When we were 16, one of my best friends had a psychotic episode. He was sectioned, and diagnosed with paranoid schizophrenia. He’s never had a job, has been in and out of psychiatric facilities, and I think I’m the only friend who has kept in touch with him.
When I go to see him, he’s not always very well. In the last few years, he often repeats the same handful of sentences over and over, how the NHS is a criminal enterprise, how pseudo-psychiatrists are feeding him bad drugs, how he’s actually a spiritual healer.
Sometimes the drugs, or his experiences, are just too strong for him, and he stares silently into space.
At the end of our meetings he asks me ‘how am I doing?’ And I wonder, how are we doing? Is my friend just suffering from an awful, debilitating biological illness, or are we failing him?
I read an excellent new book on this topic, called The Heartland: Finding and Losing Schizophrenia, by Nathan Filer. He’s an award-winning novelist, and former mental health nurse.
The Heartland is a refreshingly honest and humble exploration of what Filer calls ‘so-called schizophrenia’, and the flaws in how psychiatrists define and treat it.
As well as presenting case studies of people who have experienced psychosis, he presents the work of a group of psychologists, psychiatrists and ‘service users / survivors’, mainly in the UK, who are associated with a movement called A Disorder for Everyone. This movement challenges the basic assumptions of psychiatry.
The basic assumptions of mainstream psychiatry, also sometimes known as biomedical or Kraepalinian psychiatry (after the German psychiatrist Emil Kraepalin), are fourfold:
1) Mental illnesses can be classified into certain diagnoses, with names like ‘schizophrenia’, ‘bipolar disorder’, ‘personality disorder’, ‘depression’ and so on.
2) Psychiatrists can recognize and diagnose these conditions through the typical symptoms they lead to, such as mania or paranoid delusions.
3) These conditions have biochemical causes. They are malfunctions of the brain.
4) They’re best treated with mind-altering drugs.
These assumptions are deeply influential in our culture, shaping our sense of self and reality and fuelling our reliance on psychiatric drugs. But they’re breaking down.
Firstly, it is increasingly recognized by both psychiatrists and psychologists that psychiatric diagnoses are flawed.
American psychiatry has tried for 50 years to prove it is a genuine respectable science by formulating a handbook of diagnoses, a Bible, called the Diagnostic and Statistical Manual (DSM). It was first published in 1952, and the fifth edition came out in 2013.
Each edition was radically different – diagnosis appeared and then disappeared as fashions changed (homosexuality was a disorder in the first edition). Huge new drug markets would burst into life as a new condition was included (like social anxiety in the DSM III).
But the problems and criticisms with the DSM system persist. Many people will collect multiple different diagnoses over time. Symptoms overlap – a person may show aspects of mania, depression, delusion and anxiety at different times.
Most psychiatrists and psychologists now accept that, while the DSM does identify certain typical clusters of symptoms, words like ‘schizophrenia’ do not point to actual underlying biological conditions.
Despite hundreds of billions of dollars in research, psychiatrists have been unable to find biological markers for what Filer calls ‘so-called schizophrenia’. There is no evidence for chemical or physical differences in the brains of those diagnosed with schizophrenia.
There is some evidence for a genetic basis for schizophrenia. But this evidence also undermines the DSM diagnostic model. It suggests there is no single gene for particular disorders, rather, a cluster of genes make certain personality dispositions stronger or weaker.
What we presently call ‘schizophrenia’, for example, may really be the extreme end of a disposition which exists on a continuum throughout the population. That disposition could involve traits like schizotypy, unusual thinking, absorption, or dissociation.
We are all on that continuum. I am probably a bit on the stronger end of it, and this brings gifts and frailties. It enables me to think unusually, wittily and empathetically, and it also makes me prone to anxiety, occasional delusions, and dissociative episodes.
Robert Plomin, a leading genetic scientist, writes about schizophrenia in his new book Blueprint: ‘it makes no sense to try to reach a decision about whether someone ‘has’ the disorder or not. There is no disorder – just the extremes of quantitative dimensions…A shift in vocabulary is needed so that we talk about ‘dimensions’ rather than ‘disorders’.
Our genetic disposition then interacts with our environment, when bad shit happens to us.
