Two Views on Global Mental Health - Evidence-Based vs. Cultural Sensitivity

The two articles cited below were referenced in one of the weekly "best of" lists that I read, sorry that I can't remember which one. But these two articles offer very different takes on the topic of mental health as a global health concern.

In 2010, a team of scholars from the Harvard School of Public Health and the World Economic Forum issued a report on the current and future global economic burden of disease.

In 2010, the report’s authors found, noncommunicable diseases caused 63 percent of all deaths around the world, and 80 percent of those fatalities occurred in countries that the World Bank characterizes as low income or middle income. Noncommunicable diseases are partly rooted in lifestyle and diet, and their emergence as a major risk, especially in the developing world, represents the dark side of the economic advances that have also spurred increased longevity, urbanization, and population growth. The scale of the problem is only going to grow: between 2010 and 2030, the report estimated, chronic noncommunicable diseases will reduce global GDP by $46.7 trillion.

One surprise was that the report predicted that the largest source of future financial costs would be mental disorders, which the report suggested would account for at least a third of the global economic burden of "noncommunicable diseases" by 2030.

Taken together, the direct economic effects of mental illness (such as spending on care) and the indirect effects (such as lost productivity) already cost the global economy around $2.5 trillion a year. By 2030, the team projected, that amount will increase to around $6 trillion, in constant dollars—more than heart disease and more than cancer, diabetes, and respiratory diseases combined. 


The above quotes are taken from a very recent article in the Jan/Feb 2015 issue of Foreign Affairs, "Darkness Invisible: The Hidden Global Costs of Mental Illness." The article is written by Thomas R. Insel (Director of the National Institutes of Mental Health), Pamela Y. Collins (Director, Office for Research on Disparities & Global Mental Health National Institute of Mental Health), and Steven E. Hyman (Director of the Stanley Center for Psychiatric Research and a core member at the Broad Institute of MIT and Harvard).

All three of these authors have skin in the game, so to speak - their jobs are based on the existence of mental disorders on a wide scale that must be treated. That makes me suspect of their opinions. 

Still, their article is worth a read.  

In the post that referenced that article, the author also mentioned an alternative view presented by Doerte Bemme and Nicole D’souza at a collaborative website called Somatosphere, "Global Mental Health and its Discontents." Their article was spurred by a then-recent series of articles and conferences on the topic of Global Mental Health.

Recently, an article in Nature entitled “Grand Challenges in Global Mental Health” (2011) identified mental health priorities for research in the next 10 years, sparking controversy and debate about the appropriate methods for establishing priorities, research themes, and interventions in GMH. This year’s annual Advanced Study Institute (ASI) and Conference, hosted by McGill’s Division of Social & Transcultural Psychiatry (July 5-7 2012) in Montreal, Canada, sought to address these concerns and focused on ways to generate critique of the GMH movement to ensure that its goals and methods are responsive to diverse cultural contexts.

Here is the rest of the introductory paragraph from their article:

The ASI workshop and conference entitled “Global Mental Health: Bridging the Perspectives of Cultural Psychiatry and Public Health.”, was chaired by Laurence Kirmayer and Duncan Pedersen, and was animated with intense discussions about various themes related to the GMH endeavour. The three-day ASI series sought to address ongoing controversies and tensions between a public health approach to mental health (grounded in current evidence-based practices largely produced by high-income countries and exported and adapted to local situations) and a culturally-based approach (which emphasizes local priorities and community-based resources and solutions). The first two days took the form of a workshop bringing together experts in cultural psychiatry, public health and medical anthropology for a consideration of ways to bridge various perspectives on GMH.

The authors present their coverage of the conference discussion "in the form of a debate, giving voice to those in attendance." It's definitely worth the time to read.

Broader Topic

This topic points out one of the many issues with the standard position taken on tackling mental health issues, locally or globally - the opposition between one-size-fits-all, "evidence-based" models approach and an individually and culturally sensitive approach that may not fit the "evidence-based" standards of the NIMH.

Living and working in Tucson has provided me with an opportunity to see this conflict in my daily work. A large percentage of our clients are Hispanic, many of whom are Catholic, but others hold beliefs tied to their indigenous heritage (pre-Spanish influence). Even within our Anglo clients there are wide differences in cultural beliefs, religious beliefs, and socioeconomic status, all of which affects their understanding of themselves and of their place in the world.

The treatments favored by the authors of the first article are very often psychopharmacological, i.e., medications, many (if not most) of which create more problems than they solve. For example, antipsychotic drugs used to treat schizophrenia (the costliest of the mental health issues faced in any nation) actually perpetuate the problems they are meant to treat.

During the mid 1990s, MRI studies found that antipsychotics can cause basal ganglion structures and the thalamus to swell, and the frontal lobes to shrink. Then, in 1998, Raquel Gur at the University of Pennsylvania reported that the swelling of the basal ganglia and thalamus was "associated with greater severity of both negative and positive symptoms." In other words, this research showed that the drugs cause morphological changes in the brain that are associated with a worsening of the very symptoms the drugs are supposed to treat. (Robert Whitaker, Psychology Today, May 18, 2010)

The effects of long-term pharmacological interventions are often cited to explain the apparent disparity between outcomes for psychosis between developing nations (better outcomes) and developed nations (poorer outcomes). The research cited by Whitaker supports that belief.

In a longitudinal study of schizophrenia outcomes by Harrow, Jobe, and Faull (2012), it was found that "SZ patients not on antipsychotics for prolonged periods were significantly less likely to be psychotic and experienced more periods of recovery; they also had more favorable risk and protective factors. SZ patients off antipsychotics for prolonged periods did not relapse more frequently."

In his Psychology Today article, Whitake cited another study, in Lapland, Finland, which treated first-time psychosis with a very conservative degree of pharmacological interventions- and the results are striking.

Since 1992, the medical community in the western Lapland region of northern Finland has been using antipsychotics in a selective, cautious manner. At the end of five years, only about one-third of their first-episode psychotic patients have been exposed to antipsychotics, and only about 20% are regularly maintained on the drugs. This is a "continual use" rate similar to the rate for schizophrenia patients from developing countries in the second WHO study, and here are the long-term outcomes for western Lapland's first-episode psychotic patients: Eighty-six percent are working or back in school at the end of five years, and only fourteen percent are on long-term disability. These outcomes are far better than the norm in Western Europe and the rest of the developed world.

Because Finland is a developed nation, this research supports the belief that the deciding factor in why people in developing nations have better outcomes in psychosis is not necessarily due to cultural factors (such as wider family support or better social support), but may largely be due to the pharmacological interventions that are the primary line of treatment in developed nations.

In fact, Parmanand Kulhara (2009), whose research suggests that the difference in outcomes between developed and developing nations is real, notes in his review that “culture should not be used as a synonym for unexplained variance” (Asian Journal of Psychiatry, 2(2); 55-62) - further, "exact factors and the mechanisms subsumed under “culture” that influence outcome and course are still hidden; thus, the “black box” still remains unopened."

It is unlikely that treatment methods in the U.S. are going to change any time soon - pharmacological interventions are considered the primary method, and the only beneficial treatment, for schizophrenia and psychosis.

