Why Does Mainstream Psychiatry Fear a Balanced Understanding of Psychosis?

Many people are now familiar with the BPS report, Understanding Psychosis and Schizophrenia, and they have appreciated how it integrates both science and a humanistic understanding to convey a fresh and progressive approach to difficult and extreme experiences. But it has come under attack by psychiatrists such as Ronald Pies, who wrote an article accusing it of “trivializing the suffering of psychosis” and of failing “our sickest patients.” Others offer similar arguments, such as Joe Pierre M.D. who suggests the BPS report “romanticizes” psychosis.

The arguments offered by Pies and his allies are often quite slick, and sound reasonable to the uninformed. But they are wrong, and the better we can articulate how and why they are wrong, the better we can advocate for a more humane and skillful response to people having the experiences that are called “psychosis.”

In his article, Pies states that

What is lamentably missing from the BPS report is any deep understanding of the psychic suffering occasioned by severe and enduring psychotic states, including but not limited to schizophrenia. Indeed, I believe the BPS’s attempt to “normalize” psychosis winds up trivializing the immense psychic pain and agony experienced by many persons diagnosed with schizophrenia and related disorders of reality perception.

He goes on to provide a vivid example of a man describing severe distress related to attacks he perceives as coming from others, and he suggests that psychiatrists like himself see this sort of thing all the time, while the BPS authors, he concludes, seem to be unfamiliar with deep difficulties.

But it’s not true that the BPS report fails to include mention of terrible experiences – it includes for example mention of a sense of one’s blood being poisoned, of going to hell, of “the worst feeling I’ve ever felt.” It should also be noted that the BPS report was written for a public trained to associated psychosis with horrors of various kinds. So there was really no need to spend a lot of time letting people know that psychosis could go badly. Instead, the report was aiming to increase awareness of how psychosis could possibly be met with understanding and reasonable hope.

So, we might ask, why is it so important to Pies and to others within mainstream psychiatry that the emphasis is put on what’s awful about psychosis? And why are attempts to understand psychosis as possibly not all that different from everyday human difficulties seen as so threatening?

When people intensely fear something, they look for relief from that fear in a less critical way, and they are happy to give power to whatever offers protection against the fear. Our society gives great power to psychiatry in a very uncritical way because it fears psychosis, it fears madness, and psychiatry and psychiatric drugs seem to offer quick protection. So while some psychiatrists may over-emphasize fear of psychosis simply for the same reason that we all sometimes get overly caught up in fearful reactions, it’s important to notice that psychiatry as a profession is also motivated to emphasize fear of madness because that is what causes the public to give psychiatry its power and prestige, while also inducing that same public to ignore any criticism of psychiatric practices (much like the way a public scared of terrorism will not question the military, spy agencies, or often, even the practice of torture).

Fear of others is promoted when we focus on their differences, their “otherness.”  The ways people are different should not be ignored, of course, but a better idea is to make sure we notice both commonalities and differences, in a balanced way.  Balance in general is associated with complexity and nuance, and not with certainty about a correct course of action: but psychiatric power depends on a clear belief that any “psychotic” state of mind is very very bad, and cannot be understood in an ordinary human way, and must be continuously treated by drugs to suppress it, etc.

Stories of those who recover from the depths of “psychosis” and “schizophrenia,” by coming to understand themselves and their experiences, and who obviously don’t require continued drug treatment, are very threatening to this psychiatric viewpoint or story.

Stories and research that emphasizes how psychosis is often an understandable response to adverse experiences to begin with are also threatening to the story line that mainstream psychiatry prefers. That’s one reason the NIMH, dominated by psychiatry, emphasizes possible genetic causes for “schizophrenia” and in an incredible act of “denial,” contains the following paragraph on its website:

In addition, it probably takes more than genes to cause the disorder. Scientists think interactions between genes and the environment are necessary for schizophrenia to develop. Many environmental factors may be involved, such as exposure to viruses or malnutrition before birth, problems during birth, and other not yet known psychosocial factors.

Given the quantity of research showing a connection in particular between adverse childhood experiences and the symptoms of schizophrenia, and between those experiences and the brain differences often found in those so diagnosed, it seems bizarre that the NIMH fails to mention adverse experiences like child abuse even in a speculative list of what “may” possibly lead to schizophrenia! It’s on the same level as failing to mention carbon emissions as  even a possible source of climate change. But if we understand psychiatry as being most interested in stories that promote its own power, and not so interested in what’s actually happening, then it all makes sense.

