JamesPhoto-150x150 2James McCracken: March 22, 2011

My apologies again for not being as present in the forum and this conversation.  Bluntly put, my 15 year old cat/friend is dying, and my energies have been consumed with being with her before she’s gone… I know how badly I will miss her.  This is a separate story for a separate post.

So many thoughts… so little time now to type it “out”.  I really enjoyed reading everyone’s ideas… and that article you shared, Mohammed, made me think of that Motley Crue song “Dr. Feelgood.”  My wife is in business school with a bunch of future “I-bankers,” and we’ve learned that there is a place in the world for people who live and think that way, but that place just is not for us because of the ethics that we wear.  Perhaps the metaphor for the yin and yang, or George Kelly’s “Poles” describe some of these differences well.  I personally can not imagine shifting my practice solely to accommodate my budget better…  I’d find another “day job” (sort of like what I did with music, except I found a career that also fulfilled my need to help others).

I’m not opposed to people taking medications or taking on a diagnosis if they find it helpful, but there is so much abuse that happens in the name of medicine… particularly with people who have difficulty communicating with those with power.  I’m glad to hear that there are medical doctors, such as the fellow mentioned at John Hopkins, that are taking their profession back from these stories of abuse and subjugation (I have one such friend who is in residency as a psychiatrist… he has his own wonderful story as a son of an Indian family who expected him to become a highly paid doctor and he is learning to resist temptation early on to hit the Rx pad for added financial padding), but I think the politics of how we view life, death, and ailments in the US needs a closer look as these politics greatly influence our economics and our professions.  What a big can to open up!

I’ve been reading more lately about European programs for people experiencing psychosis (i.e. Open Dialogue, Family Care Foundation “healing farms”, Swedish Soteria houses, and other TCs) and reflecting on my experience with Unitas in the South Bronx (another modified TC), and I wonder about what is it that allows those models/programs/approaches to thrive?  Unitas did not “thrive” quite so much as “survive” because of the dedication of the founder and the community.  The governments/communities that support these approaches and programs must have some part to play in the sustenance of being able to do things that are not “just making money.”  How did the Adelaide Centre operate?  I know Michael White’s presentations and conferences footed much of the bill, but was there other support?  How do each of you manage to operate in a way that fits with your ethics in your environment?  Are there things in your environment that help support what you do?  Are there things that hinder your practice?  How do you deal with them?  Are your politics different in your area such that these things are different?

My program, OASIS at UNC, is located in the Department of Psychiatry through the School of Medicine… so we are very much at the center of medical politics where medicating people experiencing psychosis is the accepted form of treatment and we social workers are generally expected to do psychoeducation with the individuals and their families, supportive services, and assist with illicit drug and alcohol reduction/abstinence and increasing medication adherence.  Our program director emphasizes that we provide therapy (individual and family), which helps us retain our flexibility, but we are required in part to run our ideas by our medical team on staff.  They retain the privilege of “making decisions” in the program.  I enjoy my position and role in this program, but I do feel limited in how I practice.  There are times when the people I work with want no more meds, and I believe they should have that right to get off of them responsibly (and that there is still a way to live well without them), but I have to be very diplomatic about how I speak with my clients about this because my job could be threatened.  Fortunately, the staff here has been open lately to having me present on “Addressing ‘Difficult Client Issues’ through a Multicultural Model” during our retreat this Summer… perhaps I can offer some alternative perspectives that step outside of a rigid medical box.

Oh… I have to get back to work.  Looking forward to hearing more of your thoughts.  And where should I post about my cat?  “I Need a Witness”?


Peggy-Sax 2Peggy: March 23, 2011

Hi James,

It’s good to have you join us – whenever you can. I think just about everyone has bouts of silence when other life pursuits take precedence. Please do tell us more about your journey with your beloved cat (Yes! “I need a witness” would be a great place).

I too am very interested in innovative European/Scandanavian programs. Let us know if anyone reading this has experience with Open Dialogue or other programs like that. Hopefully, Shona will be able to share some of her  experience regarding the Dulwich Mental Health Project.

Hope its ok if I list some other resources on this study group site, written from the perspective of insider knowledge:

-Have you read the beautiful tributes to Michael by “Power to our Journey” group?   You can find the pre-publication article on the Narrative Practices Adelaide site here.

