Rewriting the Paradigm of Psychosis
With the most recent schizophrenia/psychosis recovery research, we discover increasing evidence that psychosis is not caused by a disease of the brain, but is perhaps best described as being a last ditch strategy of a desperate psyche to transcend an intolerable situation or dilemma. To better understand how this conclusion, which is so contrary to the widespread understanding of psychosis, has come about, it will help if we break down this discussion into a short series of questions and answers.
What? Schizophrenia may not be caused by a brain disease?
The emerging recovery research and continuous lack of substantiation of any of the various brain disease hypotheses have cast serious doubts about the validity of the brain disease theory (as discussed in more detail in my book, Rethinking Madness): (1) regarding the anomalous brain structures or brain chemistry that is sometimes found in people diagnosed with schizophrenia, these are only found in a small minority of cases, and even in these cases, there is no significant evidence that these are caused by anything other than unusual life circumstances (e.g., trauma, nutritional deficiencies, and substance abuse) or by the use of psychiatric drugs themselves; (2) the research is clear that, in stark contrast to well established diseases of the brain (such as Alzheimer’s, Parkinson’s, Huntington’s, and Multiple Sclerosis), many people diagnosed with schizophrenia/psychosis make full and lasting medication-free recoveries; and (3) that many of those who experience full recoveries do not just return to their pre-psychotic condition, but experience profound healing and positive growth beyond the condition that existed prior to their psychosis, again in stark contrast to well established diseases of the brain (Williams, 2011, 2012; and more on this in a future post).
So, if schizophrenia/psychosis is not caused by a disease of the brain, then what does cause it?
This is not a simple question, and it’s further compounded by the fact that there continues to be widespread controversy over whether “schizophrenia” is even a valid construct. While there is not the room to go into the details of this issue here, the essence of this controversy is that while it is clear that many people experience anomalous beliefs and perceptions (so-called delusions and hallucinations), we still don’t have clear evidence that it’s appropriate to lump the vast range of such experiences under a single label. All that we can really say for sure is that people do experience distressing anomalous experiences (so-called delusions and hallucinations), and that such experiences cause varying degrees of distress and limitation, last for varying lengths of time, and sometimes arise with varying degrees of strong emotions and/or altered states of consciousness. Therefore, for the sake of this discussion, I find it more helpful to just use the term “psychosis,” acknowledging that what we call “schizophrenia” is essentially just long-term psychosis.
Returning, then, to the question of what causes schizophrenia/psychosis, I’ve devoted an entire book (Rethinking Madness) to a thorough exploration of this question, and unfortunately, it’s just not possible to adequately summarize the thorough answer that this question deserves within such a brief article. What I will attempt to do here, however, is to put forth the most essential concepts of this alternative understanding and encourage others to engage in a fruitful dialogue about this important topic.
What I believe is the most relevant implication of the emerging recovery research (of others’ research as well as my own) with regard to the cause of psychosis can be put like this: The individual we deem “schizophrenic” or “psychotic” is merely caught in a profound wrestling match with the very same core existential dilemmas with which we all must struggle. In other words, it appears likely that schizophrenia/psychosis is not caused by a disease of the brain but is rather the manifestation of a mind deeply entangled within the fundamental dilemmas of existence.
So what exactly are these existential dilemmas?
The term “existential dilemma” essentially refers to the dilemmas inherent in finding ourselves in a state of existence—“Here I am, alive, conscious, and feeling. Now what?” These dilemmas, at their core, relate to our need to maintain our existence, and perhaps even more importantly, our need to create a life that is worth living—where the joys and rewards of living are strong enough to overcome the inherent pain and suffering of life, and provide us with the will to go on living. Some of the most important such dilemmas that have been named by various existential thinkers are: finding a balance between autonomy/authenticity and love/belonging; finding a balance between freedom and security; coming to terms with the fact that all of our decisions and actions come at some cost; coming to terms with our own impending death; and cultivating enough meaning in our lives so that we are able to rise out of bed every morning and greet each new day.
