Hearing Voices? Or know someone who is?

August 17th, 2013

Having worked more than 2 decades in Mental Health Services, I am disappointed with the efficacy of antipsychotic drugs, and the overall cost-benefits for patients. I was spoilt early on by my exposure to the successes of family therapy, and later some other things.

I trust that there are some patients who have stunning improvements following the introduction of such medications.  However, they are likely to be a small percentage. I attended the workshop by Professor Doug Turkington (psychiatrist) in October 2012 [CBT for Critical/Command Hallucinations] – he thought that if antipsychotics were going to work, one would see the effect within 2 weeks, and about 30% of patients would get a good response “if they take them,” (but many dislike them, and do not willingly take them.) He also said that medications have very little effect on delusions.

Below I have posted a recent TED talk by Eleanor Longden, who talks about her recovery from serious problems which earned the diagnosis of schizophrenia.  She is intelligent and eloquent. She describes the journey from first hearing a voice, to the spiral into a life as a psychiatric patient, and a period of terror and torment.

Eleanor mentioned Intervoice, an organisation which promotes the use of groups for those who hear voices.  They do not try to eliminate the voices as if they were a pest.  Instead they promote dialogue with the voices, believing they are of value and hold important information one can learn from.  These groups can be in tandem with medication, or the only treatment.

I had earlier heard of Intervoice, following a short TV story about a “Hearing Voices” group in Victoria – below is a 3 minute clip showing the story.

Although not included in the clip, information on the website indicated, “many people who have previously been diagnosed with schizophrenia can – and do – safely withdraw from their medication once they have made sense of their experiences and found ways of dealing with them.”

These groups are just one way of intervening with serious problems involving voices.  I posted this so more people are aware there are more choices than antipsychotic drugs, and stories such as Eleanor’s may give families and professionals hope.

Although Intervoice was started by a psychiatrist, Professor Marius Romme, he does not favour using the term “schizophrenia,” as it is stigmatising and pessimistic.

For more information about Intervoice http://www.intervoiceonline.org/about-intervoice

Thanks.  Tom Blackford

Essay No 3. “Talking Therapy” Alternatives for Psychotic Disorders

January 9th, 2012


Many colleagues are not aware of authors who write and train in methods appropriate for psychotic disorders. Senior staff have told me they cannot believe that psychosis can be resolved without medication. Drug therapy dominates any talk of treatment for these disorders. This perpetuates the idea that these difficulties are somehow especially biologically caused and require medication. (Essay 5 will raise questions about the claimed efficacy of psychiatric medications.) This essay says there are approaches that could be included in the treatments offered by mental health services.

Apart from references to a few authors at the end, this paper is chiefly an extract of 10 pages from one book, detailing 2 case examples. They were enough to make me buy the book, which deals with a wide array of psychological disorders.

This essay is longer than the others, but is essential reading to understand that even psychotic disorders are changeable through talking therapy. Reading many examples from different family therapists has made me truly wonder why antipsychotics are ever tried first.

In the extract below, some information from previous chapters is assumed, so a greater understanding is gained by reading the whole book, which I heartily recommend.

Comment: Some may criticise the use of case studies such as those below, preferring “hard science.”  Elsewhere I refer to scientific studies. Here I offer the case studies to advertise that there are alternatives to medications, approaches that have theoretical underpinnings which are written down and taught. As colleagues do not talk about them, I presume they are not widely known.


Extract from “Knowing Through Changing: The Evolution of Brief Strategic Therapy,” by Giorgio Nardone & Claudette Portelli (Crown House Publishing, Wales, UK, 2005)

Presumed psychosis

We use the term presumed psychosis because we believe that often a wrong diagnosis of psychosis is conducted, and that it is this labelling that eventually “invents” the illness (Nardone and Portelli, 2005). From our point of view, to assume from the very beginning that a patient is psychotic means, to be caught up in a prophecy that sees no or very little possibility in treating the patient. We strongly believe that a therapist should always try to do something to alleviate the suffering of the patient and his / her loved ones, even when the case is considered clinically untreatable.

By saying it is a psychotic case, the therapist, like all the other agents around the patient, can be easily caught up by a consequential overwhelming feeling of helplessness. As Watzlawick used to say “Words are like bullets” — and they are, without doubt, responsible for the construction of one’s reality.

The word “presumed” sheds a ray of hope and thus one feels that something might still be done. Then, if the treatment works well and “the patient recovers from his psychotic symptoms, we can affirm that it was no case of psychosis, if not, at least we have tried our best to better the situation and often small positive changes still take place that help the patient and his beloved ones adjust better. But, again, we come to discover a problem by means of its solution: “Knowing through changing.”

At our Center we have had many diagnosed psychotic patients who have completely overcome their presumed psychosis. In saying this, we do not mean that we have healed psychotic patients, but only shown through successful therapies that these persons were not afflicted by a real psychosis but by invalidating symptoms defined as signs of psychosis in traditional nosographic classifications.

Having clarified this fundamental assumption, we can now proceed in presenting the phases of therapy in the treatment of these highly intimidating patients.

In the first stage of treatment, the most important therapeutic action is the complete acceptance of the distorted reality presented by the patient, as if it were actually real. In order to do this, the therapist needs to trace the logic of the patient and use his language. At a communicative, relational, and strategic level, the therapist needs to follow the patient’s narration of his reality, without alienating himself to what the patient is saying, and thus openly show that he acknowledges his suffering. This permits the therapist to establish a good and suggestive relationship with the patient and also with his family.

Once this is accomplished the first session goes into the second stage of therapy: to construct and introduce an invented reality, which realizes concrete results. In other words, the therapist must build a therapeutic representation usually followed by a ritual prescription that fits with the pathological patient’s perception and reaction, which drives it toward self-destruction.

This amounts to a strategic form of art on the therapist’s part, because he first has to follow the logic and structure of the patient’s representation of reality, then invent and introduce something tailored to patient’s non-ordinary logic, capable of achieving an effective change. This normally takes up the entire first session, so as to be able to make this new representation, based on the patient’s logic, more credible, more artistic and ”real” for the patient. The representations of reality, or the delusions, of patients with presumed psychosis follow a non-ordinary logic. To be able to alter their dysfunctional balance, we cannot disregard the patient’s delusions but, in devising therapeutic strategies, we need to use the non-ordinary logic that underlies these specific delusions. In other words, the therapist needs to follow the seemingly crazy logic that underlies the patient’s ideas and actions by inexplicitly showing the patient that what he is thinking and doing makes sense, while gently intervening by sowing seeds of doubt in what the patient has always held as absolute. This should be done with great caution so as not to dispel his delusions.” On the contrary, the therapist should make use of counter-delusions to introduce some different aspects that serve to divert the delusion toward a new, more functional balance but without driving out the old convictions.

Furthermore, we need to modify the dynamics within the patient’s interactive system with others and the world. This is carried out by the prescriptions such as the Conspiracy of Silence, the Nightly Family Ritual (both prescriptions have been already described in previous sections) and others, which help frustrate the secondary advantages offered by the symptoms.

The third and fourth stages of therapy are the same as previously described treatment protocols: guiding the person and the family to build a new balance based on the new reality after an often dramatic change. For the sake of clarification, we will use real clinical examples.

Riccardo, a shabbily dressed, bearded twenty-year-old, was brought to therapy by his father for his bizarre attitude, which had been diagnosed as “monomaniac behaviour.” Two years earlier he started attending university, where he joined the Socialist Revolutionary Political party, which became his sole and exclusive interest and encapsulated his entire existence. He left home, because he was truly convinced that the family was a social constriction that suffocated personal growth and self-fulfilment, to join party comrades at the university campus, but failed to attend lectures. His entire existence whirled around political issues and debates. He would isolate himself for days to study political treatises and texts.

[The classical definition of delusion is a false, personal belief, based on incorrect inferences regarding external reality, which is firmly upheld by the individual despite everyone else’s contrary beliefs.]

His conversations with family members and flatmates were monothematic. He would passionately lecture and try to convince others of his political ideologies, while losing his temper when others objected. He was hospitalized a number of times because he had undergone critical moments when his behaviour had gone out of control. His father tried to talk sense into him while his party comrades avoided him, annoyed by his bizarre behaviour and repetitive speeches. He came to therapy depressed but not defeated by his failed attempts to be taken back by the party.

This was a fundamental aspect that we recognized as useful so as to be able to divert the patient’s delusion to a more functional balance. This was the right lever to exploit, since he wanted, more than anything else in the world, to be taken back by the group. But the patient was convinced that to be reaccepted by the group he had to find more persuasive words. Thus, his attempted solutions were to study more about his ideology and then preach his knowledge to show his full commitment to the revolution and to the party. This was his conviction, his delusion. During the first session, it became clear that the patient would have done anything to be taken back by his party. We showed him that we could help him. And yet, following the logic of his delusion, we started sowing doubts about whether finding more persuasive words was actually the right way to be accepted back into the group.