I recommend two Dulwich Centre publications:

And don’t forget Kate’s story about her descent into and recovery from psychotic depression here.

Great conversation…

Sonja-Bar-Am_profile-150x150Sonja: March 31, 2011

Hi all, I just wanted to share this ASAP, I believe that David Epston sent it through to some of my colleagues. I believe that it may be funded by the Scientologists, but I am not sure I haven’t done the background investigation (I like to know my sources well   ).
But it is powerful and desperately needed as a public message. Maybe though some know about this movement, I would be interested to know your thoughts…Luv Sonja

JamesPhoto-150x150 2James McCracken: April 1, 2011

Hi Sonja… Hi All!

Silva (my feline soul mate) is still hanging on (see previous post) and in good spirits.  I’m reflecting that which I see in her today… it’s good to be alive.

That video is powerful!  It looks like the group promoting that video is from the Church of Scientology and Thomas Szas, and I think that’s okay.  Szas and the Scientologists are more on the fringe of mainstream accepted thought, but that doesn’t make their point any less valid.  If folks haven’t heard of Robert Whitaker and his book Anatomy of an Epidemic, I’d highly suggest you pick it up and read it.  Also check out mindfreedom.org, isps-us.org, freedom-center.org, and power2u.org.  I think all of these groups and organizations offer a potent, empowering, and alternative discourse to what I regard as mainstream mental health care.  Ah, and Ian Hacking’s The Construction of Madness AND Garfield & Mackler Beyond Medication – Therapeutic Engagement and the Recovery from Psychosis.  Radical indeed.

I got the new Michael White book… so refreshing.  I find in my work that there is this competition for dominance between the “pro-medication/biology” discourse and “no-medication/psychosocial” discourse in mental health.  Reading MW’s perspective on resistances, power and psychotherapy, and ethics has been so helpful to position myself in that “BOTH/AND” place and be open to all of the creativity that can happen in this field so long as it doesn’t serve to oppress and shut out.

Thanks for the “open door”, Peggy and group.  One day soon, I swear, I will organize my time better to get re-engaged in other readings and conversations.


Peggy-Sax 2Peggy: June 25, 2011

Have a look at “The Epidemic of Mental Illness: Why?” by Marcia Angell in yesterday (June 23, 2011)’s New York Times Review of Books. :

The review covers common themes in three books:

– The Emperor’s New Drugs: Exploding the Antidepressant Myth by Irving Kirsch
– Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America
by Robert Whitaker
– Unhinged: The Trouble With Psychiatry—A Doctor’s Revelations About a Profession in Crisis
by Daniel Carlat

Here is the first paragraph:
It seems that Americans are in the midst of a raging epidemic of mental illness, at least as judged by the increase in the numbers treated for it. The tally of those who are so disabled by mental disorders that they qualify for Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) increased nearly two and a half times between 1987 and 2007—from one in 184 Americans to one in seventy-six. For children, the rise is even more startling—a thirty-five-fold increase in the same two decades. Mental illness is now the leading cause of disability in children, well ahead of physical disabilities like cerebral palsy or Down syndrome, for which the federal programs were created.

You may not find anything “new” here, but more confirmation of what we’ve been talking about…


sarahhughes2_profile 2Sarah Hughes: June 26, 2011

Thanks Peggy – that was quite an interesting article.  I liked the explanation about the illogical nature of antidepressants
“By this same logic one could argue that the cause of all pain conditions is a deficiency of opiates, since narcotic pain medications activate opiate receptors in the brain.” Or similarly, one could argue that fevers are caused by too little aspirin.”

I also – in my long absence from the group – missed much of this whole thread and there was lots to read here.  And watch!  and think about…


JamesPhoto-150x150 2James: June 27, 2011

I found that very interesting… thanks for sharing Peggy!

If I’ve said this before in the conversation, I apologize… I revisit thoughts quite often… but it is very interesting to me how “Either/Or” things become positioned when we’re talking about “Mental Disorders/Illness.”  Maybe that’s because the whole idea of “mental” can be so “Either/Or”… but I wonder what would happen if we adopted a “Both/And” position towards some of these ideas.  I’m really drawn to this “Both/And” idea… so long as it’s not privileging some oppressive discourse (which I suppose Whitaker and many others could argue that the systematic categorization of experiences that are disruptive of people’s lives and treatments that may possibly damage them is oppressive).

