We should be careful to distinguish, first, what options a clinician has in a perhaps overall shitty psychiatric system, and what the system could look like in the future. The latter question can be semi-utopian - what if we had a better welfare state overall, what if we had more resources - without imagining some completely utopian Star Trek society.
I talked a bit over social media with RSS, the last time he was hospitalized against his will. IIRC, he was hospitalized because he was behaving weirdly when grocery shopping and someone called the cops on him. He tried to explain that he didn't have a mental breakdown just now, he's permanently mad, he IS weird, but he manages, and then no one listened.
At hospital, he was forcibly injected with antipsychotics. He insisted over and over that he didn't need the injection and DIDN'T CONSENT but no one listened. I guess he was quite upset, but also, once you've been forcibly hospitalized, it might hard to convince anyone of anything EVEN IF you manage to speak in a way that would sound rational to an impartial observer (because most clinicians, at this point, are not impartial observers, they've already labelled you hopelessly crazy). Eventually, after enough time, he managed to perform well enough to be let out again.
(If RSS reads this comment, he can correct me if I misrememeber)
Seems to me that even in our current system, clinicians could do better. Listen more, not be so quick with the forced injections ...
Also, as you discuss already in the post - some clinicians do already accept that patients might hold radically different world views; what seems like evidence for "the Mainstream World" to the clinician might not be evidence to the patient. Some clinicians already accept this and focus on whether patients, in some pragmatic sense, can MANAGE themselves and their lives, regardless of beliefs. But then again, lots of clinicians don't. Constantly insisting, to clinicians and other people, that of course you KNOW WHAT'S REAL (their reality, no alternative version), becomes exhausting, and also does violence to your self-esteem in the long run. If I ever find myself back in mental hospital, I'm gonna say this again, for pragmatic reasons. But it would be better if we didn't have to.
More utopic future vision: At Paul Lodge's and my madness conference in Oxford in 2023, we had a couple of young Americans come speak about the "mad camp" they organized after they got out from mental hospital. At the hospital, they had been warned about the dangers of staying in touch with other ex-patients, because the clinicians worried they might drive each other mad again. Disregarding this advice completely, they organized this summer camp together. There, they worked out coping strategies together. Many different ideas, but one I remember, which is highly relevant to this post, was a sort of meditation where they tried to voluntarily approach a psychotic state and then draw back again. Researchers could look into such approaches and see if they could form the basis for new therapies that might be helpful to at least a subset of psychosis patients.
The one thing that I think the discussion regarding the epistemic dimension misses is that many religious experiences are communal and group in nature: think Durkheim’s collective effervescence. They are not solely subjective, but are social facts that can be recognized publicly; and in this sense hold universal validity.
What are ways in which we can improve the "setting" for psychosis? All inpatient units that treat SMI seem to be drab copies of each other, and I have a feeling that has something to do with the Joint Commission...
Such issues gripped me during residency, and pursuit of them was supported by several of my supervisors, linking me to Jaynes, Castaneda, Erickson, and several others. I mention this because once my post-residency "real life" set in, the systems I worked in did not make much room for this, and now I get a chance here to re-visit some of this in retirement when I have more time. That in itself ought to tell us something.
Almost 30 years ago, my wife 'came back' to her Catholicism, and that (long story short) led me back to my Judaism, and I know that our re-acquaintance with spiritual or mystical things informed and enhanced my connections with patients. It also helped me more clearly sort out "psychotic with a religious theme" from "religious/mystical but not really psychotic." I'm sure I still missed a few calls.
Part of what imprisons us is language. Is there remotely consensus (outside the psychiatric world) that "mad" = "psychotically ill?" As is the case with obscenity, we all sort of think we know it when we see it, but that, while somewhat useful, kicks the linguistic can down the road. Psychiatry says mad is either bad and/or undesirable, so once we call someone mad, we're already down a road that others don't automatically follow. Ditto that we consider psychosis bad or undesirable, a dealbreaker if the presumptive patient disagrees with us.