If psychiatry were truly interested in understanding psychosis, one would see more attention to the full range of psychotic experiences. That would mean noticing not just when and how psychosis can be “awful” and distressing, but also noticing when such experiences appear to play a role protecting people from distress, at least in the short term. For example, many grandiose yet unrealistic beliefs make people feel better for a time, voices often keep people company or offer various kinds of reassurances, etc. These kind of experiences may lead to future problems, but they can also be understood as an attempted solution to problems.

And even when psychotic experiences truly do make people feel awful, it isn’t clear that they are part of some “disease” as Pies and other conventional psychiatrists would like us to believe.

Instead, it can make sense to understand even very distressing experiences as possibly resulting from people’s attempts to protect themselves. Becoming suspicious for example can be part of a strategy to protect against the possibility of new betrayals, even though it can also lead to horrible experiences of the world as one fails to also integrate some level of trust. Those who actually try to understand psychosis regularly find patterns of people engaging in strategies meant to protect themselves which often fact backfire and make things incredibly worse: but a strategy that is backfiring is not well described as “illness.”

And it’s even more complex than that, because the wild experiences we call “psychosis” can involve not just failed attempts to solve problems, but also sometimes wild experimentation and extreme states of mind that can lead to people making discoveries about themselves and the world, discoveries that once integrated can contribute to future success for the person themselves and possibly others. People who have had psychosis and then recovered often report that something positive emerged out of their experiences.

“Normalizing” psychosis as resulting from possibly extreme versions of normal attempts at coping, and from difficulties possibly related to when those coping attempts go wrong, can help people make sense of their experience. It doesn’t mean we see psychosis as being inevitably fun and romantic, but it means we become willing to see it in a complex, nuanced, and human way, and as an experience like many others that can have a variety of outcomes depending on how people react to it and the kind of help they receive.

But Pies wants us to think that any “normalizing” of psychosis will inevitably be damaging to the people who suffer from it. He writes that

Indeed, I believe the BPS’s attempt to “normalize” psychosis winds up trivializing the immense psychic pain and agony experienced by many persons diagnosed with schizophrenia and related disorders of reality perception.

For example, the report asserts, “Many of us hear voices occasionally, or have fears or beliefs that those around us do not share.” Well, yes—but this shallow and superficial description of the psychotic experience does scant justice to the nightmarish reality of severe psychotic states. It is a bit like saying to someone with advanced cancer, “Many of us experience very rapid cell growth occasionally, or have lumps or tumors that others do not have.”

Again, Pies does a slick job of making himself sound compassionate and wise, but relies on the reader to overlook key facts. For example, a person with cancer has a physical problem, and it does little good to downplay it’s seriousness by emphasizing it as being a variation on normal cell growth. But a person with a nightmare, or a nightmarish daytime experience of psychosis, is having a mental event, and mental events are very much affected by how we interpret them.

Many experiences seem terrible, but really aren’t, once we get perspective on them. For example a terrifying nightmare may seem quite awful at the time, but later we find that it was just an experience, perhaps even one that overall becomes part of the richness of our life.

Pies wants us to think of psychotic experiences as being like cancer, as being in themselves really and objectively bad. But they often aren’t that way, at least once one “wakes up” and sees that they aren’t as bad as they seemed. When Eleanor Longden (one of the contributors to the BPS report) was at one point quite horribly distressed by voices, she was ready to literally drill holes in her head in an attempt to extract them. Later however she learned to understood them in a different way, she learned to see these same voices as meaningful experiences that were related to what had happened to her and to her attempts to make sense of things, and she no longer found them to be distressing.

When people are terrified, and are then told that the terror they feel means that something really bad is happening to them, then what we tell them reinforces the terror and becomes part of the person’s problem, creating and feeding a vicious circle. In other words, it’s not so much the experience itself that is terrible, but what is made of it; and what is made of it is often partly the responsibility of the psychiatrists and other mental health professionals who claim to objectively know that what is happening is truly awful.

It’s important of course to acknowledge people’s distress and terror, and to avoid any minimizing of it. But it’s also critically important then also to normalize their experience, to look at how it may be understandable once we know their story, and to explore how things may not be as bad as they seem. This can help people find a way to accept their experiences rather than fear them, to make sense of them, and to get on with their lives.

