by Al Galves, PhD

Schizophrenia is a devastating illness. It is extremely impairing to people, makes it difficult for them to connect with other people and to use their abilities in satisfying ways. It is scary and troubling to family members and loved ones who are typically unable to react to people in effective ways. We haven’t found a good way to treat schizophrenia. The conventional treatment is antipsychotic medicine. Using that treatment people recover at a rate of less than 10 percent.

Following are descriptions of three new treatments for schizophrenia that have higher recovery rates than the conventional treatment.

Soteria Houses

The first Soteria House operated in the San Francisco Bay Area from 1971 to 1983. It was a home-like residence that was designed to treat persons who were experiencing their first psychotic break.

Such persons could go to Soteria House and be safe both physically and psychologically as they went through the psychotic experience. There was no pressure on them to get better, get back on track or stop having those thoughts or hallucinations. Rather, they were told that they could stay there until they recovered and the staff would be with them and help them go through the experience they were having. The treatment was based on relationship and the goal was to help the person go through the experience in a safe place where they were understood, supported and affirmed and could slowly and steadily recover.

Most of the staff were trained peers and other non-professionals who were able to relate well with the residents and help them slowly to make sense out of what was going on, understand what had triggered it and begin to feel less agitated, upset and alienated. Although some of the residents were using psychotropic medication, medication was not used as a primary modality of treatment.  The primary modality of treatment was safety and affirming relationship.

The Director of the House was a licensed clinician and the House had a contract with a psychiatrist who provided services as needed.

Residents were involved in taking care of the house and cooking. As they were able, they began to participate in community activities, education, supported employment, recreation, therapy and other forms of community involvement. The typical resident would become stabilized in about six weeks and residents would stay at the house for an average of three months.

A well-done scientific study compared the outcomes of persons who were served at Soteria House with those who were treated in hospitals.¹ At one and two-year follow-ups the patients treated at Soteria House were doing significantly better in terms of symptoms, re-hospitalization, social functioning and employment status.  And the cost of Soteria House was one-third the cost of hospitalization.  Nevertheless, instead of testing other versions of the Soteria approach to treating psychosis, the NIMH shut it down, fired Loren Mosher, the psychiatrist who founded and directed it, and buried the data on it.

Since then, there is a Soteria house in Bern, Switzerland that has been operating since 1978. There was one in Anchorage, Alaska that operated from 2009 to 2016. There are four in Jerusalem and there is one in Burlington, Vermont that has been operation successfully since 2015. All of these Soteria houses report recovery rates that are much higher than recovery rates with conventional treatment.

Soteria Vermont is funded by the state of Vermont and operated by Pathways Vermont. You can learn about Soteria Vermont by going to www.pathwaysvermont.org, and clicking on “Soteria" link. The Soteria page includes a 10-minute video of testimonials by three young people who were treated for psychosis at Soteria Vermont and fully recovered. You can learn about the original Soteria house, Soteria Alaska and Soteria Israel by going to www.rethinkingpsychiatry.org and clicking on the “YouTube Channel” link.

Open Dialogue

The Open Dialogue Approach is a treatment for early psychotic episodes that was developed and is being used by Dr. Jakko Seikkula and his team in Finland. Here is the way it works:

At the first sign of a psychotic break – delusions, hallucinations, disorganized thinking, catatonia – a team of two or three providers meets quickly (within 48 hours) with the patient. They bring together a group of people who are involved in the patient’s life. This might include parents, grandparents, uncles, aunts, siblings, friends, teachers, bosses, boyfriend, girlfriend, spouse, etc. The treatment team facilitates meetings of the group – including the patient – every day or every other day for two or three weeks, as long as it takes to do the work. The treatment team works to create an environment in which people feel free to share their experiences of what has happened or to share their personal experiences that might be helpful. The team creates an environment of openness, tolerance of uncertainty and a focus on understanding. The goal is to develop some understanding of what has happened and what can be done to help. At opportune times, the treatment team stops the discussion and has a discussion among themselves, focusing on important and interesting things that have been said, encouraging more talk about the same and wondering about what has happened and what can be done about it. All treatment decisions are made in the presence of the entire group. The meetings continue until there is some resolution of the situation or it makes sense to stop meeting. Psychotropic medication is not part of the treatment approach. Medication may be used but only in dire circumstances and very judiciously.

Dr. Seikkula and his team have demonstrated a full recovery rate of about 80 percent of patients. The following is a research citation from a peer-reviewed journal: Seikkula, J et al. (2006). Five-year experience of first-episode nonaffective psychosis in open-dialogue approach. Psychotherapy Research 16(2), pp. 214-228.

American clinicians are now being trained in Open Dialogue and it is being used at the Howard Center in Vermont, Advocates, Inc., a community mental health center in western Massachusetts, the Parachute Project in New York City and Emory Medical School and Grady Memorial Hospital in Atlanta.

Other research findings can be found by entering “Open Dialogue” into search engines on the Internet.

Healing Homes

Healing Homes places persons diagnosed with psychotic disorders in homes of ordinary families. The families are provided with the training and supervision they need to provide a safe, affirming environment in which persons can go through the psychotic experience and recover. The patients become integral parts of the family, sometimes as in the case of farm families, working with the family.

Two therapists work as a team to help the person and the family. The family receives supervision from a therapist with whom it meets at least once every 14 days. The patients have a therapist with whom they meet at least once every 14 days and often more frequently than that. The families and the patients have the phone numbers of the therapists and are encouraged to call if they need to.

The family, patient and therapists meet together at least once a month.  Meetings based on the Open Dialogue approach are held as needed.  If desired by the patient, one of the therapist stays in close contact with the family of origin.

The program provides this service to adolescents and adults. It is run by the Family Care Foundation in Gothenburg, Sweden. The founder and the director of the program is Carina Hakansson.

For more information you can watch a feature-length documentary by Daniel Mackler by going to YouTube and entering “Daniel Mackler Healing Homes.” You can also learn more by searching for “Carina Hakansson Healing Homes" on the web.

