Slowing Psychiatry: Would That Improve Treatment?

The next ISPS-US online meeting/webinar will be titled “Slow Psychiatry: A Way forward” with Sandra Steingard, M.D. presenting her perspective and then answering questions and participating in discussion. This will occur on Monday May 23 2016, 4:20 PM EDT

In this meeting, Dr. Steingard will discuss the problems that have arisen from an overly medicalized approach to conceptualizing what falls under the label of psychiatric conditions. She will then propose a model in which psychiatry continues to assume an expert role in the use of psychoactive drugs but does so in a drug-centered rather than a disease-centered way. She will explain the distinction between these approaches. She will then discuss need-adapted approaches and will outline how psychiatry, using a drug-centered model, can work with people in distress, their families, and other clinicians in a more humane and democratic way.

There will be time for questions and discussion, including looking at how these ideas might be applied in specific practice situations.

Sandra Steingard, M.D. is Chief Medical Officer, Howard Center, Burlington, Vermont and Clinical Associate Professor of Psychiatry at the University Of Vermont College of Medicine. For over 20 years her clinical practice has primarily included patients diagnosed with schizophrenia and other psychotic illnesses. She was a local principal investigator at a NAVIGATE site for the NIMH sponsored Recovery After an Initial Schizophrenia Episode (RAISE) Early Treatment Program, she studied for two years at the Institute for Dialogic Practice in Northampton, Massachusetts, and she worked for nine months as a consulting psychiatrist to Pathways Soteria Vermont.

She is on the Boards of the Foundation for Excellence in Mental Health Care and Mad In America Continuing Education. She is also on the board of National Alliance of Mentally Ill – Vermont from whom she received an Exemplary Psychiatrist Award in 1996. She was named to Best Doctors in America in 2003. She recently helped to create the Critical Psychiatry Network – North America. She writes a blog called Anatomy of a Psychiatrist on the website “Mad in America Science Psychiatry and Community”, www.madinamerica.com.

If you would like to read up on her ideas in advance of the meeting, you can check out Slow Psychiatry: Integrating Need-Adapted Approaches with Drug-Centered Pharmacology or other posts at Mad in America

ISPS-US online meetings are free to ISPS members, with a donation of $5-$20 requested from others, though no one turned away for lack of funds. Please do register if you want to attend!

These meetings are recorded and shared on the ISPS website for later viewing.

To register, go to https://slowpsychiatry.eventbrite.com

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Getting Back to Dialogue – The Core of Healing!

When people are “mad,” they are often insisting that certain things are so, and frequently seem unwilling or incapable of appreciating or learning from other perspectives.  Yet when the supposedly “sane” mental health system approaches those who are mad, it typically does the same thing – it insists that its own view of what’s going on is correct, and seems incapable of appreciating or learning from others, whether they be the patient, the family, former users of services, or anyone who understands madness in a different way.

So what’s going on with that?

One way of understanding it is to reflect on the very human tendency to narrow one’s perspective when feeling threatened.  When people feel threatened, they tend to narrow their focus down to what they believe may avert the threat, and to shut out other perspectives that seem “wrong,” or that could lead to doom.

That works fine when the threat is relatively straightforward, and a solution can be arrived at which reduces the sense of threat.

But what about when it can’t?

When individuals are facing situations where there seems to be a dire need to solve a problem, yet no solution nor path toward such a solution is apparent, the person naturally enters into a state of conflict.  On the one hand there is above mentioned drive to narrow attention in response to the threat, but on the other hand, there is a drive to expand awareness and experiment with unusual ways of looking at things, so as to possibly find a pathway to a solution that otherwise appears impossible.

It may be that it is the collision between the two tendencies, the narrowing of attention to focus on threat, contrasting and conflicting with the expansion of awareness while seeking to control what otherwise appears uncontrollable, that is responsible for the wild states we call psychosis, or madness.

So we see people who seem creative in some ways, often coming up with very imaginative interpretations of reality, yet who also seem very unimaginative and closed minded when it comes to seeing any down side in their point of view or being able to follow how and why others see things differently, or seeing how to negotiate in a world where others do see things so differently.

Those who are “mad” can then seem difficult to communicate with – their attention seems narrowed and entrenched in their point of view.  We might say they are stuck in “monological thinking” and have difficulty with dialogue, with really appreciating and reflecting on the views of others and learning from them.

Unfortunately, these difficulties can be so intense that those around the “mad” person typically enter into their own kind of threat response, and narrow their own attention, and become stuck in their own “monological thinking” in an attempt to cope.

In the monologue of the traditional mental health system, a “solution” for the problem of madness is outlined.  The mad person is simply experiencing an illness, one that has a name and a clear treatment plan, organized around attempts to suppress that “illness.”

The great thing about having this sense of a “clear path forward” is that it helps professionals and those around the mad person not feel mad themselves.  That is, rather than feel there is a problem that urgently needs solved yet for which there is no identified path forward (the bind that could lead to madness), it is now possible to feel there definitely is a path forward – just narrow down one’s thinking and doing to the medical style approach, and no doubt or further reflection or inner conflict is required!