This also raises the matter as to how RSS ( or some other person) gets us in the first place. If he didn't come voluntarily - and why would he? - it points to many factors well beyond what the role of a psychiatrist should be - and who assigned us that role. If the police brought him in, we have some duty to the police and the larger society, and it's not just a negotiation with RSS ( or other). Awais notes this well.
Can every person having a mystical experience who is in a psychiatric situation turn on and off the sanity behaviors required to be let loose? If s/he doesn't show those, who sorts out if that is because s/he cannot or will not? Secondary gain has to be in the equation here, too.
Different traditions have different ideas about whether prophecy still occurs. Judaism generally says it ended about 2500 years ago. I don't see psychiatrists making the call if the next patient is a prophet.
But people do experience God still, of course. I recall a lovely woman I treated who heard God regularly, and we only had a problem when she told me that He told her it was fine to drive on the wrong side of the freeway and He'd protect her -which she did enough times to warrant police attention. She got that others were concerned, but she was just doing His bidding, though she didn't know why He told her that.
Even a mystic is part of our society, and one bottom line, also underlined by Awais, is that obligations are mutual. Those owed society may be different from those owed to a family or a workplace, but they are there. Would a mystic say that they are entitled to, say, financial support from the family while they pursue their spiritual path? How about disability payments? Presumably that would involve at least some (feigned or real) acknowledgement of incapacity due to a condition we call illness.
Again, to narrowly frame this as a problem only between psychiatrists and (tentatively) patients would be to miss a lot.
It seems to me that psychotic people who are in fact experiencing an episode of religious ecstasy are a small subset of those who become psychotic.
I know that with the severely ill, I used to emphasize ADL (Activities of Daily Living) as a frame of helping them understand their experience. How could what they were experiencing fit into ADL, if it could be at all?
It was a way of teaching compartmentalization—not to suppress their experience but to contain it in a way that could be managed.
It was common that a lot of rage was expressed over why they had to compartmentalize anything about themselves. This was the real them, after all. Why couldn’t people understand and accept that?
The short answer for that was that other people, particularly those they loved, were hurt terribly by their actions. Sometimes pts. cared about that; sometimes they didn’t.
This points to a kind of narcissism—“I must be me, no matter what it costs you.”
Narcissists inevitably end up alone. Sometimes that suits them, but some continue to rail against those who can’t accept them as they are. I think narcissistic pathology is best understood using a developmental model—this kind of pt. is perennially stuck at age 2. Toddlers can be charming but often they’re irritable, demanding and tantrum prone. Fortunately, most move on to age 3, where the beginnings of socialization emerge. By 4-5, they’re ready for the social demands of school.
The enraged insistence on acceptance by such a pt. leads to “compassion fatigue,” as you’ve described elsewhere. Close associates (family) in the absence of any attempt at compartmentalization grow tired. Those that hang in there do it as a dulled commitment—in doing that, they lose themselves.
Children, almost inevitably, cut contact in order to save their own lives. The pt. may or may not understand this.
Very few, if any, come to share the religious ecstasy, if they even can see it in that way to begin with. How could a loving, kind God unleash this horror upon them?
This is such a delicately coherent set of thoughts, Awais. And I imagine it will help a lot of psychiatrists reading.
All I have to add is a back up to your argument – the tension between listening to people in extreme mental (mystical) states and communicating that functionality is an important goal is difficult.
I cannot say I have ever had mystical experiences (if anything the opposite - my years spent in extreme anxiety meant I thought/imagined death/dying/graphic-suffering pretty much all the time), though I can add that the extreme state feels as alien to me now as ordinary human consciousness did when I was really sick.
While people could reach me on an intellectual level, they could not reach me on an emotional one. Which was where the tension arose.
Those that were able to help me the most were the ones that listened to me talk about death & suffering (I felt these were issues of paramount importance), even if they had absolutely no idea what I was going on about (so perhaps there is pretending that has to go both ways!), so the discussion could be led gently to how to improve functionality. Whether there is the time available to psychiatrists & patients to do this is another matter.