Commentary

It is not surprising that the recovery rate with conventional treatment is less than 10 percent.  First, patients are told they have a brain disorder.  That is a very disempowering and cynical message.  What is a person going to do about a brain disorder?  The only options are antipsychotic medication and electroshock both of which are fraught with harmful “side effects.”  Then you tell the patient they are going to have to take antipsychotic medication for the rest of their lives.  That medication reduces the amount and impedes the processing of dopamine in the brain.  Dopamine is a neurotransmitter that is associated with vitality, creativity and reward.  So you are taking the life out of the person.  Antipsychotics are very powerful sedatives that take people down.  Sure, they may reduce the salience and intensity of the symptoms.  But they do it by dumbing down and tranquilizing the entire organism.  And if people take the antipsychotics for more than a year they are at risk of tardive dyskinesia (Parkinson’s-like symptoms), brain shrinkage, cognitive impairment, increased risk of diabetes and early death.  Again this is no surprise.  Parkinson’s disease is caused by a deficiency of dopamine in the brain.  The medicine for Parkinson’s is synthetic dopamine.  Psychiatrists will argue that the early death is a result of obesity, smoking and poor medical treatment.  But the association between neuroleptic medicine and early death is dose responsive.  The more neuroleptics a person takes, the earlier they die.

Soteria houses, Open Dialogue and Healing Homes are based on the understanding that schizophrenia is a move by a wounded psyche towards survival, healing and recovery.  Prior to the takeover of psychiatry by neuroscience and biological psychiatry, the conventional wisdom among American psychiatrists was that psychosis was a reaction to what a person had experienced, not a brain disorder.  John Weir Perry, a psychologist who worked in California in the 1950’s spent a lot of time interacting with people diagnosed with schizophrenia.  He wanted to understand what was going on in their psyches.  He came to believe that, as people who have been hurt, abused and rejected approach adulthood, “a change is initiated.”  Their psychic energy is attached to a more powerful but imaginary part of their psyches.  That enables them to survive in a toxic world with toxic human beings and, if they have an opportunity to develop healthy, nourishing relationships, gives them an opportunity to recover.  Many other keen observers of human functioning have similar beliefs:

Bert Karon, author of Psychotherapy of Schizophrenia: Treatment of Choice, believed that people who experience psychosis are terrified of the world and of human beings – usually for good reason.

Jack Rosberg, founder of the Anna Sippi Clinic in Pasadena, CA said “they have split from reality.  Their identity crisis leads to a dissolution of their identity.  So they go inward to find a place to regroup their defenses so they can survive the breakdown of their system.”

For Dan Fisher, psychiatric survivor, psychiatrist and first Executive Director of the National Empower Center, psychosis is a retreat into monologue as a result of overwhelm from stress or trauma.

Here is Paris Williams, psychiatric survivor, psychologist and author of Rethinking Madness: “Psychosis is an intrapsychic split experienced by someone who is terribly torn between a longing for freedom and autonomy, on one side and a longing for love, belonging and nourishing connection on the other, or; another way of seeing it – torn between a fear of loneliness and isolation, on one side and a fear of being oppressed or ‘losing oneself’ within relationship on the other.”

Frieda Fromm-Reichman, psychiatrist and long-time clinician at Chestnut Lodge, wrote that “psychosis occurs when a person becomes overwhelmed by a dilemma in which they both intensely long for and intensely fear the close, intimate relationship with another.”

For Gregory Bateson, anthropologist and author of Steps to an Ecology of Mind, "psychosis occurs when a child faces a ‘double bind’ in which the authority figures in the family set up conflicting injunctions so that it is impossible for the child to satisfy one without violating the other.  This causes such overwhelming distress in the child that s/he is forced into a kind of psychotic reaction as a strategy to tolerate this otherwise intolerable situation.”

R. D. Laing, psychiatrist and author of The Divided Self, saw psychosis as a special strategy that a person invents in order to live in an unlivable situation.  It is an attempt to communicate worries and concerns in a situation where that was not possible or not permitted.

Here is Alice Miller, Austrian psychologist and author of For Your Own Good: “You only have to do two things to create a mentally ill person. First, don’t let them be who they are. Second, when they get angry about that, don’t let them be angry.”

As John Weir Perry put it, the first message a person experiencing psychosis receives from the mental health system will make a big difference in their ability to recover.  If you are told you have a brain disorder and will have to take a medicine for the rest of your life, you have very limited options, you have little control over your future and you might have little hope for recovery.  If you are told you are going through a hard time, what you are experiencing has some meaning in your life and you will be helped to go through the experience, you will have a greater sense of agency and greater hope for recovery.

¹ Bola J & Mosher L. (2003). Treatment of acute psychosis without neuroleptics: Two-year outcomes from the Soteria project. The Journal of Nervous and Mental Disease. 191(4). Pp. 219 - 229

Dr. Galves is a clinical psychologist in New Mexico and Colorado. He has worked as a psychotherapist in community mental health centers, in health clinics, and as a school psychologist in public schools. He is a board member of MindFreedom International and the author of Harness Your Dark Side:  Mastering Jealousy, Rage, Frustration and Other Negative Emotions. Dr. Galves was the ISEPP Executive Director from 2011 to 2013.

Mad Camp is an innovative approach for those with extreme states and experiences, and who want support and understanding outside traditional psychiatry. The past two in 2023 and 2024 were each a resounding success. The 2025 schedule is July 3 - July 7 in Austria; and July 31 - August 4 in Middletown, California. Read more and sign up!

Read Mad in America's story about the program.

This past April, the FAA loosened its standards regarding pilots' use of antidepressants. However, "...expanding pilot use of antidepressants flies in the face of mounting evidence of serious adverse effects associated with antidepressants. There is ample reason to question whether any antidepressants should be approved for pilots."

Flying While Depressed? The FAA’s Troubling New Antidepressant Standards

Due to circumstances beyond our control, we had to cancel this year's conference.