But now we really have two clashing and very imperfect monologues – that of the “mad “person, and that of the mental health system and those persuaded by it.  And what happens when two fixed views confront each other?  Research shows the tendency is for people who feel confronted to dig in and get more entrenched in their views – and the possibility of dialogue, of reaching across the divide, and of healing, becomes more remote.

But fortunately, there are better approaches!  They are less simple, and involve deliberately accepting uncertainty, and taking some risks, while also attending to safety concerns.  These methods emphasize dialogue, and fight back against that tendency for narrow thinking in response to threat.  Instead they embody a wisdom that recognizes we all best face complex issues when we are willing to be wide and open enough to hear all the voices, and that “sanity” is most likely to emerge through this sort of dialogical process, when it takes place not just within the “mad” person but also within the social network and treatment team.

The Hearing Voices Network makes really important strides in this direction – emphasizing for example changing relationships with voices rather than defining them as illness or suppressing them.  There are now some forms of psychological therapy for “psychosis,” such as the style of CBT for psychosis that I teach (online as well as live) which emphasize relating in a dialogical way.  But it is Open Dialogue, and the dialogical practices it has inspired, which have uniquely framed mental health work as being fundamentally about encouraging dialogue, and which often achieve amazing results just by aiming to support dialogue on all levels.

I’m inspired to write about this now because I’m publicizing an “online meeting” or webinar with Mary Olson, titled “Introduction to Dialogic Practice.”  This could be a great opportunity for some of you to hear “live” from one of the experts in the field about how these practices work, and to get some of your questions answered.

This online meeting happens on Friday 3/25/16, noon EDT.  Here’s more details, and the registration link:

Dialogic Practice emphasizes listening and responding to the whole person in a context – rather than simply treating his or her symptoms. In psychiatric settings, this is accomplished primarily through a treatment meeting, or Open DialogueArising from the influence of the philosophical writings of Mikhail Bakhtin on systemic family therapy, Dialogic Practice can also be effectively applied to more ordinary couple, group, and family therapy, as well as community work in schools.

This conversation, or dialogue, is not “about” the person, but is instead a way of “being with” the person and living through the situation together. Referred to as “Withness Practices” by Tom Anderson, M.D., this process mitigates the sense of isolation and distance that a crisis can produce and gives the person at the center of the dialogue greater voice and agency. Ultimately, this allows them to participate more meaningfully in both the conversation and the resulting decisions about their own lives.

After eliciting the person’s point of view at the meeting outset, there is typically a back-and-forth exchange between this person and the therapists both to develop a more lucid way of expressing the situation and to create a shared language.  The voice of each participant is then woven into this conversation to create a new fabric of meaning and engagement to which everyone contributes.

In this online meeting, Mary Olson will help us understand more about what Dialogic Practice is and isn’t, what it requires, and what it looks like in action.  (Those interested in learning Dialogic Practice in some depth might consider attending the Introductory Intensive in Dialogic Practice which happens May 25-29 in NYC.)

Mary Olson, PhD is an internationally-recognized leader in the development of Dialogic Practice.  She is the founder of the Institute for Dialogic Practice in Haydenville, MA and is a faculty member of both UMass Medical School and the Smith College School for Social Work.  She has written numerous articles and book chapters on Dialogic Practice, including “The Key Elements of Dialogic Practice in Open Dialogue” (2014, with Jaakko Seikkula & Doug Ziedonis), and maintains a private practice in Western Massachusetts.

ISPS-US online meetings are free to ISPS members, with a donation of $5-$20 requested from others, though no one turned away for lack of funds. Please do register if you want to attend!

These meetings are recorded and shared on the ISPS website for later viewing.

Use this link to register:  I hope to see some of you there!

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“Schizophrenia Breakthrough” – Or a Case of Ignoring the Most Important Evidence?

Last week, the headlines were blaring: Schizophrenia breakthrough as genetic study reveals link to brain changes!  We heard that our best hope for treating “schizophrenia” is to understand it at a genetic level, and that this new breakthrough was now getting us really started on that mission, as it showed how a genetic variation could lead to the more intense pruning of brain connections which is often seen in those diagnosed with schizophrenia.  We were told that this study was very important.  “For the first time, the origin of schizophrenia is no longer a complete black box” was one quote.  And the acting director of the National Institute of Mental Health (NIMH) described the study as  “a crucial turning point in the fight against mental illness”.

But is all this hype justified?

A “back story” to this article is that the NIMH has a long history of bias toward biological approaches to understanding mental and emotional difficulties, with an accompanying tendency to ignore even the most obvious evidence that these difficulties often relate to problems in living experienced by people.  For example, even though numerous studies confirm that adverse childhood experiences make a later diagnosis of schizophrenia much more likely (more so than do any particular genes), the NIMH, on a website about the possible causes of schizophrenia, claims it’s “unknown” what kind of psychosocial factors might contribute to putting people at risk.

But it really isn’t a mystery.  To people like NYU professor Brian Koehler who have been following both the biological and the psycho-social research for decades, it’s clear that the real story is that the biological differences we often see in people diagnosed with disorders like “schizophrenia” are often the result of stressful life events, not something that requires specific genes (even though it may be true that some genetic variations increase vulnerability to some limited degree.)

