It has been a while since I have had time to look at my other blog (forfreepsychology), but as I`m working on a book based on what I and others have written, I found an article from Judee about children`s mental health. Since I am working with children now, I read the article with interest. I hope you all like it as much as me!
I used to work in a mental health hospital that was a 19-bed unit for children and adolescents that required temporary hospitalization. Many times, we saw the effects of acting out due to anger issues. And on many occasions, there were absolute mental health issues that included behaviors with depression, bipolar disorder and obsessive compulsive disorder.
During the time I worked there, I had the honor of meeting a real gem of a child psychiatrist who not only involved himself with the medication component of these children’s care, but also who helped us to become better therapists and counselors as well, having a positive impact on this aspect of their therapy while they were with us, as well.
One of the children admitted to our care during my time there, came face to face with this amazing man, regarding a major blow-up he had with another patient. He showed his true colors and caused a huge disruption on the floor after something happened, that angered him severely. The issue required more than just a brief sit-down and involved this man, who was in charge of the ward.
I recall the incident as if it were yesterday, although it is many years later. But the part I recall the most, involved this Doctor talking with the young, angry boy afterward in which he explained to him that there were really only two different scenarios that could play out for the remainder of the young man’s life. He began by telling him that he could promise him there would be many more times that this young man was going to come face to face with situations that angered him. Sometimes he would become exactly as angry as he had just become. Other times, he wouldn’t be nearly as angry and more than likely, there would be other times when he would become even angrier than he was here. Doctor Z. stated clearly, three or four times, that he could guarantee this young man of this.
He emphasized that this young man had absolutely no choice in this. There was nothing that any of us could do, no matter who we were and how much we may want to help him, that could prevent the situations from happening in the future and then he surprised this young boy by telling him that he wasn’t going to do anything to try and prevent the young boy from getting angry in the future over these things. He told him that if anybody expected to be able to prevent their anger was a fool.
I had never heard of this type of a technique when it came to dealing with anger or any emotion for that matter. I was young and fairly wet behind the ears and I though my job was to help these children from becoming too angry or too anxious or too sad. But I learned from Doctor Z. that if I intended to prevent such things, I not only was foolish, but I would fail miserably.
The Winner Is…
That day, Doctor Z. taught me and that young man that there is indeed a choice, but that the choice is about whether that feeling rules us or whether we rule that feeling. It isn’t about having the feeling or about how strong the feeling is. It is about who ends up in control – us, or our feelings?
I share these concerns, though not because I believe that mental health problems have no biological basis, nor because I think environmental factors invariably play a role in mental ill health; I simply wouldn’t know. But because I do know from listening to the stories of dozens of fellow service users, that adverse life experience such as physical and sexual abuse, racism, bullying and neglect is depressingly common on a psychiatric ward, and understood by a great many patients to have played at least a significant role in the development of their problems. Moreover, it is striking how often problems with housing, for example, or the stress of being assessed for benefits (which are, ironically enough, supposed to support the most vulnerable) are understood by patients to be the trigger for a relapse.
In this context, it seems to me that the decision of the BBC to portray mental health problems simply as brain disorders is a highly troubling one. While some people do undoubtedly interpret their mental health in this way, there are many who do not, many indeed who would resist the attachment of any diagnostic label, who see their mental health difficulties as a natural, rational response to adverse experience. In failing to represent their perspective, the BBC has not only presented an extremely one-sided picture, it has broadcast a message to such individuals, and to society generally, that their experience doesn’t matter.
Of course, it would be rather convenient if it didn’t. It would be especially convenient for David Cameron. It would mean that when he talks about our need to “focus on mental health”, at the same time as bringing in benefit changes that have been found to have led to the suicide of at least one person and beenimplicated in the deaths of dozens of others, we might almost be able to take him seriously. It would mean that we wouldn’t have to worry about creating a more equal society. Mental health problems are repeatedly shown to be most prevalent in countries with the highest levels of financial and social inequality. What a relief to realise it doesn’t matter!
A purely biological view of mental ill health locates the problem firmly within the head of the individual, and as a society this is dangerous because it absolves us of the responsibility, the need, to examine ourselves. Imagine a lung cancer specialist who refuses to talk about the link between smoking and lung cancer. I’m sure the comparison is simplistic but I don’t believe it’s entirely inaccurate either. There is copious evidence to suggest that adverse events, especially in childhood, increase the likelihood of developing all sorts of mental health problems. Which is not to say that biology doesn’t play a part as well. But as a society there’s little we can do to tackle the causes of mental ill health on a biological level. Whereas, with adequate will and commitment, there is absolutely masses that could be done to create a mentally healthier environment for children and adults alike.
