What is recovery? Recovery in mental illnesses can mean living a meaningful and productive life despite a disability. It can also refer to a reduction or complete remission of symptoms and a healing transformation of the self. For most people, it refers to the power of hope in healing disorders that were once thought to be hopeless. As Henry Ford once said, "Whether you think you can, or you think you can't, you're right."

Wednesday, December 30, 2015

Please Call Me By My True Names

a poem by Thich Nhat Hanh

Don't say that I will depart tomorrow—
even today I am still arriving.
Look deeply: every second I am arriving
to be a bud on a Spring branch,
to be a tiny bird, with still-fragile wings,
learning to sing in my new nest,
to be a caterpillar in the heart of a flower,
to be a jewel hiding itself in a stone.
I still arrive, in order to laugh and to cry,
to fear and to hope.
The rhythm of my heart is the birth and death
of all that is alive.
I am a mayfly metamorphosing
on the surface of the river.
And I am the bird
that swoops down to swallow the mayfly.
I am a frog swimming happily
in the clear water of a pond.
And I am the grass-snake
that silently feeds itself on the frog.
I am the child in Uganda, all skin and bones,
my legs as thin a bamboo sticks.
And I am the arms merchant,
selling deadly weapons to Uganda.
I am the twelve-year-old girl,
refugee on a small boat,
who throws herself into the ocean
after being raped by a sea pirate.
And I am the pirate,
my heart not yet capable
of seeing and loving.
I am a member of the politburo,
with plenty of power in my hands.
And I am the man who has to pay
his "debt of blood" to, my people,
dying slowly in a forced labor camp.
My joy is like Spring, so warm
it makes flowers bloom all over the Earth.
My pain is like a river of tears,
so vast it fills the four oceans.
Please call me by my true names,
so I can hear all my cries and laughter at once,
so I can see that my joy and pain are one.
Please call me by my true names,
so I can wake up
and the door of my heart
could be left open,
the door of compassion.

Tuesday, December 29, 2015

Compassion Focused Therapy (CFT)

        I've personally found compassion-focused therapy quite helpful in my own quest to be my own therapist (in addition to any other therapist I may have at the time). Visit http://compassionatemind.co.uk and click "resources" to access a ton of free resources on this topic which are helpful in self-help work and in working with others. Below is a summary of CFT I wrote for graduate school in a paper entitled Mindfulness and Compassion for Psychosis. The lesson? Love yourself! You may not feel that you deserve it, but your brain needs that self-love to be healthy. 

Compassion-focused therapy was developed with and for people who have chronic and complex mental health problems linked to shame and self-criticism and who come from difficult backgrounds (Gumley, et al., 2010). It addresses emotional aspects often missed by cognitive therapies when clients understand their issues logically but don’t feel better (Gilbert & Procter, 2006). In CFT, clients are first introduced to the compassion-promoting ideas that evolution has not given us brains that are easy to manage and that “we all just find ourselves here.” The three neurological affect regulation systems are then explained. 
The threat and self-protection system (“fight or flight”) operates within the amygdala and the hypothalmic-pituitary-adrenal (HPA) axis and produces feelings of anger, anxiety, and disgust (Gilbert, 2010). Problems with the system include the types of triggers that activate it, the type, frequency, rapidity, duration, and intensity of the threat-protection response, and unhelpful coping responses to its activation (Gilbert, 2010). Nearly all therapies focus to a greater or lesser degree on difficulties within the threat and self-protection system (Gilbert, 2010). According to Gumley, et al. (2010), the unbearable affect in psychosis is linked to the threat protection system and is accompanied by a hypersensitivity to threat.
The incentive and resource-seeking, drive-excitement system is a dopaminergic system that motivates us to seek out resources for ourselves and our loved ones, such as food, sex, comfort, friendship, or recognition (Gilbert, 2010). People with mood disorders have problems with this system: it is over-activated in mania and under-activated in depression (Gilbert, 2010). 
The soothing, contentment and safeness system uses endorphins and oxytocin to calm us when there are no threats to face and no goals to pursue in the present moment (Gilbert, 2010). It is this system that promotes and is promoted by mindfulness and compassion (Gilbert, 2010). It can be left underdeveloped by early attachment difficulties, trauma, and neglect — all problems which are are extremely prevalent in persons with psychotic disorders (Gumley, et al., 2010).
A secure attachment allows children to learn to turn to others for support and soothing, and also enables them to activate their own soothing, contentment, and safeness system to soothe themselves and others when needed (Gumley, et al., 2010). Psychosis, in contrast, is associated with insecure avoidant attachment (Gumley, et al., 2010). Physical and sexual abuse, homelessness, assault, and other trauma are also linked to the development of psychosis, after controlling for other factors (Gumley, et al., 2010; Read, et al., 2008). The threat protection system, already over-activated and under-soothed after these and other experiences, can be exacerbated by the external threats of forced treatment and stigma and the internal threats of fear of relapse and shame (Gumley, et al., 2010). This is worsened by unhelpful safety strategies and the subsequent unintended consequences of those safety strategies (Gumley, et al., 2010). In a compassion focused formulation, all of these challenges are addressed by activating the soothing, contentment, and safeness system with compassion, as shown in Figure 1. 

Interpersonal Environment and Experiences 

Compassion, love, and support 
Breakdown of family relationships
Service responses to seeking help
External Threats

Others untrustworthy
External shame/stigma
Psychiatric interventions

Internal Threats

Internal shame
Fear of recurrence
Cognitive/perceptual change
Emotional distress
Safety Strategies

Cognitive, emotional and interpersonal avoidance
Withdrawal and disengagement
Preoccupation and worry
Subordination and submission
Unintended Consequences 

Loss of affect
Impaired reflexivity and theory of mind
Social isolation
Increased emotional distress
Criticism/Emotional Overinvolvement 
Coercive service responses

Compassionate responding

Sensitivity, sympathy, distress tolerance, forgiveness, empathy, non-judgment, acceptance, warmth, care for well-being, balance/proportion, ease with imperfections 