Below (with his permission) I am quoting a recent email from Brian Koehler, where he shared some of what we would be hearing from the media if the medio were being given the whole story.  (His writing will make more sense to you if you understand that microglia are the type of brain cells active in the synaptic pruning that was being discussed, though only in reference to possible genetic causes, in the articles about the recent “breakthrough”…..)

In the late 1970s & early 1980s, as a result of some biochemical research I was conducting and my work in psychotherapy with people on an inpatient unit of a NYC hospital, I became very interested in the pervasive effects of chronic and significant anxiety on our brain and body. I partly made it my life’s work to study and demonstrate that the neuroscience of what we call “schizophrenia” (a highly problematic term) is in actuality, and often in many persons, the neuroscience of severe, chronic stress/anxiety/fear. I am grateful for the opportunity to be educated on the neuroscience of psychosis and stress at such places as the Nathan Klein Institute of Psychiatric Research (NKI), which is managed by the NYS Office of Mental Health and maintains a strong academic collaboration with New York University.

I quickly observed in the persons I was working with on inpatient and outpatient settings, that the content of what we call “delusions” and voices, are re-traumatizing to the person experiencing them. Not only may they be attempts at “cure” or “restitution” (as Freud thought), but they may create significant distress for many persons experiencing them, especially if they feel not in control of aversive threats, accusations, danger situations such as social exclusion, etc. Psychological and social traumas, I quickly learned in the 1970s and 1980s, were prevalent in the histories of many of the persons I was working with. Surviving survival of various social and psychological traumas also played a role in the neurobiological and immunological changes we were observing (even in persons who had not yet started taking antipsychotics, which we now know can cause neural atrophy, mostly subtle, but atrophy nevertheless). In the 1990s, I learned of transgenerational transmission of traumas (specifically, the transmission through epigenetic channels of inducible defences against threats to survival) first in plants, then insects and then in mammals. Since 1990 I have checked on every single finding in the neuroscience of “schizophrenia” and have cross-checked with the emerging literature (thanks to sMRIs, fMRIs, PET, etc.) on the neuroscience of chronic stress. To this day, I still have not found one single specific neuroscience finding in “schizophrenia.” The findings are mostly non-specific (I am leaving the door open, in the name of science, for specific findings). When one is emotionally and intellectually invested in a particular belief, it is important to look even more intensively at the evidence that disconfirms one’s belief and to strive for intellectual and emotional honesty. I admire the current Dalai Lama for when he was asked if science definitely disproved reincarnation, what would he believe? He said, he would give up his belief in reincarnation!

The latest findings in the neuroscience of psychosis have included the role of microglia and neuroinflammatory processes. (e.g., “Microglial activation and the onset of psychosis” by Tyrone Cannon, published in the American Journal of Psychiatry, January 2016). Microglial cells, are glial cells (which are at least as plentiful as neurons in the brain, of which there are close to 100 billion with trillions of connections with other neurons-the connectome) are innate immune cells of the brain. They have a role in the regulation of the extracellular milieu and they participate in neuronal regeneration. They respond quickly to injury and produce a wide variety of pro-inflammatory molecules, neurotrophic factors, and neurotransmitters. Microglial cells can be activated by several factors including systemic infection, physical trauma, oxygen and energy depletion, and some neurodegenerative disorders.

Stress definitely activates the microglia-and this has been known for quite some time. I am no longer surprised when persons researching “schizophrenia” present their findings without checking the research on such important factors as social adversities and chronic stress. I strongly believe that in many, if not most, persons with a diagnosis of “schizophrenia” the neuroscience findings could never fully be understood without reference to the whole person living in a particular sociocultural context, both of which are impacted by social adversities across the generations (e.g., the individual and social traumas of one’s parents, grandparents, social group, etc.). Not so easy to study with only neuroimaging, genome wide association scans, microarrays, etc!!

I have included only a few recent research studies documenting the effects of stress on microglia from such journals as Molecular Psychiatry, Stress, etc.

Brian Koehler PhD
Stress 2015 Jan;18(1):96-106. doi: 10.3109/10253890.2014.995085. Epub 2015 Jan 8.
Microglia activation regulates GluR1 phosphorylation in chronic unpredictable stress-induced cognitive dysfunction.
Liu M1, Li J, Dai P, Zhao F, Zheng G, Jing J, Wang J, Luo W, Chen J.

Abstract
Chronic stress is considered to be a major risk factor in the development of psychopathological syndromes in humans. Cognitive impairments and long-term potentiation (LTP) impairments are increasingly recognized as major components of depression, anxiety disorders and other stress-related chronic psychological illnesses. It seems timely to systematically study the potentially underlying neurobiological mechanisms of altered cognitive and synaptic plasticity in the course of chronic stress. In the present study, a rat model of chronic unpredictable stress (CUS) induced a cognitive impairment in spatial memory in the Morris water maze (MWM) test and a hippocampal LTP impairment. CUS also induced hippocampal microglial activation and attenuated phosphorylation of glutamate receptor 1 (GluR1 or GluA1). Moreover, chronic treatment with the selective microglial activation blocker, minocycline (120?mg/kg per day), beginning 3?d before CUS treatment and continuing through the behavioral testing period, prevented the CUS-induced impairments of spatial memory and LTP induction. Additional studies showed that minocycline-induced inhibition of microglia activation was associated with increased phosphorylation of GluR1. These results suggest that hippocampal microglial activation modulates the level of GluR1 phosphorylation and might play a causal role in CUS-induced cognitive and LTP disturbances.