Therapist: So the group does not want you anymore?

Patient: No, no.

Therapist: OK. But what are you doing so that you can get back to your group, so that you are accepted once more?

Patient: Yeah, in fact, that is what I need to understand.  I need to understand better what I need to do.

Therapist: Hmm, but what have you done till now so that they would take you back?

Patient: No, I mean, that is no…continuing in this way, for example, I don’t know, doing my best to diffuse the left-wing ideology in all schools, however, within normal limits, like others do, within normality…

Therapist: Hmm [nodding], and this is all that interests you? There is nothing else in your life?

Patient: Right now, no.

Therapist: So, when you can’t meet people, you have your texts, which you study in great depth so that you will be well up in them? Do you speak about your texts with anyone or you keep them to yourself?

Patient: Yes, I do, but then people speak less to me, they become rubber walls (an Italian expression meaning words just bounce back off people; people do not understand)  I come to face rubber walls.

Therapist: So, you try to speak to them but they refuse you, therefore the more you speak the more they refuse you.

Patient: It’s a great mess.

Therapist: So, correct me if I’m wrong but trying to convince them with words is the best way to draw them always more away from you?!

Patient: Yes, in fact

Therapist: However, for you, the desire to profess your faith, your ideology is uncontrollable or else you have come to understand that the more you speak the more this distances you from them. What do you think is best now?

Patient: Now it’s best to calm down a bit.

Therapist: Are you able to do so?

Patient: Yes. However, I manage quite poorly.

Therapist: Well, I’ll help, OK? [Pause] Well, when they keep you away, this provokes in you depressive moments, i.e. you feel bad that they ignore you or you get angry?

Patient: I get angry and bury myself in my books.

Therapist: As if like saying, “Since you people are like that, I’ll isolate myself and read, or else …”

Patient: Look for others.

Therapist: Others?

Patient: Yes, others, who knew what was happening in my life but who led their own tranquil life

Therapist: But these people listen to you for five minutes and then they send you away and tell you to go to hell.

Patient: Yes, they greet me, “Hi, Riccardo”—and that’s it.

Therapist: Or maybe even if they see you around, they would try to avoid you.

Father: He’s monothematic.

Therapist: Monothematic. However, you have come to comprehend that the more you run after them, the more they run away.

Patient: The more they run away.

Therapist: You said that you would like to speak up, state your case, but nobody is now willing to listen to you

Patient: Yes.

Therapist: Or else they listen to you for five minutes and then they tell you to go to hell? On the other hand when you talk to your dad, your dad discusses it with you? But after a while you will start to quarrel, true?

Father: We do not quarrel: we discuss.

Therapist: You start to quarrel because you [toward the father] are not so much in agreement with his ideas. You get into a sort of political debate and you clash

Father: [Nods.]

Therapist: OK, we would like you to follow our indications to the letter, that is, we would like you to allow a precise period of time for your orations. We would like you to give out a speech every day while [speaking to the father] you and your wife are in his presence. Therefore, what we would like you to do during the coming two weeks, every evening, you get together in your living room, you and your wife seated in absolute silence, you [pointing to the patient] standing. You set an alarm clock to ring after half an hour, because your speech should be managed within an adequate period of time and you, for half an hour, should carry out your speech on a chosen argument regarding  your ideology and for half an hour you have to stand there and give, out your speech—talk and talk.

You and your wife [referring to the father] should remain the entire half an hour in absolute silence. When the alarm rings, stop, it’s all over until the following evening you have to avoid to speech about your ideology and studies  you have to keep what we call conspiracy of silence: you [to the father] have to really avoid it if it happens that he starts speaking. Tell him, “Tell us about it this evening during the half an hour.” Postpone it. Riccardo, this goes for everyone. I mean, during the coming two weeks we would like you to restrict your need to speak about this important thing to the half-hour. Therefore, we would like you to avoid speaking about it with anyone–after all nobody really listens to you, they avoid you! But since you feel the need to express your faith, your belief, you will do so with them [pointing at the parents]; for now let us limit ourselves to at least educate them. Let us start off from this first stage so that we can then move onto the rest, you agree?

Patient: Yes, yes.

The following session, Riccardo reported that he followed the prescription and that every evening, in just half an hour, he managed to develop his speech and bring it to a closure. He also declared that, besides the half-hour oration, he did not try to persuade the world of the revolution. He said he kept at heart what we had said the previous session. So, on meeting his friends, especially a female friend, he avoided speaking about his revolutionary ideology and he noticed that people started to hang around with him more.

The prescription also changed the family dynamic. Both Riccardo and his dad said that they had more tranquil days, when they spoke about sport, cinema, university, and other topics that had hitherto always been put aside to leave space for their usual political debates. At the end of the second session Riccardo was invited to continue giving out his speeches during the half-hour once a day, underlying their fundamental didactic purpose, while keeping a silence throughout the rest of the day just as he had managed to do so far. Furthermore, he was asked to carry out an experiment. We told him, “At a specific hour of the day, which you are free to choose, we want you to ask yourself, ‘What would I do with my time if I were no longer interested in my revolution project? How would I spend my time differently from what I do now, if I were no longer interested in the revolution?’ And for an hour every day, not more than an hour, carry it out. Let’s see what you would choose to do for an hour a day, just an hour, not more, as if you were no longer interested in the revolution.”

The patient arrived at the third session gladly itemizing all the new things he managed to do during the past two weeks. He confessed that he even had a date with a girl he liked, when they spent a pleasant evening talking about sweet nothings. Furthermore, during the last Week, he felt the need to start reading other books such as novels.

Even though the as-if prescription was limited to just an hour a day, it triggered off what Thom (1990) has called the “butterfly effect” (which we touched on earlier) throughout the patient’s entire daily routine. At the end of the session he claimed that, even though he was still loyal to his ideals, he thought that, every now and then, one had to take one’s mind off things.

Patient: Well, observing other people’s daily activities, even though they have not taken big life decisions-—however, they have chosen their life—each one of them has an occupation or something else .. . but they try to take their minds off it by doing something else. For me life was just commitment to my ideals and that’s it. Then I tried to understand what other people do in their free time, go to the cinema, read novels and magazines…

Therapist: Therefore, what you are saying is that what you previously considered as anti-revolutionary miseries now you look at them differently?

Patient: That is, not as anti-revolutionary but as a form of distracting, uninterested attitude;  now I’m trying to be more interested in art, there are so many beautiful things here in Tuscany, even in Arezzo, Piero della Francesca…

Therapist: Not only, Poliziano and others.

Patient: I know. In fact this brings to mind even linking this to the commitment of certain historical leaders such as Trotsky and Lenin when they visited London. Lenin said, “Look, Westminster, it is wonderful.” But Trotsky showed no interest: “No, I want to look at Russia… just let me be.” He did not want to see…

Therapist: He did not want to see beyond his ideology. Therefore, you mean that your boundaries are getting elastic, more flexible?

Patient: Yes, a bit, yes.

During the following sessions, Riccardo reported that he went back to university, that he was dating other girls and that he no longer needed the half-hour podium. At home they finally had pleasant conversations. Every time, we acknowledged Riccardo’s good work but suggested he continue with the prescriptions, each time increasing the length of the as-if session by an hour. This was fundamental at this stage, where we needed not to be blinded by results but work to consolidate the results achieved so far.

At the fifth session, we asked him to continue observing others just as anthropologists do, so that he would get to know more about others, especially about the female world, so that he would come to understand better what to do to enhance his practical capability. We also started working on his appearance, which still had something of the “revolutionary” about it, giving him some problems when he approached others. He was very rather taken by Oscar Wilde’s maxim that it is only superficial people who don’t judge by appearances. A “new” Riccardo arrived at the next session: he had shaved his beard, trimmed his hair and wore a clean T-shirt and a pair of denim jeans; he also looked and behaved his age, as a handsome, pleasant twenty-year-old.

Another exemplary case is of another twenty-year-old (whom we shall call Roberto) who arrived at our centre with his parents after having been to various specialists in the field, who held divergent opinions and diagnoses of his “mental state.” For more than five years, Roberto had segregated himself within a sector of his parents’ mansion because he feared that certain people such as the handicapped, old people, and also his own brother would draw “beneficial energy” out of him. So, he avoided all sort of contact with the outside world and the few times he eventually went out he would perform some sort of “preventive ritual” before leaving the house and then a “repairing ritual” on his return to block the “draining process.” But, since his brother still lived at home with them, for Roberto the danger was also inside the house, so the family—-even though at first they tried to convince him of how much his brother loved him and that he should not be afraid of him—finally gave up and proceeded partitioned the house to prevent the two brothers from meeting.

