Peggy-Sax 2Peggy Sax: June 23, 2011

Who shares special interest in psychotic experience and discourse?

For several reasons, I’m starting this special interest topic.

I just read that James is now working with individuals and families at the University of North Carolina at Chapel Hill in a first episode/early onset psychosis outpatient clinic.

Dan, do I remember correctly that you expressed a particular interest here?

Recently, I’ve been reviewing Michael White’s writings on psychotic experiences while working on the “honoring our legacy” online course. I will list a few of my discoveries here. Unfortunately, I don’t have copyright permission to post them here but maybe you find them:

– Michael wrote “Family Therapy & Schizophrenia: Addressing the ‘in-the-corner’ lifestyle” in 1987 (Dulwich Centre Publications, reprinted in Selected Papers, 1989). Here, Michael emphasizes the social history, self-descriptions and externalizing conversations to map the participation of family members around the problem.

– “Psychotic experience and discourse” draws from two interviews with Ken Stewart (Re-authoring Lives: Interviews & Essays, 1995, Dulwich Centre Publications). The chapter begins by quoting Michael’s 1990 response to being asked about his theory of pathology,“The word (pathology) makes me wince! When I hear it, I think about the spectacular success of clinical medicine in the objectification of persons and of their bodies, and the extent to which the pathologizing of persons is the most common and taken-for-granted practice in the mental health/welfare disciplines, and the central and most major achievement of the psychologies.”
– The Community Mental Health Project” that began in 1992 at the Dulwich Centre in Adelaide as a collaborative initiative to link people with psychiatric diagnoses with therapists, community workers and carers, all of whom held onto hope that lives could be different for people diagnosed with chronic mental illness.
– Personal reflections by members of the Power To Our Journeys Group, along with Jussey Verco & Shona Russell, to “honour Michael and all that he contributed to our lives” as well as to honour Brigitte, a key member of the group who died in 2006: “Re-membering Michael (published in The Australian and New Zealand Journal of Family Therapy, August, 2009) is now posted on the Narrative Practices Adelaide website:
https://www.narrativepractices.com.au/publications.html

My own contribution feels meager in relation to these – but I do want to share Kate’s story of (in her words) “descent into and recovery from psychotic depression: Teaching Stories (Chapter 8).

Who shares this special interest?

Peggy

“Who shares this special interest?”

JamesPhoto-150x150 2James McCracken: June 23, 2011

ME ME ME ME!  I sure hope others do too… if there is ever a topic that gets to the center of issues around how we think of and treat “mental disorders/illness”, I think this is it.

I do, indeed, currently work for the University of North Carolina at Chapel Hill in a program that serves individuals that are experiencing what some call “First Episode Psychosis” or “Early Onset Psychosis,” and their families/communities.  A little more information for those interested: The program is called the “OASIS Clinic” (The acronym stands for “Outreach And Support Intervention Services”) and we’ve been around since 2003 (I’ve only been with the program for a year now).  It’s an interdisciplinary program, housed within a larger community mental health center, housed within the School of Medicine and the local hospital.  More specifically, we serve people ages 16-36 (most often 18-26) who have had a psychotic disorder (I’ll say something later about why I choose my words very deliberately about “psychotic disorder” v. “psychotic experience”) begin within the past 5 years, people who are considered “high risk” or “prodromal” (more on that word later) for developing a psychotic disorder, and these individuals’ families/communities.  We provide medication management, case management, psychotherapy, family therapy, network therapy, group therapy, recreational therapy, and referral to “wrap around” services (like nutritional support, exercise programs, supported employment and education programs, and such).  Other areas of the world have similar programs like EPPIC in Australia, IRIS in the UK, and Fraser Health EPI in Canada.  Very interesting data that has been coming out of research from these programs in recent years.

A client of mine just walked in to the clinic, so must be going for now, but I’ll write some of my ideas further later.  I’ll end for now by saying that OASIS is a very interesting place to work as a social worker, and it has given me a great opportunity to challenge my thinking about these things we call “psychotic” and how we go about treating people with psychotic experience and those who develop psychotic disorders.