This is why mental health must be seen as an urgent political and social issue, as well as a biological and psychological one. And it’s not just a question of responding to the needs of people with mental health problems, though this is of course important, but of being prepared, as a society, to consider what we might do to reduce people’s risk of developing them in the first place. I’d like to see a programme on that.
Good Friday to everyone! Are you ready for the weekend?
I have had a good day at work, with interesting meetings and memorable conversations. I have also had some time to read a bit, and came across two interesting metaphors. In addition, a doctor I work together with, also pulled a metaphor up his sleeve, and when I came down to my office, I had to write them all down. Then I got the idea? Wouldn`t it be great with a book full of metaphors (it probably exists already, but an update is always welcome) ? And then I started to wonder:
Do you have metaphors fitting for life in general and for psychotherapy?
Belgium, 1992. I completed my psychiatric residency. Five years of training gives me, among other things, a good psychodynamic foundation and an exposure to a range of psychiatric medications, including the newest ones being touted as, ironically, both scientific and miraculous. In my heart there is an eagerness to learn more, a penchant towards borderline pathology and a desire to relieve souls in suffering.
Since then I have journeyed through very different places: from hospitals and private practice in the European system of universal healthcare (albeit only for its citizens), to the streets, prisons, outpatient services and psychiatric emergency rooms of Los Angeles, a multicultural jungle, and a place where extremes either collide or else ignore each other completely.
Although I was a young psychiatrist convinced of the effectiveness of psychotherapy, there was definitely something thrilling in the ‘Decade of the Brain’ and its ’intelligent molecules’, which were presented as having no serious side effects. Not only would they be a cure for debilitating chronic illnesses but the molecules themselves (or the imbalance thereof) would be the long-awaited scientific explanation of mental illness itself. Suddenly, my new profession, whose ethics were so often questioned (remember the Gulag and lobotomies) and challenged as to its ‘real’ scientific value (Popper and psychoanalysis), acquires the seal of scientific respectability.
Almost overnight, the psychiatrist-prescriber becomes the expert of the new sciences of chemical imbalance, methodical classifications of illnesses and evidence-based treatment. The new science of human consciousness has arrived, a modern discipline where pesky existential questions seem obsolete. In the euphoria of the late twentieth century, pharmaceutical companies and psychiatrists discover one another and embark on a risky love affair. Lavish international conferences are organized during which prestigious panels of experts attempt to give concrete meaning to the inexplicable and in doing so propel the exponential expansion of the market base of the drug industry.
Clinicians (of which I am one) and academics, in a surprising moment of “méconnaissance intéressée” in the words of Derrida, do not seem (or want) to be aware of the potential conflicts of interest in this thrilling adventure. Very quickly, both international psychiatric research and physician’s education become more and more dependent on money from pharmaceutical lobbies.
In medical school, psychotherapy starts to look outmoded. Young doctors are amazed (and perhaps reassured) by the molecular and genetic versions of human passions, and build themselves a new identity, that of the psycho-pharmacologist. The psychosocial model in force in the mental health community no longer seems to apply to a ‘modern’ psychiatry. In libraries, Freud and Frankl are taken off the medicine shelves and end up in the literature department with Albert Camus and Jean Paul Sartre.
At the same time, other voices are speaking up – those of the mental health patients themselves and their families. As part of the wave of civil rights movements that were rushing through America in the 1960s and ‘70s, patients and former patients, some calling themselves “Survivors of Psychiatry”, demand an active role in their own care. “Nothing about us without us”, is their war chant. Under their influence, terminology changes, too. The word ‘patient’, with its implication of suffering and passivity gives way to ‘users’, ‘clients’, and ’consumers’ in keeping with the more active participation of a patient in his or her own treatment. Importantly, this new terminology is also more in sync with a capitalist world where ‘care’ becomes more than ever an object of consumption with profit its underlying goal.
It is into these turbulent waters that I dove when, in 1999, I came to the United States to continue my interest in borderline personality disorders (BPD). Curiously, in these times of medical exhilaration, this group of patients seems to balk at any reductionist classification. BPD doesn’t respond to the “pill-to-heal-everything” approach. BPD patients’ long resistance to both psychiatric and psychoanalytic treatment has earned them a history of rejection and disqualification, the alleged reason being that these patients are difficult, manipulative, or worse, not really sick. It appeared as if only a categorical diagnosis or a treatment validated by modern science could bestow on these sufferers the seal of authenticity.