 Figure 1. A compassion focused formulation. Gumley, A., Braehler, C., Laithwaite, H., MacBeth, A., & Gilbert, P.. (2010). A compassion focused model of recovery after psychosis. International Journal of Cognitive Therapy, 3(2): pp. 186-201.
In compassion focused therapy, clients are taught to deliberately focus attention on compassionate thoughts and images, to use reason to bring about a balanced perspective, and to learn compassionate ways of alleviating distress to replace unhelpful safety strategies (Gilbert, 2010). Clients learn to use compassionate self-correction rather than shame-based attacking (Gilbert, 2010). A compassionate body scan and a soothing breathing rhythm are used to encourage mindfulness (Gilbert, 2010). Imagery work develops the inner compassionate self, compassion flowing out to others and in from others, and self-compassion (Gilbert, 2010). Clients learn to write compassionate letters to themselves and to deal with blocks to compassion (Gilbert, 2010). 
A study found that participants in a Compassionate Mind Training (CMT) group exhibited significant reductions in depression, anxiety, self-criticism, shame, inferiority, and submissive behavior (Gilbert & Procter, 2006). (Gilbert has not clarified the difference between the earlier term Compassionate Mind Training and his later use of the term Compassion Focused Therapy, but if there is one it seems to be a difference of group versus individual therapy. The theory and techniques appear generally the same.) There was also a significant increase in the participants' ability to self-soothe and focus on feelings of warmth and reassurance. 
Mayhew and Gilbert (2008) used CMT with three cases of persons hearing malevolent voices. Participants showed decreases in depression, psychoticism, anxiety, paranoia, obsessive-compulsive disorder, and interpersonal sensitivity. The hallucinations of the participants became less malevolent, less persecuting, and more reassuring. Two of the participants showed a remarkable increase in functioning, although the third did not allow himself to fully embrace self-compassion due to a shameful sexual secret.

Heather Laithwaite (2010) adapted Compassionate Mind Training for use in a high security forensic setting and named the resulting program Recovery After Psychosis (RAP). Fifteen men with schizophrenia and three men with bipolar disorder participated. Eight of these participants had also been diagnosed with anti-social personality disorder. The subjects demonstrated a large magnitude of change for depression and self-esteem, a moderate magnitude of change for social comparison and general psychopathology, and a small magnitude of change for shame. Participants continued to show these changes six weeks later.
Gilbert, P. & Procter, S. (2006). Compassionate Mind Training for people with high shame and self-criticism: Overview and pilot study of a group therapy approach. Clinical Psychology and Psychotherapy, 13: pp. 353-379.  
Gilbert, P. (2010). Compassion Focused Therapy: Distinctive features. New York: Rutledge. 

Gumley, A., Braehler, C., Laithwaite, H., MacBeth, A., & Gilbert, P. (2010). A compassion focused model of recovery after psychosis. International Journal of Cognitive Therapy, 3(2): pp. 186-201. 
Laithwaite, H. (2010). Recovery After Psychosis: A compassion focused recovery approach to psychosis in a forensic mental health setting. (Doctoral Dissertation, University of Glasgow). Retrieved from http://theses.gla.ac.uk/1759/1/ PhD_thesis_Final_April_2010.pdf
Mayhew, S.L., & Gilbert, P. (2008). Compassionate Mind Training with people who hear malevolent voices: A case series report. Clinical Psychology and Psychotherapy, 15: pp. 113-138. 
Read, J.,  Fink, P.J., Rudegeair, T., Felitti, V., & Whitfield, C.L. (October 2008). Child maltreatment and psychosis: A return to a genuinely integrated bio-psycho-social model. Clinical Schizophrenia and Related Psychoses, pp. 235-254. Retrieved from http://www.integration.samhsa.gov/pbhci-learning-community/child_maltreatment_and_psychosis.pdf

Monday, December 28, 2015

Intentional Peer Support

Intentional peer support (IPS) is the best peer support model I've encountered since I first worked as a recovery coach (peer specialist) in 2005. Check out my doodle regarding IPS principles and learn more at www.intentionalpeersupport.org.

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Friday, December 25, 2015

Happy holidays

May you be filled with the spirit of gratitude, giving, and love, this season and always. 

Thursday, December 24, 2015

Connecting with regressed loved ones

The holidays can be a very difficult time of year for people due to lost loved ones, holiday stress, trauma triggers, and separation from family due to severe mental illness or other reasons. While I walk through the season with my own combination of heartbreak and joy, my heart is also with others around the world who are struggling now for various reasons. One area of difficulty is when people in recovery are so extremely regressed due to psychosis or developmental disabilities that they are not able to communicate normally over the holidays and otherwise. 

Garry Prouty’s Pre-Therapy Method can help extremely regressed and psychotic persons get in touch with and strengthen their sense of self, reality and others (2009). In pre-therapy, the therapist uses "contact reflections" to help the client reconnect with reality, emotion, sensation, and the ability to communicate, by noting what is going on in the outer world or in the client or by repeating back statements that the client made (Prouty, 2009). Several studies show this method has high efficacy (Prouty, 2009). Prouty designed the method based on efforts to communicate with his own severely regressed brother, and anecdotally it has been successful in helping family members and caregivers connect with their loved ones who seem otherwise very difficult to reach. 

Have the best possible holiday season, no matter your challenges and joy. 

Figure 2.1 shows the types of contact reflections used in pre-therapy to help re-focus the person on the world around them. 

Contact Reflection



Situational Reflection

Reflecting reality

(if happening) David is petting the cat. The child is pushing the train.

Facial Reflection

Reflecting emotions

You look sad. Your neck muscles are tense. There are tears in your eyes. 

Word for Word Reflections

Reflecting words: Offers client the experience of being a human communicator

Client says, “stamp...[mumble] hat... [mumble] dog.” Therapist repeats, “Stamp, hat, dog.”

Body reflections

Reflecting bodily expression

Client stands on one foot. Therapist stands on one foot. Or therapist says, “You are standing on one foot.”

Reiterative reflections

Repeating any of the above four reflections in an effort to “re-contact” 

Therapist says, “Last week you pointed to your belly and said, ‘baby.’” Or therapist repeats one of the above reflections several times in a row.