Check out a new collective of ethical practitioners and consider joining. The Conscious Clinician Collective was recently launched. According to the website:

Our bold mission is to cultivate a community where individuals and families engage with ethical mental health specialists and ALL healthcare professionals dedicated to upholding the principles of informed consent, medical freedom, and respect for personal autonomy. In the face of widespread ideological and industrial deception, we will provide access to a spectrum of science-based health information across disciplines, empowering people to make informed decisions about their mental health and overall well-being.

by Niall McLaren, MBBS, FRANZCP

I have been having another round of to and fro with psychiatrists over whether ECT is “essential, helpful, safe, effective…” and all the other stuff the mainstream claims. My case is that, using figures supplied by ECT advocates themselves, it is crystal clear that every such claim is false.¹ The fact that there are parts of the world where it is banned and many other places where it is severely restricted or just not available shows that it isn’t essential. Psychiatrists use ECT because they like it, and they like it for a number of reasons:

1.      They believe that mental disorder is a biological disturbance of brain function that requires physical methods of treatment. This is an unproven ideological claim.²
2.      They have run out of options, don’t know what else to do. If so, they should get help from somebody who does know.
3.      ECT is terribly medical and helps bind psychiatry into mainstream medicine as the “science of mental disorder.” A technique does not make a science.
4.      For something that requires practically no intellectual effort, ECT pays very well, (currently $175.15 for briefly pressing something against an unconscious patient’s head).

Some less doctrinaire psychiatrists say: “I’m not keen on ECT but sometimes use it for treatment resistant depression or psychosis.” While what is now called treatment resistance is an old concept, it’s popped up again lately. It conflates three or more themes which should be seen separately.

The first sense of “treatment resistance” is also called “lack of insight.” This is the notion that a psychotic person doesn’t know that there are no voices coming from the air conditioning, or that there are no X-rays being beamed down from a geostationary satellite and so on. The person obviously believes it and has the experiences but, objectively, they’re not true. These people don’t believe they’re sick so, naturally enough, they’re resistant to the idea that they should be locked in a mental hospital and forced to take unpleasant drugs or have ECT. This is especially true for anybody who’s already experienced the boredom and infantilism of what CS Lewis likened to “hell on earth”:

Their very kindness stings with intolerable insult. To be ‘cured’ against one’s will and cured of states which we may not regard as disease is to be put on a level with those who have not yet reached the age of reason or those who never will; to be classed with infants, imbeciles, and domestic animals.

The issue here, which has never been explored properly, is whether detention with forced treatment is actually better than no treatment. Most people forget that involuntary treatment is a gross abuse of human rights. A person who commits murder has the inalienable right to a carefully managed trial with judge, jury, defence lawyers and so on, all provided per courtesy of the state. At the same time, another person who has broken no laws can be grabbed at home, wrestled to the ground, handcuffed, thrown in a police wagon, taken to a mental hospital, held down, stripped, injected and then held in solitary confinement with no right to speak to family or relatives, no phone, cigarettes, etc., just because somebody thinks “Oh, he's crazy.” Don’t say this doesn’t happen, it most certainly does.

Unsurprisingly, there are people who don’t want to be dragged off the street and slung into a nuthouse, but their anger at being treated as “infants, imbeciles, and domestic animals” is deemed “treatment resistance” by the psychiatrists. However, the peak human rights and health bodies in the world, the UN High Commissioner for Human Rights (HCHR) and World Health (WHO) have recently determined that all coercive and/or involuntary treatment is an unacceptable breach of human rights and should be phased out.³ Their carefully argued advice has run into another sort of resistance, the refusal of psychiatrists to recognise the need for progressive change, just as retired GP and historian of science, Robert Youngson, described:

The whole history of science, right up to the present, is a story of refusal to accept fundamental new ideas; of determined adherence to the status quo; of the invention of acceptable explanations, however ridiculous, for uncomfortable facts; of older people of scientific eminence dying in confirmed possession of their life-long beliefs; and of painful readjustment of younger people to new concepts.⁴

The second theme in “treatment resistance” comes from Sigmund Freud, the founder of psychoanalysis, who died 85 years ago. Freud’s idea of unconscious mental events was quite shocking at the time because humans (read: wealthy educated white men) liked to see themselves as fully rational and in control at all times. They didn’t like being told that a lot of what they did was driven by completely irrational impulses from the past that they couldn’t access. Psychoanalysis was directed at bringing these forbidden impulses to full consciousness but, Freud said, they were repressed by powerful ego mechanisms of defence. Therefore, the analyst had to work hard to overcome this resistance.

Let’s take an example from this morning’s Economist newsletter (July 1st, possibly a paywall) which states: “Australia is trying to buttress its defences to deter Chinese military aggression …” All the terribly sensible and realistic people in Canberra who take it in turns to decide which country is to be this week’s enemy would be deeply offended by being asked: “What aggression?” They believe that the world’s biggest economy and our major trading partner is such a grievous threat to this country that they have to spend hundreds of billions of dollars on weapons such as F-35s and nuclear submarines and mesh ourselves ever-deeper into the world’s biggest and most destructive military machine. Yet when asked for examples of Chinese aggression toward this country, they can’t provide any, just because there aren’t any. No Chinese troops or ships have served south of the equator since Admiral Zheng He’s expeditions in the thirties. To be clear, that’s the 1430s.

Any evidence that says China is not a threat is batted away without so much as the blink of an eyelid: it simply doesn’t penetrate what passes as their collective consciousness. Every attempt to get them to see that fact is resisted aggressively, which is precisely as Freud described it a hundred years ago. The ego mechanism of defence called “projection” sees to that. Projection means “attributing an impulse or emotion to another person when it is actually our own.” It’s usually negative, such as saying other people are aggressive when it’s really us who want to attack them, but it can be positive as in assuming everybody agrees with our likes or dislikes. Freud said the analyst must work hard to overcome treatment resistance, but that made it impossible to tell when the patient was telling the truth or was showing unconscious resistance. In practice, it was always the latter as the psychoanalyst was never wrong.  

The last types of resistance come from general medicine. When antibiotics were first discovered early last century, it wasn’t long before physicians became aware that the drugs quickly lost their effect on some bugs. It’s due to rapid genetic mutations which allow the bacteria to break the antibiotic down, rather than the other way round. Another physiological form of resistance is seen in diabetes, where cells become resistant to the effects of the glucose-lowering hormone, insulin. This is seen in obesity, in sedentary lifestyles, with certain sorts of medication, with a high fat-low fibre diet, or with various other medical conditions. Insulin resistance is real and is becoming more important. The best treatment is to exercise, lose weight and lay off the junk food, which is a hard sell to teenagers.