CNS Neurol Disord Drug Targets. 2015;14(3):304-8.
Commentary: the effects of psychological stress on microglial cells in the brain.
Yuan TF1, Hou G, Zhao Y, Arias-Carrión O.

Abstract
Psychological stress leads to activation and proliferation of microglial cells in different brain regions. These effects are mediated by inflammatory cytokines, as well as stress hormones including glucocorticoids and norepinephrine. Eliminating microglia from the nervous system or blocking their activation prevented the stress-induced impairments on brain cognitive functions. We conclude that microglial cells are important meditators underlying anti-depression therapies.

Molecular Psychiatry 2014 Jun;19(6):699-709. doi: 10.1038/mp.2013.155. Epub 2013 Dec 17.
Dynamic microglial alterations underlie stress-induced depressive-like behavior and suppressed neurogenesis.
Kreisel T1, Frank MG2, Licht T3, Reshef R1, Ben-Menachem-Zidon O1, Baratta MV2, Maier SF2, Yirmiya R1.

Abstract
The limited success in understanding the pathophysiology of major depression may result from excessive focus on the dysfunctioning of neurons, as compared with other types of brain cells. Therefore, we examined the role of dynamic alterations in microglia activation status in the development of chronic unpredictable stress (CUS)-induced depressive-like condition in rodents. We report that following an initial period (2-3 days) of stress-induced microglial proliferation and activation, some microglia underwent apoptosis, leading to reductions in their numbers within the hippocampus, but not in other brain regions, following 5 weeks of CUS exposure. At that time, microglia displayed reduced expression of activation markers as well as dystrophic morphology. Blockade of the initial stress-induced microglial activation by minocycline or by transgenic interleukin-1 receptor antagonist overexpression rescued the subsequent microglial apoptosis and decline, as well as the CUS-induced depressive-like behavior and suppressed neurogenesis. Similarly, the antidepressant drug imipramine blocked the initial stress-induced microglial activation as well as the CUS-induced microglial decline and depressive-like behavior. Treatment of CUS-exposed mice with either endotoxin, macrophage colony-stimulating factor or granulocyte-macrophage colony-stimulating factor, all of which stimulated hippocampal microglial proliferation, partially or completely reversed the depressive-like behavior and dramatically increased hippocampal neurogenesis, whereas treatment with imipramine or minocycline had minimal or no anti-depressive effects, respectively, in these mice. These findings provide direct causal evidence that disturbances in microglial functioning has an etiological role in chronic stress-induced depression, suggesting that microglia stimulators could serve as fast-acting anti-depressants in some forms of depressive and stress-related conditions.

Curr Immunol Rev. 2010 Aug 1; 6(3): 195–204.
Responses of glial cells to stress and glucocorticoids
Jauregui-Huerta,1 Y. Ruvalcaba-Delgadillo,2 R. Gonzalez-Castañeda,1 J. Garcia-Estrada,1,3 O. Gonzalez-Perez,1and S. Luquin1

Microglial cells are the innate immune cells of the brain. Like astrocytes, they have a role in the regulation of the extracellular milieu and they participate in neuronal regeneration [4]. Like other immune cells, they respond quickly to injury and produce a wide variety of pro-inflammatory molecules, neurotrophic factors, and neurotransmitters [59]. Microglial cells can be activated by several factors including systemic infection, physical trauma, oxygen and energy depletion, and some neurodegenerative disorders [60].

Psychological stress and glucocorticoids have long been shown to suppress immune responses [61]. Thus, GCs could be expected to exert immunosuppressive actions on brain resident microglia. Consistent with this immunosuppressive hypothesis, in vitro studies have shown that treatment of microglia with GCs decreases the ability of these cells to proliferate [62], to produce proinflammatory cytokines [63, 64], and to produce toxic radicals [65]. These anti-inflammatory actions were confirmed in a spinal cord injury model treated with methylprednisolone [66]. However, recent in vivo studies suggested that stress and GCs can enhance immune function within the brain [67]. Restraint stress combined with water immersion, for example, induces massive microglial activation in the rodent brain [68]. In addition, brief tail-shock [68], immobilization [69], and social isolation stress [70] increase the expression of interleukin-1?(IL-1?) in the rat brain [71]. Moreover, four sessions of restraint stress were capable of increasing the proliferation of microglia, apparently due to corticosterone-induced, NMDA receptor activation [72]. This proinflammatory evidence has lead to the suggestion that stress-induced microglial activation may be involved in the progression of neurodegenerative disorders [73].

In conclusion, maybe the real “breakthrough” we should be working for, would be to get the NIMH and eventually the media to become interested in a “person in context” view of mental distress and mental disorders, so that biological facts will not be taken out of context, and we can orient our institutions both toward doing more prevention of distress and disorder in the first place, and more appropriate interventions once problems have occurred!