The diagnosis-based approach of mainstream psychiatry pays remarkably little attention to the environmental causes of mental illnesses, such as poverty, inequality, childhood trauma, being an immigrant, experiencing racism, or living in cities – all of which increase the likelihood of you having an emotional disorder or psychotic experience.
A friend of mine experienced a manic episode recently. He went to see a psychiatrist, who after a half-hour conversation gave him a diagnosis of bipolar disorder. He didn’t ask a single question about whether my friend had suffered trauma at some stage in his life.
My friend had the advantage of being rich, educated and white. You are much more likely to be sectioned and put on anti-psychotic medication if you’re from an ethnic minority.
Finally, there is the question of treatment. If mental illnesses don’t have a chemical basis, what’s the point and what are the risks of treating them with drugs?
Some people find anti-depressants helpful for emotional problems but (as I wrote recently) such drugs are only very slightly more effective than placebo. And there’s growing evidence that their risks and side-effects have not been properly explained to the public by psychiatrists.
What about the risk of anti-psychotic drugs? If there is not a chemical basis for schizophrenia or bipolar disorder, what exactly are these drugs doing? They’re basically sedating people. Calling them a treatment is a bit like saying someone suffering from grief should drown their sorrows in a bottle. It’s not really a treatment, it’s just a way of suppressing your feelings.
Some people still find that helpful. But if you keep on dosing yourself every day with very strong mood-altering chemicals, for decades, it’s going to take a toll. You will be protected from the highs and lows of psychotic experience, but at the cost of being emotionally flattened.
One of the more terrifying suggestions in Filer’s book is that some of the symptoms we presently attribute to schizophrenia – emotional flattening, detachment, difficulty focusing, lack of pleasure or purpose– may be caused by the drugs, not the illness.
Just to repeat that. The drugs may actually cause the symptoms which psychiatrists take as evidence you’re ill. So they keep on prescribing you more drugs.
Filer writes: ‘It feels clear to me that doctors and other mental health professionals need to be much, much more cautious about getting people started on these drugs in the first place. It’s also clear to me that in the words of one academic I interviewed, there’s a ‘gaping chasm in the evidence for when to stop prescribing’.
So we have a psychiatric system that uses flawed diagnostic criteria, based on an unsupported theory of the biochemical basis of mental illnesses, to justify spending trillions of dollars on toxic mood-altering drugs.
That’s messed up. But psychiatrists often hide the weakness in their evidence because, as well as wanting to help people, they also want to be respected and taken seriously by other scientists and society at large. They want status, meaning and intellectual certainty, even if it means denying meaning to others. That is their pathology.
This is not to say that psychiatry doesn’t have an important role. Medication helps people sometimes, and sometimes people need to be sectioned, for their own safety and the safety of others. Psychiatrists can (and should) act as counsellors to the disturbed, treating them as suffering humans whose experiences are meaningful, rather than broken machines who just need pills.
But what is the alternative to drug treatments? One alternative is psychological therapies like Cognitive Behavioural Therapy or Compassion-Focused Therapy, which help people change their relationship to negative thoughts, beliefs and voices. People can learn that they don’t have to identify with, or act on, their thoughts. They can learn to recognize and accept difficult emotions and trauma which may underlie their disturbance. They can learn to develop a more compassionate inner voice.
Another alternative is to help people find supportive communities. I joined a support group for social anxiety in my 20s, and it was hugely helpful for me. If mental illnesses often have social and environmental causes (poverty, inequality, prejudice, isolation), then some of the solutions will be social as well. Connection. Support. Love. Activism.
And a third alternative is to help people find more positive frames and meanings for their experiences, rather than dismissing their experiences as the meaningless products of biological pathologies.
This brings me to the only criticism I want to make of Filer’s book.
He shows admirable sympathy and intellectual humility throughout the book…except when it comes to religion and spirituality.
On this topic, he displays some of the arrogance and contempt that has long been typical of psychiatrists.
I noticed that bias, or blind spot, early in the book, when he writes: ‘There is no ghost in the machine. There’s nothing more to us than the brain.’
Huh? How does he know? He’s a novelist and former mental health nurse, not a physicist. What, amid our collective ignorance about the nature of consciousness or the relationship between mind and matter, gives him the confidence and authority to make such a certain pronouncement?
