Written by Brad Dixon

blankThis incredible book written by my good friend and psychologist Paris Williams (Phd) totally changes the current thinking about mental health, psychosis, and the way the West could view it, and treat the individual struggling with it. As the subtitle states, Rethinking Madness moves the reader “towards a paradigm shift in our understanding and treatment of psychosis.” I wanted to give an overview of some of the research and psychological models that allowed Paris to come up with his model, then reinforce that none of us can escape struggle in our lives. Embracing it, working through it with understanding, and not trying to mask it with quick fixes may be what our society needs to fully heal and then live in more harmony.

Over the last century and billions of dollars later, the research still cannot show any substantial evidence that many of the psychiatric disorders are actually caused by brain disease. No biological markers or physiological tests that can be used to diagnose schizophrenia have been found. Through the weaving of six case studies throughout the book, Paris shows that full recovery is not only possible but surprisingly common when other treatment methods are put in place outside the traditional western medical model. The information that I found most disturbing was that patients diagnosed with a psychiatric disorder and told they had a brain disorder (requiring lifelong medication) were much less likely to recover than those in some of the poorest nations on earth. In these places, they were treated with a far more holistic model of care. One of the most damaging consequences of the West’s medical model is the dehumanisation, stigma, and general hopelessness when people are labeled with a “mental illness.”  Long term use of antipsychotic medication within the current medical model has been shown to cause more harm than benefit in many cases. The stories woven within this book show that people who recover from psychotic episodes undergo a “profound positive transformation.” It has been written that when people who go through a successfully resolved psychotic episode, in addition to reframing their own function, they are often able to contribute unique creativity to society. Examples of some well-known people throughout history that have contributed in this way are Sir Isaac Newton, Joan of Arc, Vincent van Gogh, and Black Elk of the Sioux (he had a shamanic illness in his youth helping his people integrate with the Europeans), Virginia Woolf, Carl Jung, and John Nash (winner of the 1994 Nobel Memorial Prize in economic science). If you get a chance, check out the movie “Beautiful Mind”.

“The goal of the recovery process is not to become normal. The goal is to embrace our human vocation of becoming more deeply, more fully human…to become unique, AWESOME, never to be repeated human being that we are called to be.” Patricia Deegan

The Agnews Hospital Study

This 3 year study in 1978 at the University of California was one of the most significant studies that directly compared anti-psychotic use with a placebo. 80 male patients recently diagnosed with schizophrenia were divided into 4 groups….

  1. Remained on chlorpromazine (antipsychotic medication) both in the hospital and on discharge
  2. Those on it in hospital but “non-compliant” out of hospital
  3. Those on a placebo in hospital, and on chlorpromazine afterwards
  4. Those on a placebo in and no antipsychotic drugs during the 3 years.

All participants were in the hospital for an average of 6 weeks and were checked on at regular intervals over the 3 years. Rappaport (head of the research group) found that over the first 6 weeks the members of the group on the medication did significantly better (this has been replicated in numerous other studies). However, within a short time, the participants not taking the medication fared significantly better. After 3 years the group on the placebo and no medication afterward were doing by far the best (only 2 out of 24 rehospitilisations) and the two groups still taking the meds were quite clearly the worst (16 out of 24 readmissions for the group on the meds during and after the initial hospital stay). Rappaport concluded that those that never received the medication “showed greater clinical improvement and less pathology at follow up, fewer re-admissions, and less overall functional disturbance in the community than other groups of patients.”

WHO studies

These studies, including 15 and 25 year longitudinal studies, have shown that people suffering from schizophrenia in developed countries have far worse outcomes than those who live in so called “developing” countries such as India, Nigeria, and Colombia. It makes interesting reading that the use of antipsychotic medication is inversely correlated with good recovery outcomes. The patients in rural Chandigarh, India, showed the highest rate of complete remission (71% showing no psychotic symptoms within 2 years of the final follow-up, and 79% assessed with good to very good overall functioning).

The open dialogue approach that takes place in Finland doesn’t involve residential space but incorporates freedom of patients with an expectation of full recovery within an environment that creates safety, empathy, and authentic interpersonal interaction. It sees psychosis in one individual as often being a symptom of problems within the larger social systems, so their main treatment in a form of family therapy. 5 years following initial diagnosis, 86% of members of the programme had returned to work or education, and 82% were assessed as fully recovered (didn’t have any residual psychotic symptoms, and were not on any psychiatric drugs).

One conclusion that could be made of the current medical model in treating schizophrenia and psychosis is that it contributes further to brain malfunctioning and very likely reduces the rates of recovery. The research also shows that when people are supported in a compassionate and empathetic environment, psychosis often resolves automatically.