For another, more detailed look at this same subject, I recommend the article by ISPS member Noel Hunter,

Breaking News! The “Cause” of “Schizophrenia” Finally “Discovered”!(?)

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Supporting People in Getting Active in Their Own Recovery

Often, especially with big mental health problems like those we call “psychosis,” almost all the discussion and attention tends to revolve around what the rest of us should do to help the person, and not what the person could do to help himself or herself.

And often the “help” that is offered makes people less inclined to do things to help themselves than they would otherwise be.  People are encouraged to give up trusting themselves and instead to think of themselves as “mentally ill,” and they are encouraged to take drugs which have a general effect of making people more passive or “tranquilized.”

Of course, it can seem like a good thing to have people lose trust in their “crazy” ideas or perceptions, and to have people be passive rather than engaged in activity we see as “psychotic.”  But to really recover, people need to find ways to trust themselves again and to become active toward their own values.  So we need something different from standard kinds of “help” if we are going to really help people move into “agency,” or really taking responsibility for their own recovery.

In their presentation for the next ISPS-US online meeting/webinar, which will happen at noon EDT  on Friday 9/25/15, Lewis Mehl-Madrona MD and Barbara Mainguy MA will share their views on this topic.

In their own words, they plan to “explore the interface and the movement between at least two different worlds in which people diagnosed with psychosis interact. First and dominant is the biomedical world in which the solution to virtually all of life’s woes is to take a pill and not to make personal, relational, or lifestyle changes. Important to recognize, we believe, is that these beliefs are as prominent for medical illnesses as they are for the so-called psychiatric illnesses. Then comes the Recovery Community in which people work from passivity (the biomedical model) toward agency in which they can actively contribute and create their recovery.

“We want to suggest that most psychiatrists are so saturated in the passivity model that they do not recognize when patients present from the agency model. We suggest that the two models are more widespread than mental health and represent fundamental differences in approaching health and disease. We review some of our results in working within both worlds. Specifically, the people with whom we work within a Recovery model improve and those within the passive, biomedical model, do not.”

Lewis and Barbara will be discussing what they have found may assist people in making this shift from passivity toward agency, especially telling stories of characters with agency to indirectly implant ideas of the possibility of agency. With patience, and with the practice of “radical acceptance,” they have found that this can be very effective!

ISPS online meetings are free to ISPS members, with a donation of $5-$20 requested from others, though no one turned away for lack of funds.  Please do register, by going to https://from-passivity-to-agency.eventbrite.com if you want to attend!

(Some of you may also want to read a recent article by Lewis Mehl-Madrona, Working to Recover, or Adjusting to Illness?)

 

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Online Course, “CBT for Psychosis” Is Now Available

Udemy cbt imageCognitive Behavioral Therapy (CBT) for psychosis is an evidence-based method to reduce distress and disability related to psychotic experiences, and to support a possible full recovery. Psychotic experiences are conceptualized as being understandable in relationship to an individual’s life story, and capable of being altered when people experiment with different ways of thinking and behaving. Learn how to collaborate with people having these experiences, “exploring the evidence” rather than imposing beliefs, and developing coping options so people are not forced to rely entirely on the often limited effectiveness of medication to address problems.

This new online course starts by examining the nature of psychosis and CBT, providing a foundation for understanding how CBT can be helpful. Then the basic style of CBT for psychosis is introduced, followed by an introduction to two of the most important techniques. Finally, applications of CBT are explored for some of the main problem areas, such as hearing distressing voices, paranoia, delusional beliefs, disorganization, and negative symptoms.

Included in the course are video lectures, slides with some diagrams, video demonstrations of CBT for psychosis being practiced, and links to additional resources for further study. Periodically, there will be live question/answer sessions, and recordings of past question/answer sessions will also be available.

CBT for psychosis uses a minimal amount of jargon, and the concepts and practices tend to be easily understandable.

In this introductory seminar on CBT for psychosis, you can learn to:

  • Collaborate with people in exploring difficult experiences, helping people develop their own perspective and their own solutions rather than telling people what to think
  • Reduce fear of psychotic experiences, and build hope for coping and for recovery. using the CBT approach called “normalizing”
  • Help people develop a coherent story or individualized formulation of what led to psychotic difficulties, which then guides efforts toward recovery
  • Become familiar with a broad range of psychological strategies which have been found helpful for experiences such as paranoia, hearing voices or other “hallucinatory” experiences, delusional or disorganized thinking, and “negative symptoms.”

5 CE credits are available for social workers, psychologists and nurses in the US.

Cost:  The regular cost for this seminar is $89, however, prior to July 15, 2015, it’s being offered for the discounted price of only $49.  If you register before then, 1/3 of your registration fee will go directly to ISPS-US (the rest will go to me, Ron Unger, since I am the author and producer of the course.)

To register, or for more information including a free preview of the section on “normalizing,” go to this link.

Also, if you are interested in this course and you are a non-professional, for example a person with lived experience of psychosis or a family member, you are welcome to register for free, using this link.  Note that this free offer is only until July 15, 2015, after that the scholarship rate will be $10.