If you develop symptoms and are lucky enough to find a therapist who understands that psychosis is "a natural though very risky and haphazard process initiated by their psyche in an attempt to cope and/or heal from a way of being in the world that was simply no longer sustainable for them" (Paris Williams; Brain Blogger, Full Recovery from Schizophrenia?, May 29, 2012), you will have a much better chance of maintaining a full-recovery.

Best Psychology & Neuroscience Books of 2014 (according to me)

Here are some of the best books I have been exposed to this year. Obviously, I cannot read everything, so this is a partial list at best. They are listed in alphabetical order. Descriptive text is from the publisher's blurb on Amazon.

A few of these books warrant the RECOMMENDED READ classification.

Adult Attachment Patterns in a Treatment Context: Relationship and Narrative

Sarah Daniel

Attachment theory posits that the need for attachment is a life-long phenomenon that becomes especially relevant in times of crisis or trauma. When adults experience illness, accidents, assaults, psychological difficulties or losses, their attachment-behavioural systems are activated, motivating them to seek help and support from family and friends and/or from helping professionals. However, the resulting request for help is affected and shaped by earlier experiences regarding the support and trustworthiness of attachment figures. Can others be trusted? Is it safe to show vulnerability? How should one behave to increase the likelihood of receiving the help needed? 

Adult Attachment Patterns in a Treatment Context provides an integrated introduction to the subject of adult attachment. Research into adult attachment patterns offers professional helpers a theoretically sound insight into the dynamics underlying a range of client behaviours, including some of the more puzzling and frustrating behaviours such as denying obvious pain or continually pushing the professional for more personal involvement. Sarah Daniel shows how applying knowledge of attachment patterns to treatment settings will improve the way in which professionals engage with clients and the organization of treatments. This book will be relevant to a range of helping professionals such as psychotherapists, psychologists and social workers, both in practice and in training.

Affect Regulation Training: A Practitioners' Manual

Matthias Berking and Brian Whitley 

Emotion Regulation is currently one of the most popular topics in clinical psychology. Numerous studies demonstrate that deficits in emotion regulation skills are likely to help maintain various forms of psychological disorders. Thus, enhancing emotion regulation has become a major target in psychotherapeutic treatments. For this purpose, a number of therapeutic strategies have been developed and shown to be effective. However, for practitioners it is often difficult to decide which of these strategies they should use or how they can effectively combine empirically-validated strategies. Thus, the authors developed the Affect Regulation Training as a transdiagnostic intervention which systematically integrates strategies from cognitive behavior therapy, mindfulness-based interventions, emotion-focused therapy, and dialectical behavioral therapy. The effectiveness of ART has been demonstrated in several high-quality studies. 

Attachment and Interaction: From Bowlby to Current Clinical Theory and Practice

Mario Marrone

Attachment and Interaction is an accessible introduction to the history and evolution of attachment theory, which traces the early roots of attachment theory from the work of its creator John Bowlby through to the most recent theoretical developments and their clinical applications. Mario Marrone explores how attachment theory can inform how therapists work with their patients, and what the practical implications are of using such an approach. By mixing personal anecdotes from his own experiences as Bowlby's supervisee with clear explanations of Bowlby's ideas and how they have evolved, Marrone creates a memorable and engaging account of attachment theory. This new, updated edition includes new material on bereavement, sexuality and the application of attachment-based principles to individual, family and group psychotherapy. This clear exposition of attachment theory is relevant and valuable reading for trainee and practising individual and group psychotherapists, family therapists and mental health professionals - as well as anyone with an interest in John Bowlby and the evolution of psychotherapy.

The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma

Bessel A. van der Kolk 

RECOMMENDED READ.

A pioneering researcher and one of the world’s foremost experts on traumatic stress offers a bold new paradigm for healing

Trauma is a fact of life. Veterans and their families deal with the painful aftermath of combat; one in five Americans has been molested; one in four grew up with alcoholics; one in three couples have engaged in physical violence. Such experiences inevitably leave traces on minds, emotions, and even on biology. Sadly, trauma sufferers frequently pass on their stress to their partners and children.

Renowned trauma expert Bessel van der Kolk has spent over three decades working with survivors. In The Body Keeps the Score, he transforms our understanding of traumatic stress, revealing how it literally rearranges the brain’s wiring—specifically areas dedicated to pleasure, engagement, control, and trust. He shows how these areas can be reactivated through innovative treatments including neurofeedback, mindfulness techniques, play, yoga, and other therapies. Based on Dr. van der Kolk’s own research and that of other leading specialists, The Body Keeps the Score offers proven alternatives to drugs and talk therapy—and a way to reclaim lives.

Brain, Mind, and Consciousness in the History of Neuroscience

C.U.M. Smith and Harry Whitaker, Editors

This volume of essays examines the problem of mind, looking at how the problem has appeared to neuroscientists (in the widest sense) from classical antiquity through to contemporary times. Beginning with a look at ventricular neuropsychology in antiquity, this book goes on to look at Spinozan ideas on the links between mind and body, Thomas Willis and the foundation of Neurology, Hooke’s mechanical model of the mind and Joseph Priestley’s approach to the mind-body problem.

The volume offers a chapter on the 19th century Ottoman perspective on western thinking. Further chapters trace the work of nineteenth century scholars including George Henry Lewes, Herbert Spencer and Emil du Bois-Reymond. The book covers significant work from the twentieth century, including an examination of Alfred North Whitehead and the history of consciousness, and particular attention is given to the development of quantum consciousness. Chapters on slavery and the self and the development of an understanding of Dualism bring this examination up to date on the latest 21st century work in the field.

At the heart of this book is the matter of how we define the problem of consciousness itself: has there been any progress in our understanding of the working of mind and brain? This work at the interface between science and the humanities will appeal to experts from across many fields who wish to develop their understanding of the problem of consciousness, including scholars of Neuroscience, Behavioural Science and the History of Science.

Cyclical Psychodynamics and the Contextual Self: The Inner World, the Intimate World, and the World of Culture and Society

Paul L. Wachtel

Cyclical Psychodynamics and the Contextual Self articulates in new ways the essential features and most recent extensions of Paul Wachtel's powerfully integrative theory of cyclical psychodynamics. Wachtel is widely regarded as the leading advocate for integrative thinking in personality theory and the theory and practice of psychotherapy. He is a contributor to cutting edge thought in the realm of relational psychoanalysis and to highlighting the ways in which the relational point of view provides especially fertile ground for integrating psychoanalytic insights with the ideas and methods of other theoretical and therapeutic orientations. 

In this book, Wachtel extends his integration of psychoanalytic, cognitive-behavioral, systemic, and experiential viewpoints to examine closely the nature of the inner world of subjectivity, its relation to the transactional world of daily life experiences, and the impact on both the larger social and cultural forces that both shape and are shaped by individual experience. Here, he discusses in a uniquely comprehensive fashioning the subtleties of the clinical interaction, the findings of systematic research, and the role of social, economic, and historical forces in our lives. The chapters in this book help to transcend the tunnel vision that can lead therapists of different orientations to ignore the important discoveries and innovations from competing approaches. 

