognition in the average person mind a celebrity would, but in the minds of hundreds of people all around the world who have a connection with the field of disability, health and mental health, in particular she will continue to inspire a fondness, appreciation and thankfulness. To overcome the damage done from early age to oneself, creating a vast ecosystem to support others and healing herself from the injustice(s) life has meted out to her, this woman stood as an exemplar of the truly heroic. When I saw it last her WhatsApp status showed a desire to be nondescript: leave no footprints. At least Bhargavi can rest in peace knowing her footsteps will remain indelible on the sands of time.

Kaaren Mathias

Bhargavi’s generosity to me was hugely instructive as we formed Burans, our mental health initiative in Uttarakhand in 2014. On several visits to Bapu Trust in Pune Bhargavi shared her ideas and wisdom with me. One key learning was the value of ‘corner conversations’ and dialogue to build knowledge and skills for mental health in communities (vs the one-way monologues that too often are used for ‘health education’.) Another approach that we find so helpful is psychosocial support groups modelled from Bapu Trust. On a personal front, Bhargavi and I loved sharing ideas about sourdough bread and the relative merits of Bajra vs Madua vs Ragi flours for a great loaf. Bhargavi’s roof garden was an oasis and definitely her happy place. Much respect and much sadness with Bhargavi’s passing from me and the Burans team.

Jaswant Guzder

I was very sad to hear that we have lost Bhargavi Davar, a great humanist and advocate for the mentally ill. She established the Bapu Trust as an extraordinary and innovative community engagement and collaborative care center, a unique mental health outreach program. Dr Sushrut Jadhav had spoken of her work for many years before I reached out to her. They shared an interest in those at the margins, reaching out to those oppressed by caste prejudice, gender violence, indigenous peoples, the poor, forgotten  and  invisible to most mental health outreach.

She was so generous in accepting my invitation to offer sessions in my course on arts and healing at the  McGill Summer School in Social and Cultural Psychiatry for many years. She was one of the special guests along with other healers from Brazil, Jamaica, Sri Lanka and USA. She shared not only a window into her team’s unique mental health  approaches integrating ritual, body work, art making , home visits and therapy offered to vulnerable patients –these individuals would never have come to a clinic. She shared her team’s outreach to villages and minority groups who integrated therapeutics with well being through dance, music, spiritual approaches. She shared their stories and creative solutions as individual and collective responses to grief and suffering.

But the most extraordinary sharing she offered  was her personal journey  from childhood watching the suffering of her mother.  Bearing witness to her mother’s life had transformed in adulthood to her remarkable empathy and creative responses to healing. As a child she had witnessed with her brother the maternal  suffering of years of indignities and distress of asylums, harassed by police and misunderstood by her family. The spiritual journey of her mother shone through in this stories,  as she became a kind spiritual benefactor for villagers who came to  her later in her life when she  was perceived as a gentle healer, welcomed by her gentle kindness. So many suffering women in India have retreated from trauma into the spiritual realms and suffered in silence.

Bhargavi was an exceptionally courageous woman and honoured us with these stories of her mother. With extraordinary humility and intelligence these early experiences of childhood led her to found an  exceptional center  for mental health care. Indeed she mirrored Gandhi’s (affectionaly called Bapu)  journey of calling for dignity, equity,  social change and  human rights. Bhargavi was an humanitarian and teacher who offered leadership and shared her revolution with all of us. She believed in the inherent strengths of communities and individuals and fostered change, mediating  between police or other agencies to find solutions  that engaged with strengths and inherent inner resources, and capacities. She offered no -judgmental approaches  and she knew how to listen deeply. And respectfully. She built teams attuned to solutions to the invisible distressed in the streets and villages of India.

Liam MacGabhann

When the predominantly male white privileged radicals of the north western hemisphere liked to talk about our alternatives in mental health; Bhargavi reminded us where we got the alternatives, who was colonised in the gathering and who is now suffering because we can afford to export psychiatry—‘the Global South’. A beacon of light who showed women, the classless and the dispossessed that inclusion can become a reality in solidarity. World changer, I will miss you.

Justin Karter

Bhargavi Davar’s life and work stand as a testament to the transformative power of activism in the realm of mental health and psychosocial disability. As a survivor of psychiatric institutions in India, Bhargavi’s personal experiences fueled her critical stance against the medical model of mental health, which she deemed violent and dehumanizing. Bhargavi dedicated over 30 years to rejecting this model, publishing books and papers that exposed its failures. In 1999, she founded the Bapu Trust, India’s first national organization challenging the mental health system’s values and practices. Her work extended to creating the largest peer support program for low-income communities in the Global South, emphasizing zero coercion and community-based support. Bhargavi’s impact was global–Through her work with TCI (Transforming Communities for Inclusion), she advocated for the rights of people with psychosocial disabilities across Asia and the Pacific. Bhargavi was committed to legal reform and action-oriented research, striving to replace the dominant psychiatric paradigms with rights-based, community-driven alternatives. On a personal note, Bhargavi was a guiding light for my own research, offering critical feedback that enriched my understanding of psychosocial disability advocacy in the Global South. Her legacy is one of dedication to transforming mental health care, advocating for inclusive policies, and fostering communities where rights and humanity are respected.

Will Hall

Peter Lehmann

What a great loss of an energetic, gifted, supportive and warm-hearted woman. My condolences go especially to her daughter. I was happy to met Bhargavi twice, the first time at the 5th Congress of the European Network of (ex-)Users and Survivors of Psychiatry (A joined congress of ENUSP and the Users and Survivors of Psychiatry) “Networking for our Human Rights and Dignity” (July 17 – 21, 2004 in Vejle, Denmark).

Sudarshan Kottai

I am extremely saddened by the demise of a gem of a person who was an interesting amalgam of intellect and humility, a rare combination to find. I was introduced to the writing, research and advocacy by Bhargavi Davar by my PhD supervisor Dr Shubha Ranganathan at Indian Institute of Technology Hyderabad opening up a whole new world of vision, ideas and philosophy in mental health which was out of reach for me as a clinical psychologist trained in mainstream mental health institutions. I was deeply influenced by her mental health activism (when most mental mental health professionals prefer to be apolitical and value-neutral) in addition to the research and scholarship on alternative approaches to mental health care stemming from lived experiences and sustained community engagement.

When I met Bhargavi for the first time at a conference on Community mental health in Kolkata in 2016, I was taken aback by the total absence of ‘unmindful disregard’ often aired by ‘senior’ academics when ‘junior’ fellows try to interact with them. I was politely requested to replace Madam with Bhargavi while addressing her. I was carefully heard and acknowledged. I staunchly feel that it is the foundation for any healing relationship but which is almost always undermined by the overdominence of protocols and diagnostic algorithms that come with check-lists of signs and symptoms. I could sense the best manifestation of genuineness, empathy, unconditional positive regard, and, most importantly, groundedness which are rare characteristics to find amongst the mainstream mental health practitioners who are increasingly becoming, objective, value-neutral, technocratic and mechanical in the quest to pose themselves as ‘scientific’ and ‘professional’. I met Bhargavi again at Anweshi Research Centre for Women’s Studies in Hyderabad in 2017 where she held a session on madness and colonialism. The pop-corn kind of to-the-point, insightful answers to questions raised by participants revealed her deep scholarship delivered in very accessible language. I remember a question on transgender people and her answer was potent enough not to vanish with the moment. “The lack of public language is the major determinant for transgender peoples’ mental health issues’’. It speaks a lot about her deep appreciation of the structural determinants of mental health drawing from local knowledge gained through long association with the stigmatised and voiceless people. To express deepest concerns in gentlest terms is an ability gained through real world engagement and doesn’t come by arm chair academic pursuits. I am reminded of the conversations on UNCRPD when I was invited by Bhargavi in 2020 to contribute to the What we need campaign of TCI Asia Pacific. I was truly humbled by the organised way in which she guided me through the UNCRPD and related complexities in mental health jurisprudence in India via multiple phone conversations. Those learnings were one of the inspirations to start a course on mental health jurisprudence at Indian Institute of Technology Palakkad.

I still use her short book Mental Health for Everyone for my teaching which explains mental health from person-centric perspectives. Her ideas about mental health interventions will continue to be guiding lights when confronting sufferings produced by stereotypes, rules and norms related to caste, class, ethnicity, gender, psychosocial disability, race, regional and religious identity, sexuality and various other social problems to plan interventions that resist, manage and subvert toxic structures that produce fatal vulnerabilites and socio-psychological pressures.

Bhargavi’s words still linger. Her message of resistance still linger. We celebrate her words. We contemplate her vision. Let us reaffirm ourselves to work towards her dream of a much more inclusive, kind and equal world.

****

Editor’s note: Anyone wishing to add a remembrance to this post can send it to rwhitaker@madinamerica.com.

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Recently I as Chairperson of Hearing Voices Network Ireland (HVNI) got to spend some time with Hearing Voices Network Athens (HVNA), in Athens. I received a warm and loving welcome from the Network there, participated in one group, would have liked to join a second, if not for an episode. We also played music—doura & guitar—ate together and hung out at the HVNA premises in Athens. There were lots of hugs and laughter, as well as the serious business of who we are.

The HVN Athens/Greece has approximately 60 members which, like HVNI hold a monthly steering Committee. They organise two self-help groups for voice-hearers in Athens City, also Herakleion, Chania, Agrinio, & Thessaloniki. There are two self-help groups for family and friends in Athens with potentially a third one to come. There is a group for collaborative practice and self-education for mental health professionals and trainees. There are 3000 people on the HVNG newsletter list.

The Athens network host many extracurricular social, arts, and café groups also. There is a yearly seminar. I was invited to be part of one, hosted by HVNA and the psychology department of the University of Thessaly. Other seminars of HVNA have been in mental health hospitals—including on the infamous psychiatric hospital on the island of Leros, which in 1989 became internationally known for the maltreatment of patients and embezzlement of funds. Also seminars have been held with user & family associations, NGOs, and universities.

HVNA have collaborated with Initiative for a Polymorphous Movement for Mental Health, family associations for mental health, collective worker’s publishing houses in Athens, city movements, events, discussions in organisations and political places, etc. They have published or intend to publish titles by Joanna Moncrieff, Lucy Johnstone, & others in the field of critical psychiatry.

The aims of Hearing Voices Networks worldwide are the same, that is to provide support, foster acceptance, meaning-making & metaphor to the condition of hearing voices, for voice-hearers and their family and friends. We prefer the term ‘voice-hearers’ rather than ‘psychosis’ or ‘schizophrenia’ as the former term is less stigmatising and more human,  common, and everyday.

As HVNA have said in their article for Asylum Magazine (Spring 2018, “Spreading the word—Eight Years of HVN Greece, Creating Space for Our Voices”) what the HVN do is “a vivid, autopoietic system that aims at producing meaning and therefore life”. It states that we as psych survivors “have been violently attacked from neoliberal politics that aim to destroy the community”. The HVN Movement aims to keep people connected. As the HVN have stated, “there is no life without connection, there is no life for human beings without meaning”. Voice-hearers participate at all levels of our actions, which empowers us. Voice-hearers challenge ourselves by exposing personal issues and, speaking through our experience, present a new perspective about ‘psychosis’ to professionals. A more human approach is adopted. Our community work brings us in touch with other social movements such as associations for human rights, antifascists movements, etc.

To quote: “a recovery movement incorporates pain, experiences significant turning points, and enjoys the benefit of companions who chart their own paths. The pain concerns more people than the person directly experiencing psychosis; included are also family members called to stand in support and manage an endless series of dilemmas, personal anxieties, fears and the duty for responsible action as prescribed by society. Also included is, the mental health professional, who is faced with the same endless series of dilemmas, personal anxieties, fears and the mandate for responsible action issued by society; and, last but not least the ordinary citizen-viewer, who is coming face-to-face with an unfamiliar condition usually stigmatised by fear, in response to which s/he is invited to reconsider ethical, ideological and personal self-evident beliefs in what is also a confusing challenge to overcome oneself.”

All HVN offer self-help groups. Those groups are not in themselves a form of therapy; rather they offer therapeutic support and education.

Experience shows that recovery is not feasible unless there are some important others available, those who will believe in the reality of the experience, who will feel the pain and suffering experienced and who will trust that recovery is possible despite the mythology about incurable schizophrenia and chronic neurodegenerative diseases that the medical gospel presents. To quote Marianna of HVNA, sister to a voice-hearer; ”things are more difficult for anyone who has suffered the disrespect and the irrational violence of a system that is unresponsive and places preconceptions, trade interests and insecurities and the contributions of insurance funds before human beings.”

The HVN Greece article in Asylum Magazine also includes a paragraph with the heading ‘The recovery of the Mental Health professional’ which quotes U. Galiberti, who points out that,  mental health professionals, deprived as they have been of their own humanity, attempt to explain man objectively like any natural phenomenon.

And in conclusion, it is important to remember that ”when the ruling psychiatric practice is dominated by one-way institutionalisation and suppression, the Network of Voice-hearing People in Greece Advocates alternative ways of dealing with mental discomfort through searching for meaning in the discomfort.”

“Overall, we strongly believe that the HVM offers a paradigm shift (in the Kuhnian sense) in the area of mental health, that it opens new horizons for a different and innovative understanding of people who have been diagnosed with schizophrenia; and most importantly: IT WORKS!”

Laugh, Love, Always.

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Here is her introduction:

The word ‘trauma’ is everywhere accompanied by ‘triggers’ and ‘trauma informed services’. There are geographical differences in how it plays out as well as its limits. It was not always like this. Initially it was specific to Post-Traumatic Stress Disorder’, a category appearing in DSM and ICD in the 1980s. But it has gradually been complexified so that it can mean almost anything. In one reading this means it is meaningless. I trace the histories to show this. I then take a detour into linguistics to show how it works at the level of language and other symbolic systems including the body which figures hugely in some writings.

I think it is this detour into linguistics that has led to the piece being labelled ‘academic’. It is certainly true that many readers will not be familiar with Continental semiotics and the unfamiliar can be read as ‘academic’. For those who know the field I will be accused of ‘oversimplifying’. A double-bind. My response is that if you are dealing with unfamiliar terrain, and one that flows from a different continent to boot, you need difficult language. But I understand the response and especially the response to stop reading. It is a risk I will take.

Trauma-informed care seems to be simply the opposite of usual care. The argument is that trauma-blind systems retraumatise those who have already been traumatised previously, which in the writings of some means practically everyone. UK writers tend to focus on coercion, which is hardly new as this is and always has been a pillar of the survivor movement. Compassion appears frequently and is a virtuous aim but is applicable to all, not just those who have been subject to trauma.

Some argue that memories of trauma are not available to consciousness as they are stored in a special part of the brain called the limbic system. As this is a system we share with our distant ancestors, this is also called the ‘reptilian brain’. Aside from the fact that modern  neurologists have all but rejected this idea of ‘localisation’ in how the brain functions, that certain functions are the province of different parts of the brain, the racist and sexist implications of this are clear. It gives a biological basis to the barbarism / civilisation ladder.

As to politics, this narrative on trauma claims to be survivor-led. So who are the activists? If nearly everyone has experienced trauma then it looks like a general uprising is being called for. It should be noted that most writings on this subject emanate from the Global North. Is trauma the ‘same’ in the Global South? The literature suggests not, that even something as clear-cut as rape means something different in, for example, Africa, than it does in Advanced Western Democracies. It means losing your land, the ability to feed your children and that is just at a material level. These are not the consequences of rape here, they are intrinsic to what it means.

Read the essay

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As an urban community mental health therapist, part of my job is meeting with new intakes and completing their comprehensive assessment—their first step in getting connected to a primary therapist and psychiatrist, and a document they’ll need if they apply for any special programs. The role always gives me anxiety, because I never know what I’ll get—except, of course, paperwork. Recently, I had an intake come in with the records from all his previous psychiatry treatment—a thick stack, easily 300 pages. He seemed to think it would help him get cash assistance, but this was just a therapy intake. He was confused, not fully out of the psychotic episode that had landed him in the hospital weeks before.

His confusion was warranted. What sense did it make that he had been through hundreds of pages of notes worth of treatment (multiple other “comprehensive” assessments and progress notes written by assorted behavioral health staff, in addition to legal language justifying his involuntary admission, the use of neuroleptic medications, and the safety of his discharge to outpatient care) and yet was still essentially un-helped? After he left our hour-long meeting, I spent another hour writing, adding on to his stack of papers.

I couldn’t help but reflect that my interview with him could have been more helpful in at least one concrete sense—that I could have paid closer attention to the emotional dimension of his predicament—had I not had the completion of this unwieldy document in mind. This scenario in public psychiatry settings is, unfortunately, a familiar one.

The topic of mental health is on the public’s mind, whether it’s the popularizing of therapy speak, the increased attention paid to severe mental illness and homelessness, or pop psychology advice on TikTok. It is clear that the federal and state governments, while they have made efforts to address what has been called a crisis—the new 988 suicide hotline, for example—have put little more than a dent in the problem. Thomas Insel points to this issue in his book Healing: Our Path from Mental Illness to Mental Health, remarking that the problem with the mental health care system in the US is that there isn’t actually a system in the first place. It’s a piecemeal, parcelized collection of public institutions, non-profits, and private agencies, funded by an equally complicated system of public and private money managed by insurance companies.

This “system,” however, is an elaborate bureaucracy with voluminous policies, as well as reams of data, assessments, and progress notes on people using care. To look at the records it produces, you would believe the result was comprehensive, thorough treatment. (I calculated that, if my clinic printed its notes, they would equal to a half ton of paper in one year!). Yet it’s a “system” that leads to the all-too-common scenario of my intake patient and his records.

Admittedly, paperwork in bureaucratic settings is an easy target, but there is something disingenuous going on when there is such a gap between the amount of writing and bureaucratic labor and actual health outcomes. Public psychiatry’s documentation creates an elaborate fiction about what treatment addresses and looks like, a fiction that under scrutiny ends up exposing the system’s many flaws, contradictions, and inefficiencies. And though a fiction, it has a real impact, interfering with the actual work of treatment: clinicians and patients are implicated in it, embedded within its rigid terms, often so thoroughly that they cannot get beyond it.