As a final thought - Oddly, there might be overlap here with how to communicate with people who have completely different political views…
The perpetual challenge of balancing the need to discuss how we make the system better and how we do better in the system we’ve got. I agree with you, Awais; in those acute/crisis situations it’s less about trying to work out if the thoughts/beliefs are ‘real’, and more about if those thoughts are leading to behaviours that pose immediate and life threatening risk to self and others. Understanding the mind takes time and patience and trust and safety - Most of the time it just isn’t possible to assess and respond to risk AND delve under the hood. But I like to believe that when we do the former well, with compassion, humility, and openness, we might get the opportunity to do the other at a later date. I recently had a session where a client and I we were able to talk through some deeper stuff after about six months of crisis presentations. I’m grateful my manager allowed me to persist with this case, and honoured that the client is beginning to open up to me. Time, patience, persistence, curiosity, compassion, humility… it always comes back to these for me.
I appreciate this so much and I have a LOT to say on this topic! I've had two experiences with mania/psychosis and both have been deeply spiritual, profound, and life changing as well as extremely messy, complicated, scary, and embarrassing.
The piece that jumps out at me most is the comparison between psychosis and psychedelic experiences - I have a really deep research interest in this and I have written about it on my own Substack. "If psychiatrists paid attention to the (rich white) world of psychedelic studies and took the same care over ‘setting’, they might make psychosis more beautiful; and they might attend to how their patients could learn how to come down through their own volition, assisting with the integration of their experiences through the ontological trauma on the climbdown, not by interfering with my brain by chemistry, but by showing sensitivity to the question of how they might help me to live my best life."
I feel this in my bones. I have similarly written about how I believe the psychedelic principles of "[mind]set, setting, sitter" could be applied to those in psychosis - yes, to make the experience more beautiful if possible, but even if simply to reduce the trauma that can come with psychosis and especially with psychiatric hospitalization as it exists now. In my own psychotic experiences, I noticed that when I had these three "bases" covered and felt emotionally and physically safe, I was able to have more profound spiritual experiences AND stay more in control of my symptoms. The more I increased my emotional and physical safety, the more I was able to reduce my symptomaticity. When any of these pieces slipped, I became more symptomatic and my symptoms devolved into the more distressing, scary, and paranoid. I strongly believe that those in psychosis are routinely being forced into non-metaphorical "bad trip" in psychiatric environments during psychosis because of the acute fear, distress, fight-or-flight of it all. Can you imagine taking shrooms and then being forced into a psych hospital?
Re: "sitters", I am a huge proponent of revamping the entire mental health system, but it seems that actually having someone - anyone - around to listen and truly witness us during extreme states, these most intense experiences of our lives, would be transformative and revolutionary without even requiring rebuilding the system from the ground up. I have been hospitalized several times and never had access to a 1-on-1 therapist once during those hospitalizations, for example. Being heard and witnessed directly decreases my stress and the intensity of my symptoms in extreme states.
As Saville-Smith alluded to, another piece from formal psychedelic therapy I think is missing for psychotic people is integration after the extreme states end. These states are so emotionally intense and vulnerable, and to have no one to discuss, process, make meaning of spiritual experiences with during or after altered states is one of the most traumatic parts. I have felt expected to just write off the most intense experiences of my life as if they're just pointless aberrations in brain chemistry. This has GREATLY contributed to my depression and suicidality in the aftermath of extreme states.
Finally - if there were noncarceral spaces where people in extreme states could get this type of help and support, be heard and listened to, and access medication and conventional treatment without the fear of being held against our will, we would use them. I have always been willing to seek help and support during psychosis, especially during the early stages. But I have run from hospitalization - why would I seek out a traumatic bad trip? So every time, I've been in this desperate scramble to find this kind of support, trying to do internet research and figure out what's covered by my insurance while increasingly impaired by mania/psychosis until I end up hospitalized anyway. I feel like this kind of support barely exists, or only exists for people with a ton of money (e.g., more holistic longer-term psychiatric rehab facilities that do not accept insurance and cost $10k/month.) I love peer respites but most will only allow you to stay for a week or two due to financial constraints.
A few thoughts:
We should be careful to distinguish, first, what options a clinician has in a perhaps overall shitty psychiatric system, and what the system could look like in the future. The latter question can be semi-utopian - what if we had a better welfare state overall, what if we had more resources - without imagining some completely utopian Star Trek society.
