Soteria4Oz

Soteria Letter writing campaign

2011-05-08T04:05:00.000-07:00

Further to my previous post, I encourage those interested in the development of Soteria based alternatives in Australia to write a letter to a relevant politician.

Anyone is welcome to copy or adapt the text of the letter in the previous post. I had originally intended to get a petition style letter going, but now believe that individual letters would be more effective.

According to this website, handwritten letters are best and e-mails are the least effective method of getting politicians' attention.

Below are links to relevant politicians addresses. The letter I have written addresses policies of the federal government, so would need some adaptation for State government politicians. Writing to your local MP would also be very worthwhile, as they are the ones who want your vote.

Go for it!

Prime Minister

Minister for Mental Health and Ageing

Minister for Health

NSW

Premier

Minister for Health

Victoria

Premier

Health Minister

Queensland

Premier

Minister for Health

South Australia

Premier

Minister for Health

Western Australia

Premier

Minister for Mental Health

Tasmania

Premier

Minister for Health

Northern Territory

Chief Minister

Health Minister

ACT

Chief Minister

Minister for Health

Letter to Mental Health Minister

2011-05-08T01:26:00.000-07:00

Below is the text of a letter I have sent to Mark Butler, the Minister for Mental Health and Ageing on 8 May 2011:

Dear Minister,

I write to you in relation to the current care facilities for people experiencing psychotic illnesses.

I welcome the commitment of your government to reshape mental health services and would like to draw your attention to an alternative to the current hospitalisation practises for people experiencing such illnesses.

Hospital environments are often not optimally conducive to recovery and can be stressful, crowded, and overly reliant on heavy doses of medication. For too long the importance of psychosocial care in an empowering and recovery oriented environment has been neglected for those experiencing psychosis.
Thus, I believe consideration should be given to a model of care based upon that of Soteria Berne in Switzerland.

Treatment at Soteria Berne is based on the following therapeutic principles:

1. Small, relaxing, stimulus-protecting and as "normal" as possible therapeutic setting
2. Continual personalized "being with" the service user
3. Personal and conceptual continuity over the whole period of treatment
4. Continued close collaboration with family members and other important persons of reference
5. Clear and concordant information, for service users, family and staff, on the illness, its treatment and the existing risks and chances
6. Elaboration of common realistic goals and expectations for future housing and work
7. Consensual low dose neuroleptic strategies, with the aim of controlled self-medication
8. After-care and relapse prevention for at least two years.

Please refer to the attached documents for more information about Soteria Berne (http://www.ciompi.com/pdf/WP-2004-10-Soteria.pdf) and research outcomes on the Soteria model (http://schizophreniabulletin.oxfordjournals.org/content/34/1/181.full).

Research in relation to the Soteria model has found that continuous human closeness with the person experiencing psychosis (“being with”) in a small, supporting and protective non-hospital setting allows the achievement of similar or better therapeutic effects than conventional psychiatric settings for equivalent or cheaper cost, without the need for heavy doses of neuroleptic medication. The therapeutic focus on the sustained reduction of emotional tension has highly beneficial effects, whilst the accepting environment reduces stigmatisation and secondary psychosocial impacts associated with hospitalisation. Furthermore, in the relaxing Soteria atmosphere incidents of serious violence against self or others have been shown to be extremely rare.

I note that the federal government has made a $1.6 billion commitment to deliver 1,300 new sub-acute care beds nationally by 2013-14. We believe that this presents an excellent opportunity to institute services along the lines of the Soteria Berne model. Soteria based services would also align well with early intervention strategies to prevent relapse and reduce the long term impact of psychiatric conditions.

Such a model would work for the benefits of all Australians in terms of reduction in long term costs; humane and ethical treatment; and in encouraging social reintegration and recovery.

I urge you to consider this model and to take action to implement it in Australia and look forward to your response.

Yours Sincerely, etc

The Sluggishness of Psychiatry

2011-02-05T19:41:00.000-08:00

I was ruffling through some boxes in the garage the other day and came across the clipping below. It is an article regarding Tardive Dyskinesia from 1993 from Canberra's daily newspaper, The Canberra Times.

Besides the moving and tragic account of the sufferer in the article, I thought it was also of contemporary relevance due to the attitude and comments of the unnamed psychiatrist. The article, which is referring to older generation antipsychotics and not the newer atypical antipsychotics, states that the psychiatrist said "only 5 per cent of those taking neuroleptics would end up with mild forms of the disease and less than 1 per cent with severe forms of it."

