Dr. Carpenter’s BLOG

From time to time I will be adding posts here.  Some will be short essays, some will be pictures or photographs, some will be poems.  All will touch on the topic of psychotherapy to some extent or other.  Current software permits no responses from readers on this page, although I would be interested in responses.  If you wish, you can email me your reactions:  info@DrJimCarpenter.com.

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Things that Aren’t There

What do you think of hallucinations?  How do you think they work?  Is this something you ever wonder about?

Recently I talked about this with a woman I know well and long, who was experiencing some as we spoke.  One thing was the “bugs” (microphones) that she saw scattered around the room that she assumed had been put there because she was coming in, by people who wanted to keep track of everything she said, and might hurt her at any point.  She could literally see the bugs.  I could not.

Martha is in her mid-30’s.  Her bright blonde hair is natural.  She sat on one side of a corner from me, her body tense and passive at once, the odd mixture one sees with people who are gripped with inner distress but whose musculature is flattened out by atypical antipsychotics.  She carries the tight, extra weight that also accompanies those drugs.  Her eyes are shy and furtive, checking the room, checking my face.

She is a very intelligent person and is very vexed by people telling her that such things are not real.  She cannot doubt her senses, and she sees them.  (I say, “I agree.  I don’t doubt my senses either”).  Same thing with the voices speaking to her on the turned-off radio.  She understands that I do not see and hear these things, but she does. 

She puts the question to me that carries deep implications of challenge and shame, “Do you think they are real?”

An answer came out of my mouth that I had never quite thought or read before, but as I heard it, it seemed to me to be true.  At least true as far as I can know.

“It’s not as simple a question as we usually think.  We usually think that whatever we perceive is just simply what is there.  Perception equals reality.  However, we now know from tons of research that every perception we have is actually constructed by the unconscious mind which then instantly hands it to consciousness.  What the unconscious mind largely uses to do this constructing is sensory stimulations.  This sensory information is almost all of the raw material, most of the time.  We grasp this information with our senses, we process it with our brains unconsciously, and the product enters our consciousness.  Because we all share this sensory world, we do very similar unconscious constructing.  We can both look at this lamp. . . “  I point to it.  “and we both see the same lamp, as far as we can ever know.  It’s easy to say, this lamp is real.”

She trusts me, so she was hanging in with this.

“However, sensory information isn’t all the unconscious mind uses to create experience.  It really makes reference to anything, any concern or issue that is pressing enough.  If a person, like you, is dealing with a huge amount of fear and sort of meaningless agitation, the unconscious factors this into perception as well.  You’re in the middle of a withdrawal syndrome from Geodon and Seroquel, and your brain is hugely agitated.  You also grew up with an amazing amount of secrecy and danger and abuse.”  I could see in her face that she was remembering some of the things she had told me about.

I went on, “these associations come in and get factored in too.  Agitation feels like danger and danger brings up being exposed and hurt and shamed.  These things get factored in too.  All unconsciously.  You perceive the product of all that.  Same lamp and room as me, but some additional things, like the bugs and the radio talker.”  The radio man is an accusatory talker.

“So the answer to the question about is it real. . . It’s not that the lamp is real and the bug isn’t, it’s that your constructed reality has some things in it right now that my constructed reality doesn’t.  It’s not that my version is real and yours isn’t.  They’re both real, but both constructed, only out of somewhat different materials.”

She answered thoughtfully, “That seems true.”

I said then, “I think that when we have done more work on your terrible memories and on danger and shame, and all that is more out and somewhat neutralized, you’ll have an easier time getting off of Seroquel.”  Seroquel is a big weight-gainer, so a big priority. 

“Yes, probably,” she said.  Then she had a long thoughtful pause.  Then seemed to change the subject.

I won’t relate what she changed the subject to.  It was a very private and difficult story.  Not of childhood sexual abuse or beating or shaming, but something much more recent that also underscored the dreadful danger of her parents.  We talked about it in depth, back and forth.  Then at the end of the session (I was very moved) I thanked her for the story (which she had never told to anyone before).  She thanked me for listening.

Talk of suicide, which had begun our meeting, was gone for now.

I want to make some more points with this story.  I want to point out that the way this went is different from the scenarios that usually play out with patients and those who treat them. 