However, the curious aspect of this case was that therapy began before our first encounter. Before coming to us, Roberto had read various books about our approach and. treatment and so, in the time span between his call to fix the appointment and our actual meeting, he had tried to face his fear and embraced his brother, but this frightened him even more, so he had decided not to do it again.

Once more, our intervention was first to follow the patient’s seemingly “crazy logic,” enter his delusion by utilizing his same language, identify the attempted solutions put into operation by the patient and also by the family that maintained and worsened the situation, and then proceed to block the attempted solutions, by sowing a seed of doubt in the patient’s convictions, and then proceed to find a creative yet credible way of turning the logic against itself.

Therapist: And yet you did something you were afraid to do before: you touched and embraced your brother and he did not drain all your beneficial energy? How do you explain this?

Patient: I don’t know.

Therapist: Therefore, you have, till now, held a wrong idea. Until now, you have protected yourself from him. You could not even stand to see him, thinking that if you touched him he would suck out your beneficial energy. Now you have touched him and nothing happened on the contrary you we able to hold it back, true? Let me explain to you one thing. In such situations as this, when you feel that some sort of osmosis takes place, where beneficial energy passes from you to your brother—OK?—what one tends to rationally do is to think, “I need to defend myself by avoiding such situations; therefore, I need to avoid him; I should avoid to touch him, to even look at him.” Or, better still, you have come to practice total avoidance.

Patient: What?

Therapist: You had come to a point where you had constructed extreme evasion  you could not even stand to see. Unfortunately, this rational reaction does not function. Because, in case of energy influx, the more you run away, the more energy gets lost.  So if you want to learn how to keep your beneficial energy, you need to gradually start doing the very opposite … the more you avoid the feared situation – that is the more you avoid your brother, afraid that he would drain energy from you, the more energy will get lost by itself and passes on to him. In fact, when you embraced your brother, you did not lose all your beneficial energy, true?

Patient: No, I did not lose all my energy.

Therapist: OK.

Patient: But then I decided not to embrace him anymore because when I was in the car getting here, I thought about my brother and energy escaped out of me.

Therapist: Be careful! It escaped without his being present. You have imagined it. Once more you did everything by yourself. Just think that during the past years, in reality, you’ve built your own trap, which you’ve got into but can’t get out of. ln what way? By avoiding confronting something that could have enabled you to hold in your beneficial energy. Instead, running away has made you weaker and weaker, so weak that energy gets lost by itself. Now to fortify yourself we are very glad that we can start doing this with you from today because you have already set in motion a great change while you were waiting to come here. You have spontaneously found your way out. Now we have to proceed without getting frightened and return to the trap. In these days, you have to get used to gradually holding within you your beneficial energy, by gradually coming into contact with your brother. From now till the next time we meet, we would like you, every morning, to wake up and embrace your brother before he goes to work. OK? When he gets back, embrace him once more and then before going to bed. You have to keep in mind that this is the first step, which you discovered spontaneously, in starting to hold in your energy. By running way-

Patient: But I have to give him my energy?

Therapist: No, you will hold it within you. This will help you keep it for yourself and not give it to him. Before, by running away, by hiding, by avoiding contact, you were always making yourself weaker and weaker and energy passed to him. You are right in wanting to keep your energy and the attention of your parents to yourself. He has his own, he has other things and the same goes for the outside world.  Do the same thing, OK? Besides this ritual, you [addressing the parents] should avoid—from now till the time we meet again—talking or asking about his fears. The more you speak about it, the more you work together to overcome it, the weaker Roberto becomes. So, throughout the day, you should keep what we call conspiracy of silence. You should avoid speaking about his fear and difficulties, or else this will exacerbate them, OK? You will get weaker and beneficial energy will get lost. But in the evenings, after dinner, get together all the family in the living room, get an alarm clock and set it to ring after half an hour, during which you [to the parents] will remain seated in absolute silence, and you, Roberto, standing. You will tell them all about the fears you felt throughout that day, all your worries, all those things that disturbed you. You [referring to the parents] should listen in absolute silence. When the alarm rings, stop—it is all over. Until the following evening avoid speaking about it.

Mother: There has to be his brother too?

Therapist: I would prefer the brother to be present too so that in this way you fortify yourself even more…  OK? And why not? In this way we send him some unbeneficial energy, the other type … no? [Everyone bursts into laughter.] But do not let him know, OK? We won’t tell him.

Patient: OK, we won’t tell him [laughing].

The family arrived the next session overwhelmed by the “miraculous” change that took place. They reported that Roberto carried out the (counter-) ritual three times a day throughout the entire two weeks, without fearing his brother; on the contrary, Roberto starting looking forward to his brother’s return from work, when they spent time chatting, watching TV, playing with videogames, etc. Furthermore, from the following session, Roberto was seen alone in therapy, and reported that he had started going out, going to the gym (with his mum), and to mass, and was eager to go back to school the following academic year. On one of his outings, he had met a disabled child whom he hugged lovingly, and, in therapy, he exclaimed that he could not understand why he used to fear handicapped people – they were so unfortunate and yet so caring. The rest of the therapy focused on establishing a new, more functional equilibrium both for Roberto and for the entire family. It is necessary to consolidate successes that have already been gained, so, by the end of the ten sessions, we had started working with the patient in developing social skills.

These clinical examples show that even such severe disorders can be treated in a short time, without recourse to traditional therapy. We do not “eliminate the delusion” but direct it toward its self-destruction. The principle that forms the basis of our treatment with presumed psychosis is “to add so as to reduce.” Our intervention aims to circumvent the patient’s resistance (Type 4 resistance – patient unable to collaborate) and to lead him to change his perception of reality. We use his own logic and mode of representing reality, and lead him through a series of “corrective” emotional experiences, until he begins to doubt his previously inflexible convictions.

As Goethe wrote, things are actually much simpler than one might think, but much more complicated than one might realize.

(End of extract)

A few resources

Elsewhere on my site you will find a case study of a client I assisted – she was diagnosed with Schizo-Affective Disorder. I utilised a systemic approach for psychosis, described by Jay Haley, a prominent American family therapist. [Ref: “Leaving Home: The Therapy of Disturbed Young People,” Second Edition, Brunner/Mazel, 1997.]

[Cloe Madanes also wrote describing that approach: “The Prevention of Rehospitalization of Adolescents and Young Adults,” Family Process, 1980. pp 179-191.]

http://www.isps.org/  This site is “The International Society for the Psychological Treatments of the Schizophrenias and Other Psychoses.” It has many resources, including links to numerous published books for professionals and consumers.

“A Way Out of Madness: Dealing with your family after you’ve been diagnosed with a psychiatric disorder,” by Daniel Mackler & Matthew Morrissey, 2010. This book can be found at the US branch – http://www.isps-us.org/  The stated purpose of the book is a “guidebook to help people diagnosed with psychiatric disorders to deal more effectively with their families…”  The second half has stories from 12 contributors, mostly who have been consumers with diagnoses of schizophrenia or bipolar disorder. All have freed themselves from the psychiatric system and medications, some after very long involvements. For those who do not believe people can do well without medications could benefit from reading these stories. And many clients will find hope from such examples.

(Go to essay 4.)

Essay 10. Summary & Conclusion to Essays on Constructivism.

January 9th, 2012

In summary, the purpose of these essays was to explain constructivism, and show something of the vast therapeutic interventions that arise from that perspective.


My first essay explained constructivism by referring to the anecdote of the three umpires.  It highlighted that we make ‘reality’ by the parts of experience we select, emphasize and describe.


Next a case study showed the grave error of diagnosing a client (Josie) with schizophrenia, an error which is a direct consequence of not understanding constructivism.


The third and fourth essays gathered examples of therapy that I do not hear discussed in mental health services. They reveal more possibilities when working with those diagnosed with psychosis and other disorders.


The fifth essay raised questions about the efficacy of psychiatric medications. It suggested that review articles and meta-analyses are more trustworthy than individual studies. It encourages people to examine claims of efficacy rather than believing the information we are given is accurate and unbiased.


Essay six returns to constructivism. It questions the objectivity of psychiatric diagnoses, and uses more examples of therapy to show why therapy should be favoured as the first choice of treatment.


Essay seven summarises some of the harm that arises from the biological paradigm, and adds that we should be honest with clients about the diverse views regarding medication in this field.


Essay eight explains there are errors in thinking, which easily occur and lead people to think psychiatric medications are more effective than they are. Promoting medications, particularly as a first choice may diminish clients’ belief in their own capabilities.


Essay nine highlights the famous Pseudo-patient study and reminds us of the message of constructivism, that psychiatric labels are not objective and reliable. Doing without them might remove a cause of harm, and promote a focus on behaviours and difficulties, which are more solvable than an alleged ‘illness.’



I encourage you to spend 15 minutes watching the story this link takes you to…

Caroline Casey, talks about her life. She is inspiring and courageous. She shares something she discovered about herself at age 17 – it is amazing, unimaginable, and challenging. There are lessons for the listener about disability and how we handle it, and what we aim for in our lives. [Warning: the TED website is addictive!]