I talked a bit over social media with RSS, the last time he was hospitalized against his will. IIRC, he was hospitalized because he was behaving weirdly when grocery shopping and someone called the cops on him. He tried to explain that he didn't have a mental breakdown just now, he's permanently mad, he IS weird, but he manages, and then no one listened.
At hospital, he was forcibly injected with antipsychotics. He insisted over and over that he didn't need the injection and DIDN'T CONSENT but no one listened. I guess he was quite upset, but also, once you've been forcibly hospitalized, it might hard to convince anyone of anything EVEN IF you manage to speak in a way that would sound rational to an impartial observer (because most clinicians, at this point, are not impartial observers, they've already labelled you hopelessly crazy). Eventually, after enough time, he managed to perform well enough to be let out again.
(If RSS reads this comment, he can correct me if I misrememeber)
Seems to me that even in our current system, clinicians could do better. Listen more, not be so quick with the forced injections ...
Also, as you discuss already in the post - some clinicians do already accept that patients might hold radically different world views; what seems like evidence for "the Mainstream World" to the clinician might not be evidence to the patient. Some clinicians already accept this and focus on whether patients, in some pragmatic sense, can MANAGE themselves and their lives, regardless of beliefs. But then again, lots of clinicians don't. Constantly insisting, to clinicians and other people, that of course you KNOW WHAT'S REAL (their reality, no alternative version), becomes exhausting, and also does violence to your self-esteem in the long run. If I ever find myself back in mental hospital, I'm gonna say this again, for pragmatic reasons. But it would be better if we didn't have to.
More utopic future vision: At Paul Lodge's and my madness conference in Oxford in 2023, we had a couple of young Americans come speak about the "mad camp" they organized after they got out from mental hospital. At the hospital, they had been warned about the dangers of staying in touch with other ex-patients, because the clinicians worried they might drive each other mad again. Disregarding this advice completely, they organized this summer camp together. There, they worked out coping strategies together. Many different ideas, but one I remember, which is highly relevant to this post, was a sort of meditation where they tried to voluntarily approach a psychotic state and then draw back again. Researchers could look into such approaches and see if they could form the basis for new therapies that might be helpful to at least a subset of psychosis patients.
The one thing that I think the discussion regarding the epistemic dimension misses is that many religious experiences are communal and group in nature: think Durkheim’s collective effervescence. They are not solely subjective, but are social facts that can be recognized publicly; and in this sense hold universal validity.
Great piece though Awais.
What are ways in which we can improve the "setting" for psychosis? All inpatient units that treat SMI seem to be drab copies of each other, and I have a feeling that has something to do with the Joint Commission...
It so happens, I have a post on the topic! https://www.psychiatrymargins.com/p/why-we-need-a-psychiatric-museum
Figures you would have already thought of this! Thank you.
Another fascinating theme.
Such issues gripped me during residency, and pursuit of them was supported by several of my supervisors, linking me to Jaynes, Castaneda, Erickson, and several others. I mention this because once my post-residency "real life" set in, the systems I worked in did not make much room for this, and now I get a chance here to re-visit some of this in retirement when I have more time. That in itself ought to tell us something.
Almost 30 years ago, my wife 'came back' to her Catholicism, and that (long story short) led me back to my Judaism, and I know that our re-acquaintance with spiritual or mystical things informed and enhanced my connections with patients. It also helped me more clearly sort out "psychotic with a religious theme" from "religious/mystical but not really psychotic." I'm sure I still missed a few calls.
Part of what imprisons us is language. Is there remotely consensus (outside the psychiatric world) that "mad" = "psychotically ill?" As is the case with obscenity, we all sort of think we know it when we see it, but that, while somewhat useful, kicks the linguistic can down the road. Psychiatry says mad is either bad and/or undesirable, so once we call someone mad, we're already down a road that others don't automatically follow. Ditto that we consider psychosis bad or undesirable, a dealbreaker if the presumptive patient disagrees with us.