A key error of mainstream psychiatry is to assume that if a person is having very major distress or terror, and especially if it lasts a long time, then it must be a very serious problem, a very serious illness or disease. A wiser perspective is that of the Hearing Voices Network HVN), which shares the understanding that people who are seriously distressed do need and deserve help, but which doesn’t share the assumption that the problem, once understood, is really something “wrong” with the person. Instead, it may just be that the person has not learned a good way of relating to what they are experiencing. Once they learn how to relate better to their experiences, they may even find them to be on the whole helpful, as when voices that speak in disturbing ways become seen as providing vital clues about underlying stresses or traumatic memories that need to be dealt with.  See for example to stories of Ron Coleman and Debra Lampshire, who spent 10 and 18 years respectively as apparent victims of  severe “schizophrenia,” and yet who recovered when they learned a different way of relating to their voices and other experiences.

Of course, Pies would argue that the messages of the Hearing Voices Network are over-emphasized in the BPS report which he believes has a “fixation on “voices.”” He wants more emphasis on the “cognitive dysfunction” which he argues is a stronger “determinant of functional outcome” of “schizophrenia.” But while Pies wants us to imagine that any such “dysfunction” is certainly connected to an “illness,” we get a different perspective when we actually talk to people who have experienced periods of mental impairment and then recovered.

One thing that can indeed impair orderly thinking is opening one’s mind to vast numbers of associations beyond those usually made, and/or narrowing one’s focus way more than is usually done. Young people who wander off the beaten track of mental development may for a period of time lose their ability to follow everyday thinking, and some may not find their way back, but others do, and we can learn a lot by listening to them and learning from how they eventually made sense of, and often found value in, their difficult experiences.

Using myself as an example, I can say that as a young person, I went through a period of questioning the meaning of everything, and experimenting with new ways of seeing things. Looking back I can see this as an effort to liberate myself from oppressive ways of processing reality that I learned during a traumatic childhood. But from a psychiatric point of view, this whole process could be seen as “loosening of associations” or cognitive “dysfunction” (and note that the whole idea of “dysfunction” relies on ideas about how minds should function, and questioning meaning involves questioning that functioning.)

There were times for example I watched movies and I was sure there was no plot, I became sure that the filmmakers were experimenting with new ways of seeing things that didn’t involve plot. Years later, I watched some of the same movies, and was surprised to find that there was, indeed, an obvious plot, which I had completely missed! (The expression “losing the plot” is of course one simple way of describing the process of “going mad.”)

Notice however that anyone looking at me in the psychiatric way, identifying me as a person experiencing “dysfunction” due to “illness,” would have themselves been missing or “losing the plot” of what was going on with me, they would have failed to see an understandable story to what had happened and was happening, and they would fail to notice that it wasn’t a biological illness.

Of course, I’m not trying to say that medical or biological factors can never contribute to anyone’s state of “psychosis.” It is apparent that they can, in some cases. But the problem with Pies and Pierre and the rest of mainstream psychiatry is that they ask us to “jump to the conclusion” that the more distressing or disruptive psychosis may be, then the more certain it is that biology is at the root of it. This conjecture has no basis in evidence (and we might note that, like “losing the plot,” jumping to conclusions” is well known to be part of psychosis.)

So, psychiatry routinely makes the same kind of errors as do people it purports to be helping. And these errors commonly lead to harm, though commonly harm to the patient rather than the psychiatrist. But psychiatry routinely misses this possibility that its own mistaken ideas about the problem can become part of the problem of its patients. That is, it is so sure that people’s problems are internal to them, part of their brains, that it forgets that we are talking about “mental” problems after all, and minds exist in relation to other minds, and we all participate in each other’s minds.

Unfortunately, mainstream psychiatric is very resistant to getting “insight” into this process. Just as it can’t imagine that drugs that seem to help in the short term might make things worse in the long term, it doesn’t see how its own mistakes in conceptualizing extreme states can possibly then become part of what keeps people trapped in those states. It likes to think its ideas are “objective,” it imagines that mental states themselves are like objects that can be classified by experts according to their characteristics, and it forgets that it is actually participating in those mental states through the effects of its own ideas, and should at least consider that it might be contributing to the problem when troublesome states persist.