The typical script is something like this:  “of course the bugs and the man on the radio are not real.  However, you shouldn’t feel responsible for this.  No one else is to blame either.  You have a serious mental illness.  You were born with it, but sometimes it takes decades to develop, as it did with you.  You are experiencing these delusional and hallucinatory symptoms because you have tried to go off of some of your medication, and this relapse is proof again that your illness is still there and must continue to be treated.  Unfortunately, this will probably always happen, so you must try to live as normally as you can with these medications for the rest of your life.  It’s like the diabetic who must always take insulin.  Like any medications, these have some difficult side-effects, but these can often be treated with other medications and kept to a minimum.  They are the price a person has to pay for the bad luck of being born with such an illness.”  This speech may be delivered more sternly or more warmly, depending upon which seems more likely to result in medication compliance. 

Are there drawbacks to this script?  I think there should be, because most of it isn’t true.  And there clearly are drawbacks.

I am an older therapist, now in my 70’s.  When I was trained I was taught that in the majority of cases, an acute psychotic break with delusions and hallucinations is a naturally self-limiting condition.  It will often last no longer than a year, sometimes no longer than 6 months.  With kind, safe, custodial care, and good psychotherapy, remission is frequently quicker and more stable.  Many studies bore this out.  And my own experience with psychotic patients in several settings bore this out.  I have always had a lot of interest in psychosis, and a lot of sympathy for people gripped by it.  I have worked persistently with many people who have shared their experiences with me to try to understand as much as I could about it – from the inside as well as the outside.   The more I learned about the inside of it, the more it seemed clear to me that people who became that messed up had generally been badly hurt by life, usually early in life, often by people upon whom they were vitally dependent.

Now young psychologists and psychiatric residents in training are taught that psychosis is no one’s fault, it is a biological defect of the brain, and it lasts a lifetime.  And their subsequent experience bears this out too.  When patients are given powerful brain-altering medications, their symptoms usually go away quickly.  Therefore, the brains must be disordered.  And when they are taken off of meds, the symptoms come back.  Therefore, the disorder must be a lifelong fact.

How can both these things be true? 

Does acute psychosis frequently tend to remit or does it last a lifetime?  Has madness changed?  Well yes, it has.  What has changed madness is our treatment of it.  Our powerful drugs change brains in ways that make them profoundly drug-dependent.  Coming off of these drugs is very tricky business.  You can quickly become crazier and/or more anxious and/or more depressed than you ever were before starting the meds.  The psychiatrists I know who are currently at the top of my personal referral list are those who are not only good at treating symptoms with medications, but also skillful at helping people terminate their medications.  The latter seems to be by far the more difficult problem.  (Martha’s psychiatrist, thankfully, is one of this skillful group). 

You may think I am a bit mad here myself, since what I am saying is so counter to what has become culturally accepted.  Yet it is supported by a great deal of good research reported in our best journals of psychiatry.  For a summary of these problems see the very disturbing book by Whitaker (Whitaker, 2011).  He spells out what is known about the neurophysiological changes that underlie these profound withdrawal syndromes.  I have searched for solid, scientific information contrary to Whitaker’s points, but have not been able to find it, although there is certainly controversy (see the scathing review by Torrey [Torrey, 2012], and the rejoinder by Whitaker [Whitaker, 2012]). Among the many fascinating facts that Whitaker has gathered is that if you suffer a psychotic breakdown, your odds of complete recovery are much, much better if you are being treated in a third-world country that cannot afford psychotropic medication.  In poor countries they treat with various forms of social support, and leave the brain alone and unaltered.

Is psychosis a brain disorder?  Hypothetically yes, but as far as we can tell, actually no.  Of course our brains are involved in all of our experience.  This is a trivial truth.  But there actually are no demonstrable differences between the brains of psychotic and non-psychotic people.  We may be told that there is no physical test that will discriminate these groups.  But if we are told that, the words “not yet” are always added, since there is complete faith that such a test is just around the corner.  This faith is very robust.  It fits our favorite filters for reality.  The rebellious psychiatrist R. D. Laing somewhere quipped 40 + years ago that people were always finding something in the urine of schizophrenics.  We could now say that people are always finding something in the MRIs of bipolars.  The problem is, these “imminent breakthrough” never hold up.  With more and careful research, they evaporate.  If psychosis were a brain disease we should be able to find it in brains, but we cannot.

What we have instead of a brain disease is a handful of metaphors that can be bundled together into a simple narrative that feels very sensible in an age in which all of our humanity is reduced to our brains, and all problems can be salved if not really solved with pills.