Figure 2.1. Types of Contact Reflections in Pre-Therapy. Constructed from definitions and examples in Prouty, G. (2009). Making contact with the chronically regressed patient. In D. Garfield, D. Mackler, (Eds.), Beyond medication: Therapeutic engagement and recovery from psychosis (pp. 50-64). New York: Routledge.

Wednesday, December 23, 2015

Can narcissists recover?

This article argues that they can.


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Tuesday, December 22, 2015

Addressing Sexual Trauma in Clients with Psychosis

Studies show that clinicians are less likely to ask about child abuse if a client is psychotic, even though studies show a strong correlation between childhood maltreatment, including sexual abuse, and psychosis (Read, et al., 2008). People with psychotic disorders also experience increased rates of adult sexual assault (Read, et al. 2003; Elklit & Shevlin, 2008). Sadly, people with psychotic disorders are not only less likely to be asked about trauma but also less likely to have their needs met if they do disclose (Read, 2006). This post will examine facts and clinicians concerns about sexual trauma in people with psychosis, followed by a discussion of how to ask about it, how to respond, treatment options available, and clients’ sexuality and intimacy needs after the trauma. 
Facts about Sexual Trauma and Psychosis
A meta-analysis of forty studies found that 50% of female outpatients with psychotic disorders had experienced childhood sexual abuse (Read, 2006). Among male outpatients with psychotic disorders, the rate was 28% (Read, 2006). 79% of women with severe mental illness have been sexually assaulted as an adult, and 17% of men (Read, 2006). A causal relationship is suspected (Read, et al., 2008; Elklit & Shevlin, 2011). One study based on a Danish registry of sex offenses matched women who had been sexually assaulted with controls and found that sexual assault was a significant predictor of later psychosis, even when controlling for other factors (Elklit & Shevlin, 2011). 
Although this post focuses on sexual trauma, trauma in psychotic disorders is not limited to sexual trauma. Trauma affects psychosis in three major ways: by the influence of childhood trauma, by the trauma of diagnosis and treatment, and by further instances of trauma that frequently result from increased vulnerability to victimization (Callcott & Turkington, 2006). A study of 275 patients with schizophrenia and bipolar disorder found that 98% had experienced at least one traumatic event, with 43% concurrently qualifying for post-traumatic stress disorder (Mueser, et al., 1998). 70% of people who hear voices started hearing them immediately following a traumatic event (Romme & Escher, 2000). Among the various types of trauma in psychotic disorders, one study “found that sexual abuse and bullying were the most common traumatic events… They may also be the most toxic” (Smith, et al., 2006, p. 256). 
Sexual trauma informs the content of hallucinations, either directly (i.e., the voice of the abuser or what was said during the abuse), or indirectly (i.e., hallucinations about being otherwise violated or having one’s trust betrayed, or hallucinations representing the dynamic between the victim and the abuser)  (McCarthy-Jones, 2011; Smith, et al., 2006). Clients who have been abused tend to have earlier first hospital admissions, longer and more frequent hospitalizations, more time in seclusion, higher doses of medication, increased self-mutilation, and higher global symptom severity (Read, 2006). Abuse is also linked to the high rate of suicidality in schizophrenia, and one study found this factor to be more important than depression (as cited in Read, 2006). More treatment options than are widespread now need to be made available, particularly because those whose psychotic symptoms are linked to trauma have a particularly poor response to medication alone (Callcott & Turkington, 2006).
Clinician Concerns
In treating psychosis, other problems often seem more pressing than a history of trauma, and sometimes they are. For this reason and other clinician concerns, it is not uncommon for a trauma history to be delayed indefinitely (Read, 2006). However, clients are not likely to disclose this information without being asked; one study showed that women take an average of sixteen years to disclose childhood sexual abuse (as cited in Read, 2006). 
Clinicians often fear that psychotic clients will get upset and may decompensate if asked about sexual trauma (Read, 2006). In fact, clients are often more disturbed about not being asked (Read, 2006). As one person put it: 

There were so many doctors and registrars and nurses and social workers in your life asking you about the same thing, mental, mental, mental, but not asking you why. I think there was an assumption that I had a mental illness and because I wasn’t saying anything about the abuse I’d suffered no one knew. I just wish they would have said, ‘What happened to you? What happened?’ But they didn’t. (qtd. in Read, et al., 2008)