So, yes, the over use, or long term use of “anti-depressants” and/or “anti-psychotics” can have some rather nasty effects on the brain and other organs and systems, and that could be taken into better consideration, but so can the over use or long term use of nearly any medication (anti-biotics, aspirin and other NSAIDS, synthetic thyroid hormones, etc.).  Oxycontin, an opiate used for serious pain conditions, is merely a synthetic version of heroin… over use and long term use causes the same terrible dependency as heroin.  Any sensible prescriber would take that into consideration before doling it out… I’d hope anyways.

I’ve known people both personally and professionally who have found these “psychiatric” medications both harmful and helpful.  I’ve also known people both personally and professionally who have found illicit substances (some may say “personal” medications) both harmful and helpful, and the same for other drugs (be they “medications” or otherwise).  Personally, I take an “anti-depressant,” but not for depression… I take a drug called “Nortryptyline” at a very low dose to help with the prevention of migraine headaches that I get regularly.  Does it do other things to me that may not be so desirable?  Perhaps, but I know my life would be pretty miserable now and into the future without something to stop that awful pain behind my eyes that happens every few days (I’ve tried for years to manage it other ways to no avail).

Getting back to the narrative metaphor, I’m always curious how these ideas plug into how people live with their experiences.  I am currently working with a client who has been struggling with a Depression for 2 years now, and recently experienced a Psychosis.  Giving a very brief account of what happened, his experiences were very troubling to him, and Depression/Psychosis really screwed up his life pretty badly (put him in isolation, forced him out of college, made him dependent on his parents when his peers were moving to adulthood, gave him a great insecurity with who he was).  He found his way to us via a hospitalization, where he was treated with a regimen of “anti-depressant” (I think they should rename these “Serotonergic Drugs”) and “anti-psychotic” (… “Dopaminergic Drugs”) medications.  After about 4 weeks of medications, the “symptoms” of these two disordered episodes abated, and around that time he started psychotherapy/counseling with me.  In the past two months since starting work with me, he has started to taper off of medications (one of the most responsible things anyone on these drugs can do, I think), and he is focusing more on what sustains him/makes him well.  The studies on discontinuing medications after the onset of psychosis show that after 5 years, something like 90% have a relapse of psychosis, which he is aware of.  His idea about caring for himself is that he knows the drugs work if he needs them (just like if he has an infection requiring antibiotics, he can use them), and he is aware of the warning signs that things are going back to that place.  He also says, I think rightfully, that he will discontinue psychotherapy one day when he doesn’t feel it is helpful or necessary, knowing that he can come back if needed.  This young man, in my opinion, has a very balanced view of managing his life despite these experiences.  He knows he is vulnerable to having them re-intrude into his life, so he takes safeguards (doesn’t use drugs, limits stressful relationships and has clearer boundaries now, sleeps enough, minds his social needs and spiritual needs) and has emergency plans (medications/therapy if necessary).  He has taken, what I see as a “Both/And” position towards managing his Depression and Psychosis.  He doesn’t like the broken brain metaphor, so he says instead that it is a spiritual psychosocial thing that affects his brain… and it works for him!

What stories do you all have about people you’ve worked with who identify having a “mental illness/disorder” in their lives?  Do they seem to have a “Either/Or” position OR (ha!) a “Both/And” position (could it be both positions?  Is that possible?)?  Has this had any effect on how they manage their lives or see themselves?

Mohammad-Arefnia-150x150 2Mohammad: July 11, 2011

Hi All,

Here is the second part of Marcia Angell’s comments on this topic published in the New York Review of Books under the title “Illusions of psychiatry:

This weekend’s op ed at New York Times by Peter Kramer was intended to be rebuttal to her comments titled: “In defense of Antidepressants“:

And then a prompt and powerful response to Kramer’s comments by Robert Whitaker himself posted yesterday in Psychology Today.  Mohammad

Mohammad-Arefnia-150x150 2Peggy: July 12, 2011

Thank-you, Mohammad! I just read all three articles while eating my breakfast. Very sobering.  I especially appreciate Marcia Angell’s part 2. I am so glad this debate is going public – finally! I wish there was a way to bring in the complexities without having to resort to polemics and taking sides in an argument. We don’t need another version of the pro-choice/pro-life or Palestinian/Israeli debate.What might make earnest dialogue more possible?  Does anyone have experience with conversations in your places of work that open space for new understandings? James? Mohammad? Or? ….This is such an important time in the history of psychiatry.