In my new American reality, I am on the frontlines observing how theoretical, political and social contexts can affect the expression or the occurrence of a symptom, its recognition and what we choose to do (or not do) about it. With BPD patients in particular, the fact that there is no pill to treat them encourages some ER staff members to discharge them swiftly without really addressing their issues. Verbal complaints and “scratches” that may lead to necessary treatment in my previous home of Belgium will generally bring disdain in a US emergency room, where much deeper self-mutilations is required in order to hold the patient long enough to initiate therapeutic engagement . So, the self-inflicted wounds of Otto Kernberg’s and Marsha Linehan’s patients in the US somehow appear more threatening and bloodier than the ones I observed in my small European country. It seems necessary to shout louder in the US in order to have our healthcare system decide finally to take care of you.
Social and political contexts also influence the writing of a prescription. An antipsychotic medication identified as “very safe” in Belgium, might suddenly bring a lawsuit in the United States, due to the fact that a rare side-effect is emphasized in a ‘Black Book’, a tome sold primarily to lawyers.
During my second residency, I was lucky enough to be trained in cognitive and behavioral therapies (CBT). Contrary to the naïve and/or arrogant belief of the psychoanalytical circles in which I did my original training, I realized how well these techniques can work and how easily teachable they are. I have been impressed by the willingness of practitioners of cognitive therapy to prove the effectiveness of their methods, thus gaining ‘scientific’ legitimacy and resulting financial reimbursement.
Forced to question my theories and techniques, I discovered research that suggests that, for a majority of conditions treated in psychotherapy, all the major modes of psychological treatment produce similar outcomes . In fact, this research suggests that only 8% of the variance is due to the type of therapeutic technique, while 70% is due to the overall effect of treatment itself, such as the factors of empathy, a good working relationship between the therapist and his or her client etc. The residual 22% of the variance remains unexplained.
Fascinated by these oddly un-‘modern’ results, I felt reassured in my belief that the individual caregiver’s role is central to the therapeutic process. After all, isn’t modern psychiatry but a new iteration of the age-old combination of witches and wardens?
While the paths of neuroscience and psychology may seem to diverge, an expert interested in both disciplines, Eric Kandel, is trying to force a dialogue between them. In the early 2000s, armed with his recent Nobel Prize for research in neuroplasticity, he proposed a “biological” legitimacy to psychotherapeutic techniques . He has helped us to understand how environment affects the development of our brains as much or more than a chemical molecule does.
If only something biological gives legitimacy to a ‘modern’ treatment, then we must recognize that the interaction between two human beings is also a biological treatment , because it affects our brain’s function and development. For example, the environment may affect the way our genome is translated into proteins, building blocks of cellular receptors essential to our learning mechanisms .
Along this line, researchers have started studying the interactions between the modalities of attachment and molecular genetics , and a new Society of Neuro-psychoanalysis has been created. In borderline patients, neuro-imaging studies have discovered abnormalities specific to their struggles . This is apparently what is needed for science to finally recognize them as real patients.
What mental disorder do you have? With the danger of offending you already, I ask you to not hate me yet. I`m asking this provoking question because I want to philosophize for a bit. So let me continue asking blood-pressure elevating questions: Have you ever done something wrong? Then you might have a antisocial personality disorder! Do you have mood swings? Well, that must mean you`r suffering from an affective disorder. Do you sometimes see things that aren`t there? Poor you, you must be schizophrenic. I could go on, but I know my readers are smart enough to get my point. But to clarify: No matter which questions I`d ask, I could interpret the result and make them fit neatly into a psychiatric box handmade for you.
Off course, I`m exaggerating wildly. We have extremes, and we have normality. But no matter what problems you have or don`t have, isn`t the most important thing that you figure our for yourself what you need to do, to change your life? Some mental issues are more important to get the correct label on, than others. If you are bipolar, medication might be a life or death prerequisite. If you are psychotic and think that you can fly if you jump from a building, medication might again be useful. Serious depression also must be addressed with medication and therapy. I don`t mean that we should forget about mental health and do nothing, I just want us to think about how we think about it. We must never forget to look for the normal in the abnormal. 50 % of us will have some mental health issues during our lives, and that means that 50 % of us will benefit from care and love from someone else. Actually, a 100 % of us needs this, more than anything else.
We have a whole manual for categorizing mental health issues, but unlike somatic disorders, our DSM-IV bible don`t give us exact answers. A patient might have five different diagnosis’s because symptoms overlap. Some doctors scratch their heads when this happens, and try one medication after another. When a patient is readmitted to a psychiatric unit, they frustrate as him/her must have gone off their medication. They might try another cocktail. My questions when this happens is: If someone is readmitted 10-50 times, might it not be an idea to try something different, too? Aren`t we obliged to do everything we can for our patients and our society?
We are all unique. There are 50 shades of normality and abnormalities. This isn`t a bad thing, it is what makes life and people fascinating. Considering this, we need tailor-made treatments addressing all these differences.