In virtually all of the research and case studies I have come across that have looked closely at the actual subjective experiences of those who have fallen into a psychotic process, we see evidence that, prior to the onset of psychosis, these individuals had found themselves in overwhelming existential dilemmas similar to those mentioned above, but to a far greater degree than that which the average person ordinarily experiences. In one of the most well-known of such studies, R. D. Laing, a Scottish psychiatrist renowned for his pioneering research on schizophrenia and his clinical work with those so diagnosed, closely studied the social circumstances surrounding more than 100 cases of individuals diagnosed with schizophrenia, and he concluded that “without exception the experience and behavior that gets labeled schizophrenic is a special strategy that a person invents in order to live in an unlivable situation [author’s emphases]” (1967, pp. 114-115). Bertram Karon, one of the world’s most renowned clinicians specializing in psychotherapy for those diagnosed with psychotic disorders, stated his belief that any one of us would also likely experience psychosis if we were to have to live through the same set of circumstances as those of his psychotic clients (Karon & VandenBos, 1996). We see other evidence of this again and again in the plethora of biographical and autobiographical accounts that have been written and filmed (for example, Bassman, 2007; Beers, 1981; Dorman, 2003; Greenberg, 1964; Modrow, 2003).
The original focus of my own research (Williams, 2011, 2012) was to explore the change within my participants’ experience and understanding of the world and themselves (their personal paradigm) that took place throughout their entire psychotic process, from onset to full recovery. The findings that emerged with regard to the onset of psychosis were very much in alignment with the findings of the other research mentioned above—there is clear evidence that every participant in all three of my own studies had also experienced such an overwhelming dilemma prior to the onset of psychosis. After thorough analysis of the data in the final and most comprehensive of the three studies, I arrived at the conclusion that there are essentially two fundamental dilemmas that appeared to lie at the crux of both the onset and resolution of these participants’ psychotic process:
(1) The need to achieve a sustainable balance between autonomy (personal choice/personal freedom/authenticity) and connection (love/belonging/acceptance)
(2) The need to maintain a relatively secure and stable sense of self when the very fabric of our being and indeed of the entire universe is profoundly groundless, impermanent, and interconnected.
What is particularly interesting about these dilemmas that seem to play such an important role in psychosis is that they may be the very same dilemmas that lie at the core of all human experience, regardless of one’s degree of sanity or lack thereof. It’s likely that most of us can easily relate to the first dilemma—we only need to think of the various challenges we’ve had in our relationships with family members, partners, and other loved ones. We can easily witness this dilemma occurring within toddlers as they struggle to find a balance between the drive to explore the world and assert their autonomy while still wanting to be unconditionally loved and accepted by their caretakers. And of course this dilemma never fully goes away for most of us. The second dilemma mentioned above is probably a little more difficult for some of us to relate to, especially for us Westerners (many practitioners of some of the Eastern traditions such as Buddhism, Taoism, and Advaita Vedanta have thoroughly explored this dilemma). This dilemma generally lies a little more deeply beneath our conscious awareness than the first dilemma, though it often becomes conscious in unusual circumstances, such as during contemplative practice (such as mindfulness meditation), psychological/emotional crisis, and hallucinogenic drug use.
So, if these existential dilemmas are universal, then why do some individuals become more overwhelmed by them than others, and go on to develop psychosis?
The research suggests that there are two main factors that may make someone vulnerable to experiencing one or both of these dilemmas to a very high degree:
With regard to the first dilemma (autonomy vs. relationship), it has long been established in the field of developmental psychology that healthy childhood development requires that we find a healthy balance between our sense of autonomy and our trust that we are loved and accepted by others. Attachment research has been exploring and validating this idea for decades. Childhood abuse (physical, sexual, and/or emotional), trauma, neglect, and a poor fit between the temperament of a child and her/his caretaker(s) all clearly interfere with establishing a healthy balance in this regard, and all of these are well established in predisposing someone to developing serious emotional and psychological problems, and in more extreme cases, psychosis (Karen, 1994; Mahler, Pine, & Bergman, 1973; Rathus, 2006; Schore, 2002; Slade, 1999; Wallin, 2007; Williams, 2011, 2012).
Regarding the second dilemma, recall that this dilemma refers to our need to maintain the sense that we are a relatively secure and stable self living in a relatively secure and stable world, when the reality of our situation is very different than this. To better understand how someone can be overwhelmed by this dilemma, it will help to first touch on the concept of cognitive constructs. The term cognitive constructs refers to the belief systems and interpretations that each of us has constructed throughout our lives that allow us to make sense of the world. They can act somewhat like a double-edged sword for us. On one hand, they provide us with the means to distinguish one object or being from another, and they give us the general sense that we “kinda know what’s going on” so that we can meet our needs and navigate our way through life. They also give us a sense that there is some solid ground beneath our experience—in other words, that we are a secure and stable self living in a relatively secure and stable world. But on the other hand, our cognitive constructs can close our minds to other perspectives, and they create the illusion that the world and our self are much more stable and secure than they actually are.