In fact, it was well known in 1993 that the incidence rate of Tardive Dyskinesia for those taking older generation neuroleptics was between 20 and 40%. For instance, refer to this article. Also, Jack Gorman's 1990 edition of The Essential Guide to Psychiatic Drugs stated a rate of between 20 and 40 %.

It is interesting that the quoted spokesperson from the Citizens' Commission on Human Rights, which is often dismissed by psychiatrists as an extremist scientologist organisation, actually had a much better grasp of the facts than the professional psychiatrist.

This, of course, would not have been the first time that psychiatry as a profession has been disturbingly sluggish to acknowledge or respond to the adverse effects of the treatments it advocates.

Perhaps part of the reason for this is revealed in the remark of the psychiatrist in the article that "there was no alternative". Of course, the fact is there are no drug or low drug alternatives which don't have the adverse effects of treatments offered by biopsychiatrists.

Soteria is one such alternative.

Linking Phenomenology and Neurobiology

2010-12-29T20:09:00.000-08:00

In recent years, there has been considerable interest in research linking the phenomenological and biological aspects of mental illness ( for example, this paper co-authored by Patrick McGorry ). It is welcoming to see a rapprochement of these distinct but nevertheless complementary ways of describing and understanding human experience and behaviour.

Much of the recent work (including the paper above) focuses on the use of phenomenological investigation as a tool in identifying individuals at risk of psychosis. But of course, phenomenology is relevant not only to the identification of individuals at risk of psychosis, but also to shedding light on its development and progression. Phenomenological description gives clues as to the effect of environmental and psychosocial factors on neural processes, and perhaps to ways in which the control of the former factors can influence the latter. Thus, examining psychiatric hospitalisation from a phenomenological perspective can suggest what the neurobiological impacts of hospitalisation on the psychotic patient might be.

In this respect, the experience of being in a psychiatric hospital from the perspective of the patient paints a disturbing picture. It is a process of invalidation ,negation, stigmatisation, regimentation and compartmentalisation. The Lebenswelt of the psychotic patient within a hospital setting is characterised by inner turmoil exacerbated by external invalidation and assault. In the process from ‘patching’ to ‘dispatching’, the patient whilst exhibiting symptoms is regarded as a non-person and a non-self.

The effect of all this on the breakdown of the self and concomitant disturbances in perception, sense of presence, corporeality, stream of consciousness, self-demarcation, and existential reorientation in psychosis is not hard to infer - the external invalidation compounds the inner deterioration.

Identifying the specific neurobiological effects of psychiatric hospitalisation and their phenomenological correlates would make an interesting and fruitful area of future research. But in the meantime, something should be done to ameliorate the deleterious effects which can reasonably be inferred.

The obvious question that arises is, what is the alternative?

The answer is that there is a humane and proven alternative from the phenomenological tradition already there. This is the Soteria based principle of "being with" rather than "doing to" the psychotic patient; an approach in which the patient is allowed to reintegrate his or her sense of self in a conducive, supportive and non-threatening environment.

As things stand, I believe that as well as our immigration detention centres being factories for producing mental illness, our psychiatric hospitals may be factories for protracting it.
　

Irregular Behaviour and the Concept of Self in Bali

2010-12-28T02:18:00.000-08:00

I wrote the following (long!) essay for a Medical Anthropology unit I did at Uni some time ago. The relevance to Soteria I think is that it illustrates the importance of culture and the surrounding environment on the development and progression of 'mental illness'.

Also, of note on this topic is the recent book Crazy Like Us: The Globalisation of the American Psyche, By Ethan Watters. This book describes how the export of Western psychiatry and concepts of mental illness across the globe have impacted on local cultures, sometimes producing the illnesses it is supposedly combating. It is on my 'to read' list - looks very interesting.

Introduction
　
Both the way in which a behaviour is interpreted within a society and the form of the behaviour itself are dependent on the properties and characteristics which are used to define persons within that society. These properties and characteristics - which in this essay shall be referred to as ‘the concept of self’ - have a substantial impact on whether behaviours are considered acceptable, unusual or deviant. They also influence the behavioural possibilities which are open to an individual and consequently, the way he or she acts.