Anyone else here work with people who experience psychotic phenomenon?  People in the beginning stages of these experiences?

johan-150x150 2Johan Van de Putte: June 24, 2011

Hi James, I surely do. Since 6 months I work on a ward with people who have to deal with psychotic phenomena, and I would like to share a bit about my work and about some of my dreams about that work, and the challenges around my wanting to integrate my narrative ideas and practices in this work.

 

sarahhughes2_profile 2Sarah Hughes: June 23, 2011

Hello,
I do as well in my position as a community mental health worker.  I am the only person doing this kind of work in a small rural town – so I see everyone that can fit under that category of “mental health and substance use issues” so a wide range of stuff comes up.  When I think about it – I don’t think I offer great services to the people I work withe who deal with psychotic phenomena – beyond listening and often supporting family.  Hmmmm…..

I would love to hear more about your dreams and challenges Johan as that might help support me in my work.  ANd James I am very interesting in your ideas too – your service seems so thorough compared to what I offer.  But I guess I have to remember that there are pros and cons to having so many services around.  I do have a psychiatrist I consult with – he is a mixed blessing. And I am contracted by a larger mental health agency in a bigger town.  I am happy to have them at times to consult with – ie last week when I was struggling with what to do with a man who was yelling at childenr in the park from his hotel window. he called it poetry but it was threatening.   But I am also happy to have them at arms length so I am free to work in ways that fit more with my ideas of narrative practice.

But maybe in this area I need to think/learn/understand more about what my ideas are….

Sarah

JamesPhoto-150x150 2James: June 26, 2011

Hi Sarah & Johan!

Sarah, poetry via yelling at children, eh?  That sure does sound challenging!  And working with someone who is a “mixed blessing” sounds challenging too… I’d love to hear more about this.

Johan, what kind of ward is it that you work on?  An inpatient acute ward, or a place where people stay much longer?  I’d love to hear your dreams about that kind of work too.  Neat stuff I’m sure.

If you’ve read some of my other postings, you may have picked up how there is some strange politics where I work, as I am a social worker, working in a major School of Medicine program.  Our School of Social Work has shown very little interest in mental health issues unless it is directly connected with family initiatives (i.e. strengthening families with children at risk of abuse/neglect), so our social workers are pulling a lot of weight without a whole lot of institutional support, whereas our doctors and psychologists have some heavy investments in their research, and, hence, their practice.  This has led at time to some “dug in heels” (back to that “Either/Or” position I so love to look at lately).  It’s quite interesting how the politics transfer to the clients vis-a-vis the clinicians (just our trainings alone impact us pretty substantially I would suppose).  Just in the past few weeks, one of our social workers was talking about how she has really had to work hard to “unmedicalize” her thinking with a recent initiative we’ve put in place to focus more on recovery.  She’s been here for quite some time, so it wouldn’t surprise me that she “medicalized” her thinking a bit to adapt to the surroundings.

Anyways, one something I’ve been very interested in lately is this idea of how we think of Psychosis (and most human experience, in general).  Lately, there’s been this push to recognize human experience as “Biopsychosocial” or “Biopsychosociospiritual”.  Language being linear, I’ve been wondering if this tag of “Biopsychosocial” has some politics buried in it… perhaps privileging this idea that human life originates biologically first, then becomes psychological, then social, then (if you’re open to it) spiritual.  So I started looking for the oppositive tag line in our article database “Sociopsychobiological,” and I happened across a vast amount of information about “Sociophysiology,” which basically says that life originates socially, then made no mention of spirit… most of this was from the early 1900s to late 1980s… perhaps spirit wasn’t important then? I don’t know).  I got thinking… “Huh.  Sociophysiology makes just as much sense to me as Biopsychosocial ideas (afterall, Maturana and Varela’s “Origin of Species through Natural Drift” was rooted in this idea of social behavior ruling supreme in evolutionary processes).  But there still seems to be this limited “Either/Or” idea about it.”  So I started drawing (what I do when I get confuttled), and I wound up drawing this diagram where you put in any order “Biology/Body” “Psychology/Mind” “Sociology/Social” “Theology/Spirit”  (or any other major life domain that makes sense in your culture) and draw two-way arrows between all of the domains.  Suddenly, I thought to myself, there’s no real way to describe this other than to say that maybe it doesn’t matter where human experience/life originates from… it’s possible that it originates from all of it!  According to this thought, what happens in one domain, the impact possibly cascades into all other domains.