I wonder what it would be like to have this and similar stories playing in the waiting rooms of mental health offices; or run group discussions about finding meaning in our lives, about doing things regardless of disability, contributing to people’s lives.

Mental health services label people, causing harm. People are capable of so much more than the labels we give. Rather than correct what some claim to be some biological fault, how can we inspire them to dream of doing more?

If we see a person as a schizophrenic, (or “a person with schizophrenia”), we have already built a construction in our mind (and our client’s) of limitation.

If you have skipped over Caroline Casey’s talk, stop and listen to it now…J

People have the capacity to surprise us again and again. When we keep that alive in our minds, we can help them surprise us, and perhaps even themselves.

More than once a week (though it seems like a daily occurrence as I am much sensitised to this constructivist error) I hear staff in mental health services comment that one of the patients is refusing to admit s/he has a mental illness, which usually means s/he is reluctant to take medication. As with the pseudo patient study (Essay 9), patients are often required to conform to a belief system in order to gain something (eg discharge from hospital, support.)

Constructivism tells us ‘mental illness’ is just a construct, preferred by some… generally by those who have authority to control patients.  This of course can lead to a struggle…staff may struggle to convince patients they are ‘ill’; patients may struggle to convince staff they are not. How do we maximise our connection with patients rather than battling to make them comply with a belief?

Struggles like these lose opportunities to collaborate in non-medication therapies that are consistent with constructivism. Struggles lose chances of engaging in discussions about meaning and passion that Caroline Casey’s talk illustrates. Clients who do not believe they are ‘ill’ have differing beliefs. There are many choices for collaborating on a meaningful and happier life.

I have written these essays, not as a final word, but rather a beginning. I wish constructivism becomes part of everyday thinking in mental health services.  I wish we focus on people’s potential, keep exploring new ways to intervene, and inspire one another through our discoveries.

Solutions for everyone’s problems are not as simple as reading some essays or books. But these essays are to highlight information that is increasingly circulated.

By presenting stories of uncommon therapy examples I want to show possibilities.

If some practitioners get great results with therapy, how might we also achieve this with our clients? A small percentage of our workforce is devoted to exploring these? How much more can we achieve, if more are trained and encouraging each other?

What You Can Do

You can circulate these articles to your colleagues for broader discussion.

These articles will soon be posted onto www.tomblackford.com.au  where there are further articles.

You can encourage discussion of such ideas in your professional training meetings.

Perhaps agencies could enlist the services of leading therapists (eg Nardone) to demonstrate and train staff; the costs could be recouped if just a few clients avoided a lifetime career as psychiatric patients.

I am interested to receive emails to let me know what you are doing, and what ideas you have for disseminating these ideas further.   Email: tblack01@gmail.com

At some point I may suggest a meeting of those interested, to exchange information, concerns, resources and ideas about how the public mental health services can be impacted by such perspectives. So let me know if you would like to be contacted.

Thankyou for reading.

Essay No 9. Can you Tell Who Has A Mental Illness?

January 9th, 2012


Can we tell who has a ‘mental illness’ or not? That was the question raised in a famous psychology experiment in 1969. It showed how poorly the experts can tell. Read part of my speech below, given at a public speaking club. Most of the content of the speech was taken from information you can find on YouTube by searching “David Rosenham experiment” and related videos.


Extract from my speech, entitled, “The Pseudo Patient Study”

Imagine yourself as David Rosenhan, a psychologist in 1969, sitting around with friends saying, “I have an idea for an experiment. I will get 8 volunteers to join me, and each go to a different psychiatric hospital and say we are hearing a voice, which says a single word, Thud, or Empty, or Dull. We’ll say it in a way that convinces them that it is real and a concern, and see if you get admitted. After you get admitted, say that it has stopped and see what happens?”

So he and his volunteers went ahead and did this. Other friends were concerned but he said, “I’ll be all right; I can get out as soon as I want to.” He did not realise he would be in there nearly 2 months. All the pseudo patients were admitted; one was diagnosed with Bipolar Disorder and the rest with Schizophrenia. They were all prescribed antipsychotic medication.

After admission, the pseudo patients acted normally and told staff they had not experienced any more auditory hallucinations. Instead staff believed all patients exhibited symptoms of ongoing mental illness.

When they did tell staff why they were there, they were not believed. The pseudo patients openly kept notes on the staff’s behaviour but this was just seen as odd. They were kept in from 8 – 52 days; the average was 19 days. Their instructions were to get out without outside help. Eventually they realised to get out they had to agree with the doctors they were ill, but they were getting better; and they promised to continue taking their medication after release. All were released as being in remission; none were judged as sane.

Of the 8 pseudo patients, one was a psychiatrist, another was a paediatrician, 3 were psychologists, and Rosenhan said none had any psychiatric condition.

One moral of this story is never volunteer for a psychology experiment!

More importantly, this was pointing out that psychiatry is not very good at judging people – since they expect to see mental illness, they see it everywhere. They are loath to regard people as normal, a thought I have occasionally in clinical meetings I attend.

After Rosenhan reported his experiment, one psychiatric hospital boasted he could not do that with them; they could spot phony patients. So with their agreement he arranged over a 3 month period to send pseudo patients there to see if they were better at detecting them. He asked them to rate how certain they were. Of 193 patients, they considered 41 as imposters, and a further 42 as suspects. He then revealed he had sent none! This time they were identifying a large number of regular patients as imposters.


The American Psychiatric Association was embarrassed and publicly angry. They worked to tighten their criteria so they could differentiate between those with real problems and others. At least that is what they would have you believe. Are they any better at telling normal from abnormal?

Last year (2010) on Australian TV there was a BBC show, “How Mad Are You?” They gathered 5 people who had a psychiatric diagnosis, and 5 with none; then they got them to do some tasks (5 minute stand-up comedy to the group; and cleaning out a cow-shed) and asked the panel of 3 mental health experts to observe them. They identified 2 patients correctly, gave another an incorrect diagnosis, and incorrectly diagnosed 2 people who had no diagnosis. [My speech continued but is not relevant to this article.]


It is tricky to use psychiatric labels – they are not that objective really. They amount to deciding how strange or different is abnormal. In this age of Ethics committees and financial restraints, David Rosenhan’s experiment will never be repeated. The BBC program is the closest that will be devised. My impression however, is that many patients still experience the need to admit they have a mental illness, and must promise they will continue with their medications in order to be discharged from hospital.

From the perspective of constructivism this is a gross error. It is elevating one belief system (that of the professional) above another (the client’s) on the basis that one group has more power than another. There is the presumption of objective reality and the professionals are right. Rosenhan’s experiment cautions us on the danger in such thinking.

(Go to Summary & Conclusion, essay 10.)



Essay No 8. Regarding Psychiatric Medications

January 9th, 2012


It is easy to be misled into thinking that medications work, especially as it is in the interests of drug companies to make it seem so. Hence clinical trials are the attempt to use science to determine if they work.  Drawing conclusions on the basis of personal experiences with individual clients is risky. Below are some considerations.

Possible Errors in Thinking

1. Some staff are convinced antipsychotic medication works for the following reason.  Following use of these medications staff see a reduction in symptoms; the presumption is the medication caused it – possibly so.  Or there can be a different explanation.

Some family therapists posit there are times the person being labelled as sick stabilises a fragile family or marital situation (as described in my article, “There’s an Underlying Biological Illness,” http://www.tomblackford.com.au/2011/04/24/theres-an-underlying-biological-illness/ ) By labelling a symptomatic individual as ‘ill’ and medicating him/her, the focus is changed; the original crisis (often hidden) in the family is postponed while they attend to a more immediate concern.  This may stabilise the situation for months, but if the patient returns to normal behaviour the original crisis returns. Where they are still unable to manage it, the patient may relapse so the family once again focuses on him/her.  If the hidden crisis is not addressed successfully, the person labelled as a patient may become locked into the role of a sick person.

The above explanation is only a theory, just as medication improving symptoms is only a theory. I point out there are different theories, so one will recognise that occasional successes with psychiatric medications do not prove there is a biological illness.

2. Doctors might believe a medication is working because the patient may report a reduction in a symptom. That sounds good, especially if the client is happy.  However, if they are not living their life more functionally is it necessarily a success? For example, if they are now sleeping and they don’t feel so dreadful, but they have headaches, dizziness or fatigue, to the point they still stay at home, isolated and bored, do we claim progress in treating the depression?

I think it is just human that we cannot pay attention to many difficulties at the same time. If you were deeply troubled by some relationship difficulty, but then broke your leg and you suddenly could not earn money, most people would be consumed by the pain and financial worry. Most likely the original trouble would take a lower priority. With patients, they can sometimes exchange symptoms for side-effects, which is not necessarily progress.