This essay will explore the relationship between the Balinese concept of self and three forms of irregular behaviour (meaning behaviour which differs from regular behavioural norms) that occur in Bali. The behaviours to be discussed vary in that one occurs within a socially sanctioned ritual context and is socially valued; one occurs outside such a context and is not positively valued; and the other occurs outside a sanctioned context but is so valued.

The order of exposition will be that firstly, these behaviours will be described. Secondly, an outline of the Balinese concept of self will be presented. Thirdly, the relation of this concept to the Balinese interpretation of the behaviours described will be analysed. Following this, the same type of analysis will be applied to the form of these behaviours.

Sanhyang trance

There are many varieties of trance in Bali that could be used as examples of unusual forms of behaviour which are socially approved of. This essay shall describe just one of these as an illustrative example of this diverse general type. The trance variety to be considered is the folk trance sanhyangs of the Selat district of Eastern Bali, as described by Jane Belo from observations she made in the 1930’s.

Sanhyang trances involve trance states in public performance settings in which male trancers are believed to be entered by the spirit of common animals, village objects or supernatural beings and assume the characteristics of these things. They are conducted amongst the villagers of the Selat area on certain nights of the harvest season and are performed without elaborate costuming or complex ritual.

The sanhyang performance usually begins with the performer being smoked in front of an incense brazier to induce trance. Once in trance, the sanhyang begins acting like the animal or object whose spirit has entered him. For example, a pig sanhyang might start grunting and wallowing in the sand, whilst a monkey sanhyang might climb a tree and swing from the branches. The audience greatly enjoys the performance and sings and taunts to encourage the sanhyang behaviour.When it is decided that it is time to end the performance, members of the audience jump on the sanhyang to restrain him, while the sanhyang struggles to escape. Eventually he goes into violent convulsions and is then nursed back into his normal conscious state.

After coming out of trance, the sanhyang has no conscious recollection of the events that occurred, but do recall feeling ‘crazy’, ‘angry’ or ‘delicious’ when entering trance. Although sanhyang behaviour is socially approbated, the trancers themselves are ordinary villagers without special status (Belo 1960; 201-225).

Bebainan

Bebainan is a form of unusual behaviour in Bali that is not socially valued. In biomedical terms, Bebainan is a culture-bound syndrome characterised by attacks of dissociation lasting from 15 minutes to one hour.
The most common features of Bebainan are sudden feelings of confusion, crying, screaming and shouting, followed by the inability of the sufferer to control his or her bodily movements. The final stages of Bebainan typically feature spasms and convulsions of the whole body. The victim usually feels confused and exhausted after the attack and has complete amnesia of its latter stages.

Balinese believe Bebainan is caused in most instances by sorcery. It is believed that the actions of a sorcerer cause the sufferer to be entered by malignant spirits called bebai. A simple exorcism ceremony conducted by a balian (indigenous healer) is held if attacks of Bebainan are recurrent or of long duration. The balian expels the bebai from the victim, who is usually relieved of all symptoms and recovers completely.

Mos Bebainan victims are women between the ages of 16 and 30. Whilst possessed by bebai they are not considered to be responsible for their actions (Dean and Thong 1972:61. Suryani 1984: 95-105).

Buduh Kedewandewan

Buduh Kedewandewan, which can loosely be translated as ‘madness from the gods’, is a term that applies to certain types of irregular behaviour which, whilst not occurring in a socially established setting, are nevertheless socially valued. Episodes of Buduh Kedewandewan are interpreted as possessions by supernatural deities and often function as initiatory experiences that lead to the afflicted person becoming a balian (indigenous healer).

Buduh Kedewandewan is characterised by features such as hearing voices and having visions. For example, one balian recounted how everything appeared yellow and he saw mysterious fireballs everywhere during his period of Buduh kedewandewan. Another describes how he intermittently heard and saw a small white creature with pointed ears which would reveal to him various sacred omens.

Periods of Buduh kedewandewan are often accompanied by severe illness and fever. Many describe feeling confused and crazed whilst afflicted. Other features include speaking in obscure language, uncontrollable convulsions, wandering in sacred places, and wearing ceremonial clothes on ordinary occasions.

In order to interpret the behaviour of someone displaying symptoms of Budeh kedewandewan, a balian is consulted. Through observing the person and through messages received while in trance, the balian determines what sort of spirit has entered him or her and what its social significance is. Often the balian will ascertain that the afflicted person should become a balian and thereafter initiation ceremonies are held. Following these, the afflicted person will usually gradually return to his or her normal behaviour, learning to restrict periods of possession to the ritual contexts in which they ordinarily occur (as will be described further below (Belo 1960: 8,18-39. Connor 1982: 255-258).