This also raises the matter as to how RSS ( or some other person) gets us in the first place. If he didn't come voluntarily - and why would he? - it points to many factors well beyond what the role of a psychiatrist should be - and who assigned us that role. If the police brought him in, we have some duty to the police and the larger society, and it's not just a negotiation with RSS ( or other). Awais notes this well.
Can every person having a mystical experience who is in a psychiatric situation turn on and off the sanity behaviors required to be let loose? If s/he doesn't show those, who sorts out if that is because s/he cannot or will not? Secondary gain has to be in the equation here, too.
Different traditions have different ideas about whether prophecy still occurs. Judaism generally says it ended about 2500 years ago. I don't see psychiatrists making the call if the next patient is a prophet.
But people do experience God still, of course. I recall a lovely woman I treated who heard God regularly, and we only had a problem when she told me that He told her it was fine to drive on the wrong side of the freeway and He'd protect her -which she did enough times to warrant police attention. She got that others were concerned, but she was just doing His bidding, though she didn't know why He told her that.
Even a mystic is part of our society, and one bottom line, also underlined by Awais, is that obligations are mutual. Those owed society may be different from those owed to a family or a workplace, but they are there. Would a mystic say that they are entitled to, say, financial support from the family while they pursue their spiritual path? How about disability payments? Presumably that would involve at least some (feigned or real) acknowledgement of incapacity due to a condition we call illness.
Again, to narrowly frame this as a problem only between psychiatrists and (tentatively) patients would be to miss a lot.
It seems to me that psychotic people who are in fact experiencing an episode of religious ecstasy are a small subset of those who become psychotic.
I know that with the severely ill, I used to emphasize ADL (Activities of Daily Living) as a frame of helping them understand their experience. How could what they were experiencing fit into ADL, if it could be at all?
It was a way of teaching compartmentalization—not to suppress their experience but to contain it in a way that could be managed.
It was common that a lot of rage was expressed over why they had to compartmentalize anything about themselves. This was the real them, after all. Why couldn’t people understand and accept that?
The short answer for that was that other people, particularly those they loved, were hurt terribly by their actions. Sometimes pts. cared about that; sometimes they didn’t.
This points to a kind of narcissism—“I must be me, no matter what it costs you.”
Narcissists inevitably end up alone. Sometimes that suits them, but some continue to rail against those who can’t accept them as they are. I think narcissistic pathology is best understood using a developmental model—this kind of pt. is perennially stuck at age 2. Toddlers can be charming but often they’re irritable, demanding and tantrum prone. Fortunately, most move on to age 3, where the beginnings of socialization emerge. By 4-5, they’re ready for the social demands of school.
The enraged insistence on acceptance by such a pt. leads to “compassion fatigue,” as you’ve described elsewhere. Close associates (family) in the absence of any attempt at compartmentalization grow tired. Those that hang in there do it as a dulled commitment—in doing that, they lose themselves.
Children, almost inevitably, cut contact in order to save their own lives. The pt. may or may not understand this.
Very few, if any, come to share the religious ecstasy, if they even can see it in that way to begin with. How could a loving, kind God unleash this horror upon them?
Sheila Wall, MD
This is such a delicately coherent set of thoughts, Awais. And I imagine it will help a lot of psychiatrists reading.
All I have to add is a back up to your argument – the tension between listening to people in extreme mental (mystical) states and communicating that functionality is an important goal is difficult.
I cannot say I have ever had mystical experiences (if anything the opposite - my years spent in extreme anxiety meant I thought/imagined death/dying/graphic-suffering pretty much all the time), though I can add that the extreme state feels as alien to me now as ordinary human consciousness did when I was really sick.
While people could reach me on an intellectual level, they could not reach me on an emotional one. Which was where the tension arose.
Those that were able to help me the most were the ones that listened to me talk about death & suffering (I felt these were issues of paramount importance), even if they had absolutely no idea what I was going on about (so perhaps there is pretending that has to go both ways!), so the discussion could be led gently to how to improve functionality. Whether there is the time available to psychiatrists & patients to do this is another matter.
As a final thought - Oddly, there might be overlap here with how to communicate with people who have completely different political views…
Anyways – great article Awais – enjoyed it!