Explicating the pervasive role of vicious circles and self-fulfilling prophecies in our lives, Cyclical Psychodynamics and the Contextual Self shows how deeply intertwined the subjective, the intersubjective, and the cultural realms are, and points to new pathways to therapeutic and social change. Both a theoretical tour de force and an immensely practical guide to clinical practice, this book will be essential reading for psychoanalysts, psychotherapists and students of human behavior of all backgrounds and theoretical orientations.

The Future of the Brain: Essays by the World's Leading Neuroscientists

Gary Marcus and Jeremy Freeman, Editors

Including a chapter by 2014 Nobel laureates May-Britt Moser and Edvard Moser 

An unprecedented look at the quest to unravel the mysteries of the human brain, The Future of the Brain takes readers to the absolute frontiers of science. Original essays by leading researchers such as Christof Koch, George Church, Olaf Sporns, and May-Britt and Edvard Moser describe the spectacular technological advances that will enable us to map the more than eighty-five billion neurons in the brain, as well as the challenges that lie ahead in understanding the anticipated deluge of data and the prospects for building working simulations of the human brain. A must-read for anyone trying to understand ambitious new research programs such as the Obama administration's BRAIN Initiative and the European Union's Human Brain Project, The Future of the Brain sheds light on the breathtaking implications of brain science for medicine, psychiatry, and even human consciousness itself.

Contributors include: Misha Ahrens, Ned Block, Matteo Carandini, George Church, John Donoghue, Chris Eliasmith, Simon Fisher, Mike Hawrylycz, Sean Hill, Christof Koch, Leah Krubitzer, Michel Maharbiz, Kevin Mitchell, Edvard Moser, May-Britt Moser, David Poeppel, Krishna Shenoy, Olaf Sporns, Anthony Zador.

The Future of the Mind: The Scientific Quest to Understand, Enhance, and Empower the Mind

Michio Kaku 

I included this book because it is representative of the state of the science in (mis)understanding the mind. I disagree with several of the basic (reductionist) premises Kaku takes as givens.

The New York Times best-selling author of PHYSICS OF THE IMPOSSIBLE, PHYSICS OF THE FUTURE and HYPERSPACE tackles the most fascinating and complex object in the known universe: the human brain.
For the first time in history, the secrets of the living brain are being revealed by a battery of high tech brain scans devised by physicists. Now what was once solely the province of science fiction has become a startling reality. Recording memories, telepathy, videotaping our dreams, mind control, avatars, and telekinesis are not only possible; they already exist.

THE FUTURE OF THE MIND gives us an authoritative and compelling look at the astonishing research being done in top laboratories around the world—all based on the latest advancements in neuroscience and physics.  One day we might have a "smart pill" that can enhance our cognition; be able to upload our brain to a computer, neuron for neuron; send thoughts and emotions around the world on a "brain-net"; control computers and robots with our mind; push the very limits of immortality; and perhaps even send our consciousness across the universe.

Dr. Kaku takes us on a grand tour of what the future might hold, giving us not only a solid sense of how the brain functions but also how these technologies will change our daily lives. He even presents a radically new way to think about "consciousness" and applies it to provide fresh insight into mental illness, artificial intelligence and alien consciousness. 

With Dr. Kaku's deep understanding of modern science and keen eye for future developments, THE FUTURE OF THE MIND is a scientific tour de force--an extraordinary, mind-boggling exploration of the frontiers of neuroscience.

Manifesting minds: A Review of Psychedelics in Science, Medicine, Sex, and Spirituality

Rick Doblin, PhD, and Brad Burge, Editors

Featuring essays and interviews with Timothy Leary, Aldous Huxley, Ram Dass, Albert Hofmann, Alexander (Sasha) Shulgin, Daniel Pinchbeck, Tim Robbins, Arne Naess, and electronic musician Simon Posford, as well as groundbreaking research and personal accounts, this one-of-a-kind anthology is a "best of" collection of articles and essays published by the Multidisciplinary Association for Psychedelic Studies (MAPS). Topics include the healing use of marijuana and psychedelics--including MDMA, ibogaine, LSD, and ayahuasca--for PTSD, anxiety, depression, and drug addiction, as well as positive effects of these substances in the realm of the arts, family, spirituality, ecology, and technology.

Among many other thought-provoking and mind-opening pieces are the following:
• "On Leary and Drugs at the End," by Carol Rosen and Vicki Marshall
• "Psychedelic Rites of Passage," by Ram Dass
• "To Be Read at the Funeral," by Albert Hofmann
• "Another Green World: Psychedelics and Ecology," by Daniel Pinchbeck
• "Psychedelics and Species Connectedness," by Stanley Krippner, PhD
• "Huxley on Drugs and Creativity," by Aldous Huxley
• "Psychedelics and the Deep Ecology Movement: A Conversation with Arne Naess," by Mark A. Schroll, PhD, and David Rothenberg
• "Psychedelic Sensibility," by Tom Robbins
• "Electronic Music and Psychedelics: An Interview with Simon Posford of Shpongle," by David Jay Brown
• "How Psychedelics Informed My Sex Life and Sex Work," by Annie Sprinkle
• "Consideration of Ayahuasca for the Treatment of Posttraumatic Stress Disorder," by Jessica Nielson, PhD, and Julie Megler, MSN, NP-BC
• "Psychedelics and Extreme Sports," by James Oroc
• "Youth and Entheogens: A Modern Rite of Passage?," by Andrei Foldes with Amba, Eric Johnson, et al.
• "Diary of an MDMA Subject," by Anonymous
• "Dimethyltryptamine: Possible Endogenous Ligand of the Sigma-1 Receptor?," by Adam L. Halberstadt
• "Lessons from Psychedelic Therapy," by Richard Yensen, PhD
• "Psychosomatic Medicine, Psychoneuroimmunology, and Psychedelics," by Ana Maqueda
• "Talking with Ann and Sasha Shulgin about the Existence of God and the Pleasures of Sex and Drugs," by Jon Hanna and Silvia Thyssen

Memory Development from Early Childhood Through Emerging Adulthood

Wolfgang Schneider

Based on decades of established research findings in cognitive and developmental psychology, this volume explores and integrates the leading scientific advances into infancy and brain-memory linkages as well as autobiographical and strategic memory. In addition, given that the predominantly classic research on memory development has recently been complemented by more cutting-edge applied research (e.g., eyewitness memory, memory development in educational contexts) in recent years, this volume also provides in-depth and up-to-date coverage of these emerging areas of study.

Metacognition: Fundaments, Applications, and Trends - A Profile of the Current State-Of-The-Art

Alejandro Peña-Ayala, Editor

This book is devoted to the Metacognition arena. It highlights works that show relevant analysis, reviews, theoretical, and methodological proposals, as well as studies, approaches, applications, and tools that shape current state, define trends and inspire future research. As a result of the revision process fourteen manuscripts were accepted and organized into five parts as follows:

· Conceptual: contains conceptual works oriented to: (1) review models of strategy instruction and tailor a hybrid strategy; (2) unveil second-order judgments and define a method to assess metacognitive judgments; (3) introduces a conceptual model to describe the metacognitive activity as an autopoietic system.