As clinicians, the terms we are given to describe our work inevitably shape the work itself, even if we don’t agree with them, and the patient is even more powerless is this configuration. The language performs a simplification and literalization of treatment, and since public psychiatry only improves itself within it own terms, it cannot see beyond this serious limitation. I believe that there is a crisis going on in our culture that mental health care does end up addressing, but where treatment is effective, it is certainly not because of the quantity or quality of the records it produces. Indeed, these records and the bureaucracy they reflect are patronizing and absurd in the face of the magnitude of human suffering psychiatry faces.

Perhaps the most apparent issue with our documentation is the material cost: a lot of public psychiatry’s already-limited resources goes to its maintenance, from the labor cost of actually producing it, to having high-paid dedicated staff whose main function is assuring documentation “compliance,” to the hiring of expensive third-party “consultants” to further address things like demonstrating medical necessity for insurance companies, HIPAA regulations, or liability/risk assessment. Further, new therapists and clinicians have to be trained in how to document “correctly,” a burdensome take for administrators because few believe this will make any difference for the patients.

These issues emerge from the conflicting interests in public health and the resulting bureaucracy, but also from the peculiar status of the discipline of psychiatry itself: where physical medicine can be described unambiguously (at least, relatively), and we can be certain of a concrete reality to which the language refers (not to mention that a physical trace might be left on the patient), psychiatry deals with something inherently subjective. And yet it’s required to document itself as if it weren’t any different, and this language, as with all of health care, become the basis for billing, proving policy compliance, and legal protection. This is a big responsibility to put on the language—it must ignore any ambiguity inherent to the enterprise of psychiatry, while also respond to external and inflexible demands. Yet, when these terms enter the medical records, they take on the status of facts.  This creates a problem in terms of the writing: it hardly flows from the nature of what its described. On the one hand, it’s experienced as a time-consuming but superfluous nuisance to be rushed through that bears only a tenuous relationship to treatment; on the other hand, there are real consequences if it’s not done correctly.

The example of the intake I did with my confused patient is illustrative. Even without any added writing, the template and its drop-down menus add up to 5 pages. I was required to go over  with him everything from the expected psychiatric history, to social history, religious affiliation, leisure activities, the minutiae of the patient’s tobacco habits, and beyond. I was supposed to use the Columbia Suicide Severity Rating Scale, a 27-item questionnaire supposedly measuring the intensity of suicidality that, if done verbatim, reads more like something an interrogator would use to ascertain guilt than a questionnaire that is meant to be helpful.

All of this is potentially clinically relevant, but it was compressed into an hour-long session, and my patient was not psychologically organized enough to truly speak about most of these items. And where he was coherent, I still felt intrusive, given that I would not even necessarily be his therapist, and certain themes had the potential to re-traumatize him. I wrote up the document as best as I could, translating his rambling discourse into the kind of concrete information the form wants. There’s something uncomfortable about this operation, giving subjective information more appropriate for the medium of poetry the weight of “facts” in a permanent medical record. And as always, I felt the absurdity of how ineffective his treatment would most likely be in comparison to the treatment ideal implied by the exhaustiveness of my assessment.

And I also couldn’t help but conclude, as I regularly conclude when I meet intake patients, is that all that really counted was that I demonstrated adherence to policy. I am a writer: I could easily enough have written an account of my interview with the intake patient that would give an accurate impression of what he was like and what might be his problems, but this document would not likely comply with the regulations. Instead I wrote a document that was largely vacuous (and certainly rushed and sloppy), yet nonetheless one of the most important documents in his cumulative records, the birth certificate of sorts of his treatment. The best I could hope for was that, tucked away somewhere between all of my box-ticking and performative language, was a paragraph or two with some genuinely useful information for another clinician to read.

The culprits of the policies that result in such unwieldy documentation are a combination of regulatory agencies (state, federal), insurance companies and their demands for demonstrating medical necessity, and internal policies that defend against liability for poor outcomes. The whole intake form, for example, is essentially a rubber stamp.

As such, I’ve come to consider our documentation as little more than internal political legitimation rhetoric, essentially covering up for our system’s stark inadequacy while pleasing regulatory agencies, whose motives are political and financial. Publicly funded psychiatry, now more than ever, is going through a legitimation crisis. It knows it doesn’t have the means to address the problem of public mental health. For one, it’s not even clear that what it’s dealing with is always pure and simple “mental health”—it is more accurate to say it is dealing with a range of social ills (poverty, anomie, the pernicious effects of social media, political division…and so on) which often present as a psychiatric illness, but which are not reducible to this category.

Further, the state of psychiatric science simply has limitations; it has not found any “cures” for the most severe forms of mental illness (it is not even decided on what should count as a mental illness in the first place). What care really takes is a robust, comprehensive system of psychiatric treatment mixed with social programs and social assistance (the likes of which Insel notes exists in Portugal)—the sort of system which our care’s rhetoric seems to imply could or should exist, but which doesn’t. There are simply not enough resources for such a system nor a willingness to invest in it.

One of the areas I was required to assess with the same intake patient was his Social Determinants of Health. The presence of this screening in healthcare settings is relatively new, and an example of an initiative aimed at improving services. Indeed, it would seem to be a step forward that clinics would introduce this more holistic perspective on health, except that they aren’t doing anything differently other than adding to the sum total of paperwork and bureaucracy—another box to tick, one more thing for auditors to verify. We can’t actually address the social determinants of health any more than we already do. And in the case of my patient, it was simply redundant—I hardly needed an intrusive, 40-plus item inventory to know that social issues were part of his “presenting problems.” This tendency to “screen” for different conditions and problems is endemic to all of healthcare, and incredibly wrong-headed, given that adding more assessment to treatment without adding more time and resources is not going to change outcomes and arguably might make things worse, given that providers are less able to focus on what they can do within their limitations.

What makes the inclusion of this kind of assessment all the more patronizing to all involved is that it is at odds with other policy currents. It acknowledges, rightly, that health problems are related to, or even in some sense are, social problems; however, there is equal pressure from the insurance companies to demonstrate the objective “medical” nature of psychiatric issues, as if they were no different than a knee injury or a bacterial infection.  Our system’s risk management policies and overall strategy of defensive documentation is another counter-current: we document that our efforts at care (or lack of) can’t be blamed for failures. Put in other terms: our documentation is near-utopian in its scope and what it thinks treatment could address; but at the same time, it has an artificially narrow medical perspective; and finally, it rigorously, with airtight legal jargon and defensive language, obviates any responsibility for its all-too-common and frankly inevitable failures.

All of this documentation adds up to a significant psychological toll on the writer—how could it not? We are pulled in different, opposing directions, and rather than become therapists, we’ve become propaganda producers, painting a picture of our work that is supposed to legitimize it, but somehow collapses in on itself in its contradictions, and certainly does not capture what it’s like to do therapy.  We’ve done nothing more than produce flat, perfunctory, meaningless language—small black shapes on a screen taking up space that are still the only acceptable basis for demonstrating that we did our job. It’s no wonder community mental health therapists often quit and move to private practice, where they can choose not to accept insurance and document their work in the way they choose.

At times when I write my notes, I start to wonder if me, my actions and my patients have any meaningful existence at all other than in the documentation language. From an institutional-regulatory perspective all that counts, anyway, is that the correct words are there to demonstrate policy adherence; what they mean or refer to is unimportant. Sometimes the distance between the language and its supposed referent is so great that it’s as if the documentation is hermetically sealed off from any reality at all, and it’s tempting to consider that we would be better off if there were no patients in the first place. Certainly, it would free us up to do a better job with our documentation.

Take for example my intake patient from above. We did have one psychotherapy session a month later, when he was added to my caseload. In the intervening weeks he had stopped taking medication. He no longer believed he had a mental health issue or diagnosis or even cared about getting benefits. Rather he wanted to talk about a scheme against him involving implants in his brain, espionage, and attempts at mind control. Per health insurance policy I’d already written a treatment plan on him, despite only having met him once, a month ago. It was required to have “measurable” objectives (e.g. “patient will sleep at least six hours a night”) tied to his diagnosis, and also per policy the patient had to agree to it. I didn’t share my plan with him; nothing could be more absurd given that he didn’t see his problems as being psychiatric or even that what we were doing was therapy—he just wanted to talk to someone. That’s what we did. I let him tell the story of what was happening. It can actually be quite fascinating to speak with someone in the throes of psychosis—in the alleged madness, there are often glimmers of enlightenment. But this is crudely attenuated by time constraints and the fore-knowledge of the note that will be written.

In this case I wrote an account of the session that made it sound like I performed a procedure on him, offering things like “cognitive restructuring” or “reality testing” and somehow demonstrating medical necessity but without invoking the idea of psychiatric illness, given that that this would be patronizing to the patient, and he would have access to the note. I also had to document that he agreed to his treatment plan, and that he posed no danger to self or others. In effect, very little of what I wrote bore any meaningful relationship to what took place between us, and the specter of an imaginary auditor, threatening to deny payment or, worse, hold me liable for the patient’s misfortune, hung over me.

After this session—sensing I wasn’t going to helpful, I can only assume—my patient didn’t attend his next appointments with me or his psychiatrist. However, because he had been deemed “high risk” due to his previous psychotic behavior, I had to call him multiple times, his family members, and even a Mobile Crisis team that tried unsuccessfully to visit him. At some point he was hospitalized again in another facility and, determining that because of a previously undisclosed drug problem we could not treat him after discharge, I had to carefully document this reasoning and my conversations with his inpatient psychiatrist and social worker (throughout this time, I had no actual contact with the patient). I thus added another few pages to his chart. It was as if I was writing about a fictitious character, whose actual existence was unimportant compared to my linguistic presentation of him, a presentation which had to carefully show how good a job I was doing while also scrupulously protecting myself and my institution against any liability—as if somehow, from the confines of my office, I had some power over this patient’s life, if only he would just comply—and because he just wouldn’t comply, there was no one to blame for his misfortune other than himself.

This state of affairs is what is meant by the cynical expression “treating the chart.” It’s a common expression that has deep implications: we don’t do real work, we perform a linguistic representation of work.

Naturally none of this is good for treatment. Aside from the material cost of the writing, there’s the psychological risk that we begin to internalize the documentation: there’s no longer a separation from the real business of treating patients and the essentially false way have to document it. Patients become bureaucratic subjects, their status as real people diminishes, and since they inevitably fail as bureaucratic subjects, we feel that we’ve failed too, our efforts are futile. Why can’t they just be helped the way our charts and rules and regulations suggest they’re supposed to be?

This not to say that people aren’t helped in public settings and that I and my hard-working colleagues (including the administration’s whose unfortunate burden it is to enforce bureaucracy) are not doing meaningful work. But this work more than likely has little representation in in the record. For example, I once helped organize a picnic for a group of patients with severe mental illness, and this was one of the more meaningful things I’ve done in my career. Yet it was written up as a “health education” event about hand-washing to prevent the spread of covid-19. Likewise, the documentation of the subtleties of building trusting, understanding relationships with therapy patients is essentially irrelevant to questions of “medical necessity” and “measurable progress” in treatment. Often, it is as if we help patients in spite of what the rhetoric says we’re supposed to be doing.

It is, of course, not surprising that a big, underfunded bureaucratic system such as the one that regulates public mental health treatment would be ineffective. That flows from the condition of late-stage capitalism. But what I am getting at here is something more than just pointing out the policies’ many problems and contradictions. Specifically with psychiatry, there is something inherently problematic about using language as the basis for regulation and administration, because something that is tenuous and ambiguous has to behave as if it’s concrete. On the most basic level, I do not want how I describe my work as a therapist to be held to this standard. And how is my language or a clinic’s language in its charts reliable as a source on which to evaluate the quality of its services? The only way that our notes could truly be used as a way to evaluate our work would be if there were few constraints on how and what we write: then, though it would be highly subjective, our choices as writers might reveal something about the treatment.

Similarly, there is no way that from the documentation we can assess whether new polices are helpful. In fact, it seems that there is a perverse logic in which, from a regulatory standpoint, policies that are documented are good because they have been documented, and they are documented because they must be good. It’s a closed system, beside which you have a different reality taking place between clinicians and patients, patients who have no true voice, and whose deviance from the treatment fiction described in the documentation is, with more of the same rhetoric, explained away.

To address this unwieldy problem of documentation in public psychiatry would take a willingness to bar interference from outside pressures—namely, insurance companies and economic/business interest—from shaping policy and enforcing regulations. Simply put, notes should be written with the sole aim of clinical utility in mind, and perhaps they should not even be made available to any other party other than healthcare providers. Policy makers need to devise ways to assess quality of care and outcomes that actually consider the experiences of clinicians and their patients and patients’ families, and not just audits. Policies and initiatives need to be commensurate with the real capacities of institutions, otherwise they are little more than empty rhetoric that is nonetheless labor-intensive to maintain and ultimately detracts from what can be done.

I don’t believe our system in its current state is in any way meaningfully responding to the surge in need for more mental health care. The simple fact that insurance reimbursements for behavioral health are stagnant is proof enough that the new initiatives side-step a fundamental problem, that the system is underfunded and neglected. I do believe we are able to help people, in spite of all our flaws—but I doubt that anyone who has had a positive experience with community mental health care will get much of a clue as to why they were helped by looking at the massive digital paper trail their treatment created. And for anyone who has been helped, there are just as many like my intake patient, who could rightly say all he got out of treatment was 300 pages of nonsense.

The post Is Public Psychiatry Responding to the Mental Health Crisis or Just “Treating the Chart?” appeared first on Mad In America.

Even from a scientific perspective, though, there is still much about schizophrenia and psychosis that we do not understand. The scientific study of these kind of phenomena is not as well established and understood as the study of most other areas of science. But why? This to me tends to suggest a subjective personal element is present that often defies the kind of analysis that falls within the domain of science. If this be true, perhaps then it is well worthwhile even for the scientific community to consider the thoughts and reflections of those who have the insight of experience.

Schizophrenia, from my experience, is brought on when the pains and anxieties associated with living become too much to bear that the individual retreats inwardly so much so that they then seek permanent refuge there. Like being sucked into a hole that is difficult to escape from, they become dysfunctional because they are no longer capable of dealing with the business of life, its duties and responsibilities.

The difference between a functional shaman and a dysfunctional schizophrenic is, to my mind, nothing more than the ability of both the shaman and the schizophrenic to retreat inwardly to the world of spirit but for the shaman to be able to pull his or her attention out of that world and back into the everyday world of living. When an individual suffers, it is natural for them to seek out a solution to their suffering, and that solution is to be found inwardly; it is the only place where it exists. It is in this inward space that the individual encounters their unconscious, where visions and communication with spirits and gods occur, where voices are heard emanating from the deepest recesses of the unconscious, sometimes disturbing, sometimes encouraging, but nonetheless, ones that must be dealt with and appeased if the individual is to find peace. It is this encounter with these spirits of the unconscious that bring about the psychotic break that is common among schizophrenics.

Among the medical profession, psychosis has become something to fear, to be avoided at all costs due to the dangers associated with it. A psychosis, however, in my opinion, is a necessary step along the process of recovery for a schizophrenic, for it is in the psychosis that the jewel of self-realisation exists; it is here that the learning experience is found, a learning experience which albeit is difficult to pass but which contains much valuable insight into what it takes to appease those spirits that bring him there.

The fall into a psychosis is not an evil in itself, there is nothing bad about it unless the individual chooses to allow himself to remain paralysed by it, to cease trying to learn from it, to understand it and overcome it. The psychosis reveals to us where our own personal weaknesses are, and as frightening as it is both for ourselves and those around us, it consequently contains the seed to our own growth. It is unrealistic to believe that every time we try something that we will succeed and overcome it and such is the case also with the lessons and tests emanating from the unconscious that manifest as psychosis.

A further misconception of repeated psychoses in an individual is to think that whenever it is experienced, the individual has relapsed back into his prior state. Given the fact that the nature of all psychoses are different, both among individuals and within the single individual who has experienced it often, each one has a different lesson for us to learn and is an opportunity for progress along our journey. In fact, the more intense the psychosis that is felt, the greater the insight to be gained from it.

Undoubtedly such experiences are scary both for the individual and those around them, but there is nothing to suggest that such experiences, if approached carefully and with the right attitude are not beneficial to the person experiencing them. And even though an individual may have many psychotic episodes throughout his or her life, sometimes there are many lessons to learn and sometimes the same test must be had many times before we can fully learn from it. For those individuals who have been placed on antipsychotic drugs as a form of treatment for their psychotic symptoms, a point of contention often arises when a patient falls back into a psychosis as to the causes of the new psychotic episode. This contention has to do with what is attributed to the underlying cause of the current psychotic episode, that is, whether it is due to the original schizophrenic condition or whether it is due to the antipsychotic drugs themselves and the changes that have occurred to the brain as a result of the long-term use of these drugs.

Whatever the reason happens to be, there is still a lesson to be learnt in the experience of the psychosis itself. Sometimes the psychosis may be due to both factors; however, in the case of the long-term use of the drugs themselves and the resulting changes that have occurred to the brain as the cause of psychosis, in my opinion the lesson to be learnt here is that the individual needs greater patience and to proceed along a more cautious and slower withdrawal process so as to give the brain enough time to respond to the changes and adapt. This will be different for different people and will depend on their drug profile, length of time they have been on them, biology, diet, environmental stressors, etc. There is no one-size-fits-all approach when it comes to drug withdrawal; however, the need for patience can be a key factor when determining success.

Let’s now talk about the drugs themselves and how they work to suppress the onset of psychosis. My stance is that antipsychotic drugs suppress an individual’s access to their unconscious mind. Contents from the unconscious mind often make themselves known to the individual through dreams, and often during waking life itself when dreams are remembered through association with things encountered while awake. Antipsychotic drugs act to suppress the manifestation of unconscious dreams from the memory of the individual. Dreams, according to the pioneering psychiatrist Carl Jung, are an important part of the personal growth of the individual, and so to suppress dreams from the conscious mind is detrimental to the individuation process. The drugs act in a sedative manner, they suppress consciousness making it difficult for the individual to focus their concentration and they inhibit the cognitive faculty from functioning at its optimal level. You can notice particularly in those who are heavily medicated with antipsychotic drugs, the slurring of speech, how thoughts/ideas are expressed much more slowly and with difficulty. This insinuates a slowing down of cognitive ability, of the capacity to reason.