The Balinese Concept of Self

In order to analyse the interpretation of irregular behaviour within a culture it is necessary to do so from the perspective of what selfhood means within that culture. The Balinese concept of self is derived from a mixture of concepts from animistic and ancestral cults and Hinduism. Although this mixture has produced a wide diversity of ontology’s of the self throughout Bali, several common, unifying themes are evident:

Firstly, the mind-body dualism which typifies Western characterisations of the self is largely absent in Bali. Rather, the Balinese concept of self is comprised by the dynamic interaction between mental, physical and supernatural forces.

Secondly, Balinese conceive of the person as being a microcosm of the surrounding macrocosmic environment (where, for example, the hairs on the body are analogous with the trees and plants of the earth). Microcosm and macrocosm constantly interact and modify each other, in both physical and supernatural modes.

Thirdly, an individual’s personality is believed to include personified spiritual entities as integral components. Sacred texts speak of the most important of these as the four spirit siblings, who incorporate with the physical body - the fifth and youngest sibling - to constitute the person.

From this brief outline, it can be seen that rather than being unitary and self-enclosed, the Balinese self is conceived of as being a concentration of natural, supernatural, microcosmic and macrocosmic influences. (Connor 1982: 260-263).

Concepts of self within a culture affect the categories of interpretation within which a particular behaviour is framed. Western categories used to explain irregular behaviour are highly egocentric; that is, the locus of dysfunction is sought within the individual (White and Marsella 1982:15). In contrast to this, the interactive and open concept of the self in Bali means that explanation is overwhelmingly sociocentric: irregular behaviour is believed to be caused by aspects of the individual’s social, spiritual and physical milieu.

Because an essential aspect of the Balinese self is that it has the potential to be influenced by supernatural and paranormal phenomena, it is inappropriate to apply egocentric dichotomies of sanity and insanity or normality and abnormality to behavioural interpretation by the Balinese. Rather than being interpreted in terms of polar opposition to normality, irregular behaviour in Bali is interpreted as being part of a behavioural continuum. This is congruent with Kiev’s observation that in many non-western societies, diagnosis of unusual behaviour is in terms of conformity with a recognised model of marginal behaviour, not in terms of deviation from the norm (Kiev 1972:128).

A further consequence of the sociocentric nature of Balinese behavioural interpretation is that the interpretation of irregular behaviour is context dependent to a very large extent. Non-polairty and context-dependence are thus two essential aspects of Balinese behavioural interpretation, and will be delineated more clearly in the discussion that follows.

The Balinese self and the Interpretation of Irregular behaviour

The relation of the concept of self of the Balinese and their interpretation of unusual behaviour is illustrated by the contrast between how Sanhyang trance and Bebainan are regarded. There are many similarities between these behaviours. Both involve uncontrollable, often violent behaviour and terminate in convulsions. Both are believed to be caused through possession by supernatural entities. The fact that Bebainan is caused by an evil spirit does not in itself differentiate it from Sanhyangs, because some Sanhyangs also involve possession by evil spirits (Belo 1960:210).

Despite these similarities, the contexts in which these behaviours occur means they have different social significations. Sanhyang trances occur within a socially sanctioned ritual context, where they are valued as a form of entertainment. Bebainan occurs outside such a context, where the screaming, shouting and aggressive behaviour contrast strongly with the restrained, passive behavioural norm of Balinese everyday life. Thus, the way in which Bebainan and Sanhyangs are interpreted is not dependent simply upon the fact that uncharacteristic, unusual behaviours are displayed. Because the self in Bali is seen as being essentially interactive with the supernatural real, such behaviours are expected and accepted. Nevertheless, the context within which such behaviours occur provide criteria for social approbation. So possession by an evil spirit invokes awe and respect within trance rituals, but outside such a context is regarded as the consequence of malicious sorcery.