When I was in Thailand I learnt that something can look like something, but still be different. That is a lesson I’ve learnt many times, in different situation. Today I want to write about health policy. I have written about my thoughts when it comes to treatment at psychiatric wards before. I know that we all try our best, but sometimes what we think is best for others, is just assumptions that we need to be aware of. This week, I got the chance to see how something can be so alike, but completely different.
I had the chance to work one day at another psychiatric ward one hour away from the ward I’m in now. It is still in the same organization with the same leaders, and even have many of the same patients, but the treatment and attitudes are completely different. It’s hard to describe what the difference consists of, but I know they have worked hard with letting patients decide more. We have a psychiatric ward where the patients have different forms of addictions, and I know they include patients in every decision they make. The patients are even included in meetings! It is given that the patients will be heard and included in their own treatments, as it should be.
Another thing that strikes me as different, is the mood on the ward. There is more open space, and the nurses and assistants sits in groups talking peacefully. I sat there, too, discussing politics while patients sat there, playing board-games, reading the papers or simply listening to the conversations. It is so good to see that by giving people freedom and the chance to be heard, the same can be very different. For all the therapists who think that patients are ‘resistant’ or with no ‘insight’ in their own illnesses, they should see those patients. When they are given space and a listening ear, they are finally free to explore their ‘resistances’. They are more ready to take in everything they’ve been through, because the environment around them is safer. Only when safe, people are ready to explore reality. Safety in a place where people can shape their surroundings, is what a psychiatric ward should offer. So, I hope we can embrace new thoughts and transform the same old story. We need something different.
The last months I have worked as a psychologist at a psychiatric ward. I must say I find this a bit challenging, since I have often spoken up against some of the treatment given there. I find the concept a bit hard to swallow, even if I see that sometimes it really helps people to be at a place where they can start rebuilding their lives. Sometimes life gets so hard that you need some extra help to get back there again. But the problem is: I feel there is so little focus on psychological treatment while they are there.
The focus is often on medication when the therapist have their “talks” with the patients, or trying to find the correct diagnosis. This is very important, but I sometimes think we could do more. We have many people working at a psychiatric ward: Nurses, doctors, psychologists, social workers, physiotherapist and different students. Every one play an important part in the treatment of the patients. For many its important to get a regular sleep habit, start exercising, eating healthy or attend creative activities that we offer. Medication is often necessary, but I still feel we psychologists should get more involved in their mental well-being. We have the time to talk about their issues, but often doctors underline the importance of “not getting into things” because it might upset the patients when their not ready.
But who have actually asked the patients about what they would like to do?
I have just been on two course-days about dissociation, and was happy when I discovered a news-letter from ESTD (I am a member now). There I found the following post about how hard it is to become a patient dealing with abuse. I have so much respect for people who want to live a better life after abuse, since this is no easy task. I hope this can be a reminder of just that
By Esther Veerman
THE CHOICE TO BE A PATIENT
Being a therapist for patients with chronic childhood abuse and neglect needs a conscious choice. Not a lot of colleagues will do the same, and sometimes it is quite a lonely voyage that one starts to make. Becoming a patient with a history of chronic childhood abuse and neglect demands a conscious choice as well. It is not logical to start exploring the traumatic past, once a survivor has learned to avoid the memories of the same. And in the field of psychiatry, it is not easy to find the help a survivor so desperately needs. Often it takes many attempts to find good help over the years. And of course, courage to keep looking after a lot of disappointments. For me, it meant that I had to decide to take on the role of a patient, despite my aversion to this role. Of course, I rather wanted to be a helper instead of the one needing help. Maybe I can explain some of my struggle in this, in order to help the helpers understand some of the dilemmas going on in (future) patients.
Being a patient of severe childhood trauma is a choice I had to make 20 years ago. I was young, still busy studying theology, and wanted a normal, happy life. Weird things happened to me every once and awhile. During a lecture on psychology, when a movie was shown, I started to feel really sick. I had immense chest pain and feared I would die. Nothing was the matter with me, and I did not remember what the movie was about. And sometimes a horrid thought would come into my mind that, when I would have children, I could hurt them. Once I realized this thought and fear, I decided to seek for help. I would never want to have a child if I could harm it.