In treatment, deliberate reliving of trauma may need to be reduced (Callcott & Turkington, 2006) or eliminated (Smith, et al., 2006) in order to avoid psychotic decompensation, but there is no evidence that trauma assessment itself is harmful unless completed insensitively (Read, 2006). Only a minority of clients find such questions “stressful,” and even that minority report that they still benefit from being asked (Read, 2006). 
Some clinicians fear that reports of sexual trauma by people with psychosis may often be delusions (Read, 2006). However, the rate of incorrect allegations of sexual trauma is no higher in people with schizophrenia than in the general population (as cited in Read, 2006). In general, clients on inpatient units are more likely to under-report abuse than to over-report it (as cited in Read, 1997). A minority of clinicians believe that asking psychotic clients about sexual trauma can trigger false memories; this is also untrue (Read, 2006). 
Sometimes, however, clients may present with confusion about whether or not they have been abused and in what way. In this case, counseling can help people sort through their experiences and discern the truth behind their sense of having been violated (Callcott & Turkington, 2006). For example, “Harriet” was confused about whether or not she had been sexually abused by her father in a cave in the presence of Margaret Thatcher (Callcott & Turkington, 2006). With counseling, Harriet remembered that she was once lost from her mother in a cave (Callcott & Turkington, 2006). She was also very angry at her father for preferring her half-sibling and for not believing her when a babysitter he hired raped her (Callcott & Turkington, 2006). Ultimately, Harriet, with the support of her therapist, came to the conclusion that strong anger toward her father gave the visions of her father in the cave a vividness approaching that of true memories, although they were not (Callcott & Turkington, 2006). In this case, inquiry about sexual trauma led to the dissolution of false memories for Harriet. 
Other barriers to asking clients with psychotic disorders about sexual trauma include fear of vicarious traumatization, fear of being accused of “family-blaming,” the client or clinician being male, the clinician being opposite gender than the client, lack of clinician training on how to ask and how to respond, and a strong bio-genetic causal belief regarding psychosis (Read, et al., 2008). Not asking is also an extension of widespread denial and minimization of child abuse in general (Herman, 1997; Read, 1997). However, given the high rate of abuse across all diagnoses, it is important that all clients be asked about it (Read, 2006). Read (2006) recommends training for clinicians in how to ask about abuse and how to respond to it, with particular emphasis on asking those clients who are least asked: psychotic clients, male clients, and older clients. The Sexual Medicine Team in Vancouver stands out for deliberately addressing the sexual needs of clients with mental illness, and clients there are asked about sexual assault (Maurice & Yule, 2010). However, clinicians there refer to such questions as “specifically for women” (Maurice & Yule, 2010, p. 479).
How to Ask 
Simply asking, “Were you sexually abused?” will not consistently produce accurate answers. Many people who have been abused do not define their experiences that way (Hammersley, Read, & Bullimore, 2006). A more helpful question is, “As a child, did anyone ever do something sexual that made you feel uncomfortable?” (Read, 2006, p. 209). These questions should not be asked out of the blue, but instead, in the context of a more thorough assessment of the client’s psychosocial history (Read, 2006). It is important to ask during the initial assessment (Read, 2006). If there is a good reason not to ask about sexual trauma, such as flagrant psychosis or acute suicidality, clinicians should note very clearly in the chart that trauma history has not been recorded and then follow-up when the client feels less distressed (Read, 2006). “The tendency of some clinicians to wait for an imagined magic moment when rapport is just right should be challenged, not least with the point that for some clients the act of asking may be crucial to establishing rapport” (Read, 2006, p. 210). 
Hammersley, Read, & Bullimore (2006) recommend beginning with general questions, such as “What was your childhood like?” These can be followed with more specific questions, such as “What was the worst thing that ever happened to you as a child? Which person in your childhood did you feel most comfortable with? Which person, if any, in your childhood was it uncomfortable to be with?” (Hammersley, Read, & Bullimore, 2006, p. 8). Clinicians can support clients by offering ‘continuation responses’ that encourage engagement and information (Hammersley, Read, & Bullimore, 2006). Examples of these include “tell me more,” “okay… I see” and “do you feel okay to continue?” (Hammersley, Read, & Bullimore, 2006, p. 8).
If the client does not volunteer reports of abuse or assault, more specific questions can be asked:
Have you had any unwanted sexual experiences?
Did anyone ever do something to you that made you feel uncomfortable as a child?
Has anyone ever done something sexual to you against your will, or that you didn’t feel comfortable about? (Hammersley, Read, & Bullimore, 2006, p. 9)
How to Respond
Importantly, it is not appropriate for the clinician to immediately gather as much detail as possible upon disclosure of sexual trauma (Hammersley, Read, & Bullimore, 2006; Read, 2006; Read, et al., 2008). Instead, the details need to come out at the client’s own pace. An appropriate response is needed to affirm the client’s choice to disclose the sexual trauma (Hammersley, Read, & Bullimore, 2006; Read, 2006; Read, et al., 2008). After disclosure, the client may feel angry, ashamed, fearful, relieved, numb, or ambivalent (Hammersley, Read, & Bullimore, 2006). An immediate reaction which demonstrates that the client is believed and that their disclosure is acknowledged as positive can help them begin to process many of these emotions (Hammersley, Read, & Bullimore, 2006). Appropriate responses include “Thank you for telling me” and “This is an important thing you have told [me]” (Hammersley, Read, & Bullimore, 2006, p. 11). This can be followed up with a query that normalizes their feelings: “In my experience talking with people about this, people often find that although it is difficult, it can be really helpful to talk about it. How has it been/is it for you talking about this now?” (Read, 2006, p. 214). If the client demonstrates any shame or self-blame, affirm that this is a common experience but that what they went through is not their fault (Read, 2006). 
Once the client’s decision to disclose and resulting feelings are validated, it is important for the clinician to offer support (Read, 2006). If qualified, the clinician can offer, “Would you like us to talk about that at some point?” (Read, 2006, p. 214). Alternatively, the clinician can refer to someone more qualified: “Would you like to talk to someone about how you feel about it all now?” (Read, 2006, p. 214). It is important to ask if the client is still being abused, or if the possibility exists that the perpetrator is abusing others (Read, 2006). Some ways to establish safety are:
Do you feel safe now?
Is anything like that still going on?
Are you safe to leave?
Is anyone treating you like that at the moment?
I need to check now if you are safe.
As part of this I need to check if people around you are safe. (Hammersley, Read, & Bullimore, 2006, p. 13)
At the end of the session, it is important for the clinician to check-in regarding the disclosure and plan for follow-up. (Hammersley, Read, & Bullimore, 2006; Read, 2006; Read, et al., 2008). Clients need to be asked again how they are feeling about their disclosure, and given contact information for someone they can talk to if they become upset about it later on (Hammersley, Read, & Bullimore, 2006). They also need to be supported in making a plan of coping techniques they might use and support persons they might call if they do become upset (Hammersley, Read, & Bullimore, 2006). A follow-up appointment can help reassure both client and clinician that they will be able to check in again soon (Hammersley, Read, & Bullimore, 2006; Read, 2006; Read, et al., 2008).
Sadly, there are few tested treatments for people with psychotic disorders who are struggling with sexual trauma, because people with psychosis are usually deliberated excluded from trauma treatment studies (Read et al., 2003; Read, 1997). More research is desperately needed. A 1991 study on group therapy for “chronically mentally ill females” who had experienced childhood sexual abuse showed promising results, and a 1990 group therapy study demonstrated greatly reduced hallucinations in female incest survivors (as cited in Read, et al., 2003). The best available option for individual therapy seems to be CBT for traumatic psychosis, which addresses trauma of all kinds (Callcott & Turkington, 2006; Smith, et al., 2006). Although a search by this student turned up no studies examining this treatment, CBT for traumatic psychosis is based on a combination of two other best practices: CBT for psychosis and CBT for PTSD  (Callcott & Turkington, 2006; Smith, et al., 2006). 
Callcott and Turkington (2006) base their recommendations for the treatment of trauma in psychosis on the idea, proposed by Kingdon and Turkington in 1999, of five subgroups on the schizophrenia spectrum: sensitivity disorder, catatonia, anxiety psychosis, drug-induced psychosis, and traumatic psychosis (as cited by Callcott & Turkington, 2006). The label of traumatic psychosis is not necessary for treatment, however, since Smith et al. (2006) do not use the label yet make strikingly similar recommendations. Whether or not a co-occurring diagnosis of PTSD can be made, both Callcott and Turkington (2006) and Smith et al. (2006) recommend combining CBT for PTSD with CBT for psychosis in treatment. Which treatment is emphasized in the combination depends on whether client also qualifies for PTSD, whether a link appears between the trauma and the psychosis, and whether the client makes any such link themselves (Callcott & Turkington, 2006).
CBT for traumatic psychosis can help clients identify and clarify links between voice content and sexual trauma (Callcott & Turkington, 2006). In the case of “James,” CBT helped him to understand that what he had previously experienced as “out of the blue” hallucinations were vivid flashbacks from previous sexual and physical assaults (Smith, et al., 2006). In the case of Harriet mentioned above, CBT helped her come to the conclusion that she had indeed been raped by a babysitter her father had hired, but that her father himself had not abused her (Callcott & Turkington, 2006). In the case of “Tanya,” hallucinations appeared to serve as a channel for emotions that she did not permit herself to experience about sexual abuse perpetrated by her stepfather (Callcott & Turkington, 2006). Although Tanya was able to describe her sexual abuse with an astonishing lack of emotion, she was terrified by other violent images, such as an image of her having stabbed her neighbor and being covered in blood— an event that had not actually occurred (Callcott & Turkington, 2006).
Like many other therapies, CBT for traumatic psychosis is “best delivered after a period of engagement with good support in place and the cooperation of relatives and professional carers” (Callcott & Turkington, 2006). Clinicians allow ample time to work with the client to collaboratively develop an understanding of experiences that is neither psychotic nor completely biological (Smith, et al., 2006). Once this formulation of the psychotic experience is developed, it may or may not include sexual or other trauma (Smith, et al. 2006). Either way, this approach is more empowering than the promotion of “insight” into a purely biological perspective in schizophrenia, which is linked to depression in clients (Smith, et al., 2006; Watson, et al., 2006). In treatment, CBT for traumatic psychosis places less emphasis on reliving traumatic experiences and a greater emphasis on changing related schemas than CBT for PTSD does (Callcott & Turkington, 2006). Reliving trauma is not always appropriate in traumatic psychosis, but happily it is usually unnecessary (Smith, et al., 2006).
Sexuality Post-Trauma
People with psychotic disorders experience sexual and intimacy needs related and unrelated to any trauma that may have occurred. Some of the sexual challenges in this population are:

very limited social access and social skills; poor self-image and confidence; limited self-care; poverty and its links with prostitution and exploitation; sexual abuse in childhood and adulthood; the sexual content of positive symptoms; sexual disinhibition and the risk to self and colleagues; the adverse effects of psychotropic medications on libido; the secondary effects of medication, including disabling extrapyramidal signs; the results of institutionalization and stigmatization; hospital policies and the expression of sexual need in institutional settings; education and consent; safe sex and contraception; and homelessness. (McCann, 2000, p. 133)

Other concerns that may be encountered include problems experienced by the general population, such as struggles with gender identity, homosexuality, pseudohomosexual anxiety, and the paraphilias. Additionally, it is assumed that sexual trauma experienced by people with psychosis leads to sexual problems that largely do not differ from those of other people with similar trauma (McCarthy & Breetz, 2010).
However, research on sexuality in psychosis is scarce (McCann, 2010). Out of four studies this student found regarding the sexual needs and concerns of people with psychotic disorders (McCann, 2010; McCann, 2000; Harley & Boardman, 2010; Raja & Azzoni, 2003), only one study mentioned sexual trauma as a possible factor (McCann, 2000, see quote above), but this study did not explore this factor in interviews with subjects. In one more general study cited by McCann (2010), researchers using the Camberwell Assessment of Need deliberately rated all 173 mentally ill respondents as having zero need for sexual expression, due to the researchers’ discomfort in asking!
According to McCann, “there is a general assumption that people with schizophrenia ‘don’t do sex’” (2000, p. 133). However, “people are sexual beings all the time, whether they are healthy, ill, or disabled” (McCann, 2000, p. 134). Frequency of partnered sex is low in schizophrenia, particularly among men (Harley & Boardman, 2010). Yet 90% of people with psychosis reported needs in relationship to sexual expression and 83% reported needs related to intimate relationships (McCann, 2010). In contrast, only 10% of key staff rating the same clients reported their clients having needs related to sexual expression, with 43% reporting their clients having needs related to intimate relationships (McCann, 2010). 
Research demonstrates that people with psychotic illness can be safely and effectively interviewed about their sexual needs and behavior (McCann, 2000). No exacerbation of symptoms has been observed in clients who were asked, and many patients are happy to have the opportunity to discuss the fundamental issues of sex and intimacy (McCann, 2000). “Encouragement to openly discuss, explore and experience satisfactory sexual functioning and relationships is consistent with improving… quality of life and with the recovery model” (Harley & Boardman, 2010, p. 765). 
It is sad to think about the high rate of unacknowledged and untreated sexual trauma among people with psychotic disorders, but the good news is that clinicians can do something about it. By overcoming concerns about addressing it and learning the facts, clinicians can be prepared to ask clients with psychosis about sexual trauma and respond to disclosures about it. By studying CBT for traumatic psychosis and therapy for related sexuality concerns, clinicians can become prepared to treat people with this dual challenge. Through further research, training, and education, clinicians treating psychosis can be empowered to better support a well-rounded recovery of the people they serve. 