Like Bebainan, Buduh kedewandewan is a form of irregular behaviour that occurs outside a socially sanctioned setting. Yet unlike Bebainan, it is interpreted in a positive manner. These differences in interpretation can to a large extent be explained by the behavioural differences characteristic of each. Although the sufferer of Buduh kedewandewan is often highly confused and disoriented, he or she does not usually engage in violent or antisocial behaviour (Connor 1982:255). What’s more Buduh kedewandewan has specifically religious features, such as wandering around sacred places and having visions of supernatural deities. These characteristics act to support the view that the sufferer is not possessed by an evil spirit, but one that could be beneficial to the community. If a balian confirms this, then the ‘sufferer’ may also assume the respected role of balian.

Thus, although Buduh kedewandewan does not occur in an established physical context, its features mean that it can be fitted within a spiritual context. A major disturbance in the integrity of the self is not, therefore, in itself seen as an unhealthy or deleterious phenomenon. Rather, it is a signification that the nexus of forces which constitute the self is in turbulence and that such turbulence may lead to benefits for the community.

The Balinese Self and the form of irregular behaviour

Interpretation of irregular behaviour within a society, both by the person affected and the community in general, is not a passive process but directly influences the behaviour itself. In investigating this influence, it is useful to analyse the behaviour not only from its own internal cultural perspective, but also from the perspective of Western concepts of mind and body. Hence, the focus in this section will be on considering irregular behaviour as the result of the interplay of cultural and biological factors.

That cultural factors affect psycho physiological phenomena is generally agreed upon. For example, Simons has convincingly argued that the Latah reaction (a hyperstartlement reaction occuring in southeast Asia) is a ‘culture-specific exploitation of a neurophsyiologically determined behaviour potential’ (Simons 1985:44). Fabrega has taken this one step further to say that the effects of early socialisation on neuronal development means that mental illness in different cultures occur in different types of nervous systems (Fabrega 1982:55). As for the ‘healthy’ aspects of dissociative states, Kleinman has made the point that the rationalised and self-reflexive concept of self in the Wet has deprived people of the total, unreflective absorption in lived experience which characterises trance states (Kleinman 1988:50).

There can be little doubt that the behaviours discussed in this essay are greatly affected by cultural factors and that the Balinese concept of self is a major one of these. It is also true that the behaviours, involving as they do dissociation, convulsions and amnesia, have a significant biological component. Thus, the assumption here is like that of Simons; that the behaviours described are culturally modified expressions of neurophysiologically determined behaviour potentials.

The cultural conditioning of Sanhyang trance behaviour is highlighted by investigating the sensations a trancer reports feeling when he goes into trance. The inquiries of Belo have revealed that all the trancers do not consider themselves to be acting, but actually feel like the thing whose behaviour they manifest in trance. For example, a Sanhyang monkey relates that when going into trance his thoughts are like those of a monkey and that, like a monkey, he desires to seek in the forest for fruit. Similarly, a Sanhyang potato says that when in trance he feels himself to be ‘like a potato planted in the garden’ (Belo 1960: 222).

Belo has remarked that because the trancer is not consciously aware of himself whilst fully in trance, these reports are probably based on observation of fellow trancers and the conception of trance phenomena accepted by the Balinese (Belo 1960:223). Nevertheless, this does not diminish the remarkable fact that the Balinese conception of self makes is possible for trancers to say, without fear of ridicule, that they have felt what it is like to be a monkey or a potato. From this, it is clear that if the Balinese did not believe that the self was susceptible to possession by spiritual entities, it would not be possible for the trancers to enact the behaviours they do.

With regard to the physiological correlate of trance dissociation, Belo has speculated that a mild epileptic tendency may be the neurological substratum which allows some individuals to go into trance (Belo 1960: 151). This may or may not be true, but what is evident is that Sanhyang trances are the result of the distinctive cultural patterning of physiological changes associated with the potential some people have for becoming dissociated.

A study by Suryani suggests that, like Sanhyang trance, Bebainan is a socially constructed phenomenon highly linked with notions of selfhood. The approach used in his study was psychological rather than anthropological, but it still serves to demonstrate this point. Suryani investigated the life circumstances of victims of Bebainan in the compound of descendants of a royal family. He found that most victims were young women whose early socialisation contrasted strongly with the way in which they were expected to behave as adults. Being of high caste, they were spoiled and relatively undisciplined as children, but as adults they were taught that it is shameful to express anger, displeasure and other negative emotions. Thus, Suryani surmised that Bebainan allows people who are not psychologically equipped to repress socially disvalued emotions to release emotional tension in a socially acceptable manner (Suryani 1984; 110-111).

