What is Madness?
Ivor Browne
What is Madness?
• Central question to understanding nature of
mental health for over 150 years
• Critical at present time
• Often identified as psychosis/schizophrenia
– Continuing confusion
Emil Kraepelin (1856-1926)
Kraepelin
• In 1850’s French psychiatrist Morel (who
died in 1873) – catatonia, hebephrenia,
dementia paranoides (all same illness)
• Kraepelin divided psychiatric disorders into
two main categories
– Dementia praecox
– Manic depressive illness (all mood disorders)
‘Will the Real Concept of Schizophrenia
Please Stand Up’? (R.Bentall)
• Kraepelin’s views underwent a series of radical
transformations throughout 20th century
• Four giants of psychiatry
Kraepelin 1856 - 1926 Bleuler 1857 - 1939
Jaspers 1883 - 1969
Schneider 1887 - 1967
• Definition remains as confused as ever
Two Schools of Thought
1. Bio-Medical Model
2. Psychodynamic Approach
Change in Thinking
Freud and others who supported
psychodynamic viewpoint and/or the
bio-medical approach accepted
reductionist, scientific determinist view
as per orthodox science at the time
Psychodynamic Approach
– More person centred
Adolf Meyer
Described
reaction types
Harry Stack
Sullivan
Early
intervention
Gregory
Bateson
Double Bind
Hypothesis
Silvano Arieti
‘Interpretation of
schizophrenia’
Harry Stack Sullivan
As early as 1927 Harry Stack Sullivan spoke of the
importance of psychotherapeutic intervention in dealing
with psychosis – he stressed relevance of engaging
with person as early as possible….
…‘ the psychiatrist sees too many end states and deals
professionally with too few of the pre-psychotic.’….’we
should lay great stress on the prompt investigation of
failing adjustment, rather than, as is so often the case,
wait and see what happens’
Living Systems
Moving towards new science of ‘living systems’
Psychiatry Today
• Humane individuals
• Genuine desire to help patients
• Psychiatrists retain central position of
power, control and legal authority
• Only doctors (including psychiatrists) have
legal power to medicate or incarcerate
Psychiatry Today (Cont’d)
• Fear of loss of central role, power and
influence
• Profound lack of understanding of true
nature of emotional disturbance
• Recently major developments in
psychotherapy and counseling
• Solutions now being offered by nonmedical therapists
Resistance to Change
‘Ah when people are really sick and unable
to manage, or are a threat to themselves
or society and need to be contained, they
have to come to us to be dealt with’
‘A Vision for Change’
As is emphasised over and over again in the
report of the expert group on Mental
Health Policy, which is now official
government policy…..
‘This group of service users is perhaps the
most vulnerable in the mental health
service, and ultimately the quality of the
service overall can be measured by the
quality of care provided to this group’
Recent Trends
• Growing evidence of a revival of interest in
psychotherapeutic interventions:
– Loren Mosher – Soteria House
– R. D. Laing – Kinglsey House Project
– Joshua Bierer – Marlborough Day Hospital
– Gould Farm Village
– Detect programme – Early intervention - Ireland
– Western Lapland, Finland – Open Dialogue
– Patrick McGorry – Australia
UNDERSTANDING PSYCHOSIS
Are We Asking the Wrong Question?
• We’ve been asking how much is nature
and how much is environment
• After 150 years of study and research we
are no closer to a workable solution
• What should we be asking?
• Nature and nurture are part of a
continuous process of learning
Central Dogma
• ‘DNA makes RNA,
RNA makes
protein, and protein
makes us’
• ‘Language of life’
• Rosalind Franklin –
original research
1953 – structure of DNA molecule
Genetic/Environmental Influences
• Early studies poorly designed
• Looked at frequency occurring in families
• Failed to address how far influences were
genetic in origin
• Later studies – nature vs nurture
• Monozygotic and dizygotic twins
– Methodological deficiencies in design of all
studies
Two Key Omissions
1. Epi-genetics
2. Influence of environment on infant in the
womb – from conception up to and
including birth
Epi-Genetics ‘Control above Genetics’
• Profoundly changes our understanding of
how life is controlled
• Research has established that DNA
blueprints passed down through genes are
not set in concrete at birth
• Genes are not destiny!
Epigenic Control
• Misunderstanding about the true nature of
mental and emotional distress
• Genetic influence in the Genesis of
Psychosis is likely to be indirect and of
limited relevance
• Relates to ‘personality’ – not illness
Personality vs Pathology
• Personality traits are not illness
• Jung – Introvert/Extrovert – about
preferences not illness
• Either dimension can be equally
successful
Evelyn Fox Keller
‘The secrets of life have proved vastly more
complex and more confusing than they
seemed in the 1960’s and 70’s’
‘in the 1990’s we learned that chimps shared
98.5% of human DNA’
Peter Holland
‘the differences between flies and mice, and
even between chimps and humans are
unmistakeable’
‘if the genes are ‘essentially the same’, what
then is it that makes one organism a fly and
another a mouse, a chimp or a human.’
Mae-Wan Ho
‘by this exclusive focus on genes, the living
organism tends to be regarded simply as a
collection of genes,’
‘Lamarck's theory – transformation arising from
the organism’s own activities and experience
of its environment. This requires a conception
of the organism as an active, autonomous
being, which is open to the environment.’