John Weir Perry (A Carl Jung orientated psychiatrist) has more than 40 years of experience of working with psychiatric patients. He referred to a theoretical framework of psychosis as “the renewal process” made up of the same stuff that seers, visionaries, cultural reformers, and prophets go through. Perry concluded that psychosis is not the result of damage or impairment but is “actually initiated intentionally by the unconscious psyche (although not consciously wanted or invited!). He stated, “When a person finds themselves in a state of acute distress, in circumstances that have assailed their most sensitive vulnerabilities, the psyche may be stirred into an imperative need to re-organise the self.” In other words, I take this as when too much is going on to handle within your capabilities, your system shuts down to allow a defrag. Much like an overloaded computer. This can happen with a sharp sudden trauma or chronic long-term stress.

Perry discussed an aspect of the renewal process that was more expansive with the health of society as a whole – once an individual has gone through a profound reorganisation of their inner culture, they sometimes emerge with a vision of how our broader culture should be reorganised in order to continue its existence. In Western society, we try and stop this process to return them to normal as quickly as possible, compared to more “spiritually aware” societies in which people are met with more respect and validation.

Arnold Mindell has developed a framework he named “the Process Paradigm” (or Process Orientated Psychology). The main points are that we all have both primary and secondary processes operating within us at all times. The primary process is what we most presently identify with and the secondary processes are background processes with which we identify the least, some of which we are not even fully conscious of (Carl Jung refers to this as “the shadow”). The feedback loop is how we process information from our environment so we can modify our own behaviour and beliefs to “fit in.” Mindell suggests we all have filters modulating our individual feedback loops, and we all have blind spots that often self-serve us in minimising information that might be uncomfortable/painful or difficult to integrate into our worldview. The “metacommunicator” (observing ego) is that part of us that is detached from the experience and gives us more pro-activity than reactivity to situations. Access to our metacommunicator is hampered by intense fear or anger. Meditation increases this access and helps give us more space around making better responses to situations, allowing more reasoned and thought through pro-action compared to poor reaction with no space or time to think rationally. Mindell talks about the “flipping” of our primary and secondary processes (the metacommunicator usually stops this from happening) This flipping could help explain dramatic personality changes when the metacommunicator is weak (such as when intoxicated with alcohol, drugs, or overwhelmed by strong emotions)

Isabel Clarke (researcher and a clinical psychologist) has created a cognitively* orientated model that see psychosis as a result of an imbalance in our view of the world. Clarke talks about psychosis, spiritual experiences, and even large social movements like revolutions coming about from a shift or discontinuity of consciousness. Her work draws from the Interacting Cognitive Subsystem (ICS) model, put forward by John Teasdale and Phillip Barnard, which states that different modes of information processing (sight, hearing, etc.) are managed by 2 overarching “meaning making” systems

  • Propositional subsystem (logical mind, concerned with external world, language/words/symbols – correlated with the neocortex)
  • Implicational subsystem (emotional meaning and holistic perception, more the inner world, concerned with worth of self and threat to our position or survival – sees the world as more interconnected. Thought to be linked to older and deeper regions of the brain).

Clarke talked about how the establishment of our sense of self will protect against transliminal (mystical or psychotic) experiences (which we can experience as either a temporary life enhancing, spiritual event or a damaging psychotic breakdown). She suggested that a major role of religion, which can be described as a culture’s way of putting spiritual matters into an understanding framework, is to keep us connected with this holistic, mysterious, interconnected realm. However, by concentrating on the fate of the individual soul rather than on our interconnection with a greater whole, our modern religions are letting us down, letting the technology born of our “ferocious power to discriminate and to bend the material world” to our will take us to the point where the sustainability of our species is on the brink.

*Cognition – the mental processes involved in making sense of the world via perception, thinking, interpreting, and reasoning. 

*Existential – fundamental dilemmas which we all face as living conscious beings – finding meaning, joy, purpose, minimising suffering. 

Otto Rank (1884-1939) was a student of Sigmund Freud for 30 years before forming his own ideas in the late 1920’s. In 1936, he published an essay, “Will Therapy,” where he first floated his idea that the core of all fear is a dynamic dialectical system (dialectic refers to the tension existing between two opposing forces) involving 2 poles – life fear (fear of living as an isolated individual – autonomy), and death fear (fear of loss of individuality – fusion) which is when you lose your sense of self by being engulfed by too much merger and connection. Rank suggested that we find ourselves bouncing between the two poles seeking middle ground that we can tolerate at any one moment in time.

Rollo May (1909-1994) used Rank’s work as a foundation for his own formulation of psychosis. He talked about the dialectical relationship between the individual and their community. On one hand, people want to find their own uniqueness, authenticity, or sense of agency. On the other hand, the individual wants to experience love and belonging. If either need is significantly hampered, this can lead to psychological conflict, and neurotic anxiety and even psychosis can result.