It took a lot of courage for me to look for psychological help. I did not know what was the matter with me. Sometimes I stumbled upon little words: there is something with my father. But I did not understand the content of these whispers. One of my mentors listened to these words and asked me the reason why I spoke them. I was too scared to remember, and so he sent me for the first time to a psychologist. Within two or three sessions, in which I was not able to tell about the images and fears in my head, the psychologist decided to bring my father into therapy and ask for reconciliation. For me, this was a message to (again) keep my mouth shut. For some time, I succeeded in doing this. My system collapsed when I gave birth to my son. During and after the delivery of the baby I re- experienced rape intensely. I fell into a dissociative psychosis in which I experienced incinerated hands and bodies, who raped me constantly. I tried to stay at home, take care of my son, even breastfeed him, until it seemed I had no choice but to listen to the doctor and get hospitalized into psychiatry. It was a complete nightmare to be hospitalized. I was extremely anxious, did not understand my own behaviour at all, but the psychiatrist said I have a hysterical personality. I went home and got hospitalized for a second time. The next psychiatrist thought I had PTSD, but could not believe that the symptoms I portrayed belonged to trauma. I could collapse for example, in a split second. It happened at the table when all the patients had dinner, or worse, in the shower. One time I collapsed in the hallway of the psychiatric ward, and later I heard, that the psychiatrist stepped over me, and said: she is just overreacting.
Years later, when I was hospitalized in a psychiatric hospital, I was shocked and felt humiliated by the bad conditions we had to live in as patients. I learned to check out the refrigerator before eating, to look at the dates of the meat and cheese that was in there for the patients. A lot of the food was out of date date. And when a lamp, or tiles in the bathroom were broken, they were not fixed. We had to live with ten patients on a very small ward, and the staff would sit in an office with the door closed. If something bad happened, like aggression between patients, most of it was not seen by the nurses. Sometimes patients hated each other, mostly because they were scared or aggressive in themselves. For example: a patient hated me because I had screamed out of fear, and she thought I had reacted to her. So when I went to the bathroom, she would come in and vomit, so that I could not wash my hands in the sink. Another patient who was known to be highly aggressive, would throw chairs at me as I wanted to pass by. Nothing was done about this. Two times, I was locked away by “accident”. On one occasion I had permission to draw and sat in a room all by myself. I got re-experiences and hided in a corner of the room. A nurse came in the room, thought it was empty and locked the room. They did not miss me for hours. Another time, I had an appointment to talk with a nurse, she went away to answer the telephone and I again, hided in a corner, because I was so scared. After a long time, another nurse came by and locked the room. She did not come back for talking to me, she did not remember I wanted to speak with her. Another time, when I was hospitalized with serious suicidal feelings, I got away, and went back to the ward, very suicidal, and laid down under my bed, and for one day and one evening, nobody had missed me, or looked for me. I had not eaten and drunk and nobody had thought about speaking to me.
Every time I came home, after hospitalization, I was worse than before. As I described before, for me it felt humiliating to be hospitalized. It was almost impossible to keep my dignity in those periods of time. Sometimes I did not even feel human anymore. We had to ask for everything, the medicine (we had to stay in a line to receive them), the food, going out and getting back to the ward. It felt really degrading when all the power was taken off from me. One can say, maybe I was not able to take care of myself anymore. But many times, I felt that what I wanted to say was not heard at all. Of course, in those periods of time I could not express myself so well. That is true. But when people are not willing to listen, talking becomes extremely difficult. Maybe it is dangerous to say, but I think psychiatry felt for me like the environment I lived in as a child. Neglect, silence and disrespect.
But I never stopped fighting, all those desperate years. I realized that I would not survive much longer (I was highly suicidal over the years) and I tried one more attempt at getting the right help. I looked on the internet and found information about trauma therapy and dissociation. I emailed for second opinion and received this. It turned out I suffered from DID. The trauma therapist I spoke to, asked me to register myself for trauma therapy. For 6 years now I’ve been in trauma-therapy. I feel I am taken seriously now, in my desperate search for healing and the question I have asked for all of those years: help me through the nightmares and re-experiences.
Reading this, one can think that I had no choice but to be a patient. On the one hand, this is true. My life was falling apart and I would not have lived, if I had not been hospitalized and taken care of. On the other hand I had to decide to want to learn how I could get away from what haunted me. I have always wanted this. Already during the first hospitalizations I begged to be heard and for guidance to get out of trauma land. This was not honoured at all. Therapists and psychiatrists thought what was right for me. Many times they said that I had to stabilize, but it meant literally loads of sedative medication, and nobody asked me what had happened to me in my childhood. I was allowed to write my own treatment plan, but it was never honoured what I asked for in those plans. I felt more and more humiliated and thought I was really stupid.
After all these long and devastating years with more traumatizing events, the trauma therapy I am receiving (now for 6 years) now makes sense to me. For the first time a therapist explained to me what was going on in my head, with the distinction between Apparently Normal Parts of the Personality and Emotional Parts of the Personality, and their functions, inner dynamics and systems. I learned to distinguish parts within my head and body, who carried daily life (being a Mom, a Partner, one part who was always busy with music, one 8 year old, that had never grown but handled things in daily life; and scared little children in side of me, some freezing, others running away, some parts who seemed to copy the perpetrators etc. and some occupied with sexuality). Together we started to explore what was living inside of me. I did not dare speak anymore, because so many times I heard that what I told was not valid, or that a therapist would not believe me and from my childhood on, to shut up. So, I hardly could find words to describe all that was inside of me for all those years.