(Also, you might want to be aware of other online courses that are now appearing through Mad in America.  Of particular interest may be Eleanor Longden’s course The Voices in My Head.” in which she presents a radically different understanding of “auditory hallucinations,” which in turn provides a rationale for significant changes to the current standard of care.  This course is free for viewing, while the cost for obtaining CEU or CME credits is $15.)

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“Self Psychology and Psychosis: The Development of the Self During Intensive Psychotherapy…’

There are many pathways to recovery, but one thing people have often been told does not work for “psychosis” and “schizophrenia” is intensive psychotherapy.

But many of those who research the effectiveness of such therapy, and those who practice it, would beg to differ.  (You can also hear the voices of two recipients of such therapy who speak out in Daniel Mackler’s film which you can watch on youtube, “Take These Broken Wings.”)

Self Psychology is one Self Psychologyapproach to intensive psychotherapy.   On Friday June 5, 2015, at 6:30 PM Eastern Time, there will be an opportunity to hear directly from, and interact with, Ira Steinman and David Garfield, who will be speaking about this approach during an online meeting/webinar.

Ira and David will be discussing their new book, “Self Psychology and Psychosis:  The Development of the Self During Intensive Psychotherapy of Schizophrenia and other Psychoses.”

This meeting is sponsored by ISPS-US, which does request a small donation for the meeting from non-members, but does not turn away anyone who can’t afford to or doesn’t want to pay.

Read on for more information about the book, and how to register for the meeting:

Continue reading

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Reflections on Compassion and Uncertainty at ISPS 2015

In the Mad in America blog posts by Noel Hunter and by Sandy Steingard, there have already been great reports on ISPS 2015, but I would like to share my own thoughts about what was most significant and directions for the future.

For me, the strongest emotional moment came when heard the presentation by Silje Marie Strandberg, an ex patient, and Lone Viste Fagerland, her mental health nurse.  Silje shared what began as a very dark story, about her being bullied as a child, then becoming extremely withdrawn, suicidal and “psychotic,” then being hospitalized for years without hope for anything better.   This began to change only after she met a new nurse, the co-presenter, Lone.  Silje shared how she first strongly disliked Lone, yet gradually learned to trust her as Lone persisted in efforts to make contact, and especially as she offered physical touch in a way that crossed what are usually seen as “good boundaries” in mental health treatment.

Silje shared that even in her withdrawn state she had a definite sense that in order to reconnect as a human being, she was going to need physical affirmation and touch from someone outside her family; yet she also knew that in the hospital “they don’t do that kind of thing.”  It was because Lone broke out of such hospital norms, and offered hugs, extended hand holding, backrubs, hair brushing and other kinds of non-exploitive physical contact, as well as efforts to be present beyond the demands of her normal duties, that Silje was able begin to believe in herself and to re-connect with the social world.  And reconnect she definitely did:  she presented with a warm vitality that was truly impressive!

To me, this story cut right to the heart of what real mental health “help” can be.  So it’s quite sad to contrast the story she and Lone told with a tale I heard just yesterday, of a worker in an hospital who was fired for extending just one hug to a patient the worker had seen for two years, at the point where they were having to say goodbye.  Physical contact like hugs were just against policy.  That, within an institution that claims it is for healing……

The idea of connecting around our basic humanity of course isn’t new; quite a few of the presenters for example reminded us of Harry Stack Sullivan’s reminder from early in the last century that we are all “more simply human than otherwise.”  Unfortunately, it is all too easy for the mental health system to forget this common humanity when a person is in a state that seems extreme or psychotic.  I believe it is the failure to focus on this common humanity that leads to the destructiveness of so much mental health work, but it doesn’t have to be that way.

A man has been insisting to everyone that he is pregnant.  What should be done?  Aaron Beck (known as the “father” of CBT, and now 93 years old) proposed a simple answer in his talk that opened the conference.  In the story Beck related, the man was first asked what was good about his condition.  He answered that being pregnant was good because it meant he would soon have someone to love.  He was then asked if he had ever had this before, and reported yes, when he had a pet dog – so the next step in “treatment” was to help him start a volunteer job in an animal shelter, thus helping him meet the actual human need that had been presenting as a “psychotic symptom.”  Simple, but so different from standard approaches that routinely miss the person in their effort to address the apparent “symptoms of an illness.”

I found one of the most promising approaches discussed at the conference to be compassion focused therapy (CFT).  Christine Braehler, our presenter, strongly suggested that anyone practicing this approach apply the techniques to themselves first (think how much different mental health treatment would be if it were routine for practitioners to apply the techniques to themselves first!)  I especially appreciate CFT’s multi-dimensional approach to compassion, aka love:  it’s not just about the therapist being compassionate with the clients, but also helping the clients learn to practice compassion toward themselves, toward dissociated parts or voices, and also giving and receiving compassion in relations with other people.

In the absence of warmth and compassion, rigidity sets in.  This is true not just for those who are failing to receive the compassion, but for those who are failing to give it.