For most of us, our cognitive constructs are fairly solid, changing only slowly over time. However, in certain cases, such as during acute crisis or trauma, or with the use of certain psychoactive drugs, one’s cognitive constructs can become very unstable. On one hand, this can lead to the potential benefit of having a more open mind (less rigid belief systems) and a greater sense of interconnectedness and “oneness” with all (more about this in my book, Rethinking Madness); but on the other hand, the loosening of our cognitive constructs can also lead to the potential terror of experiencing just how precarious and ungrounded our existence and self really are, which can lead to profound shifts within our personal paradigm as we attempt desperately to find some “solid ground” to cling to once again. Such radical personal paradigm shifting is closely associated with so-called delusions and hallucinations—experiences that are generally equated with psychosis.
Why some people are more prone to the loosening of one’s cognitive constructs is still somewhat mysterious—it appears that certain drugs and psychological or physiological distress may play a significant role, and there may even be some genetic or developmental predisposition. However, even though some people may be more prone to the destabilization of their cognitive constructs, it seems likely that virtually anyone has the potential to experience this if exposed to an overwhelming dilemma, situation, or trauma. It’s all too easy to find cases of extreme neglect, abuse, torture, or other trauma that have profoundly shaken up one’s experience of one’s self and the world, and led to psychosis or at least psychotic-type experiences.
The research suggests, then, that both of these factors play an important role in the development of psychosis—an overwhelming existential dilemma and unstable cognitive constructs. The research also suggests that these two factors are very closely related, in that the experience of such an overwhelming dilemma makes one more susceptible to experiencing unstable cognitive constructs, and vice versa. It’s also important to emphasize that it is the individual’s own subjective experience of their situation that is most relevant. Sometimes, it’s easily evident to an observer that an individual is experiencing such an overwhelming dilemma (again, think of overt trauma, abuse, torture, etc.); but at other times, the individual’s crisis is not so apparent to an onlooker, though it is often all too apparent to the individual her/himself.
So we finally arrive at the final and perhaps most important question in this discussion: “Why would an individual’s psyche intentionally initiate psychosis?”
In other words, how can something as chaotic and as potentially harmful as psychosis act as a strategy to aid someone in transcending an otherwise irresolvable dilemma? To understand this, it helps to use as a metaphor the process of metamorphosis that takes place within the development of a butterfly. In order for a poorly resourced larva to transform into the much more highly resourced butterfly, it must first disintegrate at a very profound level, its entire physical structure becoming little more than amorphous fluid, before it can reintegrate into the fully developed and much more resourced form of a butterfly. In a similar way, when someone enters a state of psychosis, we can say that prior to the onset of psychosis, for whatever reason, they have arrived at a way of being in the world and experiencing of the world that is no longer sustainable (i.e., is poorly resourced), and it seems that their predicament cannot be resolved using more ordinary strategies. As a desperate last-resort strategy, then, one’s own psyche initiates a psychotic process. As the individual enters into a psychotic process, we can say that their very self, right down to the most fundamental levels of their being, undergoes a process of profound disintegration; and as we have seen in the recovery research, with the proper conditions and support, there is every possibility of their continuing on to profound reintegration and eventual reemergence as a renewed self in a significantly changed and more resourced state than that which existed prior to the psychosis.
This is why the intentional destabilization of one’s cognitive constructs may be so beneficial, although of course very risky. It is this very loosening of one’s personal paradigm—of one’s experience and understanding of one’s self and of the world—that allows an individual to undergo such a profound transformation at such a deep level of their being. When such a process resolves successfully, the potential amount of growth and/or healing that this allows is enormous; but of course, when such a process does not resolve successfully, an individual’s personal paradigm may remain unstable and chaotic indefinitely (think florid psychosis).
This idea is well supported in the recovery research in the findings that many people who make full recoveries from psychosis often experience a degree of wellbeing and ability to meet their needs that far exceeds that which existed prior to their psychosis (Arieti, 1978; House, 2001; Karon & VandenBos, 1996; Laing, 1967; May, 1977; Mindell, 2008; Mosher & Hendrix, 2004; Perry, 1999; Williams, 2011, 2012). It’s important to keep in mind, of course, that such resolution is not always successful, and that an individual may remain in a psychotic condition indefinitely. But we must also not lose sight of the very hopeful findings from the recovery research that suggest that such a successful resolution from a psychotic process is surprisingly common, and may even be the most common outcome given the proper conditions and support (Hopper et al., 2007; Seikkula et al., 2006).
Finally, one particularly compelling implication of these findings is that if it turns out to be true that those who have experienced psychosis have struggled profoundly with the universal existential dilemmas that most of us have only barely consciously grasped, then these individuals may have the potential to contribute greatly to the human quest to understand what it is that really drives us.