What do I do with this nutty idea?  I bring it back to my clients to try it out, of course!  Some of my clients who expressed “being stuck” with “figuring out” where all this Psychosis started/comes from (most weren’t satisfied with either the stress-diathesis model or the brain disorder model), I showed this to.  To my surprise, they didn’t think I was nuts, and they totally got what I was trying to say.  And what they’ve said they like about this is it had freed them up to be more occupied with managing aspects of those domains instead of trying to “cure” themselves by finding the root cause (like we do with infectious disease).  For example, one client looked at it this way: “instead of needing to fix my brain or fix my broken social system, I can manage my bodily needs (i.e. sleep, nutrition, exercise, reduce/abstain from drugs, take medications that are acceptable), my mental needs (i.e. expression of creative self and aggressive self, psychotherapy, meditation), my social needs (supportive relationships, better communications, feel productive and valuable by working or volunteering), and my existential needs (having a purpose, having hope, figuring out my values)?  It’s a lot but atleast I don’t have to get it “right”.”

I don’t know remember who said it, but in it’s many iterations, life is so much about effective management of our needs.  Now, who says what our needs are is a different matter entirely, but what I like about this holistic cascading idea is that you could plug in any domain that makes sense to your clients, and take it from there, and they could build on it as they go.  If that doesn’t make a new, socially relevant reality, I’m not sure what does.

I’ve been very interested in the Open Dialogue Approach in Finland lately, and wondering what it is about what they’re doing that is helping people with Psychosis, and I think it could be that they’re helping people negotiate a new reality that fits with people who are important to them in a way that is “okay” (they say “toleration of uncertainty” is key… perhaps because you don’t have to be “right” or “wrong”, which is SO much of what psychosis is about I think).

I’m blabbering on and on now… and I was about to blabber a bit about dealing with psychotic experiences (i.e. sounds like your poetry yelling fellow, Sarah, is perhaps not gathering the full gravity of what he is doing), but I will pause for now.  Thanks for reading this far!

What ideas do you have about what Psychosis “is”?  Or what human experience “is”? James

sarahhughes2_profile 2Sarah: September 2, 2011

Wow James – those were BIG questions you asked back in June.  I don’t think I have an answer to “what is human experience?”  But I have more questions about it….

I am working with a woman who is struggling horribly with her experience right now. She is sure she is infested with parasites.  She is itching and picking at her skin all over her body. She is covered with scabs.  There is not any evidence of scabies or other insects.  I took her to the hospital yesterday as she was so upset and so sure that her flesh was being eaten.  We were taken to the psychiatrist who told her there were no bugs but it is a delusion caused by stress and here take this seroquel and you will be fine…
I just spent a few hours researching delusional parasitosis and albeit interesting reading and I did not find any answers to my questions. I feel that trying to talk her out of it being real causing more distress but going with her story also causes more distress.
I was wondering how can I help her?  She does not want to take antipyschotics as she does not believe it is not real and is insulted by the psychiatric approach.  I was driving her home yesterday and really wishing for more creative thoughts – where is Michael when I need him?
What would an open dialogue approach look like here?
How can I think about this differently?   She is a wonderfully talented artist with a great imagination and sense of humour so I am trying to think of how to engage these parts to help her and I think about this differently – find other points of entry into other stories…
Any thoughts are welcome!
Thanks, Sarah

Bonnie-Miller 2Bonnie Miller: September 3, 2011

Oh Sarah! what a challenge… your invitation got me thinking about a bunch of things… one was- you say she is insulted by the psychiatric approach-I started wondering why… what particularly, insults her? what values are insulted? what might that say about how she values her own knowledge, or ways of knowing? (if the insult is to her sense of knowing…) what are her preferences and how are they contrary to the psychiatric approach? How did she come to those preferences? You know, it gets me thinking about how she comes by what she knows- how is her knowledge generated, (gut feelings, sense of what is right, something else?) are there places in life where her knowledge is respected and responded to? are there other places where it is discounted?