· Framework: offers three works concerned with: (4) stimulate metacognitive skills and self-regulatory functions; (5) evaluate metacognitive skills and self-regulated learning at problem solving; (6) deal with executive management metacognition and strategic knowledge metacognition.

· Studies: reports research related to: (7) uncover how metacognitive awareness of listening strategies bias listening proficiency; (8) unveil how metacognitive skills and motivation are achieved in science informal learning; (9) tackle stress at learning by means of coping strategies.

· Approaches: focus on the following targets: (10) social metacognition to support collaborative problem solving; (11) metacognitive skills to be stimulated in computer supported collaborative learning; (12) metacognitive knowledge and metacognitive experiences are essential for teaching practices. 

· Tools: promotes the use of intelligent tutoring systems such as: (13) BioWorld allows learners to practice medical diagnostic by providing virtual patient cases; (14) MetaHistoReasoning provides examples to learners and inquiries about the causes of historical events.

This volume will be a source of interest for researchers, practitioners, professors, and postgraduate students aimed at updating their knowledge and finding targets for future work in the metacognition arena.

The Myth of Mirror Neurons: The Real Neuroscience of Communication and Cognition

Gregory Hickok, PhD

RECOMMENDED READ.

An essential reconsideration of one of the most far-reaching theories in modern neuroscience and psychology.

In 1992, a group of neuroscientists from Parma, Italy, reported a new class of brain cells discovered in the motor cortex of the macaque monkey. These cells, later dubbed mirror neurons, responded equally well during the monkey’s own motor actions, such as grabbing an object, and while the monkey watched someone else perform similar motor actions. Researchers speculated that the neurons allowed the monkey to understand others by simulating their actions in its own brain. 

Mirror neurons soon jumped species and took human neuroscience and psychology by storm. In the late 1990s theorists showed how the cells provided an elegantly simple new way to explain the evolution of language, the development of human empathy, and the neural foundation of autism. In the years that followed, a stream of scientific studies implicated mirror neurons in everything from schizophrenia and drug abuse to sexual orientation and contagious yawning.

In The Myth of Mirror Neurons, neuroscientist Gregory Hickok reexamines the mirror neuron story and finds that it is built on a tenuous foundation—a pair of codependent assumptions about mirror neuron activity and human understanding. Drawing on a broad range of observations from work on animal behavior, modern neuroimaging, neurological disorders, and more, Hickok argues that the foundational assumptions fall flat in light of the facts. He then explores alternative explanations of mirror neuron function while illuminating crucial questions about human cognition and brain function: Why do humans imitate so prodigiously? How different are the left and right hemispheres of the brain? Why do we have two visual systems? Do we need to be able to talk to understand speech? What’s going wrong in autism? Can humans read minds?

The Myth of Mirror Neurons not only delivers an instructive tale about the course of scientific progress—from discovery to theory to revision—but also provides deep insights into the organization and function of the human brain and the nature of communication and cognition.

Neuronal Dynamics: From Single Neurons to Networks and Models of Cognition

Wulfram Gerstner, Werner M . Kistler, Richard Naud, Liam Paninski

What happens in our brain when we make a decision? What triggers a neuron to send out a signal? What is the neural code? This textbook for advanced undergraduate and beginning graduate students provides a thorough and up-to-date introduction to the fields of computational and theoretical neuroscience. It covers classical topics, including the Hodgkin-Huxley equations and Hopfield model, as well as modern developments in the field such as Generalized Linear Models and decision theory. Concepts are introduced using clear step-by-step explanations suitable for readers with only a basic knowledge of differential equations and probabilities, and are richly illustrated by figures and worked-out examples. End-of-chapter summaries and classroom-tested exercises make the book ideal for courses or for self-study. The authors also give pointers to the literature and an extensive bibliography, which will prove invaluable to readers interested in further study.

The Feeling Body: Affective Science Meets the Enactive Mind

Giovanna Colombetti

RECOMMENDED READ.

In The Feeling Body, Giovanna Colombetti takes ideas from the enactive approach developed over the last twenty years in cognitive science and philosophy of mind and applies them for the first time to affective science -- the study of emotions, moods, and feelings. She argues that enactivism entails a view of cognition as not just embodied but also intrinsically affective, and she elaborates on the implications of this claim for the study of emotion in psychology and neuroscience. 

In the course of her discussion, Colombetti focuses on long-debated issues in affective science, including the notion of basic emotions, the nature of appraisal and its relationship to bodily arousal, the place of bodily feelings in emotion experience, the neurophysiological study of emotion experience, and the bodily nature of our encounters with others. Drawing on enactivist tools such as dynamical systems theory, the notion of the lived body, neurophenomenology, and phenomenological accounts of empathy, Colombetti advances a novel approach to these traditional issues that does justice to their complexity. Doing so, she also expands the enactive approach into a further domain of inquiry, one that has more generally been neglected by the embodied-embedded approach in the philosophy of cognitive science.

The Origins of Attachment: Infant Research and Adult Treatment

Beatrice Beebe and Frank M. Lachmann

Technically, this book came out at the end of 2013, but I am including it anyway because it is a RECOMMENDED READ, especially for therapists (according to me).

The Origins of Attachment: Infant Research and Adult Treatment addresses the origins of attachment in mother-infant face-to-face communication. New patterns of relational disturbance in infancy are described. These aspects of communication are out of conscious awareness. They provide clinicians with new ways of thinking about infancy, and about nonverbal communication in adult treatment.
Utilizing an extraordinarily detailed microanalysis of videotaped mother-infant interactions at 4 months, Beatrice Beebe, Frank Lachmann, and their research collaborators provide a more fine-grained and precise description of the process of attachment transmission. Second-by-second microanalysis operates like a social microscope and reveals more than can be grasped with the naked eye.

The book explores how, alongside linguistic content, the bodily aspect of communication is an essential component of the capacity to communicate and understand emotion. The moment-to-moment self- and interactive processes of relatedness documented in infant research form the bedrock of adult face-to-face communication and provide the background fabric for the verbal narrative in the foreground.


The Origins of Attachment is illustrated throughout with several case vignettes of adult treatment. Discussions by Carolyn Clement, Malcolm Slavin and E. Joyce Klein, Estelle Shane, Alexandra Harrison and Stephen Seligman show how the research can be used by practicing clinicians. This book details aspects of bodily communication between mothers and infants that will provide useful analogies for therapists of adults. It will be essential reading for psychoanalysts, psychotherapists and graduate students.

Collaborators Joseph Jaffe, Sara Markese, Karen A. Buck, Henian Chen, Patricia Cohen, Lorraine Bahrick, Howard Andrews, Stanley Feldstein

Discussants Carolyn Clement, Malcolm Slavin, E. Joyce Klein, Estelle Shane, Alexandra Harrison, Stephen Seligman

The Therapeutic Use of Ayahuasca

Beatriz Caiuby Labate and Clancy Cavnar, Editors

This book also came out at the end of 2013, but it is an important collection of articles on a topic that has been taboo in academic circles for far too long.