I have been diagnosed with schizophrenia. Whether this diagnosis is true or not, the condition I have, whatever one wishes to call it, is spiritual in nature, not biochemical. I will however attempt to relate here why this condition seems to respond to biochemical treatment even though the condition is spiritual in nature, as this may appear contradictory. Whenever I attempt to phase off the psychiatric drugs, I can feel my inner spiritual strength growing. Naturally, this produces temptations, feelings of pride/hubris in other words, which in my own case, has in the past lead to feelings of grandeur and delusional thinking. This is a spiritual sickness.

There are two ways that such a spiritual sickness can be cured. The first way, which is the more difficult way, is to learn to deal with these feelings of grandeur by suppressing one’s ego, which involves recognising these feelings for what they are, delusional temptations. This first way of treating this spiritual sickness is the natural way and it leads to spiritual growth as it is treating the condition as it ought to be treated. Now, the second way of treating this sickness is to take away these feelings of delusional grandeur by weakening the individual’s spirit by taking away the inner spiritual strength they have cultivated. This can be achieved through humiliation. One way this can be achieved is by giving an antipsychotic drug.

The antipsychotic drug functions by altering the chemical processes in the brain but there is no body of research which tells scientists what healthy doses of brain chemicals are; it is merely based on experimentation on a case-by-case basis. However, whatever these drugs seem to be doing to the brain, they have the effect of taking energy away from the individual, of making them tired and of decreasing their control over bodily appetites, whether eating and drinking or sexual. In other words, the individual’s instinctual drives are activated.

Evidence of this is also reported in the side effects that people who take these drugs tend to report. Therefore, by taking energy away from the individual, by making them tired and by taking away the ability to control bodily appetites, they are weakened and their spiritual strength is thereby taken away slowly over time as the drug is administered. This is the second way of treating the spiritual sickness known as schizophrenia. This second way, however, robs the individual of spiritual growth. As humans we are compelled to learn and to grow and therefore, this second way of dealing with this sickness for many of us does not feel right and we fight back against the system that attempts to restrain us in this way. This at least is what I have noticed in myself.

Do psychiatrists have a right to enforce antipsychotic drugs on an individual without knowing what it feels like to take them? I have been on an off these drugs many times during my life for prolonged periods in both cases and insightfully know what it feels like to both take and not to take these drugs. Contrast this to the individual who has been on these drugs for a singular long period for most of their life and with the individual who has never been on these drugs at all. In the former case, the individuals experience of being on these drugs for a prolonged period of time has become the accepted normality of their existence and they have very little to compare it to other than the distant memory of an early period of life absent these drugs. For the individual who has never been on antipsychotic drugs, the insight is completely lacking; there is no way they could make a comparison.

Obviously, from the point of view of the psychiatric establishment, we must weigh up the pros and cons, and determine whether it is better to sacrifice some of the side effects associated with taking these pills in exchange for a relatively “normal” life. Let us pause for a moment and consider what is actually being said here. Consider the case of someone being numbed with alcohol to help them escape from their psychological problems. Alcohol does have the effect of making people forget their psychological problems, and from my own experience, antipsychotic drugs aimed at “managing” schizophrenia have a similar numbing effect, although they work by numbing the individual’s sensibility to the world of spirit.

The schizophrenic is he who is, in a manner of speaking, oversensitive to the world of spirit and, at some time in his earlier life, has called on the help of the spirits to aid him in his quest to overcome whatever problems he may have been facing. For most schizophrenics, this usually happens at the point of becoming an adult and assuming responsibility for one’s life. In many cases, it was brought about by a need and a desire to grow inwardly as a person. Therefore, for many, the approach by the psychiatric establishment to administer and enforce the use of drugs to “treat” or “manage” their condition is to rob these individuals of their desire and need to grow as a spiritual beings.

In other words, it is antithetical to the very reasons that caused the onset of schizophrenia to begin with, and is therefore a strategy that is doomed to fail for many as they refuse to comply with such treatment.

The post Psychosis Treatment: Numbing the World of Spirit appeared first on Mad In America.

After decades of research yielding little clinical or practical application, many critical clinicians across disciplines believe the biomarker search is fruitless. Some neuroscientists argue that we should rather focus our efforts on the upstream social and structural factors, such as trauma and inequity, that create the conditions for mental health concerns to arise. Psychiatrist Awais Aftab argues that “biomarkers can be approached in a more conceptually robust manner,” skeptical to the idea that biomarkers can be used to validate pre-defined diagnostic categories, but nonetheless advocating for a more integrative approach. Should we give up the search for biomarkers altogether? If we do, who might we be leaving behind?

The biomarker debate is one of many that opens up many questions about the relationship between the mind and body in mental health. Perhaps one of the most insidious barriers to truly supportive treatment is that psychiatry is stuck in an identity crisis, facing deep philosophical conundrums. On the one hand, the biopsychosocial model is the most proliferated, which in theory acknowledges psychological and societal factors alongside biological ones, but slapping these three domains together within one model does little to elucidate the interplay between them. Meanwhile in research and practice, it operates more often than not as a “bio bio bio model.”

Both traditional and critical psychiatry have long histories of separating people into two camps: those with “organic” disorders or brain diseases (e.g. autoimmune encephalitis or Parkinson’s) that can cause severe psychological impacts typically fall under neurology’s purview, and those with “psychological” or functional origins (e.g. depression and bipolar) are considered psychiatry’s domain. However, the boundaries of organic and psycho genesis are far too blurry for this dichotomy to be a very useful way of categorizing mind-body concerns. For us to be able to move forward in a non-reductive, non-pathological, and holistic way, psychiatry will have to sort out its philosophy on the relationship between the mind and body.

The mind-body problem in psychiatry has very real implications for those who suffer at the intersection of mental health and chronic illness, which is a much larger group than one might expect. Studies show that up to 74% of people who are diagnosed with a psychiatric condition also have a chronic physiological illness, as well as higher rates of mental health conditions in chronic illness populations. The majority of psychiatrized people are also multiply marginalized, and often trauma survivors. Studies show that experiences of trauma and PTSD are associated with developing chronic health issues and other mental health diagnoses.

People often interpret this interaction through a reductionist lens in regards to the mind and body, asserting that one is simply mentally ill because they’re physically sick or disabled, or they’re sick and disabled because they’re mentally ill. This creates an insidious feedback loop that does little to identify underlying causes of suffering. The reality is often far more complex and indicates the importance of elucidating how the body-mind manifests ill health and how these interactions between what we call ‘mind’ and ‘body’ occur. Both mental and physical health conditions arise from a set of multiple factors, many of which can be said to manifest from a sick society and a system that’s designed for ill health.

Anecdotally, in my own practice as a holistic counselor, I have worked with a substantial number of people at this intersection. I have seen those whose chronic Lyme disease manifested predominantly in anxiety, panic, and compulsions, those whose hallucinations seemed to begin at the same time as a major trauma and the onset of a debilitating autoimmune disease, those whose delusions and paranoia and mania stopped when they were treated for celiac disease and addressed food allergies, and those whose depression lessened dramatically after they treated chronic inflammation. My own lived experience reflects a similarly complex interplay between childhood and developmental complex trauma, autoimmunity, and psychosis.

It would be far too reductionist to propose any kind of singular model to explain these overlaps, and yet the health outcomes for those of us who simultaneously suffer mentally and physically depend on our ability to make sense of these experiences. Traditional biomedical psychiatry, intent on finding biomarkers, seems to be uninterested in truly supporting those who find themselves at the intersection of multiple chronic health concerns. Nor does the field seem amenable to seeing mental health conditions as manifestations of broader social and physiological dysfunction, rather than discrete disorders themselves. The survival of psychiatrized people may just depend on it.

This is a crucial time of transition for psychiatry, and current developments are occurring beneath the public’s awareness. New(er) projects in psychiatry have emerged such as the Research Domain Criteria (RDoC) by the NIMH, which seeks to redefine diagnostics from a dimensional approach instead of the statistically unreliable, outdated and invalid DSM categories, and precision psychiatry, which aims to use multiple biomarker tests to individualize treatment protocols. The push to individualize care rather than give everybody the same medication and treatment, and to move beyond the DSM, are productive goals. Both indicate a willingness to learn from past mistakes and shortcomings, but not enough to truly reconsider foundational assumptions about how mental health concerns manifest. Many wonder: is it possible these are simply examples of traditional disease-centered approaches dressed up in new clothes?

Over the last few decades, two related and emergent medical disciplines have advanced useful and practical insights for mental health treatment: functional psychiatry and psychoneuroimmunology. Psychoneuroimmunology is a medical discipline that examines the links between brain health, the immune system, nervous system, endocrine system, and mental health. Prominent researchers in this field such as Edward Bullmore, head of psychiatry at Cambridge University, have found immune dysfunction and inflammation underlying experiences labeled depression and schizophrenia. Additionally, a 2023 study in JAMA found that “poor body health, particularly of the metabolic, hepatic and immune systems, was a more marked manifestation of mental illness than brain changes,” showing the need to look beyond the brain and to other body systems to identify ways to support those with mental health concerns.

Functional psychiatry looks for the multiple underlying roots of mental health issues, as illustrated by the field’s tagline: “one condition, many causes; one cause, many conditions.” For example, a condition like depression can both contribute to, and be caused by, multiple other health conditions. A functional psychiatrist may consider one patient’s depression to be the compounding result of childhood trauma and hypothyroidism, and another’s to be the result of metabolic issues, autoimmunity, and food allergies. While these fields have made astounding advancements in complicating traditional biomedical psychiatry narratives, they remain largely inaccessible to the public for a whole host of systemic reasons. They also tend to rely at times on scientifically invalid tests due to lack of adequate research funding, and treatment remains inaccessible due to lack of coverage from insurance. While these models are steps in the right direction, they don’t resolve systemic issues that contribute to poor whole-body health.

Clinical psychologist Bruce Levine observes that, “once radical critiques of psychiatry are now mainstream.” Although a growing number of people are aware of problems with psychiatric treatment, what remains taboo is challenging fundamental assumptions that equate mental health concerns with biomedical disorders. Contemporary mad movement activists have worked tirelessly to illuminate the influence of social and structural dynamics on ill health, highlighting racism, classism, and colonial capitalism’s role in how we come to conceptualize what’s ‘normal’, and the carceral nature of mental health ‘treatment’ of those who are suffering. As critical lenses in mental health become more popularized across social media and pollinate adjacent movements, it becomes more important than ever that we bring awareness to all the factors that lead to mind-body suffering and chronic disability. It’s crucial that we include the whole body in our analysis of mental health.

Decades of dominant biomedical rhetoric that reduces mental health concerns to mere imbalances in neurotransmitters have led to a polarized environment, where critical resistance can also remain tethered to a narrow framework, even in its opposition to it. The dialogue around biomedical psychiatry all too often presents a false dichotomy: mental health concerns are either rooted in the brain or society. We can and should continue to locate the dysfunction within society, but we can no longer afford to turn a blind eye to biological dysfunction as intricately tied to societal dysfunction. If we are too willing to throw biology and the body out the window, I fear that we’ve left ourselves out of crucial conversations and will exacerbate the harm done to those who suffer at the intersection of mental and physical health concerns and disability. It’s our responsibility to continue to complicate the narrative around root causes of mental health concerns, and ground in a mad and disability justice framework. We currently face an important opportunity to develop more holistic and generative frameworks for understanding the complex interplay between what we consider mental, biological, and societal. What if we can draw on critical neuroscience research to open up new pathways for those suffering?

Modern neuroscientific findings seem to actually bolster some critiques of the mad movement, such as the immense impact of our social environment on our mental health, and the brain’s dynamic ability to heal and recover from neurological and mental health concerns. Rather than validating reductive biomedical science that narrowly considers genetics and neurotransmitters in isolation, broader neuroscience findings suggest a much different story about brains, bodies, and minds. Famous neuroscientist Lisa Feldmann Barrett debunks common myths and suggests better ways to understand our brain grounded in neuroscientific findings in her book Seven and a Half Lessons of the Brain. She explains that our brains are complex networks and there are multiple ways for the brain to realize any specific state of mind, a concept called degeneracy. Our brains have immense capacity to change, learn, and adapt to novel experiences, a popular concept called neuroplasticity.

Additionally, brains don’t produce a single kind of ‘normal’ mind, and there doesn’t seem to be a unifying human nature in regards to our ways of thinking and being; instead, our brains are primed for diversity and heterogeneity. Our emotions are not hardwired, innate features, nor are they located in distinct parts of the brain in opposition to ‘rationality’ or cognitive facets. Our highly complex brains evolved along with, and in direct relationship to, increasingly complex human bodies and organs, making other bodily systems intricately tied to the brain. And perhaps most meaningfully, our brains are formed by our environment, so much so that considering ‘nature’ as separate from ‘nurture’ is senseless, according to Barrett.

While there’s naturally much debate about organizing principles of the brain, or how we should interpret emerging findings, many of the questions that neuroscientists are pondering open up space for questioning prior assumptions about the mind, emotions, and mental health. Ultimately, both traditional and critical psychiatry communities will have to dramatically revise the still-dominant reductive theory of mind and mental ‘illness.’

This process of elucidating the relationship between mind, body, and society, for the sake of evolving and improving treatment for mental and physical health, will require collaboration across fields and interdisciplinarity. We need more philosophers, neuroscientists, and lived experiencers working together to excavate previously held assumptions and propose better care. Cross-disciplinary work is especially crucial to avoid the pitfalls of dressing up old paradigms with new fancy labels.

Naturally, not all facets of mental difference or what gets labeled as “dysfunction” in the eyes of capitalist-driven norms will require medical attention. There’s a way for us to honor neurodiversity, while also not leaving behind those who suffer from chronic illness and who desire support with whole body health. I don’t dare to offer a complete or definitive solution to our problems, but I become increasingly curious how critical neuroscience can help the mad movement, and what a disability-justice centered neuroscience can look like in service of whole health.

The post Who Do We Leave Behind When We Ignore the Body? Why Critical Neuroscientists and Mad Activists Must Work Together appeared first on Mad In America.

The article says that children do not outgrow their ADHD diagnosis. However, research shows that many children do this. And 50% more children born in December are treated with ADHD medication than those born in January in the same school class, which is simply because they are more immature.

The article says that people get an explanation for their problems when they receive an ADHD diagnosis. But the diagnosis doesn’t explain anything. It is just a name for a behaviour that lies at one end of a normal distribution for behaviour. Poul behaves in such a way that we choose to call it ADHD. Then we can’t say that ADHD is the reason why Poul behaves like he does. This is circular evidence, also called a tautology.

For the same reason, one cannot have ADHD, which the article claimed. We can have a car or a dog, but not ADHD. It’s not something that exists in nature that can attack us like bacteria can. It’s just a name for a certain behaviour.

It is therefore also misleading to say that 2-3% of middle-aged and older people “live with ADHD.” You can live with a cancer, which really exists, but “living with ADHD” just means living with yourself, which we all do, so this is also an empty statement.

The article mentions that ADHD has a genetic element. Surely, our children resemble ourselves to some extent in the way they behave, but that does not mean that we can find the “disease” (which is not a disease) in the genes. Genetic association studies have not proven anything, and it is not true either that people with ADHD have smaller brains than others, as it was claimed in much touted Lancet article.

The article notes that a named person, diagnosed at age 58, has clearly noticed the effect of the medicine against ADHD. It regulates her mood and behaviour and dampens her many emotional outbursts. Well, this is not exactly what was reported in the randomised trials, but science by anecdotes is very popular among journalists, just as it is among alternative practitioners.

I wrote a short comment to the newspaper, which I expected them to publish, as the article contained factual errors. But oh no! The debate editor wrote to me that they, unfortunately, could not publish it, as the article I referred to did not contain factual errors. “Your appeal is based on your views – and that is of course perfectly fine, but there is no question of erroneous facts on our part – all arguments and statements can be substantiated. But journalist Tea Krogh Sørensen would like to talk to you for a follow-up article about the debate around diagnoses, so I would encourage you to contact her by email.”

I wrote to Tea that I found it “very disappointing that the debate editor writes that there are no errors in the article, when objectively there are errors. It has nothing to do with my ‘views,’ and what I write has nothing to do with opinions, but is based on facts, and there are also logical fallacies (tautologies). I assume you got the information you bring in the article from a psychiatrist.”

We spoke on the phone and when I checked her sources, they confirmed that some children outgrow their diagnosis. So, her article was not correct. The only exception was the patient organisation MIND.

My talk with Tea led nowhere. I tried to convince her that she needed to be critical and not just accept what she was told by leading psychiatrists, and I offered her an easy example. The FDA, based on a meta-analysis of 100,000 patients who had participated in placebo-controlled trials, warns against using depression drugs in children because they increase their risk of suicide. At the same time, leading psychiatrists in Denmark, e.g. professors Poul Videbech and Lars Kessing, claim that the drugs protect children against suicide.

Tea was unable to understand my argument. She said something about different views, and other types of evidence, and when I said randomised trials were the best evidence we have and asked her if she believed more in psychiatrists than in drug regulators, I came nowhere.

Tea said she wanted to interview me, but I shall decline. It can only go wrong. When I explain such simple things to lay people, some of them having no education at all, they always understand me. But journalists? They must be among those with the lowest intelligence of all trades. There are some excellent ones, but my collaboration with average journalists have been intensely frustrating.

The post How Danish Journalism Misleads About Psychiatry appeared first on Mad In America.

A pioneering community mental health service in West Cork has been shut down—even though a report obtained by Mad in Ireland found it should be upscaled across the Health Service Executive (HSE) at national level, as it has “the potential to improve the quality of life for individuals experiencing severe and enduring mental illness.”