Yet I hear doctors tell patients they are getting better, and just need to find a way to manage the side-effect; or perhaps to change to another medication with tolerable side-effects. Sometimes after 12 months of treatment they are still trying to find a suitable medication. They eventually may settle for the best compromise, but are they living life well? I wonder would they be just as good with no medication, or learning ‘mindfulness’, or exercising more?

3. I hear psychiatrists say, “S/he has been depressed for years; you can’t expect the medication will work immediately.” Or, “her delusions are less intense,” implying improvement (but still delusional, and perhaps only given up talking about them to people who don’t believe them.)  Or, “we know it works; s/he just cannot tolerate a high enough dose.” It seems unacceptable to conclude it doesn’t work, so medications once started are rarely stopped. Usually they are added to, premised on the belief of proven efficacy.

Perhaps a Different Standard is Required

Contrast the above with Jay Haley’s personal standard. (He was a noted family therapist.) Early in his career he dismissed his own talking therapy as proven if he took many months to solve a person’s depression.  He noted that the person might have changed work, a relationship, or other important circumstances. Those could equally be the cause of improvement. Hence he focused on developing brief therapy methods. If these interventions caused lasting change in a short number of weeks then he felt successful.  Essays 3 & 4 show there are tools for serious problems that might well be tried before medications.

Years on Medication Can Be a Problem

Some people on medication can gain the desired benefit, which is great. However when they don’t, should the medication be stopped? By continually searching for a medication solution, another problem can emerge.

I know a client who is receiving 3 antipsychotics, one by injection. He is on a ‘mood-stabiliser’ morning and night; he is also on an antidepressant, and some non-psychiatric medications. He willingly accepts the medications and even seeks higher doses, hoping for improvement with his symptoms.

The last 2 or 3 years have not given a good result. I do not know in detail the level of functioning for the decades before. Perhaps there were better periods; if so, they could well have been from life circumstances as much as medication.

While he is diagnosed and the dominant paradigm is that he needs medication, carers in his life call for medication reviews to solve his symptoms and behaviour. His history of trauma and past behaviour tell us he needs connection with people, acceptance, a way to contribute meaningfully to others, and opportunities for fun. However, his carers did not see they had a responsibility to address his needs. They did the minimum by involving the mental health service.

The mental health service uses much of its resources in listing symptoms, deciding on medications, and reviewing changes. This uses resources that could be used to advocate and help meet the human needs of its clients. Since carers and families are mostly convinced of the biological theory, they frequently want medication tried – this delays other necessary interventions, sometimes permanently.

Maximising Efforts of Clients

Some psychological approaches rely on reframing people’s problems as ‘not illness,’ so they realise they have capacity to effect change in their lives. If mental health services communicate to people they have an illness, doesn’t that undermine their belief that they can find solutions other than with medication?  Is it fair to doubt them?


Many times I hear statements made to clients with certainty about medication being valuable, useful, proven. It seems the professionals are offering their beliefs, which is contradicted by the information I read. While medication may be useful to some clients and worthy of trying, are clients being given accurate information?  What do we want clients to believe about their innate capacity to find solutions? Do we want to instil reliance on others, or on themselves? What is the best way to proceed?

(Go to essay 9.)










Essay No 7. Is There Harm From The Psychiatric Paradigm Of Mental Illness?

January 9th, 2012


I have written above that there are alternatives to using medications to treat psychotic disorders. Medications and placebos do work to some degree, and would be better than not giving anything, so why am I making a fuss?

There are harmful physical effects from the medications, harmful psychological effects from labelling behaviour into illness categories, and harm by limiting the options that are made available to clients.

The Harm

1. Physical Health – education by the government agency I work for revealed that those patients diagnosed with a major psychotic disorder (eg schizophrenia) have a reduced lifespan of approximately 20 years. The reasons would be many and intertwined. The medications would be one factor – medications contribute to obesity, diabetes, heart, kidney and thyroid problems. Such clients tend to smoke more, feel sedated and live a more sedentary lifestyle etc. If therapy can be provided and obviate the need for medications (at least for some), we are a long way forward from where we are.

2. Psychologically there is much harm. Readers will understand the difference between labelling behaviour, and labelling a person. We might notice a person behave in a clever way, and we might generalise and say “s/he is a clever person.”  Generalisations contribute to the formation of that person’s identity (or beliefs about self); in contrast describing or reporting one clever instance is less impactful since it is just one among many.

Being thought of as a clever person (or thinking of oneself in that way) implies it is likely to be frequent and an enduring part of the person’s nature. Since beliefs tend to be self-fulfilling, it encourages more of the behaviour.

If a behaviour is undesirable (eg clumsy) it is kinder to describe a clumsy instance as a behaviour, rather than describe the person as a clumsy person. But with mental health diagnoses, it is so easy for people to form the identity that they are Bipolar or Schizophrenic, which massively shapes their future expectations. There have been suicides where reports from colleagues suggest the persons saw no hope following their diagnosis. The diagnosis is a label, which shapes the person’s identity and thus their beliefs about future potential. Diagnoses can demoralise.

Instead it is helpful if we treat people as having ‘difficulties’ and we then collaborate to find solutions. I recall Michael White (Narrative therapist) say, “We cannot be neutral,” meaning it is not possible to be neutral. If we tell someone they have schizophrenia, we are shaping their mind in a way that is different than saying “the voices” seem troubling. The first is a package of ideas that may shape their identity; the latter is one recurring experience they have mentioned and we can collaborate to find a solution.

If we say, “You need to take medication for the voices,” we are implying a solution is outside their control. If we offer a range of alternatives, we are undermining the paradigm of biological causation and treatment. We are not being neutral, nor is it ever possible. Offering alternatives posits people have capabilities, not limitations. If people have capabilities we can collaborate and build on them. If we view them as limited, we may find ourselves forcing medication onto them via legal orders. If they then comply, have we not already harmed them by communicating a belief they are incapable? This is a belief communicated not just to the patient, but his/her family and the community.

In contrast to this belief, I do recommend watching a British award winning documentary about psychologist, Rufus May. It is a re-enactment and follows him working with a client who hears voices. His approach is unconventional, and would stimulate debate, but it does show his utter belief that the client can manage without antipsychotic medication, which supports the client’s wish. It is available on YouTube in 6 parts (for those with extra time…about 60 minutes.)


3. Parentalism – (It seems to me that “Parentalism” is the modern non-sexist term.)

The biological paradigm is maintained by selecting and promoting certain information to clients and families. Other information which is likely to jeopardise their belief in the paradigm, and their adherence to medication treatment is not highlighted.

For instance, in September 2008 a blog reported Dr Nancy Andreasen’s research findings that antipsychotic medication causes brain shrinkage in patients. Essentially it reports that the larger the dose, and the longer it is taken, the greater the brain shrinkage. I cannot vouch for the veracity of her research. However, I understand she is a psychiatrist and scientist of very high standing.  Among other achievements she served as Editor-in-Chief of the American Journal of Psychiatry for 13 years, a leading journal in the field.

Andreasen said she delayed announcing her findings for 2 years, concerned that patients would not continue on their medications.

Information such as the above is not likely to be shared with patients.  But I would certainly like to know if I was the patient, or a family member. And I would like to know of the alternatives I could consider.


Current day mental health organisations do cause harm, physically and psychologically. If we want to build collaborative relationships with clients, we must be courageous and share our knowledge. With honesty we can find better ways forward.

(Go to essay 8.)

Essay No 6. More on “Constructivism.”

January 9th, 2012

Essay No 6.  More on “Constructivism.”


Remember the anecdote of the three baseball umpires from essay 2. The third was the constructivist as he recognised he was not reporting reality (whether the batter was out or safe); he was making reality through his declaration. Through Constructivism we understand that our involvement in exploring and describing something, affects the end result. How we examine it, what our starting knowledge is, our biases, the questions we ask, all shape the conclusions reached.

False Presumption of Objectivity

If the starting premise in psychiatry is that patients have a biological condition, (inferring that cognitive/family/environmental factors are less important) then already one pathway is favoured over others. Maybe in some instances the problem is largely biological, but if that presumption generalises to all instances, options are closed.

Constructivism points out the system of classifying psychiatric diagnoses lacks objectivity.  Case stories such as that of Josie in essay 2 are not just mistakes. They occur repeatedly. Professionals fail to appreciate the message of constructivism, that is, their role in gathering information and defining the problem is shaping what follows, not just objectively stating ‘facts.’

If a family is told their family member has schizophrenia, they will soon receive ‘education’ about what to do and what to expect, coupled with further information from the internet and relatives / friends in similar situations.  This is not wrong; it is unavoidable…people in crisis want information. However, what information is selected from all the possible information available? The paradigm we favour will filter the information we offer.