These forms of “medical resistance” are based in physiology and can readily be demonstrated in the laboratory. Antibiotic resistance is a very real problem as there’s evidence to show that resistance genes can spread from one species of bug to another. There are even breeds of insulin-resistant rats to keep researchers busy. But this is most definitely not in the same class of events as a person saying: “Stick your treatment, I’d rather look after myself.”

Mainstream medicine is built around the idea of safe treatment, as in “First, do no harm.” Medical treatments are very conventional for the simple reason that they work. Hundreds of thousands of cases establish what is the most effective therapy. If the standard treatment doesn’t work, the physician starts again: probe the history again, talk to the relatives, re-examine the patient, review the test results, get some more tests, revise the treatment and watch what happens. But, when treatment fails, unless there are compelling reasons, don’t blame the patient. This is where it differs from the idea of “treatment resistant mental disorder,” because not one of the people throwing this buzz phrase around has the slightest idea of the physiology of depression, or even whether it is the sort of thing that has a physiology. They may believe it, but they certainly can’t prove it, and it leads to conversations like this:

You’ve got MDD, major depression, which is a chemical imbalance of the brain. We’ll give you this antidepressant to fix it and you’ll get better” … “Oh, it hasn’t worked? Try this one” … “Two drugs haven’t worked? Right, that means you’ve got TRD, treatment resistant depression, we’ll book you for ECT.

When treatment fails, as it often does in psychiatry, the first consideration should be that the diagnosis is wrong, and the second that the treatment is wrong. This leads to a much bigger question: perhaps the entire approach is wrong. Perhaps what is called the “mental illness of depression” is not an illness in the sense that tonsillitis or diabetes are illnesses. Perhaps this medicalisation of emotions has gone too far, an idea explored in detail in The Loss of Sadness by sociologists Allan Horwitz and Jerome Wakefield,⁵ which explains why the drugs don’t work. If depression is a normal reaction to life events, and not an illness in any useful sense of the word, then there’s no reason to believe it will respond to drugs. “But,” mainstream psychiatry protests, “depression does respond to drugs, so that proves it’s an illness.” Maybe, but it also responds to the passage of time, to placebo (sugar pills), to support and consideration and, damn it, to exercise:

Following extensive research, exercise has emerged as an effective treatment for major depressive disorder, and it is now a recognised therapy alongside other interventions.⁶

My view is that depression is indeed a reaction to life events, specifically the class of events called ‘losses.’ The job of the psychiatrist (and psychologist, and social worker and nurse etc.) is to find out just which life events are causing the trouble. Sometimes the life events are in the recent past (bereavement, divorce, loss of job or health etc.); sometimes they are in the distant past; sometimes they are real and sometimes imaginary, but the most common cause of a recurrent or persistent depressive state is in the here and now: an unrecognised anxiety state. Anxiety wrecks lives, and if it’s bad enough, eventually the anxious person will reach the stage of saying “This is never going to get better, I give up.”

Trouble is, psychiatrists don’t think anxiety is serious. To them, it’s an also-ran, a “comorbid” diagnosis rather than a seriously disabling mental state in its own right that causes the sufferer to give up on life. We see the same thing with chronic pain: a young person with, say, a major back injury has to adjust to a dramatically downgraded life, and that directly causes a massive sense of loss. That misery is grief, not an independent “disease” called depression, and unless that sense of loss is resolved, leading to a new lifestyle, the misery won’t go away. However, modern psychiatry can’t take mental factors into account, so it invents a new “disease” called TRD. As the party line goes, new diseases must have a different genetic basis, meaning lots of research grants, papers, conferences and maybe even a promotion…

In reality, of course, the idea of treatment resistance is just another ruse for evading the critical point that psychiatry’s long-term project of hammering mental problems into the procrustean bed of their phantom “biomedical” model is going nowhere. Instead of admitting that they don’t have a model of mental disorder, and no theory of personality so they can’t take personality factors into account, and no theory of mind so they can’t integrate social factors, and no concept of mind-body integration so no idea of how pain or drugs might affect mental function … instead of admitting their personal and collective failure, they simply flip it upside down and blame the patient: “It’s him, he’s got treatment-resistant depression.” Rather, they should be saying: “Did I get it wrong? Do I really understand how this person got to be in this position today? I’d better start again.”

As the history of psychiatry shows in frightening detail,⁷ the psychiatrist is always in error but is never wrong. “Treatment resistance” is just another cloak thrown over lack of understanding. And lack of empathy.

¹ McLaren N (2017). Electroconvulsive Therapy: A Critical Perspective. Ethical Human Psychology and Psychiatry 19: 91-104.
² McLaren N (2013). Psychiatry as Ideology. Ethical Human Psychology and Psychiatry 15: 7-18.
³ UNHRC/WHO (2023): Mental health, human rights and legislation: guidance and practice. Geneva: WHO/UNHCR. https://www.who.int/publications/i/item/9789240080737
⁴ Youngson, R (1988). Scientific blunders: a brief history of how wrong scientists can sometimes be. London: Robinson. p. 293.
⁵ Horwitz AV, Wakefield JC (2007). The Loss of Sadness: how psychiatry transformed normal sorrow into Depressive Disorder. New York: Oxford University Press.
⁶ Malhi G, Byrow Y (2016). Exercising control over bipolar disorder. Evidence-Based Mental Health, 19:103-105
⁷ Scull A (2022) Desperate Remedies: Psychiatry and the mysteries of mental illness. London: Penguin.

Niall (Jock) McLaren is an Australian psychiatrist who recently retired after 50 years of practice. He has extensive experience in military, forensic and remote area psychiatry, all at the rough and unglamorous end of psychiatry. As a specialist, he went back to university to study philosophy and has published a number of monographs on the application of the philosophy of science to mental disorder, most recently brought together as the biocognitive model for psychiatry. This is based in the concept of natural dualism, and provides a working model for mental disorder as a primary psychological matter, with no reason to suspect brain pathology. He lives in the rural outskirts of Brisbane with his family and keeps busy growing trees.