One way professionals get rigid is by settling into theories, which then dominate how they see things.  An interesting presentation by Stephen Love explored “theory induced blindness” or the way having a theory often makes professionals ignore what may be key pieces of reality that don’t quite fit the theory.  Sometimes theory induced blindness in the mental health field gets pretty extreme; John Strauss for example shared his story from the 1980’s of trying to publish an outcome study showing lots of recovery after a “schizophrenia” diagnosis, and being rejected by a major journal that told him “we know this can’t be true.”  Unfortunately, there is still so very much that professionals think they know that just isn’t so.

My own presentation was on the importance of professionals admitting uncertainty about everything from the question of who is “ill” to the nature of reality itself.  Nick Putnam, involved in organizing training in Open Dialogue in the UK, said that the most challenging part of bringing the Open Dialogue approach into an existing mental health system seemed to be getting clinicians to become able to have the capacity to “not know” within their conversations.  Lewis Mehl-Madrona, a Native American psychiatrist with expertise in narrative approaches, spoke about a man he interacted with who had been hospitalized over a hundred times.  The man told Lewis that “you are the first person I’ve talked to who didn’t know what to do.”  Not surprisingly, Lewis was also more able to be helpful than those who had been so sure they knew what to do.

Of course, it isn’t as though the best helpers know nothing at all about what to do.   There are professionals who regularly don’t seem to know much of anything and don’t try anything beyond pills, and they tend to just become part of an atmosphere of hopelessness.  It seems to me that what probably what works best is when professionals have ideas, but also are able to be unsure if these ideas are correct, and so they can be available for a lively ongoing exploration.

While there were many valuable ideas offered at this conference, and while the exchange of ideas was very helpful, I was also bothered by the way a number of the plenary presenters seemed much too sure their ways of thinking were helpful, without awareness of possible down sides to their perspectives.  For example, many of the speakers were sure they were talking about something that could be safely described as “mental illness” and they were quite sure that this “illness” is something that can, without ambiguity, be thought of as something “bad.”  My belief, to the contrary, is that we will only be really good at helping people when we are less sure what is good and bad in people’s experience, and when we can engage with the openness that comes from that uncertainty.

I enjoyed Larry Davidson’s talk, and I understand he has made many positive contributions to our field.  But when he identified the scariest part of long term psychosis as the sense of losing one’s self (and seemed to imply that this experience is so devastating that it can only be understood as part of an illness) I was reminded of the period of my life when my own sense of self and my sense that anything had any meaning at all was falling apart – but the curious thing is that in my experience at the time, I found this loss of a sense of self to be profoundly liberating!

Of course, when a person grows up with lots of trauma and shame as I did, it isn’t surprising that one’s sense of self and system of making meaning is very oppressive, and so it can be liberating to have it all break down.  It is also true that such a breakdown can create huge problems, but we need mental health helpers who get that this whole process may be something other than “illness,” and who understand alternative perspectives such as spiritual approaches that see possible value in getting beyond the illusion of being a fixed “self.” In my journey I was lucky enough to find these perspectives and get the help I needed outside the system, but this kind of help should also be available inside the system.

Ultimately, I don’t think we can have a competent mental health system till we have one that can look at both the positive and the negative sides of extreme states.  We need a mental health system that can understand the human concerns that lead people, especially young people, into wild and paradoxical mental and emotional terrain, so we can help people move toward what makes sense to them in a safer way rather than insist they always stay within the boundaries of conventional society.

Karen was one person who spoke about the importance of mental health workers learning to do this.  She shared some of her own difficult yet valuable experiences, the importance of learning to affirm what was good about them, and in regards to normality commented that “I don’t have anything against normal, it’s just that I’ve always had my missions and being normal has not been one of them.”

It seems to me we are just starting to imagine what mental health services will be like if we learn to really listen to people like Karen, if we truly collaborate with people in extreme states, helping them discover their own version of health and progress, and ways to accomplish their own missions, rather than impose our own definitions and certainties about the superiority of “normal” ways of experiencing the world.  I did appreciate ISPS 2015 as one place where multiple views were considered, and my hope is that as we continue to dialogue, within ISPS and MIA and elsewhere, new ways of accomplishing the vision I have outline will emerge and will then increasingly reshape mental health practice, which is still so badly in need of a “non-violent revolution.”

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Developing a Compassionate Voice as a Step Toward Living With Voices

I’ve previously written about the possible role of compassion focused therapy in helping people relate better to problematic voices, in my posts Could compassionate self talk replace hostile voices?Feed Your Demons!, and A Paradox: Is Our System for Responding to Threats Itself a Threat?

I’m happy to see more interest being taken in this kind of approach, and a video has just become available which, in 5 minutes, very coherently explains how a compassion focused approach can completely transform a person’s relationship with their voices and so transform the person’s life!

The video is an animation developed by Charlie Heriot-Maitland working with Eleanor Longden and Rufus May who do the voiceovers.  Check it out, let me know what you think:

(You can also go straight to www.compassionforvoices.com and give feedback to the people who made the video.)

You can learn more about compassion focused therapy at the following workshop which precedes our ISPS International Conference:

Compassion Focused Therapy for Recovery after Psychosis, with Christine Braehler  18th March 2015, ISPS Conference workshop, New York, US. http://www.isps2015nyc.org/pre-conference-workshops

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Get Trained in CBT for Psychosis, and Attend the ISPS International Conference Just Afterward!