The perpetual challenge of balancing the need to discuss how we make the system better and how we do better in the system we’ve got. I agree with you, Awais; in those acute/crisis situations it’s less about trying to work out if the thoughts/beliefs are ‘real’, and more about if those thoughts are leading to behaviours that pose immediate and life threatening risk to self and others. Understanding the mind takes time and patience and trust and safety - Most of the time it just isn’t possible to assess and respond to risk AND delve under the hood. But I like to believe that when we do the former well, with compassion, humility, and openness, we might get the opportunity to do the other at a later date. I recently had a session where a client and I we were able to talk through some deeper stuff after about six months of crisis presentations. I’m grateful my manager allowed me to persist with this case, and honoured that the client is beginning to open up to me. Time, patience, persistence, curiosity, compassion, humility… it always comes back to these for me.
I appreciate this so much and I have a LOT to say on this topic! I've had two experiences with mania/psychosis and both have been deeply spiritual, profound, and life changing as well as extremely messy, complicated, scary, and embarrassing.
The piece that jumps out at me most is the comparison between psychosis and psychedelic experiences - I have a really deep research interest in this and I have written about it on my own Substack. "If psychiatrists paid attention to the (rich white) world of psychedelic studies and took the same care over ‘setting’, they might make psychosis more beautiful; and they might attend to how their patients could learn how to come down through their own volition, assisting with the integration of their experiences through the ontological trauma on the climbdown, not by interfering with my brain by chemistry, but by showing sensitivity to the question of how they might help me to live my best life."
I feel this in my bones. I have similarly written about how I believe the psychedelic principles of "[mind]set, setting, sitter" could be applied to those in psychosis - yes, to make the experience more beautiful if possible, but even if simply to reduce the trauma that can come with psychosis and especially with psychiatric hospitalization as it exists now. In my own psychotic experiences, I noticed that when I had these three "bases" covered and felt emotionally and physically safe, I was able to have more profound spiritual experiences AND stay more in control of my symptoms. The more I increased my emotional and physical safety, the more I was able to reduce my symptomaticity. When any of these pieces slipped, I became more symptomatic and my symptoms devolved into the more distressing, scary, and paranoid. I strongly believe that those in psychosis are routinely being forced into non-metaphorical "bad trip" in psychiatric environments during psychosis because of the acute fear, distress, fight-or-flight of it all. Can you imagine taking shrooms and then being forced into a psych hospital?
Re: "sitters", I am a huge proponent of revamping the entire mental health system, but it seems that actually having someone - anyone - around to listen and truly witness us during extreme states, these most intense experiences of our lives, would be transformative and revolutionary without even requiring rebuilding the system from the ground up. I have been hospitalized several times and never had access to a 1-on-1 therapist once during those hospitalizations, for example. Being heard and witnessed directly decreases my stress and the intensity of my symptoms in extreme states.
As Saville-Smith alluded to, another piece from formal psychedelic therapy I think is missing for psychotic people is integration after the extreme states end. These states are so emotionally intense and vulnerable, and to have no one to discuss, process, make meaning of spiritual experiences with during or after altered states is one of the most traumatic parts. I have felt expected to just write off the most intense experiences of my life as if they're just pointless aberrations in brain chemistry. This has GREATLY contributed to my depression and suicidality in the aftermath of extreme states.
Finally - if there were noncarceral spaces where people in extreme states could get this type of help and support, be heard and listened to, and access medication and conventional treatment without the fear of being held against our will, we would use them. I have always been willing to seek help and support during psychosis, especially during the early stages. But I have run from hospitalization - why would I seek out a traumatic bad trip? So every time, I've been in this desperate scramble to find this kind of support, trying to do internet research and figure out what's covered by my insurance while increasingly impaired by mania/psychosis until I end up hospitalized anyway. I feel like this kind of support barely exists, or only exists for people with a ton of money (e.g., more holistic longer-term psychiatric rehab facilities that do not accept insurance and cost $10k/month.) I love peer respites but most will only allow you to stay for a week or two due to financial constraints.