Listen to Professor Healy's ideas about antidepressants and the place for truth in medicine.

by Chuck Ruby, PhD

On April 28, 2024, psychiatrist Awais Aftab ridiculed efforts to challenge the medical model in his blog post, "People Are Stumbling From One Misguided Narrative About the Medical Model to Another." In it, he discounted critical psychology/psychiatry criticisms about the orthodox mental health industry's insistence on turning personal distress and behaviors into illnesses rooted in individual dysfunction. The title of his post suggests those criticisms are clumsy and ignorant views of a "diverse and dynamic" matter.

He starts by explaining his displeasure with the term "medical model"; not necessarily the "medical" part of the term, but the "model" part. He complains that it "takes something diverse and dynamic—the theory and practice of medicine—and turns it into something circumscribed, fixed, and static...." He seems to be saying that we shouldn't establish models with which to understand phenomena. If this is so, he is supporting an unbridled mental health industry that has no bounds in its ever-increasing interest in overseeing the many problems we experience throughout life. This necessarily leads to a similarly boundless and unspecified construct of mental illness - it is what we say it is.

We can debate the legitimacy of models, and (in contrast to what Dr. Aftab seems to suggest) we can adjust them as we go so they fit the data and do not become "fixed and static." However, we must have models just as we must have definitions. If we didn't use them to "circumscribe" ideas, utter chaos would ensue when discussing the issues involved and any profession that renounced clear models and definitions would not be "circumscribed," allowing it to claim dominion over increasing swaths of human life.

This isn't just an academic matter. Such a boundless model being applied to the problems of human values, meaning, choice, distress, and action has grave consequences. If the alleged illness is of mental functioning, then the diagnosed person's grasp of reality and decision-making would be compromised. This invites the diagnosing clinical professionals to step in as arbiters of human freedom. I wouldn't have as much a problem with this model if those professionals honored their ethical obligation to provide full information to the person so affected, and then obtain that person's full consent prior to doing anything. But that is not the way it works in practice. There is only a token nod to informed consent. The claim that mentality is ill or dysfunctional is the foundation of the widespread coercion, lack of due process, authoritarianism, and human rights violations so common throughout the history of the mental health industry to this very day.

Dr. Aftab has a particular problem with the American Psychological Association's (APA) definition of the medical model (So do I, but for different reasons - see below). First, in contrast to the APA's definition that the medical model is "the concept that mental and emotional problems are analogous to biological problems," he thinks it “would be more accurate to say that the medical model considers mental and emotional problems to be analogous to problems encountered in general medicine."

But what problems are encountered in general medicine? Does this mean that any complaint brought by a patient to a GP is a matter for medicine? Keep in mind that people have long been trained by the mental health and drug industries to see mental disorder behind every distressing thing. Therefore, they are very likely to approach their GP with all sorts of problems merely because they hurt. This seems self-serving for the mental health industry since it means all feelings of unease, even those without a basis in individual dysfunction, are to be assessed and treated via the medical model, thus making medicine the expert in those problems. So, even though Dr. Aftab doesn't like the term "medical model," he uses it here, but defines it in a way that doesn't "circumscribe" the matters to which it applies.

His second concern with the APA's definition is its view that the medical model involves detectable and specific physiological causes. He says this "restricts the range of possible options... when in reality, medicine deals with a very wide range of problems." (italics in the original). As with his first concern with the APA's definition, as well as his hesitation with circumscribing medicine with a model, this one reveals his interest in removing walls that would form the boundary between medical problems and non-medical problems.

I'm not sure if Dr. Aftab's criticism of the APA's definition of the medical model assumes that those within the critical psychology/psychiatry movement agree with the APA. I know many who don't, and I am among them. The APA has become just as medicalized and paternalistic as the other APA (American Psychiatric Association). To us, the important issue with the medical model, as conventionally used, isn't that it points to biological problems or specific and detectable physiological causes.

Instead, our critique is against the unfounded claim that all experiential and behavioral problems in life are pathological and the result of internal dysfunction to be assessed (judged) and treated (corrected). This claim persists despite the fact that the alleged pathology and dysfunction in the individual has eluded scientific inquiry for more than two centuries. How many more centuries must pass without such evidence of pathological origins before the mental health industry gives up?

But wait, they are forced to give up when pathology is found. That is because in these instances, the illness becomes a target for neurology, endocrinology, nutritional science, or the other medical specialties regarding that real pathology. Ironically, as long as no evidence exists, conventional psychiatry, clinical psychology, and the other clinical professions can survive.

Furthermore, critical psychology/psychiatry does not deny the complexity of those problems that get diagnosed as mental disorder, just as we wouldn't deny the complexity of physiological pathology. And, as far as I know, we have never suggested that the physiology doesn’t affect psychology, or vice versa. But this reality doesn’t justify conflating the two and pulling them within the bailiwick of the mental health industry any more than it justifies giving the clinical professions dominion over politics and economics just because they are also determinants of human problems.

In his essay, Dr. Aftab uses the example of a recent story published in the Guardian about survivor Rose Cartwright to point out how people misunderstand the medical model (and, thus, criticisms of it are said to be "misguided"). Specifically, he claims that the model is popularly, yet falsely, thought to be an essentialist approach to mental disorder. This is the belief that each mental disorder category has an underlying essence, rooted in biological or psychological features. Each category has a unique essence common to all who are diagnosed with it.

But I know of no critical psychologist or psychiatrist who thinks this. In fact, we hold the opposite and reject the essentialist view. The different diagnostic categories seriously overlap, making it difficult if not impossible to use the specific DSM criteria to distinguish one from another. This is why the DSM's categories are admittedly unreliable and invalid.

Ms. Cartwright's revelation was not about essentialism. Instead, it was about finding out that OCD, and by extension all other mental disorders, weren't brain dysfunctions. According to her: “This is what I think is wrong with the medical model: a failure to understand mental health in context. An assumption that a disorder is a [pathological] ‘thing’ that an individual has, that can be measured, independent of subjective experience.”

It is commonplace within the conventional mental health industry, and characteristic of the medical model, to claim internal dysfunction responsible for a host of problems and research efforts have been underway to support this claim. However, as mentioned earlier, those efforts have consistently failed. At best, they have shown differences in physiology and psychology, not dysfunction or pathology. It is absurd to claim something is a medical matter based only on differences.