Later, he discusses a person who suffers from religious delusions – she is Irish-Catholic, and thinks she must heal the world. He notes that many people have religious delusions, such as the belief in miracles, and writes: ‘all people, including ostensibly ‘sane people’, have a staggering capacity to believe in nonsense’.
It’s a note of striking contempt, in a book which otherwise portrays such sympathy and humility. I don’t think Filer would even have noticed his bias, because it’s so widely shared among psychiatrists and academics.
Yet this anti-spiritual bias blinds him to an important aspect of mental illness, an important way that people frame difficult experiences and cope with them.
The British Psychology Society’s excellent 2014 report, ‘Understanding Psychosis and Schizophrenia’, writes: ‘There is growing interest in the idea of that ‘psychotic’ crises can sometimes be part of, or related to spiritual crises, and many people feel that their crises have contributed to spiritual growth.’
Marius Romme and Sandra Escher, the founders of the Hearing Voices Network, write:
There are people who have developed a very positive relationship with the experience of hearing voices, and have managed without any psychiatric treatment or support. They have adopted a theoretical frame of reference (such as parapsychology, reincarnation, metaphysics, the collective unconscious, or the spirituality of a higher consciousness) which connects them with others rather than isolating them: they have found a perspective that offers them a language in which to share their experiences. They enjoy a feeling of acceptance; their own rights are recognised, and they develop a sense of identity which can help them to make constructive use of their experiences for the benefit of themselves and others.
There is a whole body of scientific research by transpersonal psychologists such as Stanislaf Grof, Roberto Assaglioli, Carl Jung, William James and RD Laing, which frames psychotic experiences as potentially healing experiences of ego-dissolution and rebirth, not unlike extended psychedelic trips. Psychosis is a moment when the ordinary self and ordinary reality breaks down and a more intense, more mythical reality reveals itself. It involves a blurring of the boundaries between inner and outer reality / self and other – which is why psychotics can be prone to grandiose delusions like thinking they’re controlling the world with their mind, or paranoid delusions like thinking the world (or some particular group) is controlling their mind.
It’s possible that the psychotic is having a glimpse of an interconnected reality beyond the illusory ego, but the experience is unstructured, overwhelming and therefore damaging. Joseph Campbell wrote: ‘The psychotic drowns in the same waters in which the mystic swims with delight.’
People can learn to swim in these perilous waters. Properly navigated and integrated, such disturbing experiences of ego-dissolution can sometimes be transitions to new levels of wisdom, maturity and wholeness.
I’ve had such experiences myself, and am co-editing a volume on the topic, which is being published in April (my co-editor is a psychiatrist, by the way – there are some good ones out there!) It is, I think, the first book to present people’s own essays on their spiritual emergencies. I think that’s important – let people tell their own stories rather than relying on you, the wise rationalist narrator, to collect their case studies and fit them into your narrative, for which you get all the praise and profit.
I find it strange that Filer completely ignores the large body of research around this area, which has shown that finding a spiritual frame for unusual / psychotic experiences is often very helpful and healing for people.
Or rather, it’s not strange at all, because psychiatry has a long history of active hostility to religion and spirituality. Psychiatry defined itself as a profession through conflict with the Church. It took a whole domain of human experience – mystical / ecstatic / altered states – and said ‘they’re unhealthy delusions’.
I am not saying that psychiatrists need to abandon their materialist beliefs and become religious or spiritual. But they should be open to the alternative ways many people make sense of their experience, and the alternative frames they choose to give meaning and structure to their lives.
They should also be aware of the evidence showing that religious or spiritual beliefs, practices and communities are often supportive to people’s mental health and recovery from illness or disturbing experiences (see The UNIQUE research group at Kings College London, or the work of Isabel Clarke).
I think of my friend, and his paranoid conspiracy that NHS psychiatrists are pseudo-scientists feeding him bad drugs which are harmful to his health. And I think, is this definitely a paranoid conspiracy?
My friend accepts he has delusions – he often sees me as Lucifer, for example, but recognizes that is probably an archetypal projection on his part.
Within the incredible adversity of his life, he has found a spiritual frame. He says: ‘I choose to forgive the psychiatrists who have harmed me. I practice prayer. Spiritual kung-fu. Monk’s business. The path of peace.’
‘How am I doing’, he asks me as I get up to go.
You’re doing amazingly, I say.
He endures, like a headland against the ocean. While the waves batter him, he endures.