The biological paradigm will mean the patient and family will progressively learn about brain biochemistry, medications, early detection of symptoms of relapse; this all shapes the whole patient-family-service system. They are likely to respond in certain ways (possible hyper vigilance by the patient, or the family, or case-worker; possibly arguments about compliance with medication; possibly lowered expectations about a speedy and full recovery, and not much chance that it can happen free of medication….)

What may seem to some, as an objective determination of the diagnosis followed by a treatment plan, has led to a pathway for the client and family.

It is one pathway among several. It is however a pathway that closes other doors.

Nardone, the author from essay 3, would likely not call it schizophrenia, but pragmatically investigate the interpersonal patterns that influence the continuation of the problem behaviours. In the two examples he presented, there were no predictions of chronic difficulty, or mental impairment that might necessitate medication.  His therapy begins with curiosity and optimism that change can occur. He looks to join with people and employ techniques in a collaborative fashion.

The fact that Nardone and other authors get results with clients that others would medicate, illustrates that mainstream treatment of those with psychotic disorders is not the treatment of necessity. Rather it is a treatment selected by professionals with limited knowledge of therapy options.

The construction of a person’s experience as an ‘illness,’ may in itself lead to a chronic course, since powerful alternatives are not employed.

Once a psychiatrist declares the diagnosis and announces the required treatment, seldom is anyone questioning whether schizophrenia is “real” as opposed to a ‘viewpoint.’  That is why patients can be managed as Josie was.  The construction has become reality.

Is This Another ‘Josie’ Type Story?

Please take a moment and watch the video link below. Although we know only a little of this patient, it raises some interesting points. The clip is of a clinical psychologist.  He tells how he got lucky in a session with a 38 y.o. patient who had a lifelong diagnosis of schizophrenia.  The patient’s problematic symptom was that she regularly heard a voice telling her, “Kill, kill.”   In this session, the woman’s command hallucinations stopped and at 12 months she was still hallucination free.

http://www.youtube.com/watch?v=wyL0jjI93OI  In this case it is evident how important the family context was.  She was weaned off her 3 medications and functioned.  In his view she no longer met the criteria for schizophrenia.

There are some things to note: firstly, irrespective of the length of the problem, the resolution will not necessarily be a lengthy process.  Examples of rapid success such as this and those in essays 3 & 4 undermine the suggestion that a person has a biochemical imbalance in their brain, (implying it has taken time to develop and may need medication to correct it.) Alternately, one may better say the person needs a different perspective; or as in essay 4, different mental strategies.

Secondly, the context of symptoms is vitally important.  Family therapy has always maintained that symptoms are best understood in context; this is why family members are so often included in therapy…not that they are necessarily part of the problem, but they often know more about the context, and do afford more possibilities for intervention. The examples in essay 3 illustrate this well.

Remember the Second Umpire

Professor Marius Romme (psychiatrist, and contributor to the Hearing Voices network and website http://www.intervoiceonline.org/ ) has challenged the validity of diagnoses such as schizophrenia. Such people are often dismissed as extremists.  I suggest detractors are not conversant with constructivist ideas.  I suggest they may be like the second umpire and think the first person got the diagnosis wrong, and they would have determined the diagnosis correctly.  But Josie probably saw a dozen doctors who also got the diagnosis wrong.  Most likely too with the YouTube patient who was treated for more than 20 years.

The Training of Doctors and Psychiatrists

It is easier for doctors and psychiatrists to entertain the notion that ‘illness’ constructions have significant shortcomings if they have a full range of intervention strategies they can employ.  Many doctors do study psychotherapy, train others and write articles.  Unfortunately the standard training psychiatrists receive does not include extensive knowledge and training in therapy models.

The majority of psychiatrists and trainees I have met in more than 20 years never indicate it is possible for patients to recover from psychosis without medication. To a lesser degree they believe medication is a valuable treatment for other conditions, or at least won’t do harm as part of the treatment plan.  There are differing viewpoints on this, as discussed in essay 7.

I expect psychiatrists feel vulnerable if they do not treat with medication.  Since the dominant paradigm is faulty biology, they justifiably anticipate being blamed if they do not medicate and a negative outcome was to occur.

Constructivism is a way out, as it rids the idea that clients are ill and medication is essential.  Constructivism can open more choices than an ‘illness’ paradigm.

Explicitly Acknowledging Constructivism

In the fields of family therapy and NeuroLinguistic Programing, many authors explicitly acknowledge constructivism, and write of approaches which do not include the creation of labels such as schizophrenia. Such authors look for pragmatic interventions to interrupt personal and interpersonal patterns that perpetuate symptoms.  In the case of De Shazer’s “Solution-focused therapy” the emphasis is on not mentioning the problem, but asks what will the solution look like; what part(s) of that are already happening; how so, and can we do more of that etc?

Constructivist therapies such as Solution-focused therapy cannot make the mistake made with Josie, since they explicitly acknowledge they are co-creating reality with the client; they don’t look for pathology, but strengths and resilience, which they foster.  By way of example, I wrote an article, “About Hope In Psychiatry – Not Labels And Limitations.”  http://www.tomblackford.com.au/2011/04/24/about-hope-in-psychiatry-not-labels-and-limitations/

At the beginning I include a story by Steve De Shazer working with a couple, both with extensive psychiatric histories.  Despite his medication, the husband was frequently hearing voices; he admitted to being bossy and angry.  They were on the verge of separating again.  Rather than thinking about medication or exploring his symptoms, De Shazer focused on how to make the relationship better.  Over the course of 5 sessions, their relationship improved and the symptoms as well.

Out of fear, a doctor might have felt compelled to recommend medication changes, taking time away from doing therapy.  Instead De Shazer engaged in a process which implies they can act powerfully to improve whatever is happening.

Can We Support Clients’ Belief In Their Capacities?

An ‘illness’ construction tends to steer patients away from believing they have the inner resources to find solutions without the aid of medication.  This undermines clients’ faith in their abilities.  The ‘illness’ construction also contributes to the over use of medication, metabolic problems and shorter life expectancy.  Where patients do not agree with the illness model, arguments can result (sometimes loudly, sometimes silently) and collaboration lost.

Many doctors and psychiatrists criticise psychiatry for placing too much faith in the claims of the pharmaceutical industry. We all know of clients who have improved while taking medications.  Yet claims of medication’s efficacy above placebo and psychotherapy are tainted by drug companies’ many tactics to increase sales.

Regardless of any “success” by a psychiatric medication, it will never show that a drug is essential for a disorder, only that it made a difference with that client (as therapy might also have done.)


While mental health services focus resources on determining the ‘correct diagnosis’ and delivering medication, less time is available to learn effective interventions which are premised on people being capable of recovery.

Many practitioners do not understand that constructing people’s problems as ‘mental illnesses,’ close psychotherapeutic options that rely on reframing problems differently.  In contrast most therapy options do not prevent a person from trialling medication and noticing what effect it has. Thus constructivism allows both options to coexist.

Constructivism adds perspective and choice to consumers. Once constructivism becomes an explicit part of the discourse in mental health services, we can find new ways to collaborate with clients.

(Go to essay 7.)

Essay No 5. Efficacy of Psychiatric Medications

January 9th, 2012


Since 2000 I have been reading the literature about clinical trials for psychiatric medications. While some people do benefit, I think there is substantial doubt whether antidepressants and antipsychotics are generally any better than placebos.

Many colleagues take for granted that psychiatric medications are proven to work. I will offer some information to question this assumption. When we scrutinize the evidence a different picture emerges.

Clinical Drug Trials

a) Being shown results from selected clinical trials can be misleading. Multiple trials are conducted on a particular drug and only a small percentage will be reported in the literature. These will mainly be the successful trials, and we may not know of the many other trials. So if we hear of a good result, it could be there are more trials that found no significant benefit compared with placebo; this is common. Adding all the trial results together we might find the drug is no better than placebo. Hence scientific papers that review multiple clinical trials or conduct ‘meta-analyses’ on the collective results are more reliable.

Some examples of large combined studies:

  • Kirsch and Sapirstein (1998), in a meta-analytic review of nineteen studies involving 2,318 people, showed that 75 percent of the response to antidepressants was duplicated by placebo. They speculated that the remaining 25 percent of the positive antidepressant effect may be attributable to the un-blinding power of side effects. [My explanation: this means the obvious side-effects of the medication usually reveal to staff and patients who are receiving the medication and who get the placebo; this biases studies in favour of the drug.] Adding to the critique, Kirsch, Moore, Scoboria, and Nichols (2002) analyzed the efficacy data submitted to the US Food and Drug Administration (FDA) for the six most widely prescribed antidepressants approved between 1987 and 1999. Approximately 82% of the response to medication was duplicated by placebo control groups—57% of the studies failed to show a drug-placebo difference. When a difference was found, the drug/placebo difference was only, on average, 1.8 points on the clinician-rated Hamilton Depression Rating Scale (HDRS). FDA memoranda intimated that the clinical significance of such a small difference was questionable (Laughren, 1998).  [My comment: The HDRS has a maximum score of 53, and commonly people will need a score of more than 20 to enter a trial. Studies on antidepressants using a clinician-rated measure are more likely to find significant changes than when using a client-rated measure, suggesting clinicians report improvements that clients do not experience.] [Ref: Barry L Duncan’s book, Heart & Soul of Change, 2010; Ch 7 Psychiatric Drugs and Common Factors: An Evaluation of Risks and Benefits for Clinical Practice.]
  • Kirsch et al.(2008) provide further evidence that the belief in antidepressant efficacy is scientifically unfounded. Meta-analytically examining all trials submitted to the FDA for the licensing of four popular SSRIs (antidepressants), the authors found no clinically significant differences between placebo and the drugs, with the exception of the most distressed in the severely depressed group. Even this negligible difference was found to be due not to the drug, but to a decreased response to placebo. [Ref: Barry L Duncan, above.]