Demonstrating that the brains or genes of people who have been diagnosed with a mental disorder are different in function than those not diagnosed is not a demonstration of a dysfunction. Likewise, demonstrating a difference in psychological functioning between those with diagnoses and those without is not a demonstration of a dysfunction. To do so in either case would be to claim dysfunction in people for a plethora of otherwise normal things such as playing the piano, holding conservative political views, and regularly exercising. But despite this failure of psychiatric research, the “theories” have survived. In no other area of medical science has this happened and there are many examples when theories were discarded because they lacked evidence (e.g., animal magnetism, miasma theory, humorism).

Those of us in the critical psychology and psychiatry movement suggest that for anything to be legitimately handled with a medical model, it must at least have good theoretical grounding in an internal pathological process (the DSM euphemistically calls this “a dysfunction in the individual”) that is responsible for the illness, and that such theory survives ongoing research attempts to disprove it. Without this, the mental health industry opens the door to Orwellian control. Medical authorities step in where religious authorities once reigned, and where legal authorities fear to tread.

The conventional medical model makes a priori moral judgments about what actions and experiences are unwanted, inconvenient, or uncomfortable, and then it dubs them illnesses. Then it sits back and ignores the long line of research results that fail to support the notion of an internal dysfunction, perpetually claiming evidence is just around the corner.

Chuck Ruby, PhD, is a psychologist who has been in private practice for the past 25 years, after a 20-year career with the U.S. Air Force. You can read more about him at his personal website. He is the author of Smoke and Mirrors: How You Are Being Fooled About Mental Illness - An Insider's Warning to Consumers. Dr. Ruby is the past Chairperson of the Board for ISEPP and has been the Executive Director since 2015.

by Niall McLaren, MBBS, FRANZCP

by Al Galves, PhD

I have this desire to demystify mental illness.  Why is that?  What makes me want to demystify mental illness?  What makes me want to do it is my sense that over the past 20 or 30 years mental illness has taken on a mysterious quality.  It seems to me that people believe mental illness just comes on people, comes out of the blue, as if it is something alien to the person, something visited upon them, an alien visitation.

What makes me believe this is the case?  Here are three pieces of evidence:

The first is the case of Simon Biles.  Biles won the Olympic gold medal in female gymnastics at the 2018 winter games.  She was the best gymnast in the world.  At the 2022 winter games she was a member of the United States Olympic team.  She told her teammates that there was so much pressure on her that she was not going to be able to perform well and, therefore, was not going to perform.  In the aftermath of that decision, the word went out that she was suffering from a mental illness and everyone seemed to accept that.  But wait.  Why add the idea or belief that this is a mental illness?  What she did was perfectly understandable and “normal” without adding the trope of “mental illness” to it.  She was under a lot of stress, so much that it was going to affect her ability to perform.  What is the purpose of adding the idea of mental illness?  Does it take away some of her agency?  She couldn’t help it.  She was under the influence of a mental illness.  Does it absolve her of responsibility for her decision?  When the idea of “mental illness” is added to it, it takes on the patina of something other than a reasonable decision by a woman who is under a lot of pressure and believes it will affect her ability to perform well.

The second piece of evidence is a series of interviews I did.  This wasn’t a scientific sample.  I sat in the back of a coffee shop and offered to interview patrons about mental illness.  Some of the ten interviewees were friends.  I asked them what they thought caused mental illness.  All of them gave me some kind of physiological answer.  It was a brain disorder, a chemical imbalance, a genetic anomaly.  I then asked them what they thought had triggered the change in the brain, the chemistry, the genetics.  They hadn’t been mentally ill and then they were.  What had happened?  They all said something happened to the person.  But, I said, you just told me mental illness was caused by some physiological dynamic and now you’re telling me it is caused by something happening to the person.  What is it?  They were all non-plussed, taken aback, chastened.  So I asked them all the third question.  Do you think there is a difference between how a person is reacting to a life situation and to concerns she has about her life, on the one hand, and a diagnosable mental illness, on the other?  They all said “Yes”.

The third piece of evidence is reports I have read about the confusion of college students when they begin to feel down, depressed, agitated, manic, anxious.  When they begin to feel that way, they ask themselves: is this a response to my life situation, to what is going on in my life and my concerns about that or is this a mental illness?  They think there is a difference between those two things.
This is evidence of confusion in the general public about the nature of mental illness.  Is it a mysterious state of being that comes out of the blue, just happens to people and is caused by some kind of physiological dynamic?  Or is it a “normal” and understandable reaction to a person’s life situation, to concerns the person has about his life and himself, to what has happened to him?

This is not just an academic question.  How people understand the states of being, moods, emotions, thoughts, intentions and behaviors associated with diagnoses of mental illnesses is going to have a big impact on their lives.  It is going to determine how they understand themselves, how they manage themselves, the kind of treatment they seek.  And the kind of treatment they seek and receive is going to determine the degree to which they recover and go on to live healthy, productive and satisfying lives.

So there are two main ways in which we can understand the states of being, moods, thoughts, emotions and behaviors associated with diagnoses of mental illness.  We can understand them as caused by physiological dynamics, i.e. chemical imbalances, genetic anomalies, brain disorders, as coming out of the blue with no discernable connection to our lives or experiences, an alien visitation upon a person.  Or we can understand them as understandable and “normal” reactions to a person’s life experience, life situation and to concerns the person has about his or her life and self, i.e. as emotional distress, a life crisis, a difficult dilemma, a spiritual emergency, a manifestation of fear, terror and overwhelm.

What are the implications of those different ways of understanding mental illness?  For starters, there is a problem with understanding mental illness as essentially physiological in nature.  If you follow that belief out to its logical conclusion, you believe that human beings have no control over their thoughts, emotions, intentions, perceptions and behavior and, therefore, have no control over their lives.  The logic goes like this:

Mental illnesses are caused by brain disorders, chemical imbalances and genetic anomalies.

Mental illnesses are states of being, moods, emotions, thoughts, intentions and behaviors.