Lynn Margulis
‘Cell heredity, both nuclear and cytoplasmic,
always must be considered for the entire
cell, the entire organism’
Infant on High Alert
• Mothers under stress, e.g.
violence or domestic abuse, can
transfer hormonal state to infant
in the womb
• ‘Fight or flight’ survival stance
• Infants anxious and miserable at
birth
• Maternal depression also
associated with newborn anxiety
and excessive crying
Social Life of Twin
Foetuses
• ‘Kind’ twins can be seen gently interacting,
playing, cheek to cheek
• Show interest in each other
• Twin boys in the same compartment can
be seen ‘boxing’ with each other
• Others can be seen kissing or holding
hands
Psychotic Individuals
• Numerous studies have demonstrated that
majority are in late teens or early twenties.
• Most vulnerable group in health service
• Can be very gifted personalities
• Can be introverted and sensitive
• Have difficulty making social relationships
• Behaviour can be bizarre or intolerable
Treating Psychosis
• Common practice to treat by admission
(voluntarily or forcibly) to a secure ward
• Administering of powerful medication to
control positive symptoms
• This method of treatment is central
question at the heart of psychiatry
Treating Psychosis (Cont’d)
• Process of moving repeatedly between
hospital and home - behaviour and
general condition deteriorates
• Become further and further separated from
the outside world
• They become entrained into a pathway of
illness.
Treating Psychosis (Cont’d)
• It is frightening how quickly this can
happen, they lose hold of their social
network; they dropout of work, school or
college, lose contact with friends, who
move on with their own lives, and become
increasingly isolated.
• Gradually their diagnosis is changed. The
psychiatrists looking after them now
decide that they are suffering from
schizophrenia.
Treating Psychosis (Cont’d)
• Concept of schizophrenia is created, due
to some supposed organic or biochemical
cause.
• Thus, it can be said that this serious
condition is partly ‘iatrogenic’ - that is
actually caused by medical treatment.
Psychotic Individuals
• Not usually possible to manage in office
environment once a week
• Frequently won’t turn up for appointment
• Usually in dependent state in parental
home
• Take little or no responsibility for
themselves
Psychotic Individuals (Cont’d)
In these circumstances it is simply not
possible for a therapist to achieve an
effective outcome
Trauma & Family Influence
•
•
•
•
•
•
•
Lack of love – unwanted
Cosseting and overprotection
Criticism - denigration
Scapegoating
Bullying in school or by friends
Physical or sexual abuse
Heavy drinking or drug abuse – a trigger
Trauma – Family
Influence
Independence
(Adulthood)
Child
Family
system
Trauma
S
e
p
a
r
a
t
i
o
n
Work
Money
Relationships
Children
Trauma
Isolation
Dependence
on family
Break with reality
Fantasy world
Psychosis
Treatment -hospitalisation
Trauma
Dependence
Philip Larkin
“They fuck you up, your mum and dad.
They may not mean to, but they do.
They fill you with the faults they had
And add some extra, just for you.
But they were fucked up in their turn
By fools in old-style hats and coats,
Who half the time were soppy-stern
And half at one another's throats.
Alternative Avenue
This presentation proposes an alternative
avenue of therapy with sustainable
recovery for this sensitive group of
individuals
CREATING A HEALING
ENVIRONMENT
Healing Environment
What is required is a total loving and
supportive environment, within which
individuals feel safe enough to undertake
the necessary therapeutic work.
Healing Environment (cont’d)
•
•
•
•
Supportive setting
Close to nature
Loving, tolerant and flexible
Informed by love and compassion on a
deep spiritual basis
Therapeutic Relationship
• Personal friendship and loving relationship
core around which all therapeutic
processes rotate
• Heart to heart – one human being to
another
• Objectivity
• Clear conditions under which work is done
• Individual must do the work – with support
Range of Therapies
• Broad range of psychotherapeutic
interventions
• Horticulture and farming (work with
animals)
• Wholesome Diet & Healthy Living
• Body therapy & homeopathy
• Arts & crafts
• Music
• House maintenance
Family Work
• Several aspects – not about blame
– Understanding the family as a separate living
system
– Open dialogue
– Exposing myths & secrets
– Crisis intervention
• Roles & responsibilities
Therapeutic Education
(Group Work)
• Distinguish that which originates from
outside from internal activity
• ‘Self’ is what is in question in psychosis
• To distinguish ‘self’ from ‘non-self’
• Help individuals to understand psychotic
process - hallucinations and delusions
Psychiatric Consultation
• Anti-psychotic medication
– May be necessary to make contact &
establish therapeutic relationship
– For as short a time as possible & in as low a
dosage as possible
• Undertake objective unbiased research
comparing this pilot project to traditional
bio-medical model of treatment
Connectedness
• Facility must remain connected to
community and society in general
• Connections to training & rehabilitation
must be maintained and strengthened
• Not all individuals will be able to integrate
into our current society
• A growing minority are choosing a more
sustainable approach to life, in harmony
with nature
Krishnamurti
‘It is no measure of health to be well
adjusted to a profoundly sick society’
Pilot Projects
• Ideally should be pilot group of four or five
residential therapeutic centres – on a
temporary basis
• Spread throughout the country – at least
one in each of the four provinces
• Must happen in a small country, where it
cannot easily be ignored
Major Implications
• If alternative development could be
demonstrated to be more effective
– Radical re-organisation of psychiatric practice
– Financially much less costly
– Fundamental change of direction
– Radical re-organisation of psychiatric training,
and operation of mental health services
generally
Thank You
Any Questions?