Buduh Kedewandewan provides a particularly interesting example of the social modulation of irregular behaviour. In this case, the behavioural irregularity receives a positive social evaluation, but at the same time the individual is conditioned to display such behaviour only in the appropriate context. Belo provides a first hand narration of an example of this conditioning process. A middle aged man had been repeatedly going into trance (involving shivering, shaking and convulsions) in non- ritual situations and believed the gods were calling him. A meeting of the village balians was held in which it was determined that this was in fact the case. Ceremonies were then held to initiate the man as a balian and he was instructed to live in the village for 42 days. During this time, the man participated in temple activities and rituals, although he would often fall into trance at improper times. By the end of the live-in period however, the man had learnt to restrict his trance behaviour to the appropriate time in rituals and in all other respects was functioning as a normal individual (Belo 1960; 47-52).

Thus, it can be seen that the positive interpretation of involuntary dissociative behaviour affects the mode in which that behaviour subsequently occurs. It is likely that the fact that the behaviour is not seen as anti-social - the fact that it is regulated but not repressed - contributes to it not developing in an antisocial direction. Of relevance here is the observations that shamans in different cultures are often selected on the basis of their hallucinatory experiences. It has been hypothesized from this that the incorporation of such schizophrenic symptoms into a socially approved role reduces the likelihood that secondary symptoms and complicating patterns will develop (Kiev 1972; 128). Similarly, the way in which Buduh kedewandewan is interpreted by the Balinese may help ensure that an individual afflicted by it does not deteriorate in an individually or socially destructive manner.

Conclusion

This analysis serves as an example of the dialectic between nature and culture which has been described as one of the central problematic of medical anthropology (Hahn and Kleinman 1983; 321). The problematic was framed here in terms of the interaction between the exploitation of biological potentialities for irregular behaviour with cultural processes of interpretation and approbation. To put it more succinctly, the dialectic has been behavioural form and interpretation.

It has been shown that a central component of the interpretative side of this interaction is the Balinese concept of self. Most important in this regard is the fact that because the Balinese self is regarded as open to supernatural influence, interpretations of irregular behaviour are not categorised in terms of the polar opposition between normality and abnormality (or between sanity and insanity). The situation is analogous to that of pre-Cartesian Europe in the Middle Ages, where madness was still ‘an undifferentiated experience, a not yet divided experience of division itself’ (Foucault 1973; ix).

A consequence of the nondivisive nature of the self in Bali is that the influence of behavioural interpretation on behavioural form has given rise to a spectrum of behaviours which could not arise in the Cartesian West. Just as western culture re-produces behaviours such as epilepsy and schizophrenia which conform with and confirm its classificatory dichotomies, Balinese culture reproduces behaviours that fit its view of what a person is. Hence, in the behaviours examined here it was shown that the realization of biological potentialities for irregular behaviour produced behaviours which could function as a form of ritual entertainment, an initiatory experience for a healer, or as a means of expressing forbidden emotions.

In each of these behaviours, the form and interpretation of the behaviour reciprocally modify and co-determine each other. When it is recognised that this reciprocal relationship includes the self-interpretation by the afflicted person of his or her sensations and psychophysiological state, it becomes clear that the mediating connections between biological and cultural influences on behaviour make it imperative not to consider either in isolation from the other.

References

Belo, J. 1960. Trance in Bali. NY Columbia University Press.

Connor, L 1982. The Unbounded Self: Balinese therapy in Theory and Practice. In Marsella, A and White, G (eds) Cultural Conceptions of Mental Health and Therapy. Dordraht Reidel Publishing Co. pp 251-267

Dean, S and Thong, D. 1972 Shamanism versus Psychiatry in Bali, ‘Isle of the Gods’: Some Modern Implication. Amer.J.Psychiat. 129:1. Pp 91-94.

Fabrega, H. 1982. Culture and Psychiatric Illness: Biomedical and Ethnomedical aspects. In Marsella and White , op. cit. pp39-68.

Foucault, M. 1973. Madness and Civilization. A History of Insanity in the Age of Reason. NY. Vintage Books

Hahn, R and Kleinman, A. 1983. Biomedical Practice and Anthropological Theory. Ann. Rev. Anthropol. 12:305-33.

Kiev, A 1972 Transcultural Psychiatry. Harmondsworth, Engl. Penguin

Kleinman, A 1988. Rethinking Psychiatry NY. Macmillan Inc.