The closure by the HSE of the West Cork Open Dialogue service is a retrograde step, as an independent expert report found it “ought to be considered alongside other and existing treatment options within West Cork mental health services with more training made available to staff across the service, to ensure that the underpinning of Open Dialogue evolves across the service.”

Expert report

The report, which has to date not been published by the HSE, was carried out by the National Suicide Research Foundation and a group of experts in mental health. An executive summary of the report has been obtained by Mad in Ireland and is published here for the first time. It is the first in-depth study in Ireland to explore and evaluate the tenets of Open Dialogue and its findings provide key insights into how the West Cork Open Dialogue service was experienced by service users, their families and clinicians and, according to the report’s authors, “serves as a marker in how mental health practices should be delivered.”

Executive Summary_Open Dialogue_

The report found that:

• Open Dialogue is considered both as a therapeutic approach to support people dealing with an acute mental health crisis and a way of organising clinical care in response to the mental health crisis. As a therapeutic approach, Open Dialogue places the person at the centre of their recovery, mirroring the values and principles of a recovery-oriented model of healthcare.
• Open Dialogue demonstrates that increased well-being is possible despite living with an enduring mental illness and that recovery is based not just on treating the symptoms but on empowering people, enabling them to be autonomous and self-directed, in pursuing their goals and dreams whilst providing tailored care and treatment.

• The dominant biomedical model of healthcare that currently exists within the HSE is inadequate to meet the complex needs of the individuals who present with an enduring mental illness and that a cultural shift is required across mental health services to ensure that services focus on the person through the lens of their whole life, and not just solely on symptom reduction.

In the report, service users and their families spoke of the inherent difference of working with a team of professionals that seemed to “truly care about their mental well-being and felt that compassion and humanity in which the network meetings were held was key to the recovery process. Of note was the shared sense of mutuality that peer support workers brought to the table in sharing their lived experience of living and managing to move forward whilst experiencing mental health difficulties.”

Dominance of the medical model

One of the barriers to recovery from mental health distress cited in the report is dominance of the medical model of mental health treatment that looks at people through a particular lens and mainly treats symptoms as biological rather than psychological. Service users expressed frustration at being prescribed psychotropic medication as the first or only alternative as opposed to other interventions.

One person said:

“When I attended my GP when I was going through quite bad depression, I was quite ill and all they wanted to do was give you antidepressants and that seems to be the same for pretty much for any (..) that just. Seems to be the first port of call to give you antidepressants. So it took me a long time to actually get to see anybody to talk to and I would like that to have been a lot quicker.”

In response to questions about the service closure, the HSE told the Southern Star newspaper in January that “a decision was made to not accept any new referrals to the Open Dialogue programme as this approach is integrated into the multi-disciplinary delivery of care.” The HSE statement called Open Dialogue “talk therapy” and said talk therapy is on offer in mainstream services.

Whilst talk therapy may be on offer in mainstream services, Open Dialogue as a systemic needs-adapted approach (as opposed to a talk therapy) is now not available in West Cork. Nor could it be integrated into a bio-psychiatric model given the clear philosophical and clinical contradictions between both models. The service was the first Open Dialogue service in Ireland, representing at the time of introduction an innovative progressive mental health service in West Cork. Ironically, whilst other mental health services around the country are only recently beginning to embrace Open Dialogue and other post-psychiatric contemporary best practices, we see an early innovator service in retrograde. Outside of the HSE’s statement, no other communique with people who would have been involved in any way with the service corroborates what it states in relation to service integration. On the contrary, the message is clear: Open Dialogue is gone from Cork.

Adrienne Murphy, who was an Open Dialogue practitioner with the West Cork team, confirmed to Mad in Ireland: “Open Dialogue was not integrated into any West Cork service once they stopped taking referrals and there appears to be no longer support for Open Dialogue in the services here.”

The Southern Star newspaper also quoted a healthcare professional, who was one of the founders of the service.

“It is very sad to hear that the clinic has been closed and difficult to understand when the research recommends for the expansion of the approach,” she said.

“Despite this very disappointing decision, I am extremely proud to have been involved in developing this service and to have worked with wonderful families and colleagues,” she added.

Progressive rights-based service

The West Cork Open Dialogue service, written about in detail here, was established in 2012, a progressive move at the time, under Dr Pat Bracken, psychiatrist, and co-founder of the Critical Psychiatry Network.

Open Dialogue is seen as an alternative to medical model treatments that are largely based on medication. It emphasises dialogue and shared understanding between service users and their support network and it was endorsed by the World Health Organisation’s Guidance on Community Mental Health Services: Promoting Person-Centred and Rights-Based Approaches report as an example of a service which engenders a human rights-based approach.

Internationally, Open Dialogue is increasingly gaining traction as a real alternative to the medical model in helping people recover from mental health difficulties.

Within Open Dialogue, psychiatric medication is used in a need-adapted manner. This means therapeutic activities are planned and carried out flexibly and individually in each case so that they meet the real and changing needs of the patients as well as of their family members. Medication is rarely initiated at the beginning of the treatment contact.

As reported by Mad in Ireland last month, new research from Finland has suggested that mental health services based on the Open Dialogue approach to mental health may reduce psychotropic drug treatment in young people.

The research suggests that the iatrogenic risks of long-term psychotropic treatment can be minimised by reducing the amount of medication prescribed, which may be a factor in the promising outcomes in treatment strategies such as the Open Dialogue approach.

The value-base and proven positive outcomes of Open Dialogue make it a unique project that needs to be expanded rather than closed under the pretext of ‘integration’.

The post Irish Open Dialogue Shut Down—Despite Expert Report Stating It Should Be Scaled Up appeared first on Mad In America.

In 2013, I estimated that our prescription drugs are the third leading cause of death after heart disease and cancer,¹ and in 2015, that psychiatric drugs alone are also the third leading cause of death.² However, in USA, it is commonly stated that our drugs are “only” the fourth leading cause of death.^3,4 This estimate was derived from a 1998 meta-analysis of 39 US studies where monitors recorded all adverse drug reactions that occurred while the patients were in hospital, or which were the reason for hospital admission.⁵

This methodology clearly underestimates drug deaths. Most people who are killed by their drugs die outside hospitals, and the time people spent in hospitals was only 11 days on average in the meta-analysis.⁵ Moreover, the meta-analysis only included patients who died from drugs that were properly prescribed, not those who died as a result of errors in drug administration, noncompliance, overdose, or drug abuse, and not deaths where the adverse drug reaction was only possible.⁵

Many people die because of errors, e.g. simultaneous use of contraindicated drugs, and many possible drug deaths are real. Moreover, most of the included studies are very old, the median publication year being 1973, and drug deaths have increased dramatically the last 50 years. As an example, 37,309 drug deaths were reported to the FDA in 2006 and 123,927 ten years later, which is 3.3 times as many.⁶

In hospital records and coroners’ reports, deaths linked to prescription drugs are often considered to be from natural or unknown causes. This misconception is particularly common for deaths caused by psychiatric drugs.^2,7 Even when young patients with schizophrenia suddenly drop dead, it is called a natural death. But it is not natural to die young and it is well known that neuroleptics can cause lethal heart arrythmias.

Many people die from the drugs they take without raising any suspicion that it could be an adverse drug effect. Depression drugs kill many people, mainly among the elderly, because they can cause orthostatic hypotension, sedation, confusion, and dizziness. The drugs double the risk of falls and hip fractures in a dose-dependent manner,^8,9 and within one year after a hip fracture, about one-fifth of the patients will have died. As elderly people often fall anyway, it is not possible to know if such deaths are drug deaths.

Another example of unrecognised drug deaths is provided by non-steroidal anti-inflammatory drugs (NSAIDs). They have killed hundreds of thousands of people,¹ mainly through heart attacks and bleeding stomach ulcers, but these deaths are unlikely to be coded as adverse drug reactions as such deaths also occur in patients who do not take the drugs.

The 1998 US meta-analysis estimated that 106,000 patients die every year in hospital because of adverse drug effects (a 0.32% death rate).⁵ A carefully done Norwegian study examined 732 deaths that occurred in a two-year period ending in 1995 at a department of internal medicine, and it found that there were 9.5 drug deaths per 1000 patients (a 1% death rate).¹⁰ This is a much more reliable estimate, as drug deaths have increased markedly. If we apply this estimate to USA, we get 315,000 annual drug deaths in hospitals. A review of four newer studies, from 2008 to 2011, estimated that there were over 400,000 drug deaths in US hospitals.¹¹

Drug usage is now so common that newborns in 2019 could be expected to take prescription drugs for roughly half their lives in USA.¹² Moreover, polypharmacy has been increasing.¹²

How many people are killed by psychiatric drugs?

If we want to estimate the death toll of psychiatric drugs, the most reliable evidence we have are the placebo-controlled randomised trials. But we need to consider their limitations.

First, they usually run for only a few weeks even though most patients take the drugs for many years.^13,14

Second, polypharmacy is common in psychiatry, and this increases the risk of dying. As an example, the Danish Board of Health has warned that adding a benzodiazepine to a neuroleptic increases mortality by 50-65%.¹⁵

Third, half of all deaths are missing in published trial reports.¹⁶ For dementia, published data show that for every 100 people treated with a newer neuroleptic for ten weeks, one patient is killed.¹⁷ This is an extremely high death rate for a drug, but FDA data on the same trials show it is double as high, namely two patients killed per 100 after ten weeks.¹⁸ And if we extend the observation period, the death toll becomes even higher. A Finnish study of 70,718 community-dwellers newly diagnosed with Alzheimer’s disease reported that neuroleptics kill 4-5 people per 100 annually compared to patients who were not treated.¹⁹

Fourth, the design of psychiatric drug trials is biased. In almost all cases, patients were already in treatment before they entered the trial,^2,7 and some of those randomised to placebo will therefore experience withdrawal effects that will increase their risk of dying, e.g. because of akathisia. It is not possible to use the placebo-controlled trials in schizophrenia to estimate the effect of neuroleptics on mortality because of the drug withdrawal design. The suicide rate in these unethical trials was 2-5 times higher than the norm.^20,21 One in every 145 patients who entered the trials of risperidone, olanzapine, quetiapine and sertindole died, but none of these deaths were mentioned in the scientific literature, and the FDA didn’t require them to be mentioned.

Fifth, events after the trial is stopped are ignored. In Pfizer’s trials of sertraline in adults, the risk ratio for suicides and suicide attempts was 0.52 when the follow-up was only 24 hours, but 1.47 when the follow-up was 30 days, i.e. an increase in suicidal events.²² And when researchers reanalysed the FDA trial data on depression drugs and included harms occurring during follow-up, they found that the drugs double the number of suicides in adults compared to placebo.^23,24

In 2013, I estimated that, in people aged 65 and above, neuroleptics, benzodiazepines or similar, and depression drugs kill 209,000 people annually in the United States.² I used rather conservative estimates, however, and usage data from Denmark, which are far lower than those in USA. I have therefore updated the analysis based on US usage data, again focusing on older age groups.

For neuroleptics, I used the estimate of 2% mortality from the FDA data.¹⁸

For benzodiazepines and similar drugs, a matched cohort study showed that the drugs doubled the death rate, although the average age of the patients was only 55.²⁵ The excess death rate was about 1% per year. In another large, matched cohort study, the appendix to the study report shows that hypnotics quadrupled the death rate (hazard ratio 4.5).²⁶ These authors estimated that sleeping pills kill between 320,000 and 507,000 Americans every year.²⁶ A reasonable estimate of the annual death rate would therefore be 2%.

For SSRIs, a UK cohort study of 60,746 depressed patients older than 65 showed that they led to falls and that the drugs kill 3.6% of patients treated for one year.²⁷ The study was done very well, e.g. the patients were their own control in one of the analyses, which is a good way to remove the effect of confounders. But the death rate is surprisingly high.

Another cohort study, of 136,293 American postmenopausal women (age 50-79) participating in the Women’s Health Initiative study, found that depression drugs were associated with a 32% increase in all-cause mortality after adjustment for confounding factors, which corresponded to 0.5% of women killed by SSRIs when treated for one year.²⁸ The death rate was very likely underestimated. The authors warned that their results should be interpreted with great caution, as the way exposure to antidepressant drugs was ascertained carried a high risk of misclassification, which would make it more difficult to find an increase in mortality. Further, the patients were much younger than in the UK study, and the death rate increased markedly with age and was 1.4% for those aged 70-79. Finally, the exposed and unexposed women were different for many important risk factors for early death, whereas the people in the UK cohort were their own control.

For these reasons, I decided to use the average of the two estimates, a 2% annual death rate.

These are my results for USA for these three drug groups for people at least 65 years of age (58.2 million; usage is in outpatients only):^29-32

A limitation in these estimates is that you can only die once, and many people receive polypharmacy. It is not clear how we should adjust for this. In the UK cohort study of depressed patients, 9% also took neuroleptics, and 24% took hypnotics/anxiolytics.²⁷

On the other hand, the data on death rates come from studies where many patients were also on several psychiatric drugs in the comparison group, so this is not likely to be a major limitation considering also that polypharmacy increases mortality beyond what the individual drugs cause.

Statistics from the Centers for Disease Control and Prevention list these four top causes of death:³³

Heart disease: 695,547
Cancer: 605,213
COVID-19: 416,893
Accidents: 224,935

COVID-19 deaths are rapidly declining, and many of such deaths are not caused by the virus but merely occurred in people who tested positive for it because the WHO advised that all deaths in people who tested positive should be called COVID deaths.

Young people have much smaller deaths risk than the elderly, as they rarely fall and break their hip, which is why I have focused on the elderly. I have tried to be conservative. My estimate misses many drug deaths in those younger than 65 years; it only included three classes of psychiatric drugs; and it did not include hospital deaths.

I therefore do not doubt that psychiatric drugs are the third leading cause of death after heart disease and cancer.

Other drug groups and hospital deaths

Analgesics are also major killers. In USA, about 70,000 people were killed in 2021 by an overdose of a synthetic opioid.³⁴

The usage of NSAIDs is also high. In USA, 26% of adults use them regularly, 16% of which get them without a prescription³⁵ (mostly ibuprofen and diclofenac).³⁶

As there seems to be no major differences between the drugs in their capacity to cause thromboses,³⁷ we may use data for rofecoxib. Merck and Pfizer underreported thrombotic events in their trials of rofecoxib and celecoxib, respectively, to such an extent that it constituted fraud,¹ but in one trial, of colorectal adenomas, Merck assessed thrombotic events. There were 1.5 more cases of myocardial infarction, sudden cardiac death or stroke on rofecoxib than on placebo per 100 patients treated.³⁸ About 10% of the thromboses are fatal, but heart attacks are rare in young people. Restricting the analysis to those aged at least 65, we get 87,300 annual deaths.

It has been estimated that 3700 deaths occur each year in the UK due to peptic ulcer complications in NSAID users,³⁹ corresponding to about 20,000 deaths each year in USA. Thus, the total estimate of NSAID deaths is about 107,000.

If we add the estimates above, 315,000 hospital deaths, 390,000 psychiatric drug deaths, 70,000 synthetic opioid deaths, and 107,000 NSAID deaths, we get 882,000 drug deaths in the United States annually.

Many other commonly used drugs than those mentioned above can cause dizziness and falls, e.g. anticholinergic drugs against urinary incontinence and dementia drugs, which are used by 1% and 0.5% of the Danish population, respectively, even though they do not have any clinically relevant effects.^1,2

It is difficult to know what the exact death toll of our drugs is, but there can be no doubt that they are the leading cause of death. And the death toll would be much higher if we included people below 65 years of age. Moreover, from the official number of deaths from heart disease, we would need to subtract those caused by NSAIDs, and from accidents, deaths by falls caused by psychiatric drugs and many other drugs.

If such a hugely lethal pandemic had been caused by a microorganism, we would have done everything we could to get it under control. The tragedy is that we could easily get our drug pandemic under control, but when our politicians act, they usually make matters worse. They have been so heavily lobbied by the drug industry that drug regulation has become much more permissive than it was in the past.⁴⁰

Most of the drug deaths are preventable,⁴¹ above all because most of the patients who died didn’t need the drug that killed them. In placebo-controlled trials, the effect of neuroleptics and depression drugs has been considerably below the least clinically relevant effect, also for very severe depression.^2,7 And, despite their name, non-steroidal, anti-inflammatory drugs, NSAIDs do not have anti-inflammatory effects,^1,42 and systematic reviews have shown that their analgesic effect is similar to that of paracetamol (acetaminophen). Yet, most patients with pain are recommended to take both paracetamol and an NSAID over the counter. This will not increase the effect, only the risk of dying.

Most tragically, leading psychiatrists all over the world do not realise how ineffective and dangerous their drugs are. A US psychiatrist, Roy Perlis, professor at Harvard, argued in April 2024, that depression pills should be sold over the counter because they are “safe and effective.”⁴³ They are highly unsafe and ineffective. Perlis also claimed that depression drugs do not increase the risk of suicide in people older than 25, which is also wrong. They double suicides in adults.^23,24

Perlis wrote that “Some still question the biological basis of this disorder, despite the identification of more than 100 genes that increase depression risk and neuroimaging studies showing differences in the brains of people with depression.” Both these claims are plain wrong. Genetic association studies have come up empty-handed and so have brain imaging studies, which are generally highly flawed.⁴⁴ People are depressed because they live depressing lives, not because of some brain disorder.

References

1 Gøtzsche PC. Deadly medicines and organised crime: How big pharma has corrupted health care. London: Radcliffe Publishing; 2013.

2 Gøtzsche PC. Deadly psychiatry and organised denial. Copenhagen: People’s Press; 2015.

3 Schroeder MO. Death by prescription: By one estimate, taking prescribed medications is the fourth leading cause of death among Americans. US News 2016; Sept 27.

4 Light DW, Lexchin J, Darrow JJ. Institutional corruption of pharmaceuticals and the myth of safe and effective drugs. J Law Med Ethics 2013;41:590-600.