This book presents a series of perspectives on the therapeutic potential of the ritual and clinical use of the Amazonian hallucinogenic brew ayahuasca in the treatment and management of various diseases and ailments, especially its role in psychological well-being and substance dependence. Biomedical and anthropological data on the use of ayahuasca for treating depression, PTSD, and substance dependence in different settings, such as indigenous contexts, neo-shamanic rituals, contemporary therapeutic circles, and in ayahuasca religions, in both South and North America, are presented and critiqued. Though multiple anecdotal reports on the therapeutic use of ayahuasca exist, there has been no systematic and dense reflection on the topic thus far. The book brings the therapeutic use of ayahuasca to a new level of public examination and academic debate. The texts in this volume stimulate discussion on methodological, ethical, and political aspects of research and will enhance the development of this emergent field of studies.

Understanding Psychosis and Schizophrenia: Why People Sometimes Hear Voices, Believe Things that Others Find Strange, or Appear Out of Touch with Reality, and What Can Help

Edited by Anne Cooke

A report by the Division of Clinical Psychology (BPS)

RECOMMENDED READ. This is an important new book in that the authors have taken a client-centered, relational perspective on psychosis, one of the most misunderstood and stigmatized psychological adaptations to trauma. And it's FREE to download.

Understanding Psychosis and Schizophrenia: Why people sometimes hear voices, believe things that others find strange, or appear out of touch with reality, and what can help has been written by a group of eminent clinical psychologists drawn from eight universities and six NHS trusts, together with people who have themselves experienced psychosis. 

It provides an accessible overview of the current state of knowledge, and its conclusions have profound implications both for the way we understand ‘mental illness’ and for the future of mental health services. 

Many people believe that schizophrenia is a frightening brain disease that makes people unpredictable and potentially violent, and can only be controlled by medication.  However research conducted over the last 20 years and brought together in this report reveals that this view is false. Rather:

• The problems we think of as ‘psychosis’ – hearing voices, believing things that others find strange, or appearing out of touch with reality – can be understood in the same way as other psychological problems such as anxiety or shyness.
• They are often a reaction to trauma or adversity of some kind which impacts on the way we experience and interpret the world.
• They rarely lead to violence.
• No one can tell for sure what has caused a particular person’s problems. The only way is to sit down with them and try and work it out.
• Services should not insist that people see themselves as ill.  Some prefer to think of their problems as, for example, an aspect of their personality which sometimes gets them into trouble but which they would not want to be without.
• We need to invest much more in prevention by attending to inequality and child maltreatment.  Concentrating resources only on treating existing problems is like mopping the floor while the tap is still running.

I have long felt that psychosis is more adequately understood when it is seen as the most extreme form of dissociation - a need so intense that it is not the body, or emotions, or memories that are dissociated, it is reality itself.

Although it is reality that is dissociated (through delusions, hallucinations, paranoia, and cognitive distortions), it is fundamentally the emotions that are most important in making sense of the psychotic features and in bringing the client back. I have no doubt that meds are important for some, but not everyone benefits from the psychological numbing effects of the atypical antipsychotics.

What my clients have taught me is that the key to recover is to reclaim the body, and with it the emotions that are so painful the person needed to create a different reality, where the client is often a different person, with different origins, and who is much more important in some ways than they ever were in their "normal" life.

This is a free article (until the end of December) from the International Forum of Psychoanalysis in which Lawrence Kirshner offers a psychoanalytic take on psychosis and its roots in trauma (follow the links to read online or download).

Full Citation:
Kirshner, L.A. (2013, Jun 4). Trauma and psychosis: A review and framework for psychoanalytic
understanding. International Forum of Psychoanalysis, DOI: 10.1080/0803706X.2013.778422

Trauma and psychosis: A review and framework for psychoanalytic understanding

Lewis A. Kirshner

• Published online: 04 Jun 2013

Abstract

Empirical research substantiates Ferenczi's conception of the etiological importance of early neglect and abuse in the development of psychosis. Abuse can derail the development of language, identity, and social relationships that are intrinsic to schizophrenia, possibly through undermining secure attachment relationships. The Lacanian emphasis on language and early proto-dialogues with the Other can be useful in understanding this process. Some therapeutic implications for psychoanalytic approaches to the treatment of psychosis are proposed.

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 Here is a bit from a section further down in the article.

Development of language, the symbolic, and attachment

 

To understand how trauma and neglect may result in schizophrenic disorders, we need to connect the typical deficits and symptoms of psychosis with developmental processes. The importance of access to language seems a promising avenue, as positive symptoms in schizophrenia are only identified and reported as speech or thoughts, and the ability to use relationships with others to modulate traumatic experience or to act as a barrier to it depends on the use of semiotic functions. Within psychoanalysis, Lacan was perhaps the most important theorist to hypothesize an inability to use language as the source of psychotic symptoms, notably as the basis for hallucinations and delusions, which are language-dependent entities (see Sauvagnat, 2003, and Vanheule, 2011, for discussions of this model). Of course, the concept of a thought disorder (in fact, a speech disorder) has been a basic feature of schizophrenia since Bleuler's work, and, recalling Crow's hypotheses, subjectivity depending on speech may be our key species characteristic, closely related to important developmental concepts such as theory of mind and intersubjectivity that have also been linked to schizophrenia (Lysaker, Outcault, & Ringer, 2010).

 

And this is from a later section.

 

Treatment issues

 

Research by Karon and Bos (cited in Ver Eecke, 2003) found that experienced clinicians were more successful with schizophrenic inpatients, especially over longer time periods. One explanation for this result may be the greater ability of experienced therapists to build a relationship with psychotic patients, which can take a long time. In general psychiatry, there is a growing recognition that individually designed approaches to treatment can be quite helpful (Mojtibai et al., 1998; Shean, 2009), suggesting the uniqueness of each therapeutic couple's construction of basic communication links. The difficulty of building alliance and trust with psychotic subjects has been emphasized by many psychoanalytic practitioners and suggests why the application of classic forms of analytic treatment may be misguided.

 

The focus of psychoanalysis on the individual subject, however, does provide the cornerstone of a psychotherapeutic approach, although the techniques of treatment may be far from traditional models (e.g., Abensour, 2008; Benedetti, 2011; Lucas, 2009). The psychotic is a person, a subject like anyone, but his subjectivity may take unusual and cryptic forms that can discourage clinicians from pursuing a treatment relationship. Lacan (1993) wrote in a late seminar about helping psychotics to ground their subjectivity through creative processes, making something new that establishes their identity through an object. In a similar approach, Abensour (2011) described how creative writing served as a kind of anchor in reality for many of her patients who suffered from the dilemma of a floating self, disconnected from the body, a past history, and relationships with others. Creative products acquire a real existence in time (like the transitional object) that can confirm the continuity of the subject and express its inner states.

TED Talk Playlist: All Kinds of Minds (9 Talks)

This is a cool collection of TED Talks entitled, "All kinds of minds." These nine talks "shatter" common beliefs and stereotypes about mental illness, or more accurately, neurodiversity.