Therefore, states of being, moods, emotions, thoughts, intentions and behaviors are caused by brain disorders, chemical imbalances and genetic anomalies.

Human beings don’t have control over their brain function, biochemistry or genetic dynamics.

Therefore, human beings have no control over their states of being, moods, thoughts, intentions, emotions and behaviors.

Since human beings use their thoughts, emotions, intentions and behaviors to lead their lives, they have no control over their lives.

That is a very cynical and disempowering belief.  It takes away agency and leaves people at the mercy of forces over which they have no control.  It absolves people of responsibility for their lives and makes it less likely they will seek help in learning how to manage themselves in healthier ways.

If, on the other hand, people believe that mental illnesses are how they are reacting to their life situations and to concerns they have about themselves and their lives, they believe they do have control over their lives and are responsible for their behavior and are more likely to seek help in becoming healthier. 

Let me try to explain more about this idea that mental illnesses are how people are reacting to their life experience and life situation.  In order to be mentally healthy, people have to be able to love the way they want to love, express themselves the way they want to express themselves and enjoy life the way they want to enjoy life.  When they can’t do that, haven’t been able to do it for a long time and are afraid they’ll never be able to do it, when they suffer significant loss or feel extremely helpless and inadequate, they become agitated, manic, angry, panicked, obsessive, depressed, anxious and psychotic.  They become mentally ill.  There is nothing mysterious or alien about it.  It makes sense that when people are afraid they will never be able to live the way they want to live, afraid they are fundamentally flawed, inadequate, not smart, personable, strategic, connected enough to make it in this life, they would become depressed, anxious, panicky, manic, obsessive, unable to sleep, dissociated, even psychotic.  Of course, every human being is a unique individual so how a person reacts to her life situation and to concerns she has about herself and her life will be unique.  But the following are some general ideas about how life experiences and concerns are associated with mental illnesses:

Depression happens when a person loses something very valuable or has deep concerns about her life.  It doesn’t have to be the loss of a person.  It can also be the loss of a sense of security, a feeling of adequacy, a sense of certainty, a relationship, financial security, a job.  When a person has deep concerns about her life, depression can be helpful.  It forces the person to stop doing what they are doing, stop focusing outside in the world and, rather, take some time to focus inside, to deal in a serious way with issues of life. 

Social anxiety disorder happens when people don’t want to be around other people out of fear they will be rejected, put down, abused, misunderstood or fear about how they will react to any interaction.  In the case of one of my patients, her social anxiety was caused by the fact that, since she had been mistreated by people all of her life, she wanted to hurt other people and knew that wouldn’t work out well.

Mania occurs when a person has had a lot of pressure put on him to be very successful, exalted, outstanding and is unable to do that.  The manic episode gives the person the illusion of being very powerful, successful and exalted.  They can do anything and everything.  They are amazingly powerful, smart, capable. Or it may be a move out of the drudgery of everyday existence.  The person is tired of having to make the decisions we all have to make every day.  What am I going to do with my time, energy and money? The possibilities are endless.  But I can only do one thing at a time.  In a manic episode, the person believes he can do it all.  He doesn’t have to make those difficult choices.  For some people mania is an opportunity to get in touch with a divinity, with the divine nature of existence in which one doesn’t have to deal with the everyday world.

Panic disorder happens when a person is facing a difficult dilemma, a dilemma that doesn’t have a good solution.  It may have a better solution but not a good one.  It is such a difficult dilemma that the person doesn’t even want to be aware of it.  But the body is aware of it.  So the body gets revved up to deal with it and causes the symptoms of panic disorder.  Here’s an example - a woman came to see me with her husband.  She was suffering from panic attacks.  I asked her if there was anything going on in her life that could account for them.  She said “No.”  We kept on talking.  It turned out that her son was about to be involved in the invasion of Iraq.  He was a foot soldier, would be engaged in mortal battle, at serious risk of being killed.  When she said that she began to cry.  She cried for a long time.  I helped her to be aware of her fear, to be with it and give in to it.  She never came back in.

Obsessive-compulsive disorder happens when a person overcontrols what he can control as a way of repressing the fear of knowing that the things which can really hurt him are out of his control.  The obsessive behavior is a way of gaining the illusion of control.  The excessive hand washing, ordering and checking may be a way of dealing with the uncomfortable truth that we don’t have any control over the things that we really need to be afraid of.  We don’t, for example, have control over other drivers whose behavior may maim or kill us, over other kinds of accidents and disasters that are outside of our control, over the safety of an airplane flight when we are on one, even over dangerous illnesses such as heart attacks, strokes, cancer and diabetes.  So the repetitive behavior gives him the illusion of having control over things so that he doesn’t have to experience the discomfort of realizing that he actually doesn’t.

As for the intrusive thoughts, perhaps they are useful in that they enable a person to avoid having to take responsibility for making decisions and addressing the difficult, real problems of everyday life – dealing with love relationships, jobs, co-workers, bosses, children, financial difficulties, moral dilemmas, competing priorities.  Since we deal with these kinds of problems all the time, perhaps we lose sight of how difficult they can be.  They often involve conflict with other people.  They often require us to make decisions and choices that involve necessary losses and understandable regret.  Carl Jung one time defined mental illness as “the avoidance of suffering.”  Some human beings will go to great lengths to avoid dealing with the difficulties of the real world.

Post-Traumatic Stress Disorder (PTSD) happens when a person has an experience in which she thought she was going to die and was unable to fight back or escape.  The symptoms associated with PTSD - recurrent and intrusive recollections of the event, efforts to avoid, activities, places or people which arouse recollections of the event, feelings of detachment or estrangement from others, hypervigilance - appear to be designed to help the person avoid the psychic and physical pain of the traumatic experience and to avoid a reoccurrence of trauma.  They also appear to enable the person to relive the experience.  It makes sense that people would want to relive traumatic experience.  Typically, people who suffer trauma carry some (usually irrational) guilt about it, believing that they somehow contributed to it happening or that they could have done something about it.  Reliving the experience holds out the possibility of resolving the guilt or imagining a different outcome, somehow making more sense out of the incident and coming to a more realistic appraisal of it.