This asked a lot of patience from the therapist. Patience and boredom perhaps. This required from me a high standard of courage. To try once more, once more, to speak the words that frightened me the most. In one of the first sessions the therapist asked me: “Esther, do you want to change?” I said: “Oh yes, I do want to change, I just do not know how.” For me, this question of the therapist was very important. I realized, when I wanted to overcome all those years of trauma, I would have to be able to change, and not stick to my Disorder. Of course, I was intensely scared to do so, but I chose not to stay the same anxious twisted person I was. At that time, I had absolutely no clue of my future. I so much lived in trauma time, that everyday life was a challenge in itself, let alone that I had an understanding of the future. From the first session on with this therapist, I mirrored the perpetrators in his face. I told my therapist over and over again he was authoritative, and I was extremely scared of him. After a period of time, he asked me, if I thought he was my father? When I realized he was right about this,I calmed down a bit. In the years that followed I realized more and more, how much I projected on my therapist. I tried to accept inside of me, that the inner parts of me where doing this. I came to an understanding that the reliving of the trauma was necessary to overcome the same. This way I sat in therapy with my hands over my face for five years. Many exercises with looking around, and trying to look in the eyes of the therapist were necessary to overcome this huge stumble block.
When the sexual abuse was addressed, even more projection came into therapy. One of my biggest fears was that the reliving of the trauma would actually take place between the therapist and me. But instead of being silent about this, I chose to speak out, that I thought sex would take place between us, and I let my inner children react as if in the situation of rape, in the way they must have reacted in the situation they were in as children. I was convinced one day it would go wrong between the therapist and me, and I heard my inner voices come out and even ASK for sex. I knew, that my therapist had all the power to be able to abuse me (again), but he always took care of me and protected me, by staying consistent and calm. I had to get used to the feeling, that, although my therapist had more power, he would never use his power in a negative way, but only to help me forward.
Becoming a patient was a difficult and courageous choice. I had to understand and realize that the problems I tried to avoid could not be solved on my own. I believe that I would have been helped from the very beginning to be grounded in my autonomy if I had met the right mental health professionals. In psychiatry I met so many people who seemed persons without the possibility to think for themselves, but I think this is not really true. A lot of problems that they create stem from their taking over the ability to think and decide what is best for a person called the patient. Like being a patient is a choice (one can chose to die, or to do something about it) and healing is the next choice to be made by a patient. But I believe here a therapist can be of tremendous help. A therapist can start to explore the possibilities and strengths of the patient and work together exploring the landscape of healing. Being a patient in itself can bring the key to healing. For the therapist the challenge is to find and guide the patient on this road.
Esther Veerman is founder of the Foundation Art out of Violence (www.artoutofviolence.com) She lives in the Netherlands, is a theologian and an artist.
Evidence that antipsychotics cause brain shrinkage has been accumulating over the last few years, but the psychiatric research establishment is finding its own results difficult to swallow. A new paper by a group of American researchers once again tries to ‘blame the disease,’ a time-honoured tactic for diverting attention from the nasty and dangerous effects of some psychiatric treatments.
In 2011, these researchers, led by the former editor of the American Journal of Psychiatry, Nancy Andreasen, reported follow-up data for their study of 211 patients diagnosed for the first time with an episode of ‘schizophrenia’. They found a strong correlation between the level of antipsychotic treatment someone had taken over the course of the follow-up period, and the amount of shrinkage of brain matter as measured by repeated MRI scans. The group concluded that “antipsychotics have a subtle but measurable influence on brain tissue loss” (1).
This study confirmed other evidence that antipsychotics shrink the brain. When MRI scans became available in the 1990s, they were able to detect subtle levels of brain volume reduction in people diagnosed with schizophrenia or psychosis. This lead to the idea that psychosis is a toxic brain state, and was used to justify the claim that early treatment with antipsychotics was necessary to prevent brain damage. People even started to refer to these drugs as having “neuroprotective” properties, and schizophrenia was increasingly described in neo-Kraeplinian terms as a neurodegenerative condition(2).
The trouble with this interpretation was that all the people in these studies were taking antipsychotic drugs. Peter Breggin suggested that the smaller brains and larger brain cavities observed in people diagnosed with schizophrenia in these and older studies using the less sensitive CT scans, were a consequence of antipsychotic drugs(3), but no one took him seriously. It was assumed that these findings revealed the brain abnormalities that were thought to constitute schizophrenia, and for a long time no one paid much attention to the effects of treatment. Where the effects of antipsychotics were explored, however, there were some indications that the drugs might have a negative impact on brain volume(4).