A much more thorough discussion of these and related topics can be found in Dr. Williams’ recently published book, Rethinking Madness (Sky’s Edge Publishing), which is available through Amazon.com and most other major retail outlets. More information is available at www.RethinkingMadness.com.
Arieti, S. (1978). On schizophrenia, phobias, depression, psychotherapy, and the farther shores of psychiatry. New York, NY: Brunner/Mazel.
Bassman, R. (2007). A fight to be: A psychologist’s experience from both sides of the locked door. New York, NY: Tantamount Press.
Beers, C. W. (1981). A mind that found itself. Pittsburgh, PA: University of Pittsburgh Press.
Dorman, D. (2003). Dante’s cure. New York, NY: Other Press.
Greenberg, J. (1964). I never promised you a rose garden. Chicago: Signet.
Hagen, B. F., Nixon, G., & Peters, T. (2010). The greater of two evils? How people with transformative psychotic experiences view psychotropic medications. Ethical Human Psychology and Psychiatry: An International Journal of Critical Inquiry, 12 (1), 44-59.
Hopper, K., Harrison, G., Janca, A., & Sartorius, N. (2007). Recovery from schizophrenia: An international perspective: A report from the WHO Collaborative Project, The International Study of schizophrenia. New York, NY: Oxford University Press
House, R. (2001). Psychopathology, psychosis and the kundalini: Postmodern perspectives on unusual subjective experience. In I. Clarke (Ed.), Psychosis and spirituality: Exploring the new frontier (pp. 75-89). London: Whurr Publishers.
Karen, R. K. (1994). Becoming attached: First relationships and how they shape our capacity to love. Oxford, UK: Oxford University Press.
Karon, B. P., & VandenBos, G. (1996). Psychotherapy of schizophrenia: The treatment of choice. Lanham, MD: Rowman & Littlefield Publishing, Inc.
Laing, R.D. (1967). The politics of experience. New York: Pantheon Books.
Mahler, M. S., Pine, F., & Bergman, A. (1973). The Psychological birth of the human infant. New York: Basic Books.
May, R. (1977). The meaning of anxiety. New York: W. W. Norton & Company.
Mindell. A. (2008). City shadows: Psychological interventions in psychiatry. New York, NY: Routledge.
Modrow, J. (2003). How to become a schizophrenic: The case against biological psychiatry. Lincoln, NE: Writers Club Press.
Mosher. L. R., & Hendrix, V. (with Fort, D. C.) (2004). Soteria: Through madness to deliverance. USA: Authors.
Nixon, G., Hagen, B. F., & Peters, T. (2009). Psychosis and transformation: A phenomenological inquiry. International Journal of Mental Health and Addiction. doi: 10.1007/s11469-009-9231-3
Nixon, G., Hagen, B. F., & Peters, T. (2010). Recovery from psychosis: A phenomenological inquiry. International Journal of Mental Health and Addiction. doi: 10.1007/s11469-010-9271-8
Perry, J. W. (1999). Trials of the visionary mind. State University of New York Press.
Rathus, S. A. (2006). Childhood and adolescence: Voyages in development. Belmont, Canada: Thompson Wadsworth.
Schore, A. N. (2002). Advances in neuropsychoanalysis, attachment theory, and trauma research: Implications for self psychology. Psychoanalytic Inquiry, 22, 433-484.
Seikkula, J., Aaltonen, J., Alakare, B., Haarakangas, K., Keränen, J., & Lehtinen, K.
(2006). Five-year experience of first-episode nonaffective psychosis in open-dialogue approach: Treatment principles, follow-up outcomes, and two case studies. Psychotherapy Research, 16 (2), 214-228. doi: 10.1080/10503300500268490.
Slade, A. (1999). Attachment theory and research: Implications for the theory and practice of individual psychotherapy with adults. In J. Cassidy & P. R. Shaver (Eds.), Handbook of attachment: Theory, research, and clinical applications (pp. 575-594). New York: Guilford press.
Wallin, D. J. (2007). Attachment in psychotherapy. New York: The Guilford Press.
Williams, P. (2011). A multiple-case study exploring personal paradigm shifts throughout the psychotic process from onset to full recovery. (Doctoral dissertation, Saybrook Graduate School and Research Center, 2011). Retrieved from http://gradworks.umi.com/34/54/3454336.html
Williams, P. (2012). Rethinking madness: Towards a paradigm shift in our understanding and treatment of psychosis. San Francisco: Sky’s Edge Publishing.
-- Paris Williams