5 Lazarou J, Pomeranz BH, Corey PN. Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies. JAMA 1998;279:1200–5.

6 FAERS Reporting by Patient Outcomes by Year. FDA 2015;Nov 10.

7 Gøtzsche PC. Mental health survival kit and withdrawal from psychiatric drugs. Ann Arbor: L H Press; 2022.

8 Hubbard R, Farrington P, Smith C, et al. Exposure to tricyclic and selective serotonin reuptake inhibitor antidepressants and the risk of hip fracture. Am J Epidemiol 2003;158:77-84.

9 Thapa PB, Gideon P, Cost TW, et al. Antidepressants and the risk of falls among nursing home residents. N Engl J Med 1998;339:875-82.

10 Ebbesen J, Buajordet I, Erikssen J, et al. Drug-related deaths in a department of internal medicine. Arch Intern Med 2001;161:2317–23.

11 James JTA. A new, evidence-based estimate of patient harms associated with hospital care. J Patient Saf 2013;9:122-8.

12 Ho JY. Life course patterns of prescription drug use in the United States. Demography 2023;60:1549-79.

13 Gøtzsche PC. Long-term use of antipsychotics and antidepressants is not evidence-based. Int J Risk Saf Med 2020;31:37-42.

14 Gøtzsche PC. Long-term use of benzodiazepines, stimulants and lithium is not evidence-based. Clin Neuropsychiatry 2020;17:281-3.

15 Forbruget af antipsykotika blandt 18-64 årige patienter, med skizofreni, mani eller bipolar affektiv sindslidelse. København: Sundhedsstyrelsen; 2006.

16 Hughes S, Cohen D, Jaggi R. Differences in reporting serious adverse events in industry sponsored clinical trial registries and journal articles on antidepressant and antipsychotic drugs: a cross-sectional study. BMJ Open 2014;4:e005535.

17 Schneider LS, Dagerman KS, Insel P. Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized placebo-controlled trials. JAMA 2005;294:1934–43.

18 FDA package insert for Risperdal (risperidone). Accessed 30 May 2022.

19 Koponen M, Taipale H, Lavikainen P, et al. Risk of mortality associated with antipsychotic monotherapy and polypharmacy among community-dwelling persons with Alzheimer’s disease. J Alzheimers Dis 2017;56:107-18.

20 Whitaker R. Lure of riches fuels testing. Boston Globe 1998;Nov 17.

21 Whitaker R. Mad in America: bad science, bad medicine, and the enduring mistreatment of the mentally ill. Cambridge: Perseus Books Group; 2002:page 269.

22 Vanderburg DG, Batzar E, Fogel I, et al. A pooled analysis of suicidality in double-blind, placebo-controlled studies of sertraline in adults. J Clin Psychiatry 2009;70:674-83.

23 Hengartner MP, Plöderl M. Newer-generation antidepressants and suicide risk in randomized controlled trials: a re-analysis of the FDA database. Psychother Psychosom 2019;88:247-8.

24 Hengartner MP, Plöderl M. Reply to the Letter to the Editor: “Newer-Generation Antidepressants and Suicide Risk: Thoughts on Hengartner and Plöderl’s ReAnalysis.” Psychother Psychosom 2019;88:373-4.

25 Weich S, Pearce HL, Croft P, et al. Effect of anxiolytic and hypnotic drug prescriptions on mortality hazards: retrospective cohort study. BMJ 2014;348:g1996.

26 Kripke DF, Langer RD, Kline LE. Hypnotics’ association with mortality or cancer: a matched cohort study. BMJ Open 2012;2:e000850.

27 Coupland C, Dhiman P, Morriss R, et al. Antidepressant use and risk of adverse outcomes in older people: population based cohort study. BMJ 2011;343:d4551.

28 Smoller JW, Allison M, Cochrane BB, et al. Antidepressant use and risk of incident cardiovascular morbidity and mortality among postmenopausal women in the Women’s Health Initiative study. Arch Intern Med 2009;169:2128-39.

29 O’Neill A. Age distribution in the United States from 2012 to 2022. Statista 2024;Jan 25.

30 Olfson M, King M, Schoenbaum M. Antipsychotic treatment of adults in the United States. Psychiatrist.com 2015;Oct 21.

31 Maust DT, Lin LA, Blow FC. Benzodiazepine use and misuse among adults in the United States. Psychiatr Serv 2019;70:97-106.

32 Brody DJ, Gu Q. Antidepressant use among adults: United States, 2015-2018. CDC 2020;Sept.

33 Centers for Disease Control and Prevention. Leading Causes of Death. 2024;Jan 17.

34 Drug overdose deaths. Centers for Disease Control and Prevention 2023;Aug 22.

35 Davis JS, Lee HY, Kim J, et al. Use of non-steroidal anti-inflammatory drugs in US adults: changes over time and by demographic. Open Heart 2017;4:e000550.

36 Conaghan PG. A turbulent decade for NSAIDs: update on current concepts of classification, epidemiology, comparative efficacy, and toxicity. Rheumatol Int 2012;32:1491-502.

37 Bally M, Dendukuri N, Rich B, et al. Risk of acute myocardial infarction with NSAIDs in real world use: bayesian meta-analysis of individual patient data. BMJ 2017;357:j1909.

38 Bresalier RS, Sandler RS, Quan H, et al. Cardiovascular events associated with rofecoxib in a colorectal adenoma chemoprevention trial. N Engl J Med 2005;352:1092-102.

39 Blower AL, Brooks A, Fenn GC, et al. Emergency admissions for upper gastrointestinal disease and their relation to NSAID use. Aliment Pharmacol Ther 1997;11:283–91.

40 Davis C, Lexchin J, Jefferson T, Gøtzsche P, McKee M. “Adaptive pathways” to drug authorisation: adapting to industry? BMJ 2016;354:i4437.

41 van der Hooft CS, Sturkenboom MC, van Grootheest K, et al. Adverse drug reaction-related hospitalisations: a nationwide study in The Netherlands. Drug Saf 2006;29:161-8.

42 Gøtzsche PC. Big marketing hoax: Non-steroidal, anti-inflammatory drugs (NSAIDs) are not anti-inflammatory. Copenhagen: Institute for Scientific Freedom 2022;Nov 10.

43 Perlis R. The time has come for over-the-counter antidepressants. Stat News 2024;April 8.

44 Gøtzsche PC. Critical psychiatry textbook. Copenhagen: Institute for Scientific Freedom; 2022. Freely available.

The post Prescription Drugs Are the Leading Cause of Death appeared first on Mad In America.

On the footpath, in a group of homeless people, sits a middle-aged saree-clad woman in absolute silence, looking nowhere. She sits close to her two giant white bags. She was brought in along with a salwar-kameez wearing middle-aged woman. In a group of 14 people, they were the only two women. The social worker gave both of them some tea and biscuits as they waited for their mental status examinations to be done by the psychologists. The saree-clad woman sipped her tea quietly and put the two biscuits in one of her giant white bags. Finally, it was her turn. The psychologist asked her name. She refrained from responding, just silently staring at the face of the psychologist. Then the social worker asked her name in Kannada, and she responded “Lata.” The psychologist asked her name in Kannada, but received no response again. On being told by the salwar-kameez woman that she called her “Afrah”, she recorded it as Afrah. When asked her age, Lata said that she was 3 years old. Hearing this, the psychologist laughed and said, “Look at you! You obviously cannot be 3 years old!” and then recorded her age as 40 years. Hearing this, Lata turned her face away and now refrained from meeting her eyes. The psychologist tried building rapport with Lata but in vain.

Lata was later referred to the women’s shelter run by the organization. When they took her there, they did not take her two big bags. Lata had kept the biscuits in one of her bags. I wondered what else stayed in the bags that remained unchecked by the social workers and abandoned on the streets. What did she carry that allowed her to live on the street as a woman? What did the contents mean and represent for her? Apart from her name, what else did she want to convey that was silenced by the mocking laughter of the psychologist?

Interested in researching mental health care experiences, I am currently doing fieldwork to understand the diverse nature of care and recovery within different mental health settings in India. This is only the first month of my fieldwork, and I wanted to share one particular event that has stayed with me and is constantly making me question what care and consent look like in the mental health context, especially for people who are homeless.

Beside the most luxurious mall in the city is an alley that houses a posh private veterinary clinic as well as a Girls High School. It is in this alley, alongside the footpath that shares its boundary wall with the mall, where a medical camp was organized for Homeless People with Psychosocial disabilities (HPPD). People in their most vulnerable states, unhygienic, wearing layers of clothes with long-matted hair, some restless, some muttering to themselves, others staring at the sky or looking nowhere, sitting on chairs and some on the ground, were being spoken to by well-dressed people, like the passersby on the street.

It is a sight that grabs the attention of the passersby naturally, but none seem moved enough to inquire about what’s going on.

How the Homeless Are “Cared” For

The medical camp intends to provide mental health services to the homeless. The camp involves multiple steps of “caring” and helping the HPPDs. First, they are brought in by the social workers to the location of the medical camp. Then, the psychologists of the team conduct the mental status examination of the clients; thereafter, the social workers help the clients become clean by helping them shower and dressing them in fresh clothes. In the case of men, this involves an additional step, which is cutting hair and shaving beards. After this, the psychiatrist checks each client and provides medications. Lastly, each client is offered a meal and is then dropped off at their usual location of stay on the street by the social worker. This sounds like a much helpful and almost “noble” practice when read without the intricate details of how these “caring” activities materialize into reality. The translation of the activities to reality made me wonder what empathetic and dignified care even means.

For the homeless people who are living on the street, the medical camp is also organized on the street itself. It is in full public view amidst noises from the passing vehicles that a mental status examination is being conducted. Them showering, cleaning their bodies, getting dressed in fresh clothes is happening in front of the public-eye. Living on the street as a homeless psychosocially disabled person and then being “cared for” in full public view again on the street made me wonder, do they not deserve dignified care? It made me think, what would I think if I were given “treatment” for mental health on the street where my life, body, and lived realities are exposed to the world to gawk at, record, click photos, and leave?

The mental status examination being conducted by three different psychologists has three different flavors. Some listen closely, make a provisional diagnosis, and try eliciting information by building rapport. Others don’t. These others barely try to establish rapport, almost force the individual to speak, do not listen to what is being said, and smirk when the response is inappropriate.

How does one conduct a mental status examination of a homeless psychosocially disabled person without establishing rapport? How does the mental status examination happen amidst the noise on the street, the intrusive looks of the passersby, and the invasive clicking of photos of their faces? How does one provide a valid diagnosis of their disability in just one conversation of barely 20 minutes, without any prior monitoring or recording of any case history due to the unavailability of sources of information? How important is the diagnosis-making activity when the person is too scared, distracted, or restless to engage in a conversation?

The social workers and psychologists hurry to get the clients “ready” for a checkup by the psychiatrist. The psychiatrist arrives on the spot only when most clients have been checked by the psychologists and showered, cleaned, and dressed by the social workers. The psychiatrist check-up happens in a closed room. As the doctor arrives, there is a sudden shift of expertise in the room, with the doctor now taking center stage. With the doctor occupying the seat on the table, the three psychologists stand by the table during the entire duration of the check-up of all the 14 clients present at the medical camp. The doctor barely spends more than 3 minutes with a client. He is quick to prescribe medications and offers advice to psychologists for better history taking and conduction of mental status examinations. He also says, “Let’s not over-diagnose” in Lata’s case, who uttered no other word except her name in front of the professionals.

However, the doctor also did not hesitate to change the provisional diagnosis of “schizoaffective disorder” provided by the psychologist to “bipolar disorder” without any symptom presentation for “bipolar disorder.” In the case of another client, medicines were still prescribed even when none of the professionals could understand one single word of what the client was saying, as the client’s language was unknown to them. They detected from his facial features and his accent that he must be Kashmiri, but no effort was made to bring in resources to help this client better or get closer to their truth.

In addition to this, the medicines prescribed by the doctor in just one sitting with a short conversation fell into the list of the medicines procured by the organization conducting the medical camp. The medicines procured by the organization are the ones that are readily available and cheap. The social workers suggested the doctor prescribe low dosages and keep the number of medicines to be low. However, there is no discussion on how the effects of the medicines will be monitored on the client who is living on the street.

The organization calls its program client-centered and considers it to be delivering social justice. However, as an outsider, I fail to see the program’s client-centeredness or the justice it offers. On one side of the street, the medical camp was organized, and they ran a simultaneous “awareness camp” on the other side of the street. I did not understand why it was called an “awareness camp” and their goal behind running a camp when all they did was tell the passersby about what they were doing in the medical camp and ask them to sign on a sheet. The conversations with the passersby were barely a minute long. It was mainly a monologue of the social worker telling them about their “caring” practices to convince them to sign on the paper. I noticed that no passersby asked questions or said anything in response to what the social worker shared with them. Many people on two-wheelers stopped on the street to see what was going on, but none asked a question, and neither did the team members approach them to talk about mental health. On receiving 100 signatures, the team members were overjoyed. They considered getting 100 signatures as a successful awareness camp. I was left wondering what awareness really is here. Will the people who signed the paper stop and think about mental health? Did they even register the shared information amidst such rush and noise? What did this awareness camp achieve?

Can One Consent to this “Care”?

This event has left me with multiple questions and no answers. I acknowledge the organization’s dedication to reaching out to HPPDs and their sincere efforts in tackling a community mental health problem. However, I also find myself questioning what care and consent mean when care is offered to achieve a target to receive funds to sustain the program, when care is offered but the lived reality of a person is colored by the lens of psychiatric diagnosis, when care is offered in terms of pills and prescriptions. In my conversations with the professionals of the team, they told me that they consider empathy and the use of no-force as care. However, the mere use of no force might not necessarily mean respect and consent. The social workers bring the clients to the camp for checkups by telling them that they will give them food, new clothes, and blankets. This makes me wonder—does the homeless person come along simply to access resources they are deprived of on the streets? They are rarely told that there will be a doctor’s consultation. Shouldn’t they be told the entire truth about the program? And shouldn’t they be asked whether they want to get medicated?

Does no-force equal consent, especially informed consent, where the client is fully aware of the treatment options, the benefits, and the side-effects? Can a homeless person in this situation, lured by the prospect of warmth and food, even give consent? I noticed that consent seemed particularly tricky when it came to the authority of the doctor. At times when clients were unwilling to interact with the social worker, were disinterested, clearly said ‘’no”, and even shooed the social worker away, they were still subject to the medical gaze via a forced video call with the doctor. This was especially true on virtual consultation days. But in the absence of the medical authority, social workers were more open to the clients’ wishes and desires. If the client appeared disengaged, the social workers respected that and often simply told them they will come back tomorrow.

The mere effort of providing help might not necessarily be empathy, especially when the person’s dignity is violated. Only because they are homeless, their right to be given care away from the public eye and their right to privacy of their body, experiences, and lived reality should not be denied in the disguise of offering care.

The post What Is “Care” in a Psychiatric Medical Camp for the Unhoused in India? appeared first on Mad In America.

In my previous article, I looked at some evidence on ‘disappointing’ long-term outcomes for early intervention in psychosis (EIP) recipients, and also some findings on ‘functional outcomes’ between drug discontinuation and maintenance treatment cohorts. I attributed these trends chiefly to the inefficacy of neuroleptics over the long-term.

I hope my discussion can contribute a little to advancing understanding of how a drug based ‘disease model’ of mental distress can often do more harm than good. The growing awareness of which owes much to Robert Whitaker’s ground-breaking work in Anatomy of an Epidemic. For a summary of the book’s arguments read this.

Here, I start by looking at some objections to ‘deprescribing’. I consider them as revealing the incoherence of certain assumptions behind early intervention, and indeed, of psychiatric diagnosis more widely.

When responding to the case that patients seem over the longer term, to have better social and occupational (functional) outcomes off standard maintenance treatment (MT), many psychiatrists will object that the risks of relapse after drug discontinuation are too great. Indeed, the dangers of withdrawal should not be taken lightly. ‘Relapses’ can have disruptive and serious consequences.

Nevertheless, most of the objections do not take into account the drug withdrawal induced ‘rebound’ effects I discussed in the previous article. The real nature of such symptoms is generally overlooked (and misdiagnosed), along with their potential avoidability. Obviously, it is imperative to minimise risks of relapse, but not at the cost of the reduced life expectancy associated with long-term use of neuroleptics.

There is a clear need for services and patients to work with more appropriate tapering regimens to enable those with remitted psychosis to reduce the drugs’ toll on their systems. Employing more gradual (‘hyperbolic’) tapers, the risks of withdrawal can be minimised and managed. The guidance which follows from this understanding can actually be considered more cautious than current standard clinical practice. For instance, when switching drugs, as well as in the protocols of pharma sponsored trials on antipsychotic efficacy. Where often four weeks or less are scheduled for drug discontinuation.

The idea of gradual tapering—with progressively smaller dose reduction increments over an extended taper period, giving the brain time to adapt—was understood informally by some in the mental health recovery community, notably Will Hall, even if it wasn’t generally recognised by prescribers, much less the majority of those who had to live with the drugs.

This kind of approach has now been given a more formal, scientific underpinning based on the ‘hyperbolic’ relation between dose level and dopamine receptor occupancy.

Source: Mark Horowitz PowerPoint presentation. More details here.

Still, however, ‘rebound’ symptoms from withdrawal are usually interpreted as demonstrating an ‘underlying illness’. Typically for those defending the status quo, that psychosis patients often ‘relapse’ following discontinuation shows they are subject to “vicious brain diseases”. This point seems to be more an article of faith for these psychiatrists rather than something of which they can generally give any determinate account.

Leaving drug withdrawal effects aside, some of the objections put forward against deprescribing can, I think, be rather revealing. I pick out a response by Ann Mortimer in her 2018 critical commentary in response to guidance encouraging more openness towards deprescribing antipsychotics.