Callcott, P., & Turkington, D. (2006). CBT for traumatic psychosis. In W. Larkin & A.R. Morrison, (Eds.), Trauma and psychosis: New directions for theory and therapy (pp. 222-238).
Elklit, A., & Shevlin, M. (2011). Female sexual victimization predicts psychosis: A case-control study based on the Danish registry system. Schizophrenia Bulletin, 37(6): pp. 1305-1310. 
Hammersley, P., Read, J., & Bullimore, P. (2006). Asking the question: Childhood sexual abuse and trauma— Enquiry and response— A workbook for mental health care workers. 
Harley, E.W., & Boardman, J. (2010). Sexual problems in schizophrenia: Prevalence and characteristics. A cross-sectional survey. Social Psychiatry and Psychiatric Epidemiology, 45: pp. 759-766. 
Herman, J. (1997). Trauma and recovery: The aftermath of violence— from domestic abuse to political terror. New York: Basic Books. 
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Monday, December 21, 2015

The History of Madness

Throughout the history of humanity around the world, many different approaches to the treatment of mental illness have been implemented, including psychological, spiritual, physical, or some combination of all three. The following paper that I wrote for graduate school attempts to point to some key ideas throughout history, from the Paleolithic Era through the Middle Ages, focusing from the 16th century forward on treatment of mental illness in the United States and its primary influences.
Shamanism is humanity's oldest spiritual practice and healing art, probably dating as far back as the Paleolithic Era (Kahn, 2008). Through altered states of consciousness, shamans mediate between humans and the spirit world. Shamanism also involves physical practices, such as herbal medicine, and psychological practices, using "suggestion, expectation, and rituals to evoke placebo effects" (Serlin, 1993). In many cultures, a psychotic episode or initiatory crisis serves to initiate a person into shamanism and teach them about the nature of life and the spirit world. The pain of the crisis may also serve to help shamans empathize with their clients, thus making shamanism a very early form of peer support. 
One early sign of possible mental health treatment is the archeological discovery of skulls with carefully drilled holes in them, dating back to the Neolithic Era at least 7000 years ago (Clarkson, 1999). This practice, called skull trepanation, or trephining, was done with primitive tools, and we can tell that a surprisingly high number of people survived this procedure by the abundance of skulls that demonstrate healing of the bone around the hole. Scientists have many ideas about why this was done; one popular theory is that prehistoric surgeons created holes to allow demons believed to cause mental illness to exit. Over the millenia, trepanation has been performed in many parts of the world, and is still performed today in parts of Africa, South America, and Melanesia (Clarkson, 1999). 
Ancient Civilizations
Ancient Mesopotamians recognized headache and head trauma as being related to the head, but mental symptoms such as “not in full possession of his faculties” and “he wanders about (in a confused fashion)” were attributed to the heart (Yuste & Garrido, 2010, p. 4). Belief in the power of demons to incur illness is evident in this passage from a Mesopotamian medical treatise, “If a man is quivering all the time when lying down, shouts like the shouting of a goat, roars, is apprehensive, shouts a lot all the time, (then it is) the hand of bennu, the demon (šēdu), deputy of Sîn” (qtd. in Yuste & Garrido, 2010, p. 4). Each disease was attributed to a particular spirit (Mohit, 2001). Sorcerer-diagnosticians known as ashipus determined the spirt cause and may have also provided psychotherapy, and ashus specialized in herbal medicine (Mohit, 2001). Messages from the gods were received through dream analysis as far back as 2200 BC (Coolidge, 2006). 
 Ancient Persians also believed that illness was caused by demons, but believed diseases could be prevented through proper hygiene and "purity of the mind and body achieved through good deeds and thoughts" (Foerschner, 2010). Different medical specialties existed; ravan-pezeshk were the equivalent of today’s licensed psychiatrist (Mohit, 2001). Although medicine was separate from priesthood, most who became doctors had a background in both (Mohit, 2007). Evil eye amulets thought to ward off evil spirits were popular, and to a lesser extent still are. 
In ancient Israel, illness was seen as a punishment by God for sinning, sometimes sent in the form of demons (Foerschner, 2010). In Deuteronomy 6:5 it is written, "The Lord will smite thee with madness" (Porter, 2002, p. 10). When Nebuchadnezzar speaks pridefully of his wonderful palace, he hears God's voice say, "the Kingdom is departed from thee," and is driven mad (Porter, 2002, p. 11). Hebrew priest-physicians believed in God's healing power and appealed to him for cures. (Foerschner, 2010). Madness was distinct from folly; folly referred to behavioral conditions linked to poor judgment rather than punishment from God (Gerig, 2007). 
Ancient Egyptians did not distinguish between physician, magician and priest (Okasha, 2005). Healers were taught medical ethics which advised them to have compassion for people with mental illness (Nasser, 1987). Egyptians believed diseases could be caused either by God and demons or by organic causes (Mohit, 2001). Like the Greeks and Romans, Egyptians believed that hysteria in women, now known as Conversion disorder, was caused by the uterus “wandering” throughout the body, and would fumigate the vagina in an effort to lure it back into place (Nasser, 1987). Ancient papyri described the brain's physical structure for the first time and acknowledged it as the seat of mental functions (Nasser, 1987). Some psychotherapeutic methods were used in ancient Egypt, particularly "temple sleep,” which was akin to hypnotherapy (Mohit, 2001; Nasser, 1987). Egyptians recognized various mental disorders (Okasha, 2005; Mohit, 2001) and recommended that those people with mental distress seek symptom relief and a sense of normalcy in music, dance and art (Foerschner, 2010). 
Therapeutics and Surgical Practice by Charaka and Susrutha, an ancient Ayurvedic medicine textbook, "states clearly that only an expert in the field of mental health should treat people with this illness" (Thara, Padmavati & Srinivasan, 2004). Conditions similar to schizophrenia and bipolar disorder are vividly described (Thara, Padmavati & Srinivasan, 2004). Ayurveda, which has continued in India to the present day, sees ill health as resulting from an imbalance between three bodily forces or Doshas called Vata, Pitta, and Kapha. Variation in balance of the doshas lead people to have different personality types and to be prone to different types of mental and physical challenges. Treatment includes appropriate diet, bodily and spiritual activity, and herbs. Also in ancient India, Siddhartha Gautama Buddha was a spiritual teacher who lived in the 6th and 5th centuries BC, upon whose teachings Buddhism was founded. Buddha’s teachings continue to influence psychotherapy today, as evidenced by the recent development of mindfulness-based cognitive-behavioral therapy.