Simons. R 1985 The Resolution of the Latah Paradox. In Simons, R.C. and Hughes C.C. (eds) The Culture -bound Syndrome: Folk illnesses of Psychiatric and Anthropological Interest. Dordrecht. D.Reidel pp 41-62

Suryani, L 1984. Culture and Mental Disorder: The case of Bebainan in Bali. Culture, Medicine and Psychiatry. Vol 8. (1984) pp 95-113

White, G and Marsella A 1982. Introduction: Cultural conceptions in Mental Health Research and Practice. In Marsella and White, op.cit. pp 1-38.

Psychiatry or AntiPsychiatry?

2010-12-10T15:32:00.000-08:00

In considering the advance of the Soteria movement in Australia, one of the issues that arises is whether this movement should work with or against the mainstream psychiatric establishment.

Loren Mosher, the founder of Soteria, ended up being dismissed from the US National Institute of Mental Health and resigned from the American Psychiatric Association. To many, it may seem obvious that Soteria based alternatives are incompatible with mainstream psychiatry’s overwhelming reliance on drug based therapy and its close links with the pharmaceutical industry.

Personally, while I have sympathies with a stance that rejects the psychiatric industry and the biomedical model of mental illness, I think from a pragmatic point of view such a stance would be doomed to frustration. Besides the fact that many get help from using medications, there is simply too much money involved in the pharmaceutical industry, the universities, the research institutes and the professions for any really radical change to be effected at the present time.

For this reason, my view is that at the present time advocating for a model along the lines of Soteria Berne has more chance of success. Luc Ciompi, the founder of this clinic, bases many of his ideas on the work of Mosher, but also see his approach as compatible with conventional psychiatry.

As detailed in this article, Ciompi regards schizophrenia as being the result of a complex interaction of biological, emotional cognitive and social factors. He bases treatment at Soteria Berne on the following therapeutic principles:

1. Small, relaxing, stimulus-protecting and as "normal" as possible therapeutic setting
2. Continual personalized "being with" the psychotic patient
3. Personal and conceptual continuity over the whole period of treatment
4. Continued close collaboration with family members and other important persons of reference
5. Clear and concordant information, for patients, family and staff, on the illness, its treatment and the existing risks and chances
6. Elaboration of common realistic goals and expectations for future housing and work
7. Consensual low dose neuroleptic strategies, with the aim of controlled self-medication
8. After-care and relapse prevention for at least two years.

Whilst some may reject the endorsement of "neuroleptic strategies" by Ciompi, this approach could at least serve as a stepping stone to drug free Soteria environments, for those who want them, far off in the future.

In the interim, pushing for a model along the lines of Soteria Berne seems the most realistic approach to me. Who knows, it may even be possible to get Professor McGorry and Big Pharma on board!
　
　

The Double Bind and the Psychiatric Hospital

2010-12-09T03:03:00.000-08:00

I wrote the following about twenty years ago and wouldn't necessarily agree with it all now. But I think it is relevant to the Soterian emphasis on 'being with' rather than 'doing to' a person in deep mental crisis:

The idea that the cause of mental illness lies in a conflict between different communication signals was most clearly elucidated in the 60’s by the brilliant anthropologist Gregory Bateson. He hypothesized that schizophrenia is an adaptation to a situation in which normal communication is impossible because contradictory messages are being conveyed at the same time. The conflict occurs between the primary message and other messages that are implied, often through body language. For example, a tired parent may ask her child to come to her while through her body language she is saying ‘go sway, I do not wish to see you’. Or a child may be spanked for a misdemeanour while the parents gestures and facial expression are saying ‘I am sorry, it is wrong for me to do this’.

These examples may appear trivial, but when such a pattern of communication is constant and relentless, Bateson hypothesised that the incompatible demands placed upon an individual cause the normal ordering of experience to break down. A persistent influx of injunctions of the form ‘Do this. Don‘t do this’, eventually results in the individual refusing to play the game. The paradoxical, antagonistic nature of such communications make them no-win situations, double binds.

Hence, the individual constructs a new way of classifying experience that provides relief from the torture of the double bind. The manifestation of this rearrangement of reality is what we call madness.

Whatever the veracity of Bateson’s ideas, I believe that the concept of the double bind has as much relevance to the treatment of mental illness as to its causation. In many ways, such as those described below, treatment in a psychiatric hospital is the ultimate double bind.