Should we even think of acute psychosis as a disorder?  Actually, I no longer think so.  I like the term used by transpersonal psychiatrist, Stan Grof:  spiritual emergency. (Grof, 1989).  Psychosis is certainly terrible and dangerous.  It can feel unbelievably awful, and some people kill themselves when gripped by it, and a very few kill others too.  Grof’s term implies that this kind of radical breakdown is a terrible bid for self-healing by a person whose life has come to be completely unlivable.  And the healing must involve a new integration of deep, inner parts of the person and deep, transpersonal forces beyond the person.  It involves new connections between the secret self and others, and the self and those sources of guidance and grace beyond the self that we refer to nowadays as “spiritual.”  When this new integration happens, it is pale and misleading to call it a “remission.”  It is a remarkable achievement.  Like the sobriety of a recovering alcoholic, it is always a work in progress.  A post-psychotic man told me recently, looking back on himself before his madness, “It had to break down.  I was too arrogant.  I couldn’t see it, but it wasn’t working, it all had to change.”  At present this man is a successful artist and a leader in a vital artistic community.

Unfortunately, in developed countries, there are precious few resources to support people struggling with psychosis that are grounded on such an understanding.  Almost all of the ones that used to exist in the United States shut their doors long ago in favor of the universal reliance upon antipsychotic medication, with very minimal psychosocial support.  This form of treatment suppresses symptoms but long-term use unfortunately hinders the real process of new self-construction.  At the same time, antipsychotics are helpful in relieving acute psychotic symptoms, which relieves the great distress of both the person who has broken down and of the people in his or her life.  In any case, their use is deeply entrenched and we have no real alternative. 

It seems to me that research tells us that our medications should be used carefully, sparingly, and temporarily.  They should always be used in conjunction with serious psychotherapy that aims to help personal reintegration (not superficial “counseling” about “how to live with your illness.”)  Just as it is helpful and humane to use painkillers until surgery can be performed, these symptom-relieving drugs can be a great mercy until reintegration can be achieved.  But not used for so long that they rewire the brain to the point that reintegration is much more difficult.  (Again, see Whitaker, 2011).

For more information about this alternative view of psychosis, I recommend in addition to Grof, good books by Perry (Perry, 1974) and Williams (Williams, 2012).

In my session with Martha, I acted on the belief that she and I are basically the same kind of person, neither more biologically normal than the other.  I went to some pains to find a way to say that her experience is as real as mine, and explain why I think that is a reasonable conclusion.  It helped a lot that I actually believed what I was saying.  Besides wanting to tell the truth, I did not want to add to her shame.  It is very difficult for us, in the best of circumstances with the most apparently secure people, not to add to one another’s shame.  We keep these secret currents invisible for good reasons.  Is there anything more shaming than telling someone that he is the product of his brain, and his brain is defective?  We should not make such statements unless we have very good reason to know that they are true.  I don’t believe they are true.

Martha and I have an alliance between two equally honorable people, although one carries oceans of secret shame that the other does not so much.  We remove pieces of emotional shrapnel as they rise to the surface.  At moments we appreciate the unanticipated powers from wherever that guide us to the next step as our work unfolds.

Works Cited

Grof, S. (1989). Spiritual Emergency: When Personal Transformation Becomes a Crisis. New York: Tarcher.

Perry, J. W. (1974). Far Side of Madness. Upper Saddle River, NJ: Prentice Hall.

Torrey, E. F. (2012). Anatomy of a non-Epidemic: A review by Dr. Torrey. Retrieved from Treatment Advocacy Center: http://www.treatmentadvocacycenter.org/component/content/article/2085-anatomy-of-a-non-epidemic-a-review-by-dr-torrey

Whitaker, R. (2011). Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America. New York, NY: Broadway Books.

Whitaker, R. (2012, May 16). E. Fuller Torrey’s Review of Anatomy of an Epidemic: What Does It Reveal About the Rationale for Forced Treatment? Retrieved from Mad in America: E. Fuller Torrey’s Review of Anatomy of an Epidemic: What Does It Reveal About the Rationale for Forced Treatment?

Williams, P. (2012). Rethinking Madness: Towards a Paradigm Shift in our Understanding of Psychosis. Cleveland, OH: Sky's Edge Publishing.

Different version was published in Aeon, a magazine of ideas and culture

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