The first written works of Traditional Chinese Medicine appeared around 100 BC, and since then, China, Japan, Korea and Vietnam have all developed their own distinct branches of the original Chinese system (Yang, 2009). Chinese describe human health and healing in terms of a vital energy called qi, the Ayurvedic counterpart of which is prana. Qi must be balanced in terms of the opposing forces of yin and yang and five Chinese elements. Major depression can be seen as excessive yin combined with a yang deficiency; mania is the opposite (Yang, 2009). An ancient text called Huang di nei jing, or the Yellow Emperor's Inner Canon, "discusses spirit, mood, soul, idea, will, anxiety, worry, wisdom, morale and their relations with human life, physiology and body-mind health" (Yang, 2004). Acupuncture and herbs are key to Traditional Chinese Medicine. Today, ample scientific evidence supports the use of acupuncture to treat various mental disorders, including depression, anxiety, insomnia and addiction. 
The Greek physician Hippocrates (460-377 BC) denounced ideas about spiritual origins of mental illness; instead declaring it to be the result of physiological processes, particularly brain pathology (Porter, 2002). Similar to the Ayurvedic doshas, or the Traditional Chinese five elements, Hippocrates came up with four bodily fluids or humors, which when imbalanced could lead to behavioral tendencies and mental illnesses. Melancholia, described by Hippocrates as “fright or despondency [that] lasts for a long time” was thought to be caused by an excess of black bile (400 BC/n.d., 6.23). Melancholia as described in Porter (2002) would today refer not only to various forms of depression and extended grief but also anxiety, mania and psychosis. Humoral balance was attempted by means of tranquility, sobriety, lots of vegetables, exercise, and blood-letting (Gerig, 2007). 
The Roman Cornelius Celsus (25 BC-50 AD) called for a return to the idea that some illnesses were punishments from gods, and believed that people with mental illness needed to experience "anything that thoroughly agitates the spirit,” including beating and starvation (qtd. in Risser, 2012). Other Romans were more forward-thinking and compassionate. Epictetus (50-138 AD) rejected the idea that emotions were beyond our control, recognizing that a correction in thinking could lead to happier feelings (Gerig, 2007; Graver, 2009). Galen (130-200 AD) believed in a balance of the bodily humors as described by Hippocrates, and recommended massage and relaxing in a warm bath with a glass of chilled wine (Gerig, 2007). 
The Middle Ages in Europe and the Middle East
The witch hunts of the Middle Ages may have been partially a persecution of people with mental illness based on the perception that mental illness is caused by sin or demonic possession. However, Kroll and Bachrach (1984) and Schoeneman (1977) concluded that the relationship between Medieval witch hunts and mental illness has been overinflated. Medieval physicians continued to rely on a belief in humoral imbalance like their Greek and Roman predecessors, and also recognized the effects of improper diet and alcohol intake, overwork, and grief (Kroll & Bachrach, 1984). To restore humoral imbalance, doctors used emetics, laxatives and blood-letting. Customized diets for “raving madmen” included “cooling and diluting” foods such as milk, barley water, and salad greens, but banned wine and red meat (Porter, 2002, p. 42). Particularly in Medieval Christian Europe, people with mental disorders were abused, neglected and restrained by their family members, who hid them in cellars, caged them in pigpens, assigned their servants to control them, or sent them away to live a life of vagrancy (Porter, 2002). Many were flogged as punishment for mentally ill behavior, in an effort to “teach” them to be well (Foerschner, 2010). 
The first mental hospital was built in 792 AD in Baghdad and was followed shortly by hospitals in Aleppo and Damascus (Foerschner, 2010). This was several hundred years before such institutions were established in Europe. The world’s oldest university, Jondi Shapour University in Dezful, Iraq, taught medical students about psychiatric diseases and psychotherapy during the Sasanide Dynasty, 224-651 AD (Mohit, 2001). Historical evidence indicates that medieval Islamic doctors probably diagnosed and treated schizophrenia (Youssef, Youssef, & Dening, 1996). Treatment in the later Middle Ages in the Middle East consisted of psychotherapy, music therapy, pharmacotherapy, humoral balance, reassurance, and support (Mohit, 2001). Ar-razi (later known as Rhazes) (865-925), chief physician in an ancient Bagdhad hospital with a psychiatric ward, was known for treating patients compassionately (Risser, 2012). 
In 1407, the first lunatic asylum in Europe was established in Valencia, Spain (PBS, n.d.). Early European asylums were dumping grounds for people abandoned by their ashamed families or sentenced by the law (Risser, 2012). They were also often lumped together with people with other disabilities, criminals, the homeless and the poor, serving more to protect society from them than to serve their residents. Other asylums opened one by one, the most well-known being London's St. Mary of Bethlehem, a monastery-turned-hospital that began accepting mental patients in 1403 and by 1547 became exclusively devoted to people with mental illness. This hospital was known derogatively and infamously as Bedlam; according to historian Roy Porter, "Bedlam became a byword for man's inhumanity to man, for callousness and cruelty" (qtd. in Forsyth-Moser, 2004). Patients lay on the cold ground in filthy straw, chained and pinned to the walls by their arms, legs, waists and necks. They were frequently taunted and abused. Of course this treatment only aggravated their illnesses, and they would thrash about violently and wail in agony. Up until 1770, the asylum charged the public to visit this spectacle as a freak show (Jackson, n.d.). Some sources say that gentler patients were sent out into the streets to beg (Risser, 2012); O'Donoghue (1915), former chaplain of Bethlehem Hospital, claims that the hospital had no association with beggars who only pretended to be patients. 
The 17th through 19th Centuries in Western Society
 By the late 1600s, madness was decreasingly attributed to demons or moral failure and increasingly to organic phenomena, or "animal passions." Unfortunately, this did not lead to better treatment of people with mental illness, as abuse was thought to tame the animal passions. Dr. Thomas Willis, also known as the founder of clinical neuroscience, exemplified the attitude of his time and place when he wrote in The Practice of Physik: Two Discourses Concerning the Soul of Brutes, “Furious Madmen are sooner, and more certainly cured by punishments and hard usage, in a strait room, than by Physick or Medicines” (qtd. in Scull, 1983, p. 238).