Margaret Wells: July 12, 2011

Hi James, I’ve just read your post about your client with the both/and position.  I love the idea.  There’s a place for medication isn’t there, as you say?  It’s a tool, that’s what I like to think.  It’s one to keep in the tool box.  I talk a lot about this with clients.  It’s one tool, but there’s lots of others.  I’ve started to talk with some folks about getting a tool box (a cardboard box) and filling it with other helpful tools (like sensory tools, relaxation cd’s, mindfulness aids, and their WRAP plans).  I get surprised that people forget these tools when their problem/struggle looms large in their life.  Some folks find it helpful to have this physical reference to refer to when their difficulty gets in the way of them moving in their preferred direction.  Is this something you use too?  Would love to learn more about your ideas.

Mohammad-Arefnia-150x150 2Mohammad: July 12, 2011

Hi Peggy,
Hi All,
Medications work great for some but not for all. As Whitaker pointed out the antidepressants are shown to be helpful with sever depression. However, the insistent demands of profit making institutions call for expansion of markets whichever way possible and assurance of ever increasing profit margins. That then colors the perception of those whose livelihood depends on fulfillment of such imperatives and allows for reading that the study indicated that even mild depression can be helped somewhat when as Whitaker points out the indication is for severe depression only.
I think the struggle that is taking place in Palestine is indeed along this same line. It is advantageous for the markets- weapons industry, security industry, etc.- for this struggle to continue on and both people of Israel and Palestine are caught in the middle, their emotions played and hostilities fomented to keep the status quo, so that the life style that some are attached to can be maintained.

Psychotherapy is not for all either. Some do fine with just medications even when it is placebo. Marketing medications at the expense of marginalizing other possible options is the problem.

JamesPhoto-150x150 2James: July 13, 2011

Hi all,

I love how serendipitous the world is sometimes… I just came across this article written by Robert Bentall and David Pilgrim called “The Medicalization of Misery: A Critical Realist Analysis of the Concept of Depression” (link here: https://www.brown.uk.com/depression/bentall.pdf).  If you’re not familiar with R Bentall, he’s an interesting fellow who has done a lot of deconstruction in psychiatry and psychology with mental disorders and treatments.  What I like about the article is how they take a “both/and” position about this issue of depression, what we call it, and how that means we interact with “It.”  The Critical Realist approach to science/social science is becoming more and more intriguing.  Bhaskar and Romme both have some incredibly interesting things to say about knowledge in general, and understanding social phenomena in particular.

I’m also re-reading now The Public Conversations Project: Fostering Dialogue Across Divides: Nuts and Bolts Guide.  They specifically address how to address these polarized topics… if I’m correct, Bill Madsen had a hand in this project, so this guide should appeal to any of our Narrative sensibilities and sensitivities.  I highly recommend a read through of this for all.

I think Robert Whitaker’s work on exposing what has happened in American/Western mental health practice and mainstream thought is profound, thought provoking, and deserves serious SERIOUS consideration, but I also recognize Robert Whitaker is an activist journalist, meaning he is going to dig his heels in when his values are opposed.  Good for him… I agree with him in many respects… but I do wonder if “digging in” helps a process get stuck.  I always think about World War I, when troops dug in along the Maginot Line on both sides.  I don’t know if conflicts get resolved very well that way.  It would be very interesting for major players on both sides to get together and understand each other better and see what comes out.

Margaret,  I don’t use a tool box… but I think that’s a great idea!  I do lend out my books to clients often, and I talk to them openly about my “tools” (which I guess you could say is lending), but a physical representation is a great idea!  So much of our selves beyond what’s happening in our memories is in our direct sensory environment… this would make sense to have something physically present.

Got to run!

Mohammad-Arefnia-150x150 2Mohammad: July 15, 2011

Thank you James!
I am looking forward to reading the article on “the medicalization of misery”- I just printed it- and the manuscript on public conversations.
I look forward to enhancing my abilities to engage in both/and conversations.