  • The World Health Organization’s studies of outcomes for schizophrenia in developed versus non-developed countries found that symptoms tend to dissipate within 5 years when medication is never used or when clients wean themselves off. Surprisingly, outcomes were better in nondeveloped countries, where most individuals did not take medication—people spent less time in hospitals with lower rates of relapse and were more likely to be employed and socially connected (de Girolamo, 1996). Harding, Zubin, and Strauss (1987) tracked 269 clients admitted to Vermont hospitals with a diagnosis of schizophrenia 32 years after their first admission. They found that about two-thirds of these former patients showed no signs of schizophrenia and had long since stopped their medications. In the Soteria Project (1971-1983) persons diagnosed with schizophrenia and randomly assigned to residential treatment with minimal use of antipsychotic medication had better 2-year outcomes than those assigned to “usual hospital” treatment (Bola & Mosher, 2003). More recently, a 15-year follow-up study of persons diagnosed with schizophrenia found that a larger percentage of those un-medicated showed better global functioning and intervals of recovery than their medicated counterparts (Martin & Jobe, 2007)—65% of those taking antipsychotics were experiencing psychosis compared to only 28% of those not medicated. Antipsychotics can remain part of the discussion, but should not be privileged. [Ref: Barry L Duncan, above.]


b) Clinical trials can be designed to get favourable results. There are endless critics of the methodology of clinical trials. For example: “Richard Smith, who resigned as editor-in-chief of the British Medical Journal because of rampant industry influence in academic research, explains that the number one aim of industry sponsored trials is to find favourable results for the company drug (Smith, 2003). He notes a host of strategies that help accomplish this goal, including comparing the industry drug against another known to be inferior, comparing a low dose of a competitor’s drug to prove efficacy and high dose to prove less toxicity, using multiple endpoints, then picking the one that casts the drug in the best light, or conducting subgroup analyses and selecting for publication those that are favourable. According to Smith, the design, conduct, analysis, and publication of clinical trials are, essentially, marketing issues.” [Ref: Barry L Duncan, above.]


c) The pharmaceutical industry in America has the most political lobbyists of any industry, far bigger than even the gun lobby. Why do they need to lobby so much if science is on their side?


Resource Information on Drug Company Behaviour


1. Below is a link to a British documentary video (approx. 60 minutes) detailing one drug company’s behaviour to increase its sales of the antidepressant known in Australia as Paroxetine. It also highlights the risk of increased suicide from using SSRIs in young people.


2. The link below allows you to listen to past radio programs by Barry Duncan on “Mind Matters,” which deals largely about the mental health industry, including drug companies.





Human beings and their biology are infinitely variable. It is not beyond possibility that occasionally a psychiatric medication has the effect the makers intend, and a placebo would not have benefitted. However, given the information from large review studies, it does not seem the norm.


If psychiatric medications are seldom better than placebos, are they worth the risk of the serious side-effects? Our society has become a society that believes them, so I do not expect they will disappear. However, as Barry Duncan says, they can “remain part of the discussion, but should not be privileged.”


Acknowledgement: I would like to thank all the doctors who take professional risks by speaking out and writing about the poor science and poor medicine in psychiatry. Psychiatrists Peter Breggin and David Healy are two authors the public may know, but there are many.


(Go to essay 6.)

Essay No 4. Interesting Examples Of Treating Psychological Disorders

January 9th, 2012


It is easy to read in areas that we already know, but we may miss easy or valuable tools. One area I read is NeuroLinguistic Programing. For those who are unfamiliar, below are three brief examples which might stimulate your curiosity to learn more. They are not fully explained for those unfamiliar with NLP, but indicative of just how quickly serious problems can be changed.

These are taken from the first of 2 e-books by Steve Andreas, entitled, “Help With Negative Self-Talk.” (Vol 1 & Vol 2, 2009 © Real People Press.)  As you read them, you might consider that some NLP techniques are like ‘hypnosis without the trance,’ in that the client becomes absorbed in their internal experience and the therapist leads them in useful directions. This is not true of all NLP techniques, but is applicable to the first two examples below.

While mental health services might diagnose and consider medication interventions in these quite serious problems, resolutions were achieved in only a single session.



Changing the location in space also works with internal images. Recently Lewis Walker, an NLP-trained MD in Scotland, (Walker, Lewis. Changing with NLP: a casebook of neuro-linguistic programming in medical practice. Oxford, UK. Radcliffe Medical Press, Ltd. 2004) saw a young woman who had witnessed two of her friends killed in a motorcycle accident the day before: When she came into my office she had already dissolved into tears before she sat down. Through the sobs she told me about the smash. One friend was decapitated, the other with a bit of leg thrown across the carriageway. As she described how “The pictures are all in front of my face,” both hands were gesturing about 2 inches from her eyes.

I said something like, “Let me take these for you,” as I reached over with my right hand and grabbed her pictures, while simultaneously making a “ripping” noise as I stood up and hauled them off to her left side, and then diagonally behind her. I asked her to “Look at all these pictures in my hand as they shrink way down in size and all the color drains away,” cupping and closing my right hand as I did so.

At this point her body in the chair was facing ahead, while her head was looking over her left shoulder. I took the images to the corner of the room near the door and said. “Now just imagine they’re fixed right here by a nail, and I hit the door post with my fist. “Now knowing that they’re fixed here, in your mind’s eye look straight ahead and tell me how things are different now. . . .”

She visibly relaxed, the tears subsided, and she felt more in control. As I sat down again in front of her I said, “Keeping them nailed over there, what happens as you take this into tomorrow, and the next day, into next week and next month (gesturing with my left hand along her future timeline out to her right) knowing that with each passing day that (pointing to her images of the accident) gets farther and farther away as it recedes into the distance.”

She was much calmer now and could tell me about what happened after the accident, and how their motorcycle group was still planning to go on a tour to Germany in 3 weeks, and that she was going to go out on her motorcycle with her husband when he got home that night.

The whole consultation lasted no more than 15 minutes, and probably saved weeks—perhaps years—of the standard approach of “talking it through.”    (Vol 1, p.4)



Most psychiatrists think of compulsive hand-washing as a problem that is very difficult to treat. Below is a lovely example of using a meaningful piece of music to quickly change this problem in a single brief session. This example was sent to me about a year ago by Ron Soderquist, an NLP-trained hypnotherapist in the Los Angeles area.

Anxious parents called, each in turn, about their 17-year-old daughter Bev, who for the past six months had obsessively washed her hands 3-4 hours a day. Both parents reported they had “tried everything.” including counseling and drugs. They were so desperate they were now exploring hypnosis, about which they were very skeptical.

Somewhat worn down by their skepticism I said to the anxious mother, “Look, because you are desperate and because you worry that once again you will be throwing money away, I will offer you a complimentary consultation. I will evaluate your daughter’s symptoms and only schedule a therapy session if I believe I can help her.” With this assurance, she made an appointment.

As family members settled into their chairs, they all appeared relaxed. They communicated with ease, and there were no overtones of hostility. Turning to the girl I asked about school and extracurricular activities. She immediately replied, “I have studied piano for many years and enjoy it very much.” Because I play both classical and ragtime piano, this was a natural opening for building rapport.

When I asked about her favorite composer, she quickly said, “Chopin.” Because Chopin is also my favorite, we were now in perfect sync. We agreed we both loved Chopin’s Nocturnes and we both played most of them. I asked about her favorite and she hummed the melody. I said, “When I practice a nocturne in the evening I often can hear that melody in my head all next day,” and she nodded in agreement. “You can hear that melody right now, can’t you?” I said. She smiled and slipped into a nice little trance. As she did so, I ventured, “Perhaps, when you get the urge to wash your hands, you might enjoy turning on that nocturne instead.”

I observed her trance deepen as she considered this, and then she nodded her head and said quietly and confidently, “I can do that.” After some further rehearsal, and talk about other matters, I concluded the session. I didn’t suggest another session. The mother wondered, “Do we need to make an appointment for Bev?” I looked at Bev as I said, “Perhaps she has already found a solution,” and Bev nodded her head.

