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.
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…
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?
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.
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!
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