Playlist(9 talks): All kinds of minds

These powerful stories shatter preconceived notions about mental illness, and pose the provocative question: What can the world learn from different kinds of minds? 

Playlist (9 talks)


14:52 - Elyn Saks A tale of mental illness -- from the inside
"Is it okay if I totally trash your office?" It's a question Elyn Saks once asked her doctor, and it wasn't a joke. A legal scholar, in 2007 Saks came forward with her own story of schizophrenia, controlled by drugs and therapy but ever-present. In this powerful talk, she asks us to see people with mental illness clearly, honestly and compassionately.


19:43 - Temple Grandin The world needs all kinds of minds
Temple Grandin, diagnosed with autism as a child, talks about how her mind works — sharing her ability to "think in pictures," which helps her solve problems that neurotypical brains might miss. She makes the case that the world needs people on the autism spectrum: visual thinkers, pattern thinkers, verbal thinkers, and all kinds of smart geeky kids.


14:17 - Eleanor Longden The voices in my head
To all appearances, Eleanor Longden was just like every other student, heading to college full of promise and without a care in the world. That was until the voices in her head started talking. Initially innocuous, these internal narrators became increasingly antagonistic and dictatorial, turning her life into a living nightmare. Diagnosed with schizophrenia, hospitalized, drugged, Longden was discarded by a system that didn't know how to help her. Longden tells the moving tale of her years-long journey back to mental health, and makes the case that it was through learning to listen to her voices that she was able to survive.


8:44 - Ruby Wax What's so funny about mental illness?
Diseases of the body garner sympathy, says comedian Ruby Wax — except those of the brain. Why is that? With dazzling energy and humor, Wax, diagnosed a decade ago with clinical depression, urges us to put an end to the stigma of mental illness.


22:18 - Sherwin Nuland How electroshock therapy changed me
Surgeon and author Sherwin Nuland discusses the development of electroshock therapy as a cure for severe, life-threatening depression — including his own. It’s a moving and heartfelt talk about relief, redemption and second chances.


5:51 - Joshua Walters On being just crazy enough
At TED's Full Spectrum Auditions, comedian Joshua Walters, who's bipolar, walks the line between mental illness and mental "skillness." In this funny, thought-provoking talk, he asks: What's the right balance between medicating craziness away and riding the manic edge of creativity and drive?


18:01 - Jon Ronson Strange answers to the psychopath test
Is there a definitive line that divides crazy from sane? With a hair-raising delivery, Jon Ronson, author of The Psychopath Test, illuminates the gray areas between the two. (With live-mixed sound by Julian Treasure and animation by Evan Grant.)


18:48 - Oliver Sacks What hallucination reveals about our minds
Neurologist and author Oliver Sacks brings our attention to Charles Bonnet syndrome — when visually impaired people experience lucid hallucinations. He describes the experiences of his patients in heartwarming detail and walks us through the biology of this under-reported phenomenon.


9:26 - Robert Gupta Music is medicine, music is sanity
Robert Gupta, violinist with the LA Philharmonic, talks about a violin lesson he once gave to a brilliant, schizophrenic musician — and what he learned. Called back onstage later, Gupta plays his own transcription of the prelude from Bach's Cello Suite No. 1.

From The New Republic, author and psychologist Martha Stout (The Sociopath Next Door, The Myth of Sanity, The Paranoia Switch) reviews the new book from brothers Joel and Ian Gold, Suspicious Minds: How Culture Shapes Madness.

This looks like an excellent and important book - we too often neglect the cultural context of "madness."

Is Modern Culture Making Us Crazier?

The science behind America's deepening disturbance

By Martha Stout
July 31, 2014 | The New Republic

A young friend recently shared with me her experience of being stopped by the police on an otherwise uneventful Tuesday morning. With one arm protectively wrapped around her shoulder bag because it had a broken latch, she’d been walking along a city street. Unbeknownst to her at the time, a shooting had occurred the previous day in the same neighborhood. Three police officers, two male and one female, approached her. They demanded to know whether she had a gun under her arm, took her bag from her, and looked inside. No gun. They checked her identification. No record. (As far as I know, this young woman hasn’t so much as a traffic ticket.) She was completely cooperative throughout.

The female officer then patted her down, which my friend said she tolerated by deliberately becoming a little dissociative—“spacing out”—until the stranger’s hands finally finished their journey over her body. Then, though there was no gun in it, the two male officers decided to search her shoulder bag again, item by item. Riffling through her wallet, they found a condom, and that discovery grabbed their attention.

“Oh look. We’ve got a young slut here,” said one, waving the condom. All three officers laughed.

My friend, very scared by now, said nothing.

Finally, they let her go. As she walked away, the female officer called after her, “Guess you came here ready to fuck anyone you wanted to, didn’t you?”

I find this officer’s parting salvo grimacingly ironic.

These days, mind-spinning stories of misogyny assail us from all over our country, and indeed, this account is hardly the worst. But knowing the victim personally, and understanding that she will carry the hateful essence of this ridicule with her for a long time to come, I was especially saddened. And for me, one of the most disheartening features of this incident was the fact that the young woman who endured it was not even taken aback. Far from being shocked and outraged, she was not even surprised. When I asked her about her reaction, she explained, “I was very upset, but no, I wasn’t surprised. If you walk around alone, you kind of expect this sort of thing to happen. It’s really only a matter of time.”

Is this frightening belief about the world a symptom of paranoia on her part? And, as the old saw goes, are you paranoid when they’re really out to get you? Most of her twenty-something years have been spent in a nation beset by furious cultural and political forces on a course to push back the legal standing and social status of women by half a century. As but two illustrations, there are Supreme Court actions such as the recent Hobby Lobby ruling and state-level abortion-restriction laws that are designed to make certain of women’s medical procedures as costly and humiliating as possible.

How much of an influence has the traumatized and reactive culture of a post-September 11 United States had on the mental status of this young citizen—and for that matter, on the mental status of the police officers who bullied her? And in general, how much, and in what ways, do events in the wider world affect our individual personalities? Societal factors clearly influence our observable behavior—what we will and won’t do in public on a day-to-day basis—but can societal, cultural, political, and even technological factors soak into our very psyches, infiltrate our inner cores and make lasting changes to who we are? This is a fascinating and in some cases alarming question, and is the basis of Joel and Ian Gold’s book, Suspicious Minds: How Culture Shapes Madness.

Suspicious Minds: How Culture Shapes Madness,
by Joel Gold and Ian Gold. Free Press.

Joel Gold, MD, Clinical Associate Professor of Psychiatry at the NYU School of Medicine, and his brother, Ian Gold, Ph.D., Associate Professor of Philosophy and Psychiatry at McGill University, discuss a number of psychotic patients who all have the same delusion—that the people in their lives are acting out a script, much like the family and friends of Jim Carrey’s character in the 1998 movie, The Truman Show. Juxtaposing recent research on schizophrenia with page-turning case studies of these paranoid patients, the Golds argue that psychotic delusions (not to mention mesmeric movie plots) are the result of interactions between the brain and the sociocultural world, and they bring to light the discipline-altering fact that culture has a role to play in the development of psychopathology generally.