I love that you say she is wonderful artist- what might be useful there- could she draw the parasites, based on what she knows at the moment about their habits?

this is just what got started for me by your description… it sounds very distressing for both of you! I look forward to what other folks might say.
Bonnie

sarahhughes2_profile 2Sarah: September 7, 2011

Thanks Bonnie,
You thoughts got my thinking going in a more creative direction as I agree that her ways of knowing are important.  Somehow your post brought me to an experience many years ago where I worked in a lodge in the kitchen.  One chef who was so wonderful and open and charming and wise.  I learned a lot about cooking from her.  I also learned about her secret kitchen cleaning technique.  She did not like the negative energy of the chef in the shift before hers so she made an imaginary can of “Bill Be Gone”  she would pull it out and do spraying motions around the room. She once told me the secret ingredients and it was very funny. it also seemed quite powerful!!
I am wondering what this woman might put in her spray.  i thought maybe I could tell that story tomorrow and we could draw a can and see what ingredients might go in.  She might not be interested but maybe it will open us up to some new avenues.

Thanks Bonnie!  I like your questions too and I am going to explore some of those ideas with her.   I am spraying some “bonnie come back” spray on my computer screen now!
Sarah

Bonnie-Miller 2Bonnie: September 9, 2011

;DThat’s Funny, Sarah- so glad my thoughts were helpful…

So, how did it go? did you make a can of bug-be-gone?

 

sarahhughes2_profile 2Sarah: September 11, 2011
She was a no show for appointment and hasn’t answered her phone.  But she left me a message to call her so I know she is around.  I will let you know if I connect with her this week.
thanks,
Sarah

PS Bonnie I got email ad for your supervision group through Hincks!  I wish I lived closer and could attend!!

Bonnie-Miller 2Bonnie: September 12, 2011

Sarah, that is such a lovely thing to say : ) Thank you : ))
Supervision is a loaded word, I wish we had a better term- I hope there will be enough folks because I’m looking forward to a rich learning experience- if we don’t have the numbers it will have to wait until next year : (

It’s so good to have colleagues to talk about our work with! and too rare…Bonnie

JamesPhoto-150x150 2James: September 12, 2011

Hi Sarah, Bonnie, All,

Yea… what a terrible situation for your client to be dealing with, Sarah!  I, too, wonder about what insults her about psychiatry.  Perhaps she’s had some experiences with psychiatrists that have not been so pleasant?  I think sometimes the way some people talk frankly about “anti-psychotic medications” is a big turn-off for a lot of folks.  Another way to look at those medications is that they are “Dopaminergic Agonists,” that can bring relieve to people experiencing serious distress that is not otherwise accounted for (these used to be called “The Major Tranquilizers”).  Does your client use stimulants or any other psychoactive drugs?  If so, it could be possible that she is having a terrible effect from one of those substances… and a brief trial of abstinence may help to ascertain this (4-6 weeks usually does the trick).

If her experience is otherwise “psychotic,” I’d be very curious, like Bonnie, about her experiences with these parasites.  When did this start?  Did it creep up on her or hit her suddenly?  Does she know how she got these?  How did she know this was happening, and particularly that it was a parasite?  Do others have these, and, if so, where could we learn to manage this?  I wouldn’t ask her questions to challenge her sense of “reality,” but rather for me to get a better idea about how she’s making sense of all of this.  If this is “psychotic,” then there is a possibility that her symptoms may not remit, BUT I am hopeful that feeling understood helps people feel more hopeful/less despondent, and that it eventually makes a difference in reducing their distressful experiences.  I don’t think her feeling understood would make her more “psychotic” if this is the case.

I don’t know that I can do justice fully to describing an Open Dialogic approach to this sort of thing in such a small space, but if you were to google search “Open Dialogue Psychosis” you will most certainly find article with process recordings about how they formulate their interactions with persons experiencing psychosis.