While wrestling with the real issues services face, she tries to dispel findings, such as Wunderink 2013, that patients subsequently do better off meds:

In my own [EIP] service, approaching half of new patients have persistent substance-induced psychotic disorder. Although patients may later attract a schizophrenia-spectrum diagnosis, there is a flaw in any contention that such patients really had schizophrenia all the time. Early chronic substance misuse in vulnerable individuals may cause subtle brain damage that is not recoverable, even after several years of anti-psychotic treatment. This is not the same thing as having schizophrenia in the first place. Clinically, such patients usually have suffered significant adversity, which perhaps explains why they develop psychosis when, fortunately, the vast majority of young substance misusers survive without it.

Such wide ‘variability’ is a challenge that EIP services have to take on board. As Mortimer notes elsewhere, referrals to EIP services greatly outnumber what would be in-line with estimates of schizophrenia’s prevalence in the population. Evaluations of EIP services have highlighted high rates of non-cases (‘bycatch’) and the potential for misdiagnosis.

Before moving on let’s remind ourselves of the rationale for EIP programmes. Two interrelated notions were that duration of untreated psychosis (DUP) was critical in determining long term course, and that there was a ‘critical period’ of 3–5 years around typical onset of first episode psychosis (FEP), with the greatest opportunity to impact on long-term course. This ‘critical period’ is usually late adolescence/early adulthood, where greater neuronal and ‘psychosocial plasticity’ is thought to be displayed.

A related innovation was the hypothetical construct of ‘ultra high risk’ of psychosis. This sought to identify those who showed ‘prodromal’ signs of ‘attenuated psychosis’, based on symptom ratings scales. However, according to a critique of this concept by Jim Van Os et al, distinguishing such a group from those already presenting to services with anxiety, depression and other ‘milder’ mental health difficulties, often proved unfeasibly difficult.

But back to Ann Mortimer’s argument above: Firstly, she writes that not every psychosis is schizophrenia and there is a flaw in the assumption that a proportion of patients had ‘schizophrenia’ in the first place. Thereby acknowledging, that misdiagnosis of ‘schizophrenia’ is not uncommon—as indeed is the conflation of ‘psychosis’ with ‘schizophrenia’. Her position seems to be that patients who go on to do well after drug discontinuation, probably didn’t really have ‘schizophrenia’ to begin with.

On the other hand, according to her line of thought, poor outcomes in maintenance treatment cohorts indicate greater disease severity, which she takes as incompatible with being able to discontinue (or reduce). Poor outcomes in this group are due to the patients’ ‘schizophrenia’ effectively preventing drug discontinuation. Attempting to gloss over the trends in this way, reveals the term ‘schizophrenia’ as, effectively, just a shorthand for poor outcomes after first episode psychosis; a shorthand that appears unexplanatory and even self-defeating.

A conceptual dead-end can be seen to arise for EIP services and research. If a referral fares well, then potentially, it was a non-case. A ‘watch and wait’ strategy would have sufficed. On the other hand, if the patients fares poorly after early intervention, then it can be put down to their having ‘severe schizophrenia’. So there wasn’t much services could have done to prevent a disappointing outcome anyway. In short, the interventions appear either unnecessary or ineffective… So what are they preventing?

To be clear I am not suggesting that all the interventions made in EIP services are unhelpful. Providing appropriate psychosocial support and practical psychological resources certainly has value. But when one considers both low rates of ‘transition’ to psychosis in those supposedly at ‘ultra high risk’ and the high rates of non-cases that evaluations raise, reviews of EIP seem to be presenting arguments for its redundancy.

If the late adolescence/early adulthood period is genuinely ‘critical’ and ‘sensitive’ for still developing brains, then it is precisely this which should make clinicians wary of biochemical interventions!

But, it is at this stage of life that mainstream psychiatrists are most keen for intervening with psychotropic drugs; interventions that inevitably produce unintended consequences. Some are foreseeable—neuroleptics are known to alter neuronal development—but also many that will be poorly understood.

The ‘critical period’ in development is probably a contributory factor in adverse reactions to selective serotonin re-uptake inhibitors (SSRIs) in the under-25s. Higher risks in the age group were eventually recognised with black box warnings for the drugs—even though regulators overlooked the data for more than a decade before responding.*

(Source)

Ann Mortimer speculates that many referrals to EIP services, ones who later attract a schizophreniform diagnosis, could be due to subtle brain damage from early chronic drug use – “that is not recoverable, even after several years of anti-psychotic treatment”—she adds, incomprehensibly. If anything will cause brain damage, it is years of exposure to neuroleptic drugs, representing a sustained intake of neurotoxins known to cause reductions in cortical volume. Is it any wonder?

But to address the issue of street drug use: there has been much media commentary about an association between cannabis use and risk of psychosis, especially ‘skunk’ strains with higher levels of the psychoactive THC. But, such drug use and its consequences do not take place in a vacuum. Many other factors will be relevant. Moreover, plenty of FEP cases may not have had chronic drug habits before presenting, nor necessarily have experienced particularly adverse upbringings.

As I’ve mentioned, any supposed ‘high risk’ group for psychosis would tend to overlap with those who may already have presented to services with ‘milder’ mental health issues. A relevant risk factor for a psychotic break can even be consumption of psychotropic drugs like SSRIs. I’ve previously discussed how these appear to raise the risks of developing psychotic or manic symptoms.

It is acknowledged that “psychoactive drugs that do not directly impact on the dopamine system can impact on dopamine release through indirect effects”. One neuroscientific theory posits serotonergic over-expression as leading to the ‘dopaminergic instability’ theoretically associated with psychosis.

Incredibly, a recent EIP research trial looking at ‘staged treatment’ to prevent psychosis in young individuals deemed at ‘ultra high risk’ tested the SSRI fluoxetine (Prozac) as an intervention. The Prozac group actually showed slightly lower symptom rating improvements and marginally more ‘transition to psychosis’ than the placebo group. The Prozac arm had the highest reported rate for psychotic events in the trial.**

It is evident that intake of an SSRI can heighten the danger of any illicit drug use resulting in mania or psychosis. The risks of antidepressant and cannabis use can be mutually reinforcing. Studies suggest that cannabis effectively increases the concentrations of SSRIs in the body, raising their activation potential, whilst it is thought that cannabis’ psychoactive THC also acts on serotonin receptors.

Note that effects like these would constitute causal pathways to psychosis, chiefly through compounding drug effects, and lead to symptoms that would likely be assessed as ‘schizophreniform’.

A subsequent period of treatment with neuroleptics would, over time, tend to result in dopaminergic supersensitivity. So if, for example, after months or years of treatment, someone experimented with drugs like cocaine, amphetamines, or MDMA—which act as dopamine agonists—any drug induced state would be more likely to develop into a persistent psychosis. With the person being increasingly liable to being assessed as “having” some life-long psychiatric condition. This is likely to entail prescription of psychiatric drugs on an indefinite basis.

As I hope I’ve just outlined, this would be a pathway by which they “attract a schizophreniform diagnosis” due to primarily exogenous causes. None of it would imply the presence of some underlying disease.

I wouldn’t deny that in such cases there may be some level of pre-existing susceptibility; meaning that when stressors arise, some threshold (vaguely understood) is exceeded or overwhelmed. But clearly, as Ann Mortimer might say, this is not the same as “having schizophrenia” in the first place. Case histories like this with, perhaps, some susceptibility and drug—or drug withdrawal—induced changes converging, do not equate to “vicious brain diseases”.

Clearly, there is a range of other factors besides drug effects that one might point to in explaining any particular case. Psychosis is widely understood as being on a continuum with everyday experience, with much of the population (8–30%) reported as experiencing transient ‘psychotic’ experiences at some point in their lives. For example, it is acknowledged that excess sleep deprivation will initiate symptoms of a ‘psychotic’ character.

(Psychiatric Times)

At the same time, experiences considered clinically abnormal such as ‘hearing voices’ can be lived with, in the course of productive and worthwhile lives. Such ‘symptoms’ may be managed and integrated without significant distress or dysfunction. As Jim Van Os concluded, ‘attenuated psychotic symptoms’ are commonplace. The rates of ‘transition’ to clinical psychosis being much as they are for the population in general.

Given that assessments of ‘psychosis’ are made on the basis of behavioural responses, and from the perspectives and interpretations of clinicians, I suggest that psychosis should be understood as a functionally and indeterminately defined state—potentially realized in the central nervous system by multiple causal mechanisms.

The quest for an explanation of ‘psychosis’ and ‘schizophrenia’ in terms of single variables has proved unsuccessful and harmful. Even reductive neuroscientific approaches now posit serotonin and glutamate signalling as playing roles ‘upstream’ of instability in dopamine pathways. Furthermore, some recent neuroscientific findings indicate that much ‘treatment resistant’ first episode psychosis cannot be associated with ‘elevated levels of presynaptic dopamine synthesis’—the dopamine theory’s more recent iteration.

The history of attempts at biochemical reduction have eventually led to a scientific interpretation of psychosis as “a network dysfunction that includes a variety of brain regions (and multiple neurotransmitter pathways), of which impairment at any level could precipitate symptoms.”

All this would rather suggest, not some discrete illness or disease process, but perhaps some overlap of susceptibilities to such anomalous functioning; including, for example, higher levels of risk arising from prenatal or perinatal complications, winter birth, or experience of childhood abuse, etc. Their joint presence amounting to a cluster of predispositions, potentially triggered or exacerbated by a wide range of external stressors; social adversity, environmental insults, urbanicity, etc. As these later risk factors present stronger correlations than any genetic associations that have been pointed to, this would underline the inappropriateness of any assumption of an underlying ‘brain disease’.

The failure of the ‘high risk’ concept and wide variability of course and outcome suggest that the ‘schizo’ paradigm—inasmuch as it assumes some reducible disease process, separate and distinct from other dimensions of functioning and well-being—can be safely dispensed with. And moreover, that it is has become an obstacle to clearer understanding. This is not to mention both the social stigma and the disheartening effect diagnosis may have on a person’s aspirations in life.

Although there has been some signs of a growing awareness that ‘schizophrenia’ is probably not a scientifically valid concept, it does seem that the old assumptions are still driving routine clinical practice. These widespread and erroneous assumptions may stem, in part, from decades of very influential drug company marketing, based on flawed research trials and publication bias.

Notes

* Critics like Peter C. Gøtzsche are, no doubt, right to point out that these risks of SSRIs extend to all age groups.

** The trial’s researchers, among them Patrick McGorry, who had pioneered the development of the ‘early intervention’ model, believed the poor results were likely due to “real-world problems of treatment fidelity and adherence”. But it is astounding to me that the researchers believed Prozac could prevent psychosis. Such a flawed choice entails, effectively, in my view, that the trial doesn’t provide good evidence, either for or against its hypothesis. Although it does further support the assessment that SSRIs raise risks of mania and psychosis.

The post Witless and Dangerous? Challenging the Assumptions of the ‘Schizo’ Paradigm appeared first on Mad In America.

Unique in the new guidance is concrete practical advice on how to implement personalized gradual tapering schedules in which the dose is gradually reduced in multiple steps, which get smaller as the daily dose gets lower. This gives the body time after each step to adjust to a slightly lower dose, which makes withdrawal symptoms less likely to occur, or not occur at all. When withdrawal still occurs, there will be more time to do something against it. Why tapering in smaller steps works better than in large steps is obvious: the risk of destabilization after a dose reduction of for example 1 mg will be smaller than after a dose reduction of 5 or 10 mg or more.

One of the practical tools mentioned in the new Maudsley Guidance are the tapering strips I have been working on for almost 15 years. In the Netherlands, they have been prescribed to more than 20,000 patients. I receive many questions about them. Can anyone can use them? Why and how were they developed? How well do they do work? This blog gives some answers.

Can anyone use tapering strips?

In most countries it will be possible for patients to use the tapering strips, when their doctor judges that they meet their needs and no alternative is available. The new Maudsley Guidance explains that tapering strips can be prescribed off-label. The UK General Medical Council (GMC) defines off-label prescribing as the prescribing of medicines which are used outside the terms of their UK license, or that have no license for use in the UK. Unlicensed medicines are commonly used in some areas of medicine, such as psychiatry. This may be necessary when ‘there is no suitably licensed medicine that will meet the patient’s need’, when ‘the dosage specified for a licensed medicine would not meet the patient’s need’, or when ‘the patient needs a medicine in a formulation that is not specified in an applicable license’ (GMC, 2021). According to the FDA, ‘healthcare providers generally may prescribe the drug for an unapproved use when they judge that it is medically appropriate for their patient’ (FDA, 2018). This also applies to the prescribing of lower than available licensed dosages for tapering, as are being used in the tapering strips—dosages which have all been batch quality controlled and certified by the independent Laboratory of the Royal Dutch Pharmacists Association.

How can tapering strips be prescribed?

Prescribing a personalised tapering schedule when using tapering strips has been made as easy as possible. Prescriber and patient together decide on the duration, start dose and end dose of a planned taper. For the pharmacy this is enough information to work out the corresponding hyperbolic tapering schedule and to provide all the required daily dosages for it to the patient. Every daily dose is precisely determined and separately packaged in the small sackets of one or more tapering strips. An option has been created to request a free tapering recommendation. This will result in personalized tapering advice that can be used as a prescription for the chosen tapering schedule, or to choose another schedule when this is judged to be more appropriate. Tapering strips are currently available for more than 60 different prescription drugs.

Why and how were tapering strips developed?

A short history of withdrawal

To explain why tapering strips were developed I first take a short dive into the history of withdrawal. Withdrawal occurred from the very moment withdrawal-causing prescription drugs were prescribed. The first reports in the medical literature are almost 70 years old. A telling example is a randomized study published in the New England Journal of Medicine in 1958. In this study, significant withdrawal was observed after abrupt discontinuation of meprobamate, a sedative that was then often used for treating anxiety and insomnia. Withdrawal symptoms observed in this study were various degrees of insomnia, vomiting, tremors, muscle twitching, overt anxiety, anorexia, ataxia, hallucinosis with marked anxiety, tremors much resembling delirium tremens and grand-mal seizures. The report ends with a spot on and surprisingly modern recommendation which is completely in line with the new Maudsley Guidance: ‘that it seems wise to discontinue slowly, to prevent the occurrence of withdrawal symptoms’. In 1958.

Why was so little done to prevent withdrawal?

Over the years, countless patients have suffered from withdrawal, often with severe consequences. Why then, despite such early recognition of withdrawal, was so little done to prevent them? An explanation that is often put forward is that withdrawal was not well recognized and mistakenly interpreted as relapse. Reinstating the drug was often the quickest cure for withdrawal, strengthening the belief that staying on the drug was necessary to prevent relapse.

There is another possible explanation that sheds more light on the development of the tapering strips. This pertains to the absence of adequate tools to facilitate gradual discontinuation, which made it very difficult or impossible to follow the sensible advice in the 1958 study I mentioned. The crux of the matter lies in the necessity for dosages lower than those typically included in the limited range of standard dosages registered by the FDA. It is now generally acknowledged that much lower dosages are required than that. Without them, safe tapering of withdrawal-causing prescription drugs is difficult or simply not possible.

In light of this, it is difficult to understand why psychiatric associations and regulatory bodies like the FDA, EMA, MHRA and NICE always seem to have assumed that the available limited range of licensed dosages are adequate for most prescription drugs—with notable exceptions like insulin. Available licensed dosages allow patients to start using prescription drugs without knowing if they will be able to discontinue them later. Metaphorically speaking, this is akin to allowing pharmaceutical companies to sell cars without having to verify if they have brakes that are functioning.

Many patients understood what the problem was

Early on there were patients who understood that lower dosages were needed for safer tapering (Moore, White, Framer, Groot). As did some professionals like Prof. Heather Ashton, who developed the Ashton Manual to help patients to safely come off benzodiazepines. The work of Mark Horowitz and David Taylor, who experienced withdrawal themselves, demonstrates how important such personal experiences can be to understand and appreciate problems of withdrawal.

How patient contributions led to the development of tapering strips

In 2004 Dutch wood carver Harry Leurink proposed the making of a ‘medication withdrawal strip’: ‘A very gradual decreasing dosage of medication packaged in strips with a time sequence’. He did this after he had desperately been trying for years to come off benzodiazepines without succeeding. Each time he tried he suffered so much from withdrawal, that he was forced to start using benzos again. I have repeatedly and reproducibly experienced withdrawal myself, each time after I forgot to take the daily dose of the antidepressant venlafaxine I had been using since 2004. This started me thinking about finding ways to prevent withdrawal also. In 2012, unaware of Leurink’s idea, in the Journal of the Royal Dutch Medical Association I proposed to develop stop-packages.

A very fortunate accident

It was a very fortunate accident that emeritus professor Dick Van Bekkum, who was then already 87 years old, read the article. I very much doubt if we would have had tapering strips today if he hadn’t. Van Bekkum was founder and Chairman of the not-for-profit foundation Cinderella, which had started a project to develop Leurink’s medication withdrawal strip for the antidepressant paroxetine. The working assumption was that a strip for a limited number of days would suffice to prevent withdrawal.

This, as we now know, was a very naive assumption, but it turned out that making this assumption was a big advantage, because it was clear that it would be technically feasible to create such a single strip, which made the project less daunting and more approachable. Van Bekkum contacted me and asked if I would work with him on a voluntary basis to develop what we now call a tapering strip for paroxetine. He was very outspoken: ‘We don’t need new guidelines to be able to do something. We can make this strip and that’s what we will do. When we have it, we will see what comes next’. A decisive moment. I agreed and added venlafaxine as a second antidepressant for making a tapering strip.

A pharmacist needed to be involved

We were faced with practical problems we knew we could only solve with the help of a pharmacist who would work with us to develop the tapering strips, make them and provide them to patients. Together, we set out to find one. The second pharmacist we approached was Paul Harder of the Regenboog Pharmacy in Bavel. He was willing to work with us and had some brilliant ideas about how to make the strips. Practical problems I had foreseen vanished in thin air. Within a year, the first tapering strips for paroxetine and venlafaxine could be made available to patients.