Being mad is like being adrift at sea, there are no beacons to guide you and there is no route to follow. Any attempt to engineer the development of a mad person’s view of reality is interpreted by such person as exactly that, a forced infliction of someone else’s view. Yet in the hospital milieu the patient is constantly being told by others that he is there to receive help. This ‘help’ takes the form of compulsory medication, regimented meal and bed times, engagement in therapeutic activities, learning the rules of conventional conversation, instruction in appropriate behavioural responses (don’t laugh too loud, don’t frown too much) and so on. This enforced moulding of behaviour - some of it overt and some not - is accompanied by genuine and apparently deeply felt assertions from others that ‘we are trying to get you better’.

What this amounts to is a patient being knowingly coerced into a particular conception of reality while at the same time being convinced that others are really helping him. Hence, liberating the patient from madness necessitates his subjugation and the double bind takes the form:

‘ We are here to help you. We are here to destroy you’.

The eventual acceptance of the imposed view of reality by a mad person brings its own contradictions. The patient soon discovers that the peace of mind that conformism brings is highly conditional. Whilst doing his best to follow the appropriate patterns of behaviour, at some stage he runs into a brick wall. When he enquires about such things as what he should do when he gets out of hospital, where shall he live, what sort of job to get, when he should contact his mother, or anything similar involving the exertion of free will, the response is ‘We can’t decide these things for you, you have to decide what to do with your life’.

Thus, having succumbed to the pressure to follow prescribed modes of acceptable behaviour, he finds that suddenly he is on his own. Decisions must be made for oneself, except when this rule does not apply. In the confused state of madness, the injunction becomes:

‘ You cannot choose. You must choose’.

Another example of the double bind of the psychiatric hospital lies in its treatment of the capacity of the patient to recover. Discussions with nurses, occupational therapists, family and friends foster the view that the mad person can help himself get better. He is encouraged to think positively and try to improve his mental condition, perhaps through activities such as relaxation classes, art and craft activities and stress management techniques.

However, all this emphasis on the patient’s healing potential is obliterated through the pinnacle of psychiatric treatment in hospital, the consultation with the psychiatrist. Although this may only take the form of two twenty minute consultations per week, it it is regarded as the most significant part of being there. What usually happens during these consultation is that the psychiatrist asks a series of routine questions and then pronounces that the patient’s brain chemistry is malfunctioning and tells him what drugs he will be taking until next appointment. So while at one level the patient is encouraged to help himself, at another level he is told that his problem is purely physiological and cannot be influenced by his subjective self:

‘ You can heal yourself. You cannot heal yourself.’

The dichotomy between reason and unreason provides another instance of the psychiatric double bind. After being convinced of the irrationality of his beliefs that he can influence events with his thoughts or that he has contact with a spiritual dimension which most people do not know exist, he finds that it is nevertheless acceptable to believe in things such as miracles, Heaven and that Jesus has risen from the dead. He is told that belief in such things is what gives meaning to some people’s lives and comes to realise:

‘ You must be rational. You must be irrational’.

Numerous other examples of contradictory injunctions and demands could be drawn from the hospital environment. Some of them may boil down to fundamental philosophical- existential conundrums such as whether there is free will, is there a God and the relation between mind and body. No-one can expect an easy resolution to such dilemmas. Nevertheless, the question remains of what is the effect of the hospital setting exacerbating the contradictory demands that may be responsible for causing mental illness?

I do not know the answer to this. But perhaps the fact that many depart the hospital setting with a feeling of depression, numbness and despair has something to do with the fact that the hospital does nothing to resolve and a lot to enflame the inner conflicts that brought them there in the first place.
　

The Solution

2010-12-03T21:03:00.000-08:00

Soteria based models provide a humane alternative to psychiatric hospitalisation and overmedication. Soteria has also been demostrated to be cheaper and have equal or superior outcomes to conventional psychiatry.

With both major parties supposedly making committments to improving the mental health services situation in Australia, it is vital that the case for alternatives to conventional psychiatry is heard.

The time to push for Soteria based alternatives in Australia is now!

The Problem

2010-12-03T21:02:00.000-08:00

There are few real alternatives for consumers of mental health services in Australia to conventional psychiatry with its heavy reliance on strong pharmaceuticals with dangerous side effects. Psychiatric hospitalisation is an often degrading and dehumanising experience for those undergoing mental crises, in which the "negation of experience and experience of negation" causes further mental distress.

There is a need for something better.