I work with a fellow currently who is convinced that he needs to behave in certain ways disturbing to those close to him because it helps him attain nirvana.  He tried to circumsize himself and has cut himself pretty deeply in the past (he says because he read that he needed to do this in the Bible), and he currently engages in behaviors that are very distressing to his parents (i.e. laughing to himself without explanation, smearing food on his bedroom walls).  When safety issues come into play, like the self harm stuff, we do intervene to keep him safe (i.e. hospitalization, hiding sharp household objects), but otherwise we spend time in our sessions talking about where his ideas come from and how these ideas affect his relationship with his parents and peers.  Despite his “craziness,” he cares very much about his friends and family, and he doesn’t want this issue to affect his relationships.  The more we understand how his mind is being made, the better he is able to adjust his functioning.  He has asked me a few times if I agree with his appraisals of things, and I tell him, “I believe you understand some of these things this way and I’m starting to see how, but I do not.”  He says he knows I don’t try to talk him out of believing what he believes, but that I do want to know more so I can understand how he understands his life.  He has recently elected to begin taking an oral “antipsychotic medication,” and it does seem to be helping somewhat, but I think, personally, he had to come to this decision on his own with his family/friends in mind, and not “just because” some doctor said so.  I do feel disturbed at times by his behaviors, and my anxiety about his potential to really damage himself because of a thought that makes no sense to me (i.e. castrating himself because the “Buddhist Book of the Dead” said so) can get pretty high… tough work this is for both “client” and therapist.

Let us know how this progresses Sarah!

-James

Bonnie-Miller 2Bonnie: September 12, 2011

So useful to read your thoughts, James! I’m guessing people experience something quite different in their conversations with you- what have you found helpful, in staying the course with these practices, if you don’t mind me asking??
Bonnie

sarahhughes2_profile 2Sarah: September 13, 2011

hello all,
I had the most amazing conversation this afternoon!  I don’t want to sound like I cured her or I am bragging but I just want to share how amazing it was to shift to a place of playfulness, imagination and curiousity.  I know I like it there better and do better work from that place but sometimes worry and other things like being conventional keep me down and in unhelpful places.

James -to answer some of your questions – Miss M is not taking any drugs right now. She has been sober for almost a year.  She has experienced ‘drug bugs” in the past but says this is different. For one thing it has lasted for weeks now.  She has told me that since she was a child she has had some phobias about bugs and she links it to her struggles with taking baths and showers as she was molested in a tub throughout her childhood.
I have read some of the Open Dialogue stuff – so I wasn’t really looking for an overview but your personal take on it.  I know I was really struck by one particular article with the word love in the title.  I will go search for it later as I know that I was really touched by the story of it and a particular physical sensation sort of love if that makes sense – connects me to that writing.  So after reading your response and Bonnies I tried to approach Miss M from that kind of feeling.

She was a bit of a mess when I saw her at first this afternoon.  She has shaved her head, lost more weight, she was shaking and upset.  We talked a bit about how hard it is and then I told her the story about the chef and how she made the bottle of Bill be gone.  She laughed and I said I wondered if we could play with that idea.  She was open but not too sure.  I drew a can on my white board and asked what it might have in it to get rid of bugs.  She started with cayenne, habaneros, sea salt, marigold, tobacco things to get rid of the bug/worms- then she talked about how tobacco is a poison and also an offering to the spirits.  She said she has wanted to call on spirits to help her but has felt too ashamed.  She said the doctors increased her shame and now it was really big.  I wondered if we moved the shame over to the other chair for just a minute and pretended it wasn’t there – then what might she use to call on her spirits.  She then had lots of ideas  insense, lotus flowers, salt water from the Atlantic ( she if from Newfoundland)…. This made her talk about her dad ( who died when she was a child) she said he had a big buddha in his studio – he was a karate instructor.  She knew  he would want her to call on Buddha.  She also wanted to call on ravens for survival, rabbits for wiliness, owls for power and the badger for energy.

