Sometime ago the World Health Organisation funded a study exploring the prevalence of psychotic disorders cross-culturally. The surprising finding was not so much that this phenomenon seems to be found in all cultures, but that the prognosis was better in the ‘developing countries’ than in the ‘developed countries’. Arthur Kleinman’s book Rethinking Psychiatry (1988) explored a number of possible reasons for this, including the debilitating effects the stigma of identity through diagnosis may be having. Although there appeared to be a widespread belief in many cultures, of “once mad, always mad”; Kleinman found that in those developing countries “Uncle Charlie was not really mad”. That is to say, Uncle Charlie’s ‘madness’ was never made ‘official’ by an authority, as we do in our developed societies.
Kleinman also laments that unlike other branches of medicine, psychiatry is moving away from the findings in other branches of the social sciences; a sure sign of excessive defensiveness. Using anthropologist Raymond Firth’s term “the uncomfortable science” to characterize any social science that calls for self-examination, Kleinman suggests that psychiatry’s role as policemen has kept their gaze fixated on seeing people as diseased rather than entertain the idea these might be sensitive people reacting to a sick society. By contrast, Martin Luther King has urged the ‘psy’ disciplines to regard their clients as human coal-mine canaries, reacting to a sick society, rather than sick in themselves. Political reaction is thwarted when we fail to see this; and the empirical evidence is now overwhelming that psychiatric problems are caused by trauma. In social psychology, we call this defensive “I’m OK, you’re not OK” attitude, where we internalize the problem in other, ‘fundamental attribution error’. Little wonder psychiatry shows little interest in other branches of the social sciences, if it is going to encounter this uncomfortable truth. And God help you, should you try to draw psychiatry’s attention to this.
Turning to those brave souls who embraced the coal-mine canaries metaphor and developed alternatives to the reductionist biomedical model of treatment, we find an interesting scattering of approaches which have been successful. Currently, for many of us, our attention is captured by work going on in Northern Finland by Jaakko Seikkula and his colleagues, called ‘Open Dialogue’. However I will review their work in another blog later. Let’s briefly review a couple of others.
Perhaps the best known study in alternative treatment was that conducted by R.D. Laing, the Scottish-born psychiatrist in an institution run by the Maudsley Clinic in east London – Kingsley Hall. Run between 1964 and 1970, Laing called mental breakdowns “metanoia” – from the Greek meaning ‘atonement’. He viewed mental breakdown’s as healing processes; they were part of the path to self-healing from very difficult life situations. No medication was used, and many of the clients experienced full-blown psychotic episodes. Many biographers describe Kingsley Hall as extremely chaotic, anarchic, and somewhat reflective of the slum area of London where it was located. However after it was closed 65 of the clients who had been there, clients who had had behavioural patterns that would have identified them as ‘certified psychotics’, were tracked down, and only 9 had been hospitalised since. This amounts to about 15%; which is the inverse of the recovery rate for SMIs (Serious Mental Illnesses) found in most Western psychiatric centers today.
Not so well known is the work of John Weir Perry, a Jungian psychiatrist who ran a house in San Francisco in the 1970’s called Diabasis. Although Laing had a mix of existentialism with his Kleinian object-relations theory to his thinking, and Perry was Jungian; Perry also believed that “schizophrenia is a self-organising healing experience”. Perry quotes Jung as saying, “schizophrenia is a condition in which the dream takes the place of reality”. Perry’s Diabasis seems to have been more organised than Laing’s Kingsley Hall, there was a ‘rage room’ – a bit like a padded cell, but no locked door, where clients could rage as they wished. There was also a ‘quiet room’ for meditation, which Perry says wryly, was seldom used. They had art, martial arts, and various other activities. But nothing was mandatory. There was only one explicit house rule – no violence to property or people. Apparently some even ran naked into the street on occasion. Again the outcome figures are impressive – he writes that 85% “not only improved without meds, but went on growing after leaving”.