Way too fast

A tapering strip to taper paroxetine ‘gradually’ in 28 days is better than stopping abruptly, but not good enough. A justified comment on the website Surviving Antidepressants was that ‘28 days to get off paroxetine is way too fast. It takes months or years’. This made us realize that we had to improve things, which we did by developing a modular system in which multiple tapering strips can be used to come up with any personalised tapering schedule a doctor wishes to prescribe.

After the first tapering strips became available, patients as well as doctors made clear to us that there was a greater demand for tapering strips than only for paroxetine and venlafaxine—that they were also needed for other antidepressants, benzodiazepines and Z-drugs, antipsychotics, opioid painkillers, anti-epileptics and other withdrawal-causing prescription drugs.

What I learned from my own tapering experiences

I began contemplating withdrawal when I discovered that forgetting a single daily dose of venlafaxine resulted in almost immediate withdrawal. An indescribable unpleasant sensation in my head appeared, sometimes within hours, and certainly within a day. This instilled fear in me, as it resurrected old anxieties and thoughts of suicide. While these thoughts didn’t immediately render me suicidal, they alarmed me. I had been severely depressed and knew that such feelings could escalate. My father had taken his own life in 1979, and I was determined not to follow the same path.

In the beginning, I did not connect these negative feelings to withdrawal, because I forgot to take my medication only occasionally. It took quite some time before I was certain that forgetting it was the cause of my misery. Discovering this was a relief and made my life much easier, knowing that taking the missed dose would make me feel better within hours or at most one or two days.

Explaining the importance of lower dosages for tapering

As many others before me, I came to realize that it would be necessary to make dose reductions smaller as the dose got lower. To explain this, in 2015 I came up with the picture below, which I used to make visibly clear that the last ‘small’ dose reduction of 18.75 mg of a linear taper of venlafaxine has about 3 times as large an effect on the occupation of the serotonin transporter as all 8 previous dose reductions of more than 200 mg combined.

When in 2019 Mark Horowitz and David Taylor published their landmark paper about hyperbolic tapering, I was thrilled. They gave us something to help convince the psychiatric community that safe tapering ‘is not quite like the standard texts say’, as David Taylor had put it so well already in 1999. The publication of the new Maudsley Deprescribing Guidelines makes me happy again. However, first and foremost, practical solutions are needed which can readily and easily be prescribed and used right now. Theory and guidelines can come later.

Do it yourself tapering should not be necessary

It is possible to taper by for instance opening capsules, counting beads and putting them back. My own partner did this years ago, to taper the venlafaxine she had used for some time without a positive effect. She succeeded, but not without difficulty. Static electricity was a problem, coughing or a draft through an open door was a problem, lack of concentration could be a problem. I found the whole process distressing and strongly felt that it was wrong that she was forced to do this because no better options were available. She was trained as a molecular scientist, had a PhD and had done years of laboratory work, which certainly helped her to successfully complete her bead-counting taper. Others may not be so lucky and will fail such a do-it-yourself taper even when they try as best as they can.

Earlier in this blog I wrote that pharmaceutical companies have been allowed to sell cars without having to verify if they have brakes that are functioning. It should not be necessary to instruct patients to make these brakes at home themselves. When they can use tapering strips they don’t have to. Tapering strips enable physicians to flexibly prescribe and implement personalized tapers without needing to work out a tapering schedule and explain to a patient how to implement it. For me, this is comparable to how we can use our mobile phones. All we have to do is click. No need to know or do all the things our phone knows and does to connect us with others.

Experiencing the practicality of using tapering strips

As a patient I have experienced how easy it is to use the tapering strips myself. In 2023, for the second time, I decided to try to come off the venlafaxine I had been using for almost 20 years. A previous attempt in 2012, to taper from 150 mg/day to zero in 8 weeks, had failed. My educated guess was that 20 weeks to taper from the 75 mg/day which I had been using since 2012 could work for me. My GP agreed, filled in the prescription and within a week I could start my taper. The figure below shows that the 20-week hyperbolic tapering schedule I used is much more gradual than the ‘gradual’ 8-week stepwise tapering schedule I used in 2012.

The big difference between my 8-week and my 20-week taper

My 2012 ‘gradual’ taper was part of an N=1 experiment published in 2016. The taper itself was not difficult for me. I experienced complaints at certain moments, but they were much less than after forgetting a daily dose. Overall, I judged my 2012 taper to have gone very well. Problems started a few weeks after I had tapered completely. I became more irritable, slept less well, and thoughts of suicide returned regularly. This was not getting better and I feared it would get worse. After about four months, I decided to restart venlafaxine, hoping it would help me—which it did. Within a matter of weeks, at a dose of 75 mg, I started to feel much better. I decided not to go back to the 150 mg/day I had been using for 8 years, but to stay on 75 mg/day, which I did for another 10 years.

Despite the fact that my taper had failed I was satisfied with this outcome, because I was able to function again. It was of less concern to me that I could not determine if I had suffered from relapse, withdrawal or some form of dysregulation. With the knowledge I have today, I consider iatrogenic dysregulation the most likely explanation.

No signs of withdrawal during my 20-week taper

My 2023 taper was completely uneventful. There were no signs of withdrawal, which made it difficult for me not to forget to fill in the self-monitoring form we urge patients to fill in daily to be able to timely adapt a tapering schedule when withdrawal occurs. For my GP, filling in a prescription was enough to do a very good job.

After my 8-week taper I got problems, after my 20-week taper I remained fine

Because my 8-week taper in 2012 had gone well, I expected that my 20-week taper would go even better, which it did. What I was anxious to find out was what would happen after I had completed my taper. In 2012 this did not go well, which forced me to start using venlafaxine again for 10 more years. What would happen this time, after a taper that was much more gradual?

I was very happy to find out that this time I remained fine—I ended my taper 10 months ago—and more than that. I have lost some weight and the sexual side effects I have experienced from the moment I started to use venlafaxine 20 years ago, which have always been manageable for me, have gotten less. Other than that, I observe little difference.

My more gradual taper enabled me to stop using venlafaxine after 20 years

I speculate that I would have been able to come off venlafaxine 10 or 15 or more years ago if I had then been able to taper gradually enough, and that I would have had to remain on venlafaxine for the rest of my life if I had not had the opportunity to do this.

How well do tapering strips work? What evidence is available?

How representative my experiences with the tapering strips are for others remains to be seen. Patients can differ strongly in how much withdrawal they experience. This may depend on a personal susceptibility, but probably more on circumstances. Patients who experience severe withdrawal often have complicated medication histories. For instance, a history of using one antidepressant after another, in quick succession and with rapidly changing dosages, perhaps using one or more other withdrawal-causing prescription drugs as well, also changing in dose and combinations. Polypharmacy in patients who experience withdrawal is not rare. Guidelines generally do a very poor job in capturing this.

Thus far, it was difficult or impossible to study personalised gradual and hyperbolic tapering

Until recently, personalised gradual and hyperbolic tapering over longer periods of time was not studied because it was difficult or practically impossible to prescribe and implement the required tapering schedules. As a result, we had no data. The introduction of tapering strips marked the first opportunity to systematically study this approach, which we have done in four observational studies, published in 2018, 2020, 2021 and 2023, with a combined number of more than 2800 participants.

Differences with respect to randomized studies

To better appreciate the results of these observational studies, it is important to mention key differences with respect to randomized studies. Participants in our studies are likely a self-selected group of ‘difficult’ patients. Many were long-time users. More than 60% had experienced severe withdrawal during one or multiple tapering attempts in the past. This allowed for a comparison ‘within the person’ for a large number of participants, which is more informative for clinical practice than ‘between group’ comparisons in randomized trials. Many participants had to inform their doctor about the tapering strips, instead of the other way around—especially in the beginning, not as much today. In contrast to randomised studies, there were no exclusions for not having a specific DSM classification, for having suicidal thoughts or for any other reason. Every patient who had been prescribed one or more tapering strips could participate. There was no additional guidance. These differences contribute to greater external validity than can be achieved in randomized studies.

Given the absence of other substantial evidence, the results of our studies should be taken seriously. In summary, the results are that 70% of all participants were able to taper completely and that after 1-5 years 68% of the participants who had tapered completely were still off the medication they had tapered—thus far this was mostly antidepressants. In our last prospective study, ‘withdrawal in hyperbolic tapering trajectories of daily tiny steps was limited and rate dependent, taking the form of an approximate mirror-image of the rate of dose reduction’. In layman’s terms: more gradual tapering leads to less withdrawal.

My conclusion

An as yet unknown, but probably significant, number of people will be able to come off psychiatric prescription drugs like antidepressants, even after years of use and previous failed stop attempts with severe withdrawal, when they are given the opportunity to taper gradually enough to prevent withdrawal.

****

Disclosures: Peter has been involved in the development and research of the use of tapering medication, but not in the production, distribution, or provision of tapering strips, stabilizing strips, or switch strips to patients, for which he receives no compensation. The User Research Centre of UMC Utrecht has received an educational grant from the Regenboog Apotheek.

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This is intended as the first part of a look at pathways and outcomes in ‘psychosis’ and ‘schizophrenia’. Here, I discuss some of what’s not right in the picture for the current paradigm; an approach which, in essence, dates from the 1950s.

By way of introduction, let’s consider a finding from decades ago. In a previous piece on how psychiatric drugs can often tend to make things worse, I referred to a series of WHO investigations (see this pdf). These found better recovery rates from psychosis in lower income countries, compared with their richer counterparts. Known as the ‘outcomes paradox’ or as the ‘better prognosis hypothesis’, it has been considered a well established feature of the global epidemiology of ‘schizophrenia’. ‘Paradoxical’, because in contrast with healthcare outcomes generally being better in ‘developed’ (high income) countries, outcomes for those who had suffered psychosis were apparently better in the ‘developing’, lower and middle income countries.

…course and outcome for subjects in the developing centers were more favorable than for their developed world counterparts… even for subjects whose early course was poor, the likelihood of later recovery favors those in the developing centers…

At the time, the findings were attributed by researchers largely to cultural factors. Perhaps it was better social inclusion of sufferers that enabled recovery.

Subsequently, the picture was challenged. Critics dismissed the better prognosis hypothesis, pointing to contrary findings like much reduced life expectancy for those diagnosed compared with the general population in lower income countries. They argued that the supposedly more favourable sociocultural context in ‘developing’ countries, is often not to be found. There is, after all, plenty of stigma against those experiencing mental ill-health in both richer and poorer societies.

As trends of urbanization and migration gained pace in the ‘developing world’, some pointed to factors like these as much increasing a person’s risk of experiencing psychosis. So perhaps greater urbanization in the industrialized countries, as opposed to more rural living in the ‘third world’ was part of the explanation for the trend.

But to my mind there seems to be a neglected factor that could help explain the trend: different levels of the use of so called ‘antipsychotic’ drugs. As far as I’m aware, this has not generally been much considered in the literature on the outcomes paradox, with few exceptions.

‘Schizophrenia’ Disability-adjusted life years, 2012 (Source)

Here I take psychotropic medicine use in general as a proxy for use of ‘antipsychotic’ drugs. Data for 2008–19 (Lancet)

Loosely, one can see here some correlation between recorded levels of disability from ‘schizophrenia’ in the first map, and the levels of use of psychotropic ‘medicines’ shown underneath. The countries with the highest rates of psychiatric drug consumption (pink to red) also tend to have higher scores for disability from ‘schizophrenia’ (darker orange to red). For example, the US, Canada, Australia and Croatia all have high rates of psych drug use and high rates of this ‘disability’; whereas India and the Philippines score low on both scales.

The use of all classes of psychotropic drugs, has some limited applicability as a proxy indicator for the extent of ‘antipsychotic’ use. Attentive readers may notice that China would appear to be an exception to the trend, with a relatively high rate of disability, despite what is recorded by the Lancet as a lower rate of psychotropic drug use overall. This is most likely under-reporting. The Lancet data is based on sales data from European market research. China, obviously, has its own large manufacturing capacity. There is actually relatively heavy use of ‘antipsychotics’ there, as this paper concludes the “proportion of antipsychotic polypharmacy in China is higher than in many other countries…”

The hypothesis that prescription rates are likely a factor in the ‘outcomes paradox’ is lent some tentative credence, by a review of the WHO studies, which noted: “important findings common to many developing sites included: high percentages of subjects who had never received biomedical treatment…”

Due to the many factors at play over time, such as under or over-reporting, and the difficulty of making like for like comparisons, the better outcomes hypothesis remains controversial and open for debate. My arguments here won’t rely on it. The above isn’t intended as definitive, but to provide a bit of background on the outcomes debate and some illustrative context for what follows.

If we accept that the supposed sociocultural advantages in ‘developing countries’ may indeed not be present, the data does, however, seem to show that something is wrong with the conventional approach. If neuroleptic ‘antipsychotics’ are the solution, then we’d expect to see more favourable outcomes where they are used the most.

Another apparent finding of the WHO studies that was widely accepted in the literature, was that increased length of time without any appropriate care intervention for psychosis looks to correlate with a poorer long-term outlook for patients. This was widely taken by psychiatrists as supporting biochemical intervention with the use of ‘antipsychotics’ at the earliest opportunity. The conclusion that duration of untreated psychosis (DUP) was a key factor determining prognosis, would later be used to justify the mainstream innovation of Early Intervention in Psychosis (EIP) programmes.

Whilst accepting that a lack of any appropriate care intervention for those experiencing psychosis is undesirable, I intend to show here that ‘treatment’ for psychosis should not be taken as being synonymous with the use of neuroleptics; and that the conventional treatment model can result in a poor outlook, often quite avoidably.

As international comparisons can be open to contestation, I turn to same country data on long-term rates of clinical remission of symptoms and ‘functional’ recovery, after patients received ‘early intervention’. Data tends to show that longer-term functional (ie social and occupational) outcome measures appear no better for those who received EIP, than for those who did not.

(Source: Ten year follow up of the OPUS trial…) Symptom and functioning scores showing that any initial benefits of EIP over standard treatment are lost by the five year point.

The evidence from the OPUS trial is that any benefits from EI are sustained only for the duration of the intervention, which in this case was 2 years. After this point, when patients are returned to standard mental health care, the difference between the two arms of the trial rapidly diminishes until there are no clinically significant differences.

Several reviews of the longer term effectiveness of EIP seem to agree that its advantages fade after the intervention has ended; noting that there is little evidence of ongoing benefit for recipients of EIP programmes over standard treatment after the intervention period of 2-3 years.

The mainstream response to this finding, insists there must be a ‘critical period’ after first episode psychosis (FEP) and the interventions just need to be sustained a bit longer to cover this period in order to realise the hoped for longer-term benefit. This hope appears to be forlorn, based, as it is on the consensus that ongoing treatment with neuroleptics prevents relapse. I’ll show that this consensus rests on shaky ground. And I’ll have some more to say about the ‘critical period’ and EIP in Part 2.

Something clearly looks awry with the orthodox paradigm. Before we continue let’s remind ourselves of a few of its key tenets:

• The dopamine hypothesis of schizophrenia — this argued back from the mode of action of the neuroleptics observed to calm disturbed patients. As the drugs blockade dopamine signalling, this was taken as indicating that schizophrenia symptoms therefore resulted from excessive dopamine signalling.
• Longer periods of untreated psychosis (DUP) correlate with poorer long-term outcomes. It was assumed then, that…
• The psychotic state amounts to a neurotoxic brain process. The idea being that if left untreated, it would damage the brain. Accordingly, it would be unethical for doctors to withhold drug treatment.
• Thus, neuroleptics are indicated for all cases of psychosis.

But there was always something lacking in the dopamine explanation. For instance, there is typically a time lag of weeks between the commencement of the dopamine blockading effect of neuroleptics and observed remission of clinical symptoms. If ‘psychosis’ is due just to excess dopamine, it would be expected to dissipate without such delay. Moreover, around 30% of patients will be deemed non-responsive to neuroleptics. At best, dopamine signalling can be said to mediate or regulate psychotic symptoms. This is not the same as accounting for their causal origin (aetiology). I delve further into reductive biochemical theories of psychosis in Part 2.

Returning to patient outcomes, a much cited 2013 study by Wunderink et al made the case for assessing social and occupational functioning, rather than just clinical remission of symptoms when looking at a treatment’s long-term effectiveness. The study found that patients with remitted symptoms after first episode psychosis would have better longer-term chances of functional recovery after drug discontinuation, or dose reduction, rather than maintaining standard treatment.

The psychiatrist Sandra Steingard concurred with the findings on recovery rates:

There are other studies that support Wunderink’s findings. Johnstone and colleagues conducted a somewhat similar study, known as the Northwick Park Study, in the 1980s. They randomly assigned 120 patients who had recovered from a first episode of psychosis to maintenance treatment with drug or placebo and followed them for 2 years. While the placebo group had a higher rate of relapse during this time, they also had an overall higher rate of employment. The authors wrote, “It suggests the disquieting conclusion that the benefits of active neuroleptics in reducing relapse may exact a price in occupational terms.”

Although discontinuation was associated with a higher chance of relapse, by the three year point in the Wunderink study the risk of relapse between the maintenance and discontinuation groups was equal. After five years the discontinuation or dose reduction group can even be seen to have a lower rate of relapse.

Despite experiencing fewer relapse events for the first three years, by five years the maintenance treatment cohort fares less well than the dose reduction cohort.

It appeared that maintenance treatment only prevented relapse over a limited time scale.* It remains the psychiatric consensus, however, that maintenance treatment is warranted, as it avoids relapse.

In what does this apparent benefit consist? I contend that much of it is a comparative statistical effect generated by drug trial participants suffering ‘rebound’ effects from drug withdrawal. This tends to happen when, according to trial protocols, participants are switched from their prior neuroleptic treatment to placebo within an unduly short time-frame. Taking this properly into account would suggest, that much of the evidence base supporting ‘maintenance treatment’ is skewed and distorted.

It is not uncommon in the UK, for patients in remission after a first episode of psychosis to be told that if they continue taking antipsychotics for two years, this will minimize their risk of relapse going forward. I believe such guidance to be ill founded. Essentially, it just reflects the fact that the trials on which the guidance is based, typically have only a two year follow-up period.