A week later the mother called to say Bev was doing fine. I was a little annoyed with myself for solving the problem when I should have held back and scheduled a regular appointment with a fee. But I just couldn’t help myself; it was too much fun just to do it. And while there was no fee, I did get a good story, and the mother soon referred a friend.

When I followed up some months later, I asked for more details of what she experienced internally. She said that when she got stressed, she first “felt germs on my hands, and then pictured them on my hands. Then the voice in my head that said, ‘You have germs on your hands. You have to wash them,’ went faster and louder and got more intense. When I turned on the nocturne, I would usually just hear the music, but sometimes I would imagine myself playing it.”

Commentary by Steve Andreas: Bev was already talking to herself in a way that made her feel bad, and that bad feeling triggered her hand-washing. The Chopin nocturne was powerful in eliciting a positive state in which she had no urge to wash her hands. If Ron had added some cheerful words, that could have created conflict. However, adding instrumental music does not create conflict, because the music does not have any words to contradict what she was saying to herself.

In addition, music is processed by the opposite brain hemisphere than the one used to process language, so any conflict would be between the hemispheres, rather than within one of them. Adding any music without words is a fairly safe intervention, especially if the person chooses the music that they think might be appropriate—and tests to find out how well it works.    (Vol 1, p.33)



Some readers might think that this example was a unique case, but it is actually fairly common. Ron sent me a report about another client he saw recently. A 30-year-old male who had hung out in his bedroom for several months, couldn’t drive a car etc. because of panic attacks, was brought in by his stepmother.

He was too anxious to leave the back seat of his car, so I went out and started the session beside him in the back seat—a first for me! He was creating his anxiety with a habitual internal voice: “You’re going to go ‘weird’ ”—which was what he called having a panic attack.

He’s a guitar player, so together we found an alternate audio, a “favourite riff” that triggered his confident musician self. (I told him the Bev story while he was searching for a trigger for his confident self, and this seemed to strike a chord with him (pardon the pun). After we practiced that for a while (I did get him into my office) he went off with his stepmother. I called the next day and he had been out hiking and feeling great, using his favorite riff to keep his musician self in charge.    (Vol 1, p.35)

I recommend Steve Andreas’ two e-books, and they can be purchased from his website. Help With Negative Self-Talk: http://www.realpeoplepress.com/pages.php?page=Downloads


I highly recommend seeing the following demonstrations of NLP applied to clients’ problems. Steve Andreas has posted some examples of his work on YouTube. The videos are a maximum of 10 minutes. Some are complete examples, and some are extracts from a larger client session.

1. Original NLP Fast Phobia Cure Part 1 – Steve Andreas.  Short clip showing the phobia cure process. The second part shows the follow up interview 25 years later.



2. Eliminating a Compulsion FAST with NLP – Steve Andreas.  A great demonstration of the “Compulsion Blow-out” technique, where you see the person responding differently immeditately.


3. Resolving Shame Quickly with NLP – Steve Andreas. A segment from a larger interview, where he demonstrates using “sub-modalities” (aspects of visual and auditory representations.) As these are altered her feelings change.


4. Treating Loss and Depression with NLP – Steve Andreas. A segment from an interview which shows him using a “Tempo Change” process; follow up interview shows the impact.


5.   24 Years of Night Terrors GONE in 1 NLP Session – Steve Andreas. A segment showing use of mental rehearsal to attach a positive resource. Positive report at follow up interview.


6. NLP Eye Movement Integration with a Vietnam Veteran (PTSD) – Steve Andreas. A segment from a larger interview – it shows the process, and there is evidence at the end that the feelings towards the traumatic memories are different.


(Go to essay 5.)

Essay No 2. Why It’s Important For All Mental Health Workers To Understand “Constructivism.”

January 2nd, 2012


There are three baseball umpires that are disputing.  The first one says, “I call ‘em as I see ‘em.”  And the second guy says, “Well, I call them as they are.”  And the third guy says, “They ain’t nothing until I call ‘em!” (taken from Constructive Therapies, Michael F Hoyt Ed. Guilford Press, 1994, P.34)

The third umpire above is the constructivist, since he understands he is authorised to ‘call’ or name an action. He is not reporting reality; he is actually creating the reality …the play is Safe! or Out!, by virtue of his call.

In mental health services we create ‘the reality’ by naming what we see. For example some behaviour such as deluded thinking may be labelled a psychotic disorder and called a ‘mental illness.’

Medicalising bizarre behaviour saved the mistreatment of those previously labelled as witches and ‘possessed’.  Doctors took over as psychology developed later, but the medicalising of behaviour is not straight forward.

What follows is a case study of a young adult woman, diagnosed with paranoid schizophrenia and treated for 10 years. It illustrates how there can be radically different labels to the one person.  These consequently shape the treatment offered, and the course of a person’s life.

Like the three umpires, we can look at the information in front of us (the client’s behaviour and reported history) and call it as we see it (eg schizophrenia); or we could criticise the first call and claim to give the real diagnosis; or thirdly we can recognise that how we are trained shapes the ‘lens’ through which we see the information.  This then determines what we see as relevant, noteworthy, or useful.  In turn this will shape our plan of intervention.

The Case of Josie

Josie was a young adult who lived with her mother. They migrated from a war-torn country.  They both spoke limited English. Josie rarely went out of the house, did not understand television programs, and the only news she got of the world was from her mother.  However, Josie’s mother had problems of her own.  Her fears infected Josie, making her wary of people.  Somehow she came to the attention of the authorities, and was deemed paranoid.  She was hospitalised, medicated and diagnosed with schizophrenia.

Josie was treated for 10 years in the standard way.  She had a number of psychiatric admissions, and in between she was treated by a psychiatrist who spoke her native tongue.  Eventually Josie was referred to Bill, a clinical psychologist.  He quickly decided that Josie did not have schizophrenia, but rather agoraphobia with avoidance.  Her life context had impacted her to be fearful and avoidant.  Together with her lack of language, Josie was not confident to go places and interact with others, which left her fearful belief system unchallenged.

Gradually inroads were made.  Bill negotiated with the psychiatrist to withdraw and cease her medication.  He arranged supports so that Josie could get out more; she learned more English, which meant she was able to gather information from more sources.  She then developed independent views, no longer reliant on her mother.  She eventually grew sufficiently confident and she moved out of home.  Josie then was able to develop a normal set of interests and activities and so lead a normal life.

What Can We Learn From This?

Josie may well have seen over a dozen psychiatrists and doctors over the course of her involvement with the psychiatric system, along with many other health professionals.  Why did she get started on antipsychotic medication, which she almost certainly did not need?  Why did she get a label of schizophrenia, instead of the more useful and less harmful one of agoraphobia?

Constructivism points to the trap that we can see what we look to findExpecting to find ‘mental illness,’ senior psychiatrists found it and called her behaviour, “schizophrenia.” This became the reality that everyone saw, even the consultant psychiatrist who spoke her native language.

Sadly Josie did not get effective treatment for 10 years.  We know that people diagnosed and treated for psychotic disorders have their lifespan reduced by 10 – 20 years, so she has been at risk of physical harm and perhaps psychological harm through her detentions.

Josie’s example highlights the risk that can come from diagnosing behaviour as ‘illness,’ rather than considering the person’s larger context.

This Is Not An Isolated Experience

Consider the debate about Bipolar Disorder and Bipolar Disorder Type 2…when is behaviour (eg moodiness) considered part of the normal continuum and when is it considered an ‘illness?’  Basically when a doctor says it is illness, is the answer; or actually a group of doctors and other professionals who by committee formulate the criteria to name a particular disorder. Then it becomes an official label in the DSM4 manual (one of the primary books used to classify psychiatric disorders.)

In practice it means that an individual doctor sees a patient, collects information about symptoms and history, views it through his or her professional lens, and decides whether to call it ‘illness.’  That is what happened to Josie above.  Those of high status named her as ‘ill’, then those with similar training, were inclined to see it in the same way.  Consensus is assumed; others with dissenting views see no point in arguing against a system that operates out of a dominant paradigm. And a life is changed.

An Italian female psychologist told me she used to do psychological assessments for a psychiatric ward. She would tell the psychiatrists from time to time that particular Italian patients were not “Bipolar;” their homicidal expressions to their husbands were their style, understandable in the Italian culture. Yet the psychiatrists dismissed this objection, continued with the medications and the psychologist gave up her attempts to educate the doctors about her culture.


Even if some Italians might disagree with her, it still illustrates the constructivist position that diagnoses are not objective – the most powerful in the professional hierarchy gets to name what is normal and what is ‘mental illness.’ Patients like Josie then experience the substantial consequences.

The following essays show that behavioural and psychological interventions do exist for mental disorders, even psychotic disorders.

(Go to Essay No 3.)