At this point she was very into the exercise and was standing beside me at the board.  I asked what should we call this can of stuff as it seemed more like an offering now? She thought for a while and said “magic carpet”  I told you she has imagination!!! I erased the nozzle of the can and added carpet fringe and voila a carpet.  I got her to use all her senses to feel this carpet – it is purple and smells of lavender, it is soft like velvet, it has handles and she can hold on and float with the birds and the clouds. Her dad is on it with her.  He is holding on to her tightly.

We were both laughing and smiling at this point.  I asked her what would help her hang on to this image.  She said she wanted to go home and paint it.  I asked if I could copy out what was on the board for future reference and she said please do. she was no longer shaking. She said she felt excited, almost hopeful and the best part was she felt her dad with her.  I asked how that felt and she said “just right’  she said she knew he did not judge her but was there to help her.

I know this was a not a miracle but my goodness it felt magical.  I felt my people with me – you guys, Michael, David, Jakko, my chef friend – The room was crowded!!

So the next time I see Miss M will be an assessment with a new psychiatrist I have been assigned to work with- hmmmm…. I will try to keep my mind open but I think I might bring some purple velvet in with us.
thanks for being my witnesses!!! I so needed to share!
Sarah

JamesPhoto-150x150 2James: September 27, 2011

Hi all,

Sarah – Awesome!  What a great session it seems!  Like playing a musical instrument, it’s so nice to get that “right feel.”  Funny how we talk about doing our work as “practice” (i.e. “private practice” or “social work practice” or “therapy practice”), when so much can come out of “play.”  I guess “therapy play” isn’t as marketable, eh?  “Private play” may give the wrong idea… well, anyways, I’m drawn to how you engaged the parts of her that really needed that, and how you brought people into the room.  I would like to get better at being more explicit/mindful about that.  I’d love to hear how things progress with her.  The Modern Psychoanalysts say that “cure” is possible for any

mental disorder… but they are very specific about what they mean by “cure,” and I don’t think they’re too far off from something reasonable.  They’re not talking about “symptom remission” (i.e. hallucinations, delusions, thought disorder), but rather the suffering that happens.  I Buddhists mean when they say, “Life is pain; Suffering is the avoidance of pain.”  I wouldn’t be surprised if every time we do such playful, heart touching work like you described, that we’re not providing some road to “cure”.  I don’t think “cure” means to “unbreak” the people we work with… it’s to help them come to feeling “okay.”  What you were doing, I bet was magical.

Bonnie – I do like to think I have very different conversations with my clients than most of my colleagues and co-workers… ones that don’t make people feel examined, torn open at the stitches, or stupid.  I always think back to how I’d want to be talked to and listened to if I were in such a spot… and how not far away from these places we all are at all times.  I know I don’t “know” much, and that helps me stay unattached to any one theory or approach or “truth.”  I read something in Chris Beels’ “A Different Story…” that really sticks that helps me keep all of this in mind: about a medical anthropologist he knew in the Bronx that said once, “A good treatment is one that joins the person’s subjective experience of illness to their culturally appropriate method of healing.”  That really feels “right” to me for some reason.  We’re all so similar, yet so different, yet so similar… and our situations are the same… and the complex interplay between us and our situations make us so unique, but if we listen closely we can understand what “good treatment” looks like to each person.  I was drawn to Narrative Therapy because of the privilege it puts on client experience and cultural information, and how it intends to not harm clients by making them feel like “others” or “less knowledgeable.”  I guess somewhere in my own story, there’s something else that really glues all this to me.  How about you?  How do you bear in mind all of these practices that promote a different story and different-than-usual process with your clients (by the way, I don’t really like to use the word clients, but I’m having trouble finding a different word that fits)? James


Dan Marjason: September 27, 2011

Dear Peggy et al, I note I am invited to write re the topic of ‘psychoses.’ I’m not sure this is a good start for a narrative conversation since it seems to have the label before the people. It is not exactly an ‘experience near definition of the problem.’ It is about as medical model as you can get coming with a pretty heavy baggage for which to load people up with medical terminology, diagrams, potential medications and what not. I should declare at the outset that I have both insider and professional interests and knowledge with regard to psychoses, but would not claim to be expert about anything apart from my own life. And even then, I may have to defer to the experts. Nonetheless, I do subscribe to the general ideas around modern power, Foucault and how the mental health system is geared to isolate the individual, to collapse problems onto the individual, and to ‘treat’ the individual. This is often at the expense of excusing the dominant culture from its part in marginalising and subjugating minorities while at the same time carrying on with modern practices of power. The mental health system would have to be one of the major areas in our society where minorities are subjugated.