If you happen not to be a psychiatrist or a psychologist, you might reasonably imagine that mental health professionals have written many other books on this crucial and intriguing question: Can zeitgeist have an enduring negative effect on the individual psyche? But the startling fact is that most of the relevant scholarly writings by psychopathologists are quite new (post-2001), and discussions for nonprofessionals are rare. Over the past 40 years or so, psychology has attempted to divvy up the causes of pathological conditions between two now-famous categories, “nature” (as transmitted genetically) and “nurture” (environmental influences). For various psychopathologies, including paranoid schizophrenia, and also normal “personality traits” (introversion/extraversion, conservatism/liberalism, rigidity/adaptability, and several dozen more), research has yielded remarkably consistent results, indicating that these differences among human beings are accounted for by genetic and environmental factors in more or less equal measure, with genetics sometimes edging out environment by a point or two (51 versus 49 percent, in some instances). This research has been indispensable to our growing appreciation of the role of genetics both in normal personality and in the mental illnesses.

Contrastingly, our conception of environmental influences has been biased and narrow. We have tended to think of “nurture” only in the familial sense: In mental health research, “environment” tends to mean child-rearing factors, which is to say the personalities and actions of parents and, to a lesser degree, siblings. That an individual’s personality or mental illness might be affected by environmental factors outside the home has been largely overlooked. Take the study of sociopathy, which is another profound form of psychopathology—this one characterized not by delusions but by the complete absence of conscience. Research indicates that the factors involved in sociopathy, like those in many other mental illnesses, are about 50 percent genetic and 50 percent environmental. But researchers have been perplexed because they have been unable to find specific child-rearing variables that would consistently account for the environment’s half in cultivating sociopaths. I maintain (in my book The Sociopath Next Door) that this half consists primarily of larger societal factors, and this idea would seem to be supported by the fact that the incidence of diagnosed sociopathy is significantly lower in certain East Asian countries (most notably Taiwan and Japan) than in North America. It seems likely that, in the United States especially, any genetic predisposition to sociopathy will be nurtured and shaped by a single-mindedly competitive and individualistic culture that regards “winning” and domination as the ultimate goods.

Why have psychologists who study pathology tried to divide up the causality universe between inborn tendencies and the family environment, and turned a mostly blind eye to influences from the wider world? One answer is that a cultural hypothesis frustrates prevention: Though correcting the child-rearing practices of a large group of people would be a tall order, setting out to alter the entrenched belief systems of an entire society is even more daunting and might eventually involve taking a political stance, something many clinical psychologists and psychiatrists are loathe to do.

Gold and Gold make it clear that psychiatry is dispensing with the possibility of cultural factors in mental disorder even more summarily than psychology has done. They write, “The social world is at the heart of our theory of delusions, and this puts us at odds with much of mainstream psychiatry.” Mental illness, they explain, “at least severe mental illness—is nothing more than genetic and neural dysfunction,” according to psychiatric dogma. They point to the large and growing number of psychiatrists who aspire to understand and treat mental disorders as brain disorders, and convincingly illuminate the losses that psychiatry may suffer on account of this new reductionism.

The central argument in Suspicious Minds derives from the increasingly accepted “social brain hypothesis,” the idea that the primary function of enlarged primate (and therefore human) brains is to deal with the cognitive challenges of living in groups. In reference to paranoid disorders in particular, Gold and Gold ask the question—“What sort of cognitive system is required to enable one to be sensitive to social threats?” In answer, they propose that the human brain contains an adaptive “Suspicion System,” which is “the solution that evolution came up with to enable us to pick up evidence of infidelity and other social threats for the purpose of early detection and defense.” In other words, courtesy of natural selection, we are all biologically prepared to be leery. They hypothesize that a healthy Suspicion System makes social life safer through “heightened responses to subtle, uncertain, and ambiguous signs of social danger,” but that a malfunctioning or overloaded Suspicion System “will sound the alarm without good reason and detect evidence poorly—that is, see malign intent where there is none.” Over time, an overreactive Suspicion System may inaugurate “an idiosyncratic belief that is firmly maintained despite rational argument or evidence to the contrary”—i.e., a paranoid delusion. The authors point out that the persecutory delusions of clinical paranoia are by far the most prevalent form of delusion the world over.



Paramount Pictures
The delusions of psychotic patients—that their lives are scripted, and that their friends are mere actors—recall the plot of The Truman Show.

Gold and Gold conclude that the “Truman Show delusions” of their paranoid patients express those patients’ fears of being controlled by what other people know about them: “Truman Show is a delusion of control in the age of surveillance.” They declare, “Reductionism in psychiatry constrains theory to operate within the skull or the skin. Our bet is that the outside world is going to matter as well.”

Suspicious Minds is a contrarian, insightful, and important book. Gold and Gold do not take on the more politically involved and incendiary aspects of our society, such as run-amok individualism—or the abuse of power and the national upsurge in misogyny that plagued my young friend on that demoralizing Tuesday morning. Nonetheless, their analysis of culture-linked paranoia comprises an effective argument that our seemingly endless struggle to align our society with our more enlightened ideals may be a fight for our very minds.


~ Martha Stout, Ph.D., is the author of The Myth of Sanity: Divided Consciousness and the Promise of Awareness, The Paranoia Switch: How Terror Rewires Our Brains and Reshapes Our Behavior--and How We Can Reclaim Our Courage, The Sociopath Next Door, and an upcoming book, The Sociopath Files.

Ann Reitan - Psychotherapy for Paranoid Schizophrenia

Interesting that this was posted today. A friend on Facebook who is in school to become a psychotherapist asked about the difference between how schizophrenia is viewed in France (where he is) and in America, and whether or not it can be cured. In France schizophrenia is an issue that can be treated successfully with psychotherapy; in America it is a chronic illness likely to last for the remainder of one's life.

I left this comment (edited for privacy and for clarity, because, you know, Facebook):

A BIG pile of research has shown that schizophrenia is a chronic illness in the U.S., but it often lasts less than 10-15 years in other parts of the world, meaning it can be cured.

I think there are two reasons for this: (1) the medications we administer here don't allow the person to go through the experience and heal, (2) U.S. culture defines schizophrenia as a chronic disease, which shapes how it is experienced, while other parts of the world see it much differently, sometimes as a calling to be a healer (Mircea Eliade noted this among various shamanic cultures).

Research suggests that 70-80% of those with schizophrenia have clear trauma histories (for schizophrenia, neglect and/or emotional abandonment are the most common antecedent traumas). There are other factors as well, including failed attachment, exposure to toxins in utero, hormonal irregularities, and so on.

In my opinion, the majority of psychoses are more clearly conceptualized as extreme dissociation - not dissociating from thoughts, or feelings, or ego states, or memories, but dissociating from one's life in whole. In this model, life becomes so intolerable for the individual that s/he dissociates from their actual life and into an unconsciously generated reality where they might have a different identity, a different family, where they might become so important (compensating for feeling entirely worthless) that their thoughts and actions are being monitored and recorded.

The key to healing this split, in my opinion, is getting the client to feel the feelings of pain and loss that made life so unbearable. In psychoses, the affect of the individual is flat or blunted and there is no expression of affective states (in general, not always).