In 2005, another American group, led by Jeffrey Lieberman who headed up the CATIE study, published the largest scanning study up to that point of people with a first episode of psychosis or schizophrenia(5). The study was funded by Eli Lilly, and consisted of a randomised comparison of Lilly’s drug olanzapine (Zyprexa) and the older drug haloperidol. Patients were scanned at the start of the study, 12 weeks and one year later and patients’ scans were compared with those of a control group of ‘healthy’ volunteers.
At 12 weeks haloperidol-treated subjects showed a statistically significant reduction of the brain’s grey matter (the nerve cell bodies) compared with controls, and at one year both olanzapine- and haloperidol-treated subjects had lost more grey matter than controls. The comparative degree of shrinkage in the olanzapine group was smaller than that in the haloperidol group, and the authors declared the olanzapine-related change not to be statistically significant because, although the result reached the conventional level of statistical significance (p=0.03) they said they had done so many tests that the result might have occurred by chance. In both haloperidol and olanzapine treated patients,however, there was a consistent effect that was diffuse and visible in most parts of the brain hemispheres.
The idea that schizophrenia or psychosis represent degenerative brain diseases was so influential at this point, that the authors first explanation for these results was that olanzapine, but not haloperidol, can halt the underlying process of brain shrinkage caused by the mental condition. They did concede, however, that an alternative explanation might be that haloperidol causes brain shrinkage. They never admitted that olanzapine might do this.
It seems as if Eli Lilly and its collaborators were so confident about their preferred explanation, that they set up a study to investigate the effects of olanzapine and haloperidol in macaque monkeys. This study proved beyond reasonable doubt that both antipsychotics cause brain shrinkage. After 18 months of treatment monkeys treated with olanzapine or haloperidol, at doses equivalent to those used in humans, had approximately 10% lighter brains than those treated with a placebo preparation.(6)
Still psychiatrists went on behaving as if antipsychotics were essentially benign and arguing that they were necessary to prevent an underlying toxic brain disease (Jarskoget al 07 Annual review). Andreasen’s 2011 paper was widely publicised however, and it started to be increasingly acknowledged that antipsychotics can cause brain shrinkage. Almost as soon as the cat was out of the bag, however, attention was diverted back to the idea that the real problem is the mental condition.
Later in 2011 Andreasen’s group published a paper that reasserted the idea that schizophrenia is responsible for brain shrinkage, in which there is barely a mention of the effects of antipsychotics that were revealed in the group’s earlier paper(7). In this second paper, what the authors did was to assume that any brain shrinkage that could not be accounted for by the method of analysis used to explore the effects of antipsychotic treatment must be attributable to the underlying disease.
The way they had analysed drug treatment in the first paper only looked for a linear association between antipsychotic exposure and changes in brain volume, however. A linear analysis only detects an association that is smooth and consistent- in other words an association in which brain volume shrinks by a consistent amount with each increment in antipsychotic exposure. The total effect of drug treatment may not follow this pattern however. It seems from other evidence that there is a threshold effect whereby being on any amount of an antipsychotic has the greatest relative effect, with a levelling out of the impact as duration of exposure reaches a certain level.(8) In any case, without a comparison group which has not been medicated, a virtual impossibility in this day and age, it is simply not possible to conclude that the whole effect is not drug-induced.
The latest paper by this research group replicates the findings on antipsychotic-induced brain shrinkage, but also claims that brain volume reduction is related to relapse of the psychotic disorder(9). Relapse was defined retrospectively by the research team for the purposes of this particular analysis, however, and not at the time the study data were collected. Moreover, the definition used does not refer to any significant change in functioning, but only to a deterioration in the severity of symptoms. But the group’s previous analysis of severity of symptoms, using data collected at the time, found that severity had only a weak association with brain volume changes, and moreover that symptom severity was correlated with antipsychotic exposure.(1)
The most recent analysis ignores the probable association between antipsychotic treatment intensity and relapse, but it seems likely that people undergoing periods of ‘relapse,’ or more accurately deterioration of symptoms, would be treated with higher doses of antipsychotics. If this is so, and the two variables ‘relapse’ and ‘treatment intensity’ are correlated with each other, then the analysis is questionable since the statistical methods used assume that the variables are independent of each other.
So Andreasen’s group have found strong evidence of an antipsychotic-induced effect, which they have replicated in two analyses now. The predictive value of the severity of symptoms, on the other hand (which is essentially what relapse appears to define) is weak in the initial analysis, and in neither analysis was it clearly differentiated from drug-induced effects.