Psychosis is a term given to behaviour where people hallucinate in various forms. It may be hearing voices, believing the CIA are out to get them, reading number plates, seeing things, etc. It has long been my suspicion that many mental health problems are connected to abuse problems somehow and yet get diagnosed into thin storylines by which people are encouraged to live by. I suppose this belief came about when I did my own psychotherapy and discovered a whole range of emotions that I could not explain. Or rather, while doing meditation I discovered a whole range of emotions that I had no explanation for and as I attempted to ‘meditate on the antidote’ I found the emotions getting stronger. In effect I think I was practising some kind of denial of emotions better understood in the context of psychotherapy. I made a saying “The way out is in.” And so in I went (to psychotherapy).  This was in stark contrast to the ‘maintenance model’ popular at the time.

Quote
I’d like to quote from an article entitled “Childhood trauma, psychosis and schizophrenia: a literature review with theoretical and clinical implications’ by Read j, van Os J, Morrison AP, Ross CA. Acta Psychiatr Scand 2005:  112: 330 – 350 c. 2005.

“Walker and Diforio (p 679) stressed the importance for understanding the causes of ‘schizophrenia’, of ‘identifying the patient characteristics that predict sensitivity to stressors’. One response was the paper entitled ‘The contribution of early traumatic events to schizophrenia in some patients: a Traumagenic neurodevelopmental model’ (167). This paper documents the research showing that over-reactivity, and dysregulation, of the HPA axis is found in abused children. It also presents evidence that dopamine irregularities so frequently cited as evidence that schizophrenia is a predominantly or purely biogenetic phenomenon are found in traumatized children. Of crucial importance were findings that these brain ‘abnormalities’ caused by childhood trauma can persist into adulthood. Heim et al. (p 592) had already suggested that: ‘HPA and automatic nervous system hyperactivity, presumable due to cortisol releasing factor hypersecretion, is a persistent consequence of childhood abuse that may contribute to the diatheses for adulthood psychopathogical conditions’

The TN model is an example of a more genuine integration of the reciprocal, complex interactions between social, psychological and biological factors than the ‘bio-psycho-social’/’stress-diatheses’ model which has for decades underemphasized the fact that our brains are effected by our environment through our life. This is especially true – due to high plasticity – during childhood.”  (p343, Read J, et al)

The article goes on to say that clinicians should screen for childhood trauma because of the strong association between trauma and schizophrenia (psychoses). To quote further:

“The few studies that have investigated the response of mental health services to disclosures of abuse suggest that our response is frequently inadequate, specifically in terms of offering information, support or treatment, or considering reporting to legal or protection agencies. People diagnosed psychotic or schizophrenic are particularly unlikely to receive a therapeutic response and are particular unlikely to be asked about abuse in the first place, especially by psychiatrists or staff with strong biogenetic aetiological beliefs.

All mental health services should establish policy guidelines for how and when to ask about trauma in general, including child abuse. In the absence of staff training, however, such policies seem to be relatively ineffective. One such training programme has been for several years in New Zealand. A recent evaluation has demonstrated its effectiveness, except in one domain: its ability to attract psychiatrists to the training sessions.” (p 345)

I will try and put this article onto our site.  Personally, I would rather know that my psychoses were a protection against traumatic memories, rather than that my brain, genes and reality is stuffed. At least my emotions would be real.