Although most psychiatrists that are in league with drug companies prefer to believe that schizophrenia is a brain-disease, and although it may relieve the guilt some families might feel for the problem, the evidence for it being a neurological impairment is very scant. It is interesting to note that papers claiming the brain disease hypothesis do not appear in neurological journals, only psychiatric journals, which I think tells the story. The brain scans of most people diagnosed with schizophrenia fall within normal ranges. Trying to make a mountain out of a molehill, famous brain-disease proponent researcher Nancy Andreason, found that 12.5% of people (in a very small sample) with early onset schizophrenia had brains that showed any difference than other folk; but she attempted to conclude that all must. And then Ismail and colleagues found that amongst those people attracting a diagnosis of schizophrenia who did have brain differences, similar differences were found amongst their siblings who were without schizophrenia. Lewin says at most we might be able to claim to have found brain differences in 20 to 33% of those diagnosed with schizophrenia, but the brains of the majority of these individuals is normal as far as we can tell. Is the finding of Laing and Perry’s work of a 15% non-recovery related to these figures? Further, those findings based on genetic differences, have at best, only identified where the glass is thin, and not accounted for the more important thing, what was the stone that broke the glass.
If we turn our attention to recovery rates from clients who have been through more traditional treatment programmes, there are some differences in treatments which have utilised medications which appear more beneficial than others. Courtenay Harding and her colleagues conducted one of the largest follow-up studies done on treatment protocols and outcome. She compared the outcome for 269 clients who had been admitted to a Vermont ‘asylum’ with a diagnosis of ‘schizophrenia’, and what had come of them years later. The average was 32 years later. Of these 65% of these so-called “back ward patients” showed no signs at all of schizophrenia. She then tracked a similar cohort in Maine, and there the recovery rate was only 48%. The difference – well in Vermont the approach taken was focused on self-sufficiency, rehabilitation, and community integration; whereas in Maine the approach was a focus on medication compliance, maintenance, and stabilisation. The clients themselves said that the key to recovery “had been finding a safe, decent place to live, and having a mentor, someone they trusted, who cared”. It would seem then, that those patients who showed what biological psychiatrists have the gall to call “insight”, by accepting the biological attribution of it being a disease of the brain, fared poorly in recovery.
What will it take for mainstream psychiatry to break from its unholy alliance with Big Pharma and stop the harm it is perpetrating on a growing number of fellow citizens?
Harding, C.M. (1995). The interaction of biopsychosocial factors, time, and course in schizophrenia. In C.L. Shriqui & H.A. Nasralla (Eds.), Contemporary issues in the treatment of schizophrenia (pp. 653-681). Washington, D.C.: American Psychiatric Press.
Harding, C.M., Brooks, G.W., Ashikaga, T., Strauss, J.S., & Breier, A. (1987). The Vermont longitudinal study of persons with severe mental illness, II: long-term outcome of subjects who retrospectively met DSM-III criteria for schizophrenia. American Journal of Psychiatry, 144, 727-735.
Ismail, B., Cantor-Grace, E., & McNeil, T.F. (1998). Neurological abnormalities in schizophrenic patients and their siblings. American Journal of Psychiatry, 155, 84-89.
Kleinman, A. (1988). Rethinking Psychiatry: From Cultural Category to Personal Experience. New York: Macmillan/The Free Press.
Lewine, R. (1998). Epilogue. In M.F. Lenzenweger & R.H. Dworkin (Eds.), Origin and development of schizophrenia (pp. 493-503). Washington, DC: American Psychological Association.
Mosher, L. (1999). Soteria and other alternatives to acute psychiatric hospitalization: A personal and professional review. The Journal of Nervous and Mental Disease, 187, (3), 142-149
Nopoulos, P.C., Giedd, J.N., Andreasen, N.C., & Rapoport, J.L. (1998). Frequency and severity of enlarged cavum septi pellucidi in childhood-onset schizophrenia. American Journal of Psychiatry 155, 1074-1079
Perry, J. W. (1974). The far side of madness. Englewood Cliffs, NJ: Prentice-Hall.
Perry, J. W. (1999). Trials of the visionary mind. New York: State University of New York Press.
Siebert, A. (1999) Brain disease hypothesis for schizophrenia disconfirmed by all evidence. Journal of Ethical Human Sciences and Services, 1,(2), 179-189.