These researchers seem determined to prove that ‘schizophrenia’ causes brain shrinkage, although their data simply cannot establish this, as none of their subjects seem to have gone without drug treatment for any significant length of time. So even though their recent analysis once again confirms the damaging effects of antipsychotics, they conclude that the results demonstrate the need to make sure patients take, and do not stop, their antipsychotic medication. The only concession made to the antipsychotic-induced changes revealed is the suggestion that low doses of antipsychotics should be used where possible.
Yet other prominent psychiatric researchers have now abandoned the idea that schizophrenia is a progressive, neurodegenerative condition, and do not consider that Andreasen’s study provides evidence of this.(10) Bizarrely, Nancy Andreasen is a co-author of a recently published meta-analysis which combines results of 30 studies of brain volume over time, which clearly confirms the association between antipsychotic treatment and brain shrinkage (specifically the grey matter) and finds no relationship with severity of symptoms or duration of the underlying condition.(11)
What should antipsychotic users and their families and carers make of this research? Obviously it sounds frightening and worrying, but the first thing to stress is that the reductions in brain volume that are detected in these MRI studies are small, and it is not certain that changes of this sort have any functional implications. We do not yet know whether these changes are reversible or not. Of course the value of antipsychotics has been much debated on this site and elsewhere, and their utility almost certainly depends on the particular circumstances of each individual user, so it is impossible to issue any blanket advice. If people are worried, they need to discuss the pros and cons of continuing to take antipsychotic treatment with their prescriber, bearing in mind the difficulties that are associated with coming off these drugs.(12) People should not stop drug treatment suddenly, especially if they have been taking it for a long time.
People need to know about this research because it indicates that antipsychotics are not the innocuous substances that they have frequently been portrayed as. We still have no conclusive evidence that the disorders labeled as schizophrenia or psychosis are associated with any underlying abnormalities of the brain, but we do have strong evidence that the drugs we use to treat these conditions cause brain changes. This does not mean that taking antipsychotics is not sometimes useful and worthwhile, despite these effects, but it does mean we have to be very cautious indeed about using them.
(1) Ho BC, Andreasen NC, Ziebell S, Pierson R, Magnotta V. Long-term Antipsychotic Treatment and Brain Volumes: A Longitudinal Study of First-Episode Schizophrenia. Arch Gen Psychiatry 2011 Feb;68(2):128-37.
(2) Lieberman JA. Is schizophrenia a neurodegenerative disorder? A clinical and neurobiological perspective. Biol Psychiatry 1999 Sep 15;46(6):729-39.
(3) Breggin PR. Toxic Psychiatry. London: Fontana; 1993.
(4) Moncrieff J, Leo J. A systematic review of the effects of antipsychotic drugs on brain volume. Psychol Med 2010 Jan 20;1-14.
(5) Lieberman JA, Tollefson GD, Charles C, Zipursky R, Sharma T, Kahn RS, et al. Antipsychotic drug effects on brain morphology in first-episode psychosis. Arch Gen Psychiatry 2005 Apr;62(4):361-70.
(6) Dorph-Petersen KA, Pierri JN, Perel JM, Sun Z, Sampson AR, Lewis DA. The influence of chronic exposure to antipsychotic medications on brain size before and after tissue fixation: a comparison of haloperidol and olanzapine in macaque monkeys. Neuropsychopharmacology 2005 Sep;30(9):1649-61.
(7) Andreasen NC, Nopoulos P, Magnotta V, Pierson R, Ziebell S, Ho BC. Progressive brain change in schizophrenia: a prospective longitudinal study of first-episode schizophrenia. Biol Psychiatry 2011 Oct 1;70(7):672-9.
(8) Molina V, Sanz J, Benito C, Palomo T. Direct association between orbitofrontal atrophy and the response of psychotic symptoms to olanzapine in schizophrenia. Int Clin Psychopharmacol 2004 Jul;19(4):221-8.
(9) Andreasen NC, Liu D, Ziebell S, Vora A, Ho BC. Relapse duration, treatment intensity, and brain tissue loss in schizophrenia: a prospective longitudinal MRI study. Am J Psychiatry 2013 Jun 1;170(6):609-15.
(10) Zipursky RB, Reilly TJ, Murray RM. The Myth of Schizophrenia as a Progressive Brain Disease. Schizophr Bull 2012 Dec 7.
(11) Fusar-Poli P, Smieskova R, Kempton MJ, Ho BC, Andreasen NC, Borgwardt S. Progressive brain changes in schizophrenia related to antipsychotic treatment? A meta-analysis of longitudinal mri studies. Neurosci Biobehav Rev 2013 Jun 13.
(12) Moncrieff J. Why is it so difficult to stop psychiatric drug treatment? It may be nothing to do with the original problem. Med Hypotheses 2006;67(3):517-23.
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