Dan Marjason

JamesPhoto-150x150 2James: September 28, 2011

Hi Daniel and all,

I haven’t read much about the “TN model” about mental disorders.  Sounds fascinating, and not too far off from much of other models I’ve read about.  Most of the research these days being done by various psychotherapy schools about extreme altered mental states centers around this idea that there’s some genesis to the problem in early experiences (by way of trauma and/or “poor person-environment fit”).  There’s also a good deal of research that Peter Fonagy has done on this issue of attachment and mentalization that looks at some common links between cognitive schemas (I think that’s another way to talk about “narratives”) and attachment patterns… very cool stuff for those who are looking at bridges between cognitive theory and psychoanalytic theory.  The big picture that I’ve taken away from much of that data is that people who experience these “psychotic” or other “disordered” problems, tend to do better the more that trauma is taken into consideration along with working relationship, cultural appropriateness, and problem-engagement.

What’s really striking to me is the research that has been done comparing the effects of medications alone, psychotherapy alone, medications with psychotherapy, family psychoeducation alone, medications with family psychoeducation, psychotherapy with family psychoeducation, and all three on persons diagnosed with did in the 80’s was fairly conclusive that medications alone worked to help prevent psychotic relapse only 40% of the time, psychotherapy alone was less effective, and psychotherapy plus medications were 50-60% effective.  BUT when you add in family psychoeducation alone or in combination with medications/psychotherapy, the efficacy jumps to (I can’t remember exactly) something like 75-80%.  That, to me, speaks volumes about how important environment is to the life of these problems.  And then I think the Open Dialogue approach research reinforces this sort of idea.  What’s that neuroscience saying?  Something like, “We are not our singular brain, for a singular brain is about as good as a singular neuron… we are our social brains, for our brains are meant to connect with one another”.

I guess where I get hung up on determining a “truth” about these things we call by the various descriptors of so-called mental disorders is that taking any particular angle too heavily can lead to unintended, potentially harmful consequences.  Heavy emphasis on medical ideas has led to a diseased-nervous system model and our current system handles this with medications; a heavy emphasis on spiritual issues is likely what led to the “witch burnings” and other crimes against humanity (although the WHO studies on outcomes for psychosis globally show that people in more spiritual communities that are in “3rd world” societies, tend to do much better than people in “1st world” societies); a heavy emphasis on psychology can lead to a cognitive only approach that leaves the individual responsible for their “dysfunctional thoughts and behaviors”; a heavy emphasis on a social construction can pathologize families (i.e. “schizophregenic mothers”) and put responsibility on others for somehow creating these conditions… there’s not much evidence for any of these singularly.  I like to think about Alzheimer’s Disease… we have no idea what causes it, and we would dare say that any one approach determines it or solves it, but holistically, a person diagnosed with Alzheimer’s can live well with all of these aspects of their lives taken into account and addressed within their own cultural context, per their experiential considerations.  Is Alzheimer’s a memory disorder, a neurological disease, one of the spirit/experience, or a social problem?  I’d like to think all of the above.

I have many clients currently that come from really loving, safe homes, and have no history of abuse or trauma (outside of being hospitalized or drugged against their will), so their “psychoses” are something different, but I also have clients that have serious histories of abuse and neglect and trauma, and their “psychoses” are entirely intertwined with these memories.  I think people’s emotions are always real, and there’s always some shred of “truth” in all thoughts… even if they are “delusional.”  I can’t remember what philosopher talks about the mind always being referent, but I like that idea.

I’m babbling on here, but I guess I get to the point where I say perhaps our way of classifying these things is too limited/ing.  When we have a fever, we now associate it with a million other things: an inflammatory response, a bacterial infection, a viral infection, some autonomic nervous problem, hyperthermia, etc.  I wonder why we don’t think of “psychosis” or “mania” or “depression” in the same way… perhaps it’s always idiosyncratic?

Thanks for sharing, Daniel!  I’d love to read that article some time.
James

Peggy-Sax 2Peggy: September 29, 2011

I want to share the link to a very relevant conversation between Gaye Stockell & Marilyn O’Neil, “Reconstructing identities and inviting preferred stories of self: Narrative practices in mental health settings and prisons.” This conversation is part of the Dulwich Centre Friday Afternoon series. Having worked for years together with groups, Marilyn and Gaye share stories about  the shift from “The Loser Group” to the “Worthy of Discussion Group,” the “Raymond black dot story;”