In 1999, Kirk Schneider created another version of the 2-pole theme – defining the 2 poles as “constriction” or “expansion” and talking about our fears coming from the “dread of ultimate constriction” (isolation/alone/no purpose) and the “dread of ultimate expansion” (losing yourself, chaos, lost in the world with no grounding).

 Ernest Becker (1924-1974) wrote the Pulitzer Prize winning book, The Denial of Death. In it, he says, “Our deepest need is to be free of the anxiety of death….but it is life itself which awakens it, and so we must shrink from being fully alive.” We then find ourselves being afraid to die, but also fearful of really living. According to Becker, this is the price we pay for being human. While most of us develop strategies that allow us to more or less mitigate this dilemma, those who really struggle with this are vulnerable to developing neurotic anxieties or even psychosis.

Paris Williams (the author of Rethinking Madness) has developed an integrative and comprehensive model for psychosis that integrates many the basic shared themes of the models above – he refers to it as the Duality/Unity Integrative model (DUI model for short). His model also incorporates the “2 pole” theory like some of those mentioned above—basically, one pole of individuality or autonomy and the other of community or greater connection with others and the natural world. A healthy balance means having a “healthy” sense of self and your purpose, which allows a “healthy” interaction with others/community/the world. Moving too far in one direction (either getting isolated or losing yourself in others or the world) creates an imbalance that can lead to dis-ease and ultimately a breakdown of some sort.

Existentially orientated thinkers in the East have been looking at different ways of explaining this 2-pole system for over 2500 years. Practitioners of Hinduism, Taoism, and Buddhism have discussed the “principle of fundamental interconnection.” The DUI model bridges the basic 2-pole system used by the Western existential thinkers (described above), which he refers to as a dualistic framework (Self vs. Other), with the Eastern principle of fundamental unity, the potential we all have to experience a transcendence of duality altogether, to experience the profound interconnectedness of the universe, or the “ground of all being.”

In Paris’s model, he unpacks the constant “dance” of experiencing life within the 2 dimensions of duality and unity. Within one dimension, we need to maintain a workable balance between the experience of duality and unity. This dimension of our experience is generally not fully conscious, and so is difficult to capture in words (it’s more easily grasped or at least pointed to by spiritual and mystical traditions). Essentially, this involves our continuous (usually unconscious) attempt to maintain the experience of having a “self” as being relatively secure, stable and coherent in a world/existence that is ultimately insecure, dynamic and impermanent. So if we have too rigid or contracted an experience of self, then we feel very disconnected from the world/God/the universe, and we feel spiritually depleted. But on the other hand, if we have too expansive/diffuse an experience of our “self,” then we can feel ungrounded, overwhelmed, chaotic, manic, even psychotic—this is the territory of both mystical/spiritual experience and certain aspects of psychosis.

The second dimension we find ourselves “dancing” within takes place inside the duality domain—this is the more everyday conscious experience we can all easily relate to of managing our various relationships between our “self” and other “selfs.” This consists of our need to find life strategies that allow us to have both enough personal autonomy/choice/empowerment and enough connection/love/belonging with others to maintain our general wellbeing. If we move too far towards autonomy, we can feel overwhelming isolation and loneliness, and if we move too far towards connection, we can feel engulfed by others, a loss of agency or generally oppressed. As other psychologists have stated, we spend our lives in a tug of war between these two states, trying to find our “window of tolerance.” And when our experience exceeds our window of tolerance by too much and/or for too long, we risk entering into those states often referred to as “mental illness,” and in the more extreme cases, “psychosis.”

I have heard many people describe life as a dance. I tell all my physiotherapy and coaching clients that motion is lotion, especially moving in nature – and what is good for the body is good for the mind and soul. Our bodies, minds, and souls exist enmeshed together. I have written about how getting to know yourself as the awesome one and only never to be repeated you (ignoring the trappings of a materialistic, consumeristic, label giving, box fitting society), then coming to understand that we are all connected – not only with each other, but also with the millions of other ecosystems within our home (with a life-giving force flowing through it all – name this what you want, God, the force, Universe, etc.)  that we all share – the beautiful planet Earth. Growing to know this is completing the circle of understanding.

Failing to protect our life support systems while allowing each other to thrive within our windows of tolerance is a dilemma creating an environment for dis-ease and dysfunction. The many constructed systems that we operate under are completely broken. It’s like everyone is looking for the answer to a question and finding out the question is not relevant. We need a completely different question – and completely different systems. Treating everyone with empathy, especially those who struggle to fit into a system that is clearly not working, could be the answer to not only saving such individuals but to saving all of us. After all, we are all collectively descending into a very chaotic “dark night of the soul,” which could even be considered a kind of collective psychosis. So by supporting and validating those who are most sensitive to this chaos (whom we can see as the “canaries in the coal mine”), by supporting them in their attempts to defrag and then reconfigure, we may just find that the dilemmas and insights that they grapple with are the very same ones that we all  must grapple with in order to change our systems and save our world.