Psychosis happens when a person who has been hurt badly – discounted, dishonored, rejected, made to feel inadequate, abused physically, verbally, emotionally – attaches his psychic energy to a deeper, more powerful but imaginary part of his psyche.  That move which is initiated by a deeper, healthier part of the psyche than the rational part is a move towards survival, healing and recovery.  In the words of John Weir Perry, a psychologist who spent a lot of time trying to understand the psyches of persons diagnosed with schizophrenia, “the psychotic process puts this power-oriented form of the self through a transformation that awakens the potential for relationship and gives it its rightful place in the structure of the personality and in the style of life.”

What evidence is there to support this idea that mental illnesses are how people are reacting to their lives and to concerns they have about their lives and themselves?  Here is one piece of evidence.  People who have certain characteristics are more likely to be diagnosed with certain mental illnesses than other people.  So people who have the following characteristics are more likely or less likely to be diagnosed with depression than other people:

People who derive their sense of self-worth from social relationships and have experienced an interpersonal loss;

Women who use a ruminating style of thinking;

People who score low on self-esteem and high on stress;

Persons who score high on a Self-Defeating Personality Scale;

Persons who suffer from chronic pain;

Persons with more emotional strength and resiliency and a higher level of ego control are less likely to be depressed;

Persons who experienced poorer pre-morbid functioning – particularly adolescent social functioning.

The following are the characteristics of persons who are more likely to be diagnosed with bipolar disorder:

Difficulty in realistic goal-setting;

Low in persistence and conscientiousness, high in neuroticism and openness to experience on the Eysensenk Scale;

Low in self-complexity and, therefore, more susceptible to mood swings in response to live events – especially intensely dependent relationships which are disrupted;

Deficient in tasks  requiring response inhibition, delayed gratification and sustained attention;

The ability to hold antithetical and contradictory ideas or concepts in their minds at the same time;

Tendency to deny the experience and necessity of loss;

Tendency to see things as either black or white, good or bad, not able to see the greyness of things, thus vulnerable to extreme swings of mood in response to minor triggers in the environment;

Has been betrayed by a significant parent figure and is compelled to force the parent to love him again;

Has lost the esteem of a loved person and denies it through regression to a state of not having to make the choices that are required in maturation.

The following are the characteristics of people who are more likely to be diagnosed with psychosis than other people:

People who have suffered physical or sexual abuse, especially in childhood;

People who have experienced 7 or more adverse childhood experiences, i.e. childhood physical abuse, childhood sexual abuse, childhood emotional neglect, parental loss, mental illness in household, substance abuse in household, , criminality in household.

This is evidence that the experiences people have had and the personality characteristics which have resulted from those experiences have a significant impact on their chances of being diagnosed with a mental illness. This is evidence that the states of being, moods, behaviors, thoughts, intentions and emotions associated with diagnoses of mental illness are not alien visitations.  They are understandable and meaningful reactions to peoples’ life experiences, life situations and concerns they have about their lives, the world and themselves.

There is another reason why how people understand mental illness makes a difference.  How they understand mental illness determines the kind of treatment they seek.  If they think it is an alien visitation, something that came out of the blue, the result of a chemical imbalance, brain disorder or genetic anomaly, they are likely to seek treatment in the form of medication and less likely to seek treatment in the form of psychotherapy.  If they think it has something to do with their life and concerns they have about their life and themselves, they are more likely to seek psychotherapy for treatment.

In my opinion, the benefit-risk ratio of treatment with psychotherapy is much better than the benefit-risk ratio of treatment with medication (Full Disclosure: I am a psychotherapist).  Here is my assessment of those benefit-risk ratios:

Psychiatric medication may help you feel better, more alive or be less agitated and more grounded.  (But one might ask if it is a good idea to feel good when you have lost something very valuable or your life is a mess). On the risk side, you are likely to experience numbing of emotions, sexual dysfunction, akathisia, increased risk of suicide and violence and, in the case of antipsychotics, tardive dyskinesia (Parkinson’s) brain shrinkage, cognitive impairment, increased risk of diabetes and early death.  When and if you stop using the medication you are likely to relapse and/or have a difficult time withdrawing.

Effective psychotherapy will help you to learn about yourself and begin the lifelong task of developing a good relationship with yourself.  It may help you learn how to use your thoughts, emotions, intentions, perceptions and behavior to live more the way you want to live and provide you with self-management skills and knowledge you can use for the rest of your life.  On the risk side, you may go through some painful feelings, go down the wrong path for a while and waste some time and money.

On balance, it seems to me that the potential benefits of psychotherapy are so large that it becomes the much better option.

There is evidence that treatment with psychotherapy is more effective than treatment with medicine.  In the case of depression patients treated with psychotherapy and medicine report similar levels of improvement but the ones treated with psychotherapy have a much lower relapse rate and their improvement is more long-lasting.  In the case of people experiencing psychosis the evidence tells us that people who never take the medicine or stop taking it have a much higher rate of recovery than people who take the medicine and stay on it.

This battle between people who believe mental illnesses are essentially physiological and those who believe they are psychological has been going on for 250 years.  Given the present state of scientific sophistication, we are not able to determine through scientific investigation which is the most scientifically valid way of understanding mental illness.  Therefore, perhaps the best answer to this dilemma is one suggested by Bradley Lewis in his book Moving Beyond Prozac, DSM and the New Psychiatry: The Birth of Postpsychiatry.  When faced with research findings for which there are various interpretations, Lewis says, we should choose the interpretation which is associated with the best outcomes for patients.  We should take a practical approach in the good, old tradition of American pragmatism.

If we did that, we would clearly choose to understand the states of being, moods, thoughts, emotions, intentions and behaviors associated with the diagnoses of mental illnesses as reactions to life experiences and life circumstances and concerns that people have about their lives and themselves and we would treat them with various forms of psychotherapy.

Dr. Galves is a clinical psychologist in New Mexico and Colorado. He has worked as a psychotherapist in community mental health centers, in health clinics, and as a school psychologist in public schools. He is a board member of MindFreedom International and the author of Harness Your Dark Side:  Mastering Jealousy, Rage, Frustration and Other Negative Emotions. Dr. Galves was the ISEPP Executive Director from 2011 to 2013.