Trial participants are usually drawn from those already taking medication rather than drug naive patients. The placebo group is withdrawn from the antipsychotic with a short taper and washout period. Whilst the antipsychotic group is simply maintained on their pre-existing drug regime. Here is a typical 4-week taper schedule, as used in the STOP Psychotic Depression II trial:

(From the Pharmacotherapy Protocol for the STOP PD II Trial)

A 4-week taper can be considered an abrupt taper. In fact eight trial participants in the placebo group ‘relapsed’ within that short tapering period. The majority of the ‘relapses’ in the placebo group then occurred within 12 weeks of the start of the taper.

(The STOP PD II randomized clinical trial) ‘Relapses’: The bulk of those in the placebo group happen within two months of the end of the taper.

By around 14 weeks the rates of relapse in the olanzapine and placebo groups are seen to have roughly equalized. This closeness in time of the ‘relapses’ in the placebo group to the drug discontinuation phase, and their subsequent levelling off, suggests that the bulk of them could have been due to withdrawal effects. This is not an uncommon phenomenon in trials of antipsychotics. Mark Horowitz found that “[i]n one meta-analysis, 60% of all relapses over 4 years occurred within 3 months of drug cessation.” This supports the objection that many of these ‘relapses’ likely arise from drug withdrawal effects.

Horowitz explains what can happen:

Withdrawal-associated relapse has been attributed to neural adaptations to long-term antipsychotic treatment (dopaminergic hypersensitivity) that persist after antipsychotic cessation…This hypersensitivity to dopamine may render patients more susceptible to psychotic relapse when D2 blockade is diminished by antipsychotic dose reduction.

The brain compensates to the dopamine blockading effect of the drug, by increasing the sensitivity or number of dopamine receptors. If the drug is then ‘washed out’ of the system, there will likely be a disruptive surge in dopaminergic signalling, among other effects.

‘Supersensitivity psychosis’ can occur in people with no psychiatric history during withdrawal from off-label use of the drug. This phenomenon is also thought to play a role in some cases of ‘treatment resistance’. The theory being that, for some people, as their brains adapt to the cumulative exposure, any capacity of the drugs to ‘tamp down’ dopamine signalling is effectively cancelled out, by the greater sensitivity arising from increased receptor density. Signs such as closeness in time to drug discontinuation and symptoms of a more somatic character may indicate that an apparent ‘relapse’ may be a drug withdrawal syndrome, and hence, not necessarily a resurgence of some ‘underlying condition’.

(Source)

Neuroscientific researchers have linked dopamine dysregulation to disrupted filtering of sensory information, associated with what they call ‘diminished functional connectivity’ between brain regions. They hypothesize that the ‘aberrant salience’ considered characteristic of the phenomenology of psychosis, may be due to this reduced ‘functional connectivity’.

One of several papers that came out of the STOP PD II trial argues that olanzapine stabilizes such ‘functional connectivity’. Participants were given MRI scans at the start and end of the trial, or if they relapsed.

Overall, functional connectivity between the secondary visual network and the rest of the brain did not change in participants who stayed on olanzapine but decreased in those switched to placebo… this suggests that olanzapine may stabilize functional connectivity…”**

But as we have seen, the effects found in the relapsing placebo participants look, most probably, to be the results of ‘antipsychotic induced dopaminergic hypersensitivity’ and abrupt withdrawal.

Nevertheless, the takeaway headline about STOP PD II was that taking olanzapine for 36 weeks ‘sustains remission’. The UK public health research body NIHR parroted that remitted patients benefit from continuing on olanzapine. By the same logic one would conclude that maintenance treatment with benzodiazepine sleeping pills was indicated for everyone who had been treated for insomnia!

As trial designs like this tend to be the rule rather than the exception, a large part of the evidence base supporting maintenance use of ‘antipsychotics’ can be seen as unsoundly based on poorly informed trial protocols.

But what happens when, instead of trials based on withdrawing antipsychotics from those already accustomed to taking them, a trial is carried out with drug naive participants. This trial at the Orygen centre in Melbourne, Australia indicated that psychosocial intervention alone could, for some, be sufficient to remit clinical symptoms:

“In the highly selected sample recruited to this study, psychosocial treatment alone was not inferior to psychosocial treatment plus antipsychotic medication at the end of the intervention period, raising the possibility that some young people with early psychosis may not require antipsychotic medications to recover.”

The psychosocial interventions had comparable clinical efficacy with administering neuroleptics. Additionally, when MRI scans were performed they showed the ‘aberrant functional connectivity’ associated with psychosis could be ‘normalized’ in drug naive patients, when they received placebo pills and intensive psychosocial intervention over three months; suggesting that psychiatric drugs may often not be necessary in order to resolve such ‘abnormalities’.

The findings are instructive in reminding us that biochemical interventions are not the only modality for affecting brain processes. Given that the human brain is the most complex object known to science, and that how it produces consciousness still remains a mystery, it is probably best that such narrowly reductive biochemical interventions are kept to a minimum. The history of harm caused to patients by psychiatric treatments more than amply testifies to the dangers.

In Part 2, I hope to show how changing assumptions about diagnosis and causality can provide a basis for reappraising treatment interventions, with the aim of minimising ongoing iatrogenic harm. But to wrap up this part of my discussion:

Why does long-term use of neuroleptics correlate with poorer social and occupational outcomes? As surmised by Wunderink et al, their prolonged use “might compromise important mental functions, such as alertness, curiosity, drive, and activity levels, and aspects of executive functional capacity to some extent.” Dopamine is generally acknowledged to play a role in motivation and ‘reward related behaviour’. I’ve noted before the flattening of emotion and expression that neuroleptic drugs tend to produce.

But, that is not all. Perhaps the most important finding of the STOP PD II trial is that olanzapine exposure thins the brain’s cortex:

“…exposure to olanzapine compared with placebo was associated with significant decreases in cortical thickness in the left hemisphere and the right hemisphere.”

The researchers assessed that 36 weeks of exposure to olanzapine would result in a 1.2% loss of a person’s cortex, which reconfirmed the results of previous animal studies where lab monkeys exposed “for 17 to 27 months lost roughly 10% of their total brain volume, both gray and white matter…”

Although STOP PD II study papers acknowledge that reductions in brain volume are “typically interpreted” as undesirable, the trial is taken as demonstrating the benefit of continuing with olanzapine. The cost of ‘sustaining remission’ for 36 weeks is just 1.2% of your cortex. Good deal, huh?

Needless to say, there are many other drawbacks and morbidities*** associated with long term use of ‘antipsychotics’. When one considers this and the above effects together, is not altogether surprising that social and occupational prospects can be dimmed in those kept on standard treatment.

Notes:

* The recent RADAR trial in the UK showed at its two-year mark that; although, more relapse events occurred in the discontinuation group, this group did not show worse ratings for clinical symptoms or functioning than the maintenance treatment arm. It is not clear to what extent the trial was able to incorporate the most recent guidance on ‘hyperbolic tapering’ and deprescribing. I cover some of this guidance in the following parts. Also, it should be noted that the trial took place amid the Covid19 pandemic and restrictions. Both the virus itself and the lockdown restrictions have been linked with raised risks of mental health difficulties.

** In fact this finding from STOP PD II was a lesser, secondary one and not the primary outcome on ‘functional connectivity’ that the neuroscientists had been hoping to see.

*** The work of Mad In America and its founder Robert Whitaker has helped pave the way for wider public awareness of the harms caused by a culture of psychiatric overdiagnosis and prescribing. Among other leading voices that have influenced my thinking are David Healy, Richard Bentall, Peter Breggin, and Joanna Moncrieff.

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The significance of semiotics extends beyond academic discourse, holding profound implications for practical application in social work. By decoding the myriad of signs and symbols that individuals and communities navigate daily, social workers can uncover more profound layers of meaning, enhancing their ability to connect with, understand, and assist their clients. Whether it’s interpreting a gesture, a piece of clothing, or the arrangement of space, each element carries potential insights into a person’s experiences, beliefs, and challenges.

However, despite its vast potential, semiotics has yet to be widely incorporated into social work practice and education. This oversight limits the depth of client assessments and the effectiveness of interventions tailored to address their unique circumstances. This blog post seeks to illuminate semiotics’ untapped power in social work and advocate for its integration as a novel approach to fostering more nuanced, empathetic, and compelling client relationships.

As we delve into the intricacies of semiotics, this blog will explore how this perspective can revolutionize traditional methods, bridging communication gaps and fostering a more inclusive understanding in multicultural and diverse settings.

The Significance of Semiotics in Social Work

At its core, semiotics is the study of signs and symbols and their use or interpretation. In the bustling, multifaceted world of social work, every gesture, symbol, and verbal exchange is critical to deeper understanding and connection. Semiotics equips social workers with the analytical tools to decipher these complex sign systems, enabling them to gain insights into their clients’ inner worlds and social realities.

Unlocking Deeper Understanding

Social workers are tasked with navigating the intricate landscapes of human emotions, behaviors, and societal pressures. Semiotics offers a framework for understanding how individuals and communities create meaning, communicate, and perceive their surroundings. Professionals can unlock a more profound understanding of the people they serve by interpreting the signs and symbols encountered in social work practice—ranging from the spoken and written word to nonverbal cues and cultural artifacts.

Enhancing Cultural Sensitivity and Inclusivity

The relevance of semiotics extends into the domain of multicultural practice. As societies become increasingly diverse, social workers frequently engage with clients from varied cultural backgrounds. Semiotics provides a lens through which cultural symbols and practices can be understood and respected. This sensitivity to cultural semiotics fosters inclusivity and enhances the therapeutic alliance between social workers and their clients by acknowledging and valuing their cultural identities.

Bridging Communication Gaps

Effective communication is at the heart of social work. Semiotics empowers social workers to bridge gaps in understanding that arise from linguistic differences, nonverbal cues, or cultural nuances. By becoming adept at reading the array of signs and symbols that individuals use to express themselves, social workers can tailor their interventions in ways that resonate more deeply with their clients’ lived experiences.

Semiotics in Action: Case Studies and Applications

To illustrate the impact of semiotics in social work, consider the following examples where a semiotic approach has enriched understanding and intervention:

Case Study 1: Engaging with Non-Verbal Communication in Psychosis

• Context: In a mental health care setting, a social worker, David, is assigned to work with Maya, a client experiencing psychosis. Maya has become increasingly non-verbal, often communicating her needs and emotions through behaviors rather than words. Recognizing the challenge, David aims to build a connection with Maya and understand her experiences to provide appropriate support.
• Semiotic Analysis: David observes Maya’s behaviors and the symbols she interacts with. He notes that Maya often arranges her room in a specific pattern, repeatedly aligning her shoes straight towards the door and organizing her books by color rather than subject. During art therapy sessions, Maya uses specific colors dominantly and avoids eye contact, instead focusing her gaze on objects in the room.
• Interpreting Non-Verbal Signs: David interprets these behaviors and preferences as Maya’s way of creating order and predictability in her environment, possibly reflecting her inner desire for stability and control amidst the chaos of psychosis. The choice of colors in her art could symbolize different emotions or states of mind. David hypothesizes that the alignment of shoes might represent a subconscious desire for escape or readiness to leave. At the same time, the color-coded books could signify an attempt to categorize and make sense of her world.
• Intervention: With this understanding, David focuses on non-verbal therapeutic interventions that align with Maya’s modes of communication. He introduces sensory-based activities, such as music therapy and tactile art projects, to provide Maya with alternative ways to express herself and engage with her environment. David also ensures that Maya’s room arrangement is respected, recognizing it as essential to her coping mechanism.
• Building Trust: To build trust and rapport, David maintains a consistent presence, sitting quietly with Maya during sessions and engaging in parallel activities rather than direct interaction, allowing Maya to become comfortable with his presence without the pressure of verbal communication. He uses gentle, non-verbal cues to express support and understanding, such as maintaining a calm demeanor, mirroring Maya’s actions when appropriate, and providing materials for her to express herself as she wishes.
• Outcome: Over time, Maya begins to trust David, evidenced by subtle nonverbal cues like brief eye contact, a slight nod in response to his presence, and more relaxed body language. While verbal communication remains limited, Maya’s engagement in therapy activities increases, and she starts experimenting with new forms of expression, such as clay modeling, which she uses to create figures representing different aspects of her experience.

Case Study 2: Interpreting Personal Symbols for Therapeutic Insight

• Context: A social worker in a high school setting notices that a student, Alex, consistently wears black clothing and has a notebook covered in drawings of dark, solitary figures. Recognizing these choices as potential symbols expressing inner feelings or identity, the social worker explores their meanings with Alex.
• Semiotic Analysis: In a series of counseling sessions, the social worker gently broaches the subject of Alex’s clothing and notebook drawings, framing them as creative expressions worth discussing. Through open-ended questions, the social worker invites Alex to share the stories behind these symbols. Alex reveals feelings of isolation and misunderstanding, which the black color and solitary figures represent. These symbols serve as a form of self-expression and a shield against the social pressures of the school environment.
• Intervention: Leveraging these insights, the social worker and Alex collaborate on identifying coping strategies that acknowledge Alex’s need for self-expression while exploring ways to build connections with peers with similar interests and feelings. The social worker incorporates art therapy sessions to explore these themes further, fostering a safe space for Alex to navigate and articulate complex emotions. The intervention focuses on validating Alex’s feelings, enhancing self-esteem, and gradually developing social skills and resilience.

Study 3: Cultural Symbols and Community Connection

• Context: In a multicultural community center, a social worker named Priya observes how different families decorate their allocated spaces. One family, the Nguyens, decorates their area with vibrant lanterns and silk fabrics, while another, the Garcias, uses bright papel picado and religious icons. Recognizing these decorations as cultural symbols, Priya sees an opportunity to foster community understanding and cohesion.
• Semiotic Analysis: Priya organizes a community event where families are invited to share the meanings behind their decorations. The Nguyens explains that the lanterns and silk represent light, hope, and the importance of family in Vietnamese culture. The Garcias discuss the significance of papel picado in Mexican celebrations and how religious icons provide them with a sense of protection and guidance. This event allows families to share and celebrate their cultural identities, creating a platform for cross-cultural understanding and appreciation.
• Intervention: Building on the event’s success, Priya introduces a series of workshops focused on cultural storytelling and crafts, encouraging families to teach each other about their traditions and symbols. These workshops promote cultural sensitivity and inclusivity within the community center and empower participants by valuing their backgrounds and experiences. Priya uses these activities to facilitate discussions on common themes, such as family, hope, and resilience, highlighting the shared human experiences that transcend cultural differences.

These examples underscore the practical applications of semiotics in social work. They demonstrate its potential to deepen client assessments and craft effective, culturally attuned, and empathetic interventions.

By embracing semiotics, social workers can expand their toolkit and incorporate a nuanced understanding of signs and symbols into their practice. This approach enriches client assessments and paves the way for interventions that are more responsive to the unique narratives and cultural backgrounds of their clients.

Challenges and Opportunities: Navigating Semiotics in Social Work

Integrating semiotics into social work practice offers a promising avenue for enhancing client understanding and intervention effectiveness. However, this journey has its challenges. Navigating semiotics’ intricacies requires a thoughtful balance between theoretical knowledge and practical application, alongside an awareness of the limitations and ethical considerations involved.

Overcoming Challenges in Semiotic Interpretation

One of the primary challenges in applying semiotics within social work is the inherent subjectivity of sign interpretation. Signs and symbols do not carry universal meanings; their interpretations can vary significantly based on individual, cultural, and contextual factors. This variability necessitates a high degree of cultural competence and reflexivity from social workers, who must ensure that their interpretations do not impose unintended meanings or biases onto the client’s experiences.

Additionally, the practical implementation of semiotics in social work settings demands expertise and training that may need to be more readily available within current educational curricula. Social workers must understand semiotic theory and have the skills to apply these concepts in diverse and often complex social contexts.

Seizing Opportunities for Enhanced Communication and Intervention

Despite these challenges, the potential benefits of integrating semiotics into social work practice are substantial. By adopting a semiotic lens, social workers can:

• Deepen Empathetic Engagement: Developing the ability to “read” and understand the signs and symbols in clients’ communication enables social workers to engage empathetically and supportively, fostering stronger therapeutic relationships.
• Cultivate Cultural Sensitivity: A semiotic approach encourages social workers to delve into the cultural meanings behind clients’ expressions and narratives, promoting a culturally sensitive and inclusive practice.
• Enhance Intervention Strategies: With a nuanced understanding of the signs and symbols relevant to their client’s lives, social workers can design interventions more precisely tailored to individual needs and contexts, potentially leading to more effective outcomes.

The Future of Semiotics in Social Work

Exploring semiotics in social work is an ongoing journey with opportunities for innovation, research, and practice enhancement. To fully realize the potential of semiotics, several steps are recommended:

• Integrating Semiotics into Education and Training: Social work curricula should include comprehensive training in semiotic theory and application, preparing future practitioners with the tools to effectively employ this approach.
• Promoting Interdisciplinary Collaboration: Collaboration between social work and disciplines such as linguistics, anthropology, and psychology can enrich the understanding of semiotics and its practical applications in social work.
• Conducting Further Research: Empirical studies examining the impact of semiotic approaches on social work outcomes can provide valuable insights and evidence to support the integration of semiotics into practice.

Embracing Semiotics for a More Nuanced Practice

Incorporating semiotics into social work represents a novel approach to enhancing client understanding and intervention. By delving into the meanings behind the signs and symbols that permeate human interactions, social workers can gain deeper insights into their clients’ worlds, fostering more effective, culturally sensitive, and empathetic engagements. While challenges exist, a semiotic approach’s opportunities and potential benefits in social work are immense. As the field continues to evolve, embracing semiotics could significantly enrich the practice, making it more attuned to the diverse and complex realities of human experience.

This exploration of semiotics within social work invites practitioners, educators, and researchers to consider how understanding signs and symbols can transform client assessments, interventions, and outcomes. By integrating semiotics into social work practice, the field can move towards a more inclusive, responsive, and nuanced understanding of the people it serves.

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