Here’s an announcement sent by Karen Stern that I am reprinting in full:

The Institute of Cognitive Therapy for Psychosis (ICTP) is very excited to announce an upcoming training in CBT for Psychosis (CBTp).  It will take place March 14-17, 2015, right before the ISPS International Conference, at nearby NYU.

This course will provide clinicians with advanced understanding and skills in using CBTp. CBTp is an evidence-based treatment,  which complements pharmacological and other psychological treatments. Its goal is to create a collaborative treatment alliance in which patient and therapist can explore distressing psychotic experiences and the beliefs the patient has formed about these experiences, in an effort to reduce suffering and improve functional capacity in the recovery process.

The course will be taught by ICTP faculty including: Page Burkholder, MD; Michael Garret, MD; David Kimhy, PhD; Yulia Landa, PsyD, MS.

Didactic training will take place over 4 consecutive days, and will be followed by 30 hours of weekly group supervision (via phone or skype).

Didactic training will take place from March 14th to  March 17th, 2015. Training will be located in the Kimmel Center (60 Washington Square South, New York, NY).

Applicants must meet the following requirements:

1.    Hold one of the following degrees: PhD or PsyD (clinical or counseling psychology), MD (in psychiatry), MSW, LCSW, NP (nurse practitioner), OT (occupational therapist), AT (activity therapist).

2.    Hold the appropriate license or certification to practice.

3.    Have familiarity with CBT theory and principles.

4.    Actively treating or have access to treat clients with schizophrenia spectrum disorders.
Applicants are accepted on a rolling first-come, first-serve basis until the workshop is full. We strongly encourage early applications for this program.

The cost of the training will be $3,850 for non-ISPS members, and $3,500 for ISPS members. This fee includes didactic presentations and supervision. All trainees receive a certificate of completion at the end of training.

For more information please visit:  https://www.sites.google.com/site/ictpsychosis/training

To register please contact the ICTP coordinator at info.ictp@gmail.com

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Listening for the Person within “Madness”

As we struggle to invent a humane approach to the extreme states that get called “psychosis” or “madness” or “schizophrenia,” it may be helpful to investigate some of the better approaches developed in the past.

While these approaches are not without their flaws, they are often surprisingly insightful.  (It can also of course be depressing to notice how truths once more widely known were so easily “forgotten” as compassionate approaches got ditched in favor of the latest coercive innovations.)

One of the pioneers in actually listening to those in extreme states was Frieda Fromm-Reichmann.  She advocated assuming that every communication from those in extreme states contains meaning, and for appreciating that there is an “ego,” however beleaguered, within even the seemingly “hopelessly deranged.”  She believed that if therapists would persist in reaching out, while respecting the person and his or her struggle, then communication would gradually become clearer, and the person’s special perspectives and talents could emerge and flourish.

Fromm-Reichmann is perhaps best known as being the therapist for Joanne Greenberg, who wrote a fictionalized version of her story of psychosis and recovery in the novel “I Never Promised You a Rose Garden,” and whose story was also covered in Daniel Mackler’s documentary “Take These Broken Wings.”

One person who has extensively studied the work of Fromm-Reichmann and others like her is Ann-Louise Silver, MD.  In the short clip below, taken from the “Broken Wings” documentary, she contrasts the kind of recovery that can come from psychodynamic therapy with what happens when people are offered what she calls the “scotch tape” approach of medication:

So how does this psychodynamic approach work, and what parts of Fromm-Reichmann’s approach could be helpful to us as we design alternatives for today’s world?

Ann will address that topic at an ISPS online meeting on Friday 2/13/15, at 3 PM EST.  This meeting is free to ISPS members, with a donation of $5-$20 requested from others, though there is also an option to register without donating if that works better for you.

You can register at https://ispsonlinewithann-louisesilver.eventbrite.com

Ann will also be a keynote speaker at the ISPS International Conference in NYC March 18-22, 2015.

Ann was the first president of ISPS-US, an organization started by people who were mostly psychodynamic therapists.  This organization has since broadened, as awareness increased about the need to collaborate with those who have lived experience, and as knowledge expanded about the effectiveness of other kinds of approaches, and of the need to have different approaches available for people who may respond better to something other than long term therapy.

It certainly isn’t too late to register for http://www.isps2015nyc.org/ where you can hear from leaders such as Mary Olson (of Open Dialogue), Aaron Beck and Tony Morrison (of CBT and CBT for psychosis), and of special importance, lots of people with both lived experience of psychosis and expertise in other areas, such as Ron Coleman, Pat Deegan, Noel Hunter,  Sascha DuBrul, and Oryx Cohen among many others.

I will also have a presentation there, titled “Admitting Uncertainty about “Illness” and “Reality” is Essential for Dialogue.”

Of course, many of you aren’t going to be able to attend big conferences like this – which is why I hope to keep working with others in ISPS to make available online meetings, accessible to all, which give people a chance to hear from leaders in our field in a live format that includes interaction with the audience.  Expect to hear more about these meetings on MIA, and/or you can always hear about what’s coming up by going to http://isps-us.org/blog/online-meetings/

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