To take a wider view for a minute, we can consider the possibility that it isn’t just the flawed ideas and practices of mental health professionals that can contribute an individual’s problems with extreme states or psychosis, but flawed ideas and practices within the wider culture can have an impact.

It’s interested that at one point, Pies critiques the BPS authors for suggesting that psychiatry often assumes a straightforward line between “mental health” and “mental illness,” and then to refute this, he quotes the DSM 5 as stating in its introduction that:

“The boundaries between normality and pathology vary across cultures for specific types of behaviors. Thresholds of tolerance for specific symptoms or behaviors differ across cultures, social settings and families. Hence the level at which an experience becomes problematic or pathological will differ….

I would argue that this is a nice quote, but one which psychiatry in general, and the DSM in particular, tends to completely ignore in practice. Because if the DSM and psychiatry took this point seriously, they would recognize mental and emotional problems as inevitably involving relationships between individuals and those around them, rather than being problems that can be localized as an illness within a person. After all, clearly I can’t be said to have a true illness such as the flu if I’m embedded in one culture or family and not to have the flu if I’m having the same physical state while embedded in a different culture or family! So if mental and emotional problems do have such different boundaries in different cultures, then they must be something very different from an individual illness or disease. Unfortunately, the DSM goes on to be all about labeling individuals, with no insight into the true role of human relations and the nuances involved.

When we do see problems as relational, we are able to see that we ourselves, whether family members, friends, or mental health workers or psychiatrists, may be part of the person’s problem. This means we understand that the things we offer as help may possibly backfire and make things worse, just as we understand that person’s problems in the first place may have resulted from their practicing strategies they hoped would help but which backfired. This doesn’t mean that it’s hopeless, only that we are acknowledging that we are all in the mess together, we are all trying to understand. Life is messy, and non-linear.

I was pleased to see Jaakko Seikkula, in his talk Challenges in Developing Open Dialogue Practice, state that it is important to see psychosis as part of life and related to the meanings people find or struggle to find in their life. That perspective is essential if we are going to be truly helpful to people engaged in such struggles.

People wanting to learn more about how to talk to people about psychotic experiences as being understandable, in ways that reduce fear of the experience, may want to view the videos on normalizing which are available as a free preview within my CBT for psychosis online course.

In conclusion, I would like to state that I believe that understanding psychosis, and normalizing it in the ways I and groups like BPS advocate for, does not mean eliminating all fear of it. I have certainly seen people who seemed to have too little fear of psychosis, and who got themselves into deep trouble by failing to take even relatively simple precautions.

What I advocate for instead is a balanced view, which sees psychosis as more like being involved in wandering into a wilderness area, and becoming lost or distressed while doing so, but still with hope of finding one’s way, and even with the hope of growing through the experience. This allows us to think of psychosis in a much more nuanced way.

When we are too sure that people’s experience and stories and ideas are mistaken and worthless and sick, we are simply incapable of respecting the people themselves. Better approaches to madness are less certain. This means being willing to talk about not just problems and errors but also issues such as the ways that wandering into psychosis may have something to do with an attempt, conscious or not, at creativity and a creative approach to life problems, or a shamanic journey, or spiritual development.    And it means being willing to see a vulnerability to psychosis as possibly a “dangerous gift” that may lead to something good once the person learns to manage it well, even if it has led to little but trouble so far.

Mainstream psychiatry of course would see any such discussion as a naïve and harmful attempt to “romanticize psychosis.” It would suggest we shouldn’t see any possible good in the person’s experience or line of thinking, because then we will somehow be unable to appreciate how bad things are. But the consequence of just looking at what is bad is not just the misunderstanding of the experience itself, but an increase in negative views of the person at the center of the experience, who is now seen as caught up in something entirely negative, and having nothing of possible worth to offer.

Wandering off into the wilderness is indeed dangerous, especially when one isn’t prepared, and/or doesn’t have support. And distressing experiences can occur, even when one is prepared and supported. Sometimes things go in truly tragic directions, and losses can be immense. But there are also mental problems associated with always avoiding anything outside the usual “safe” personal and cultural ruts, with never taking risks, and sometimes much good can come out of confused journeys that seemed nothing but distressing at the time. We need a mental health system that can appreciate the dual nature of such issues, and which is not afraid to talk about them in an open minded way, not a psychiatric system that dogmatically focuses on fear in an effort to support its own power and its often unbalanced, though quite profitable, interventions.