The article below suggests some other strategies based in cognitive-relational psychotherapy, in other words, CBT with the therapist showing empathy and communicating his or her subjective experience.

Psychotherapy for Paranoid Schizophrenia

by Ann Reitan, PsyD | October 27, 2014

Often psychotherapy is not considered to be effective with individuals dealing with schizophrenia spectrum disorders. But a cognitive-relational psychotherapy approach helps form a warm, trusting and detached relationship, conveys an understanding and concern for one’s client, and involves the therapist telling that individual their own empathic views about what that individual is dealing with.

Often clinicians assume that psychotherapy does not work well with persons manifesting what are called “thought disorders” – conceived to be irrational, unrealistic and factually inaccurate. Again, clinicians fail to understand, empathically, the circumstances of the psychotic individual. It should be noted that schizophrenics deal with non-normative experience that, in terms of hallucinations, is visceral in nature. This experience entrenches them in delusions based on hallucinations that are highly convincing.

One idea that may help schizophrenics is reflected in this line from a poem I wrote: “May you walk beyond the empty sudden blindness of existence.” To schizophrenics in crisis and even those not in crisis, the future may seem to be extremely uncertain and perhaps treacherous. They may perceive both the mental and the material worlds as incredibly dangerous. And in many ways, they are dangerous, due to the amount of suffering experienced by the paranoid schizophrenic that seems to her to be inflicted on her by these worlds.

No knowledge about knowledge

A non-epistemological stance regarding no knowledge about knowledge may help a schizophrenic replace her delusions. Essentially, the non-epistemological view represents deconstruction of knowledge with an assertion that relies on the fact that all “knowledge” is subjective. While schizophrenics have subjective views regarding their own knowledge, and although this may be communicated to them, they may be able to understand, in a similar sense, that nobody really has any kind of certain knowledge.

In terms of non-epistemology, it may not be possible to live in the world on these terms. Moreover, it may not be possible to tolerate an awareness that anything may happen to us at any time that will catapult us into crisis. The sudden death of a loved one may be an example of this.

Typically, we reside in faith that things will go normally and as planned, and they generally do so. However, the schizophrenic lacks such faith. If the therapist can communicate to the schizophrenic that she should try to get as comfortable as possible with simply “not knowing,” this may help the schizophrenic. There is a basis for “not knowing” that corresponds to everyone’s subjective experiences of the world, and this is reflected in all individuals’ perspectives on the mental and the material worlds. Realistically, it might be more threatening to the schizophrenic to “not know”, as opposed to clasping her delusional beliefs.

In terms of addressing the idea of “not knowing” with the paranoid schizophrenic, the psychotherapist may say the following: “Nobody knows what the future may bring. If you buy a lottery ticket, even if the chances are small, you may win the lottery. If you have sex, even with birth control, you may become a parent. Most events in are life happen by chance. You don’t really know what will happen, even if you fear with certainty that bad things will happen to you. Your condition of schizophrenia really causes you to suffer mostly because of your fear of bad things happening to you, rather than these things actually happening to you. Maybe the thing you should fear in your life is the fear itself. By realizing that you do not know what the future will bring, you may feel safer.”

Context matters?

Another aspect of dealing with schizophrenia is encompassed in the idea, stated by Ralph Ellison in The Invisible Man: “If you don’t know where you are, you don’t know who you are.”

This statement implies that one needs to know her context in order to know her self and her identity. Often schizophrenics fail to know their contexts. They have confused and distorted ideas about context, based on the fact that their contexts, in their minds as well as in the material world, may reflect delusions and hallucinations. This leads to ambiguity as perceived by the schizophrenic in her mental and material environments as threatening, simply because the schizophrenic may be dealing with non-normative experience.

The clinician may convey to the schizophrenic the idea of not knowing her context by stating: “It’s hard to know what you think of yourself when you don’t really know what you are dealing with in the world. This may be what causes you to be afraid of the world. And this means that you are afraid of both your voices in your mind, (for example), and the people outside in the world.”

The schizophrenic may adhere to her delusional beliefs due to the fact that she, as well as virtually everyone else in the world, thinks that knowing one’s context allows them to be safer than they would be if they did not “know what they know”, even when “knowing what they know” may be delusional. Again, the assertion that the client does not really know what her worlds signify can replace delusional ideas.

One way of communicating this idea to a paranoid schizophrenic would be constituted by saying: “You might think that being a schizophrenic makes people prejudiced towards you, and it may, but also the world we live in makes you into a schizophrenic. Your context in the world – and how the world views you – may be determined by the situation that you are in. You may believe that this is false, that you really know more than other people about the world, but you still do not know what you are in the world, perhaps because believing you are schizophrenic may be unacceptable and may not make sense to you. Nevertheless, you do not know for certain what the world is. That is why it is scary. And you don’t know who and what you really are, because you may believe one thing and others believe differently.”

Treating life as normal

Another idea for dealing with hallucinations and delusions stems from a novel by Carrie Fisher, Postcards from the Edge, which states the idea that: “Perhaps if we treat life as normal, a sense of normalcy will follow.”

This idea is highly salient to dealing with one’s hallucinations and delusions. The schizophrenic may be perhaps traumatized by her experience, but treating life as normal may lead to a gradually acquired feeling of safety.

The idea embedded in this statement from Fisher reflects the advantages of the act of challenging the delusions of a schizophrenic by the schizophrenic. Living one’s life normally in terms of habits and faith in the normative view of reality may allow the schizophrenic to experience the decay of her fears, her paranoia and her delusions. Not obsessing about one’s hallucinations and delusions, by trusting life to proceed normally, combats the punitive experience of schizophrenia and paranoid schizophrenia, in particular.

It should be noted that the ideas contained within this article represent an intellectualized framework of how the clinician or the psychotherapist may approach therapy with a paranoid schizophrenic. They may also be applicable to those who are high functioning, but may be suffering to an extreme extent.

A belief in the scientific bases for the effectiveness of psychiatric medications may be a belief that can be cultivated or even spontaneously adhered to by the schizophrenic. Nevertheless, non-normative experience may lead to non-normative thought, and the deep communication by an empathic therapist who is able to accurately imagine and recapitulate to the schizophrenic what she is dealing with may be in some sense curative.

I have applied these ideas to psychotherapy with paranoid schizophrenics with some success. One client, a paranoid schizophrenic, was struck by the idea that “if you don’t know where you are, you don’t know who you are.” She asked for a restatement of that idea based upon the connection she had established with it. Another schizophrenic stated humorously that he wanted to write a book entitled, The Fallacy of Truth.” He was able to understand a non-epistemological stance. Lastly, one client tried diligently to treat her life as normal and routine even though she was hyper-vigilant and paranoid. The trauma that she experienced precluded her from entirely benefiting from this perspective, but she became extremely high functioning.

Overall, these ideas for psychotherapy, from a cognitive relational perspective, may be of some help to some people, especially paranoid schizophrenics. However, it should be noted that the different types of schizophrenia may correspond with different interventions and treatment.

Image via Diez Artwork / Shutterstock.