In Paris, at  La Maison de Bicetre, was an environment reminiscent of Bedlam. That changed with the arrival of lay superintendent Jean Baptiste Pussin and wife Marguerite, and later, Dr. Phillipe Pinel, who had developed a passion for treatment of mental illness after a friend experienced a bout of mania (Cohen, 1932). Pinel rejected the belief that madness was incurable, and believed that therapy which paradoxically combined compassion with “a formidable show of terror” ought to be employed (Grob, 1994, p. 27). In spite of his belief in physician dominance, Pinel was opposed to chaining patients and other cruel practices. According to Cohen (1932), political suspicions related to the French Revolution extended to those housed in the asylums, so Pinel was risking his own life when he unchained the residents, beginning with a man whose legs collapsed from disuse after having been chained to the wall for forty years. A few patients were cured and all became more peaceful once given freedom to move. Although mistreatment persisted in other places, Pinel was proving that mental illness responds better to kindness than to cruelty. This was the beginning of moral treatment, first described in Pinel's 1806 book, A Treatise on Insanity. Credit also goes to William Tuke, a Quaker who independently opened a moral treatment facility in 1796, following the death of a fellow Quaker who was mistreated in an asylum. This moral treatment facility, called the York Retreat, was a quiet country community were patients could rest, read, write, dance, and engage in crafts. They also helped with chores and pursued spiritual healing through prayer while at the Retreat. The Quakers’ version of moral treatment, founded on love and empathy, even more dramatically contrasted with the abuse of the past. 
Meanwhile, in what is now the United States, Native Americans were using shamanic healing in various forms. In the 1770s, Native Americans formed the earliest recorded mutual self-help groups for alcohol problems (Risser, 2012). As Colonial Americans arrived, they brought with them a conglomeration of ideas from the Europeans, including humoral balance, blood-letting, exorcism and even astrology (Grob, 1994). Population density was too low at first to necessitate asylums; instead mental illness was dealt with by the family and by the community, and sometimes by one of the few doctors available (Grob, 1994). 
The first hospital in America was Pennsylvania Hospital, founded in 1751 by Benjamin Franklin and Dr. Thomas Bond, who were inspired to add a mental ward by the "perfectly cured” people at St. Mary of Bethlehem (Bedlam) (Whitaker, 2002, p. 4). The two endeavored to create a similar institution, which would contain the “[lunatics] going at large [who] are a Terror to their neighbors, who are daily apprehensive of the Violences they may commit" (qtd. in Whitaker, p. 4). Pennsylvania Hospital, which opened its doors in 1756, kept people with mental illness in the basement, which was comparable at first to the darkest periods of Bedlam and La Maison de Bicetre. The environment changed with the arrival of Dr. Benjamin Rush in 1783, known as the founder of American psychiatry. This was a mixed blessing. Dr. Rush, the son of Quaker parents, immediately ordered that the patients be unchained and preached kindness toward the patients. He was also enamored with European medicine, specifically his personal belief that madness was caused by "morbid and irregular" actions in the blood vessels in the brain, so he used purges and emetics and called for blood-letting up to "four-fifths of the blood in the body" (Whitaker, 2002, p. 14). Caustics induced blisters and open wounds which were kept intentionally open for months or years, and a gyrator was used to spin patients at high speeds; both techniques were intended to change the balance of blood in the brain (Whitaker, 2002). Rush was also proud of having invented the tranquilizer chair, which completely immobilized patients from several hours up to six months (Whitaker, 2002). In spite of his insistence toward compassionate treatment, Rush paradoxically called for intimidation tactics and even death threats in an effort to "cure" patients through terror (Whitaker, 2002). He was impressed with a Georgia doctor who claimed to have cured a patient by nearly drowning him in a well, so he built a tank for near-drowning; patients were placed in a dark coffin with holes and lowered into the tank where they remained until no more air bubbles came out, upon which they were revived (Whitaker, 2002). Starvation was another form of “medicine.”
Moral treatment and European medicine were a discordant combination, so when Rush died in 1813, mental health treatment was at a crossroads (Whitaker, 2002). That same year, William Tuke's grandson Samuel published Description of the Retreat. Although the intention of moral treatment was to do “little more than assist nature,” Tuke reported that 70% of York Retreat patients who had been ill less than twelve months never relapsed, and 25% of patients formerly viewed as incurable had completely recovered at the retreat (Whitaker, 2002). Other moral treatment asylums reported similar rates, and although some have questioned their accuracy, historians have concluded the reported rates were indeed accurate (Grob, 1994; Whitaker, 2002). Quaker-style asylums popped up around the country, run by lay superintendents or physicians who were opposed to European treatments, such as Dr. Rufus Wyman at McLean Hospital, who dismissed the medicine of the time as “usually injurious and frequently fatal” (qtd. in Whitaker, 2002, p. 28). Traditional physicians felt threatened and lobbied to be in charge; this led to the formation of the Association of Medical Superintendents of American Institutions of the Insane (AMSAII), which would become the American Psychiatric Association in 1921. Moral treatment was not to last much longer in any form, however, ironically due to the unintended results of one of its greatest advocates. Dorothea Dix, who’d recovered from a breakdown with the help of the Tuke family, tirelessly and brilliantly advocated for more moral treatment asylums. Sadly, when a tremendous number of huge asylums opened up in a short period of time, staff could not keep up with the requirements of moral treatment (one of which was a limit on the number of patients), and care for patients regressed (Whitaker, 2002). 
The 20th and 21st Centuries in Western Society
At the beginning of the twentieth century, the briefly-generous attitude of moral treatment was replaced by the idea that people with mental illness were “social wastage” with “defective germ plasm” who were unequal to others (Whitaker, 2002, p. 41-42). This view, called eugenics, was originated by Charles Darwin’s cousin Sir Francis Galton. Although other disabled people as well as African-Americans, people in poverty, and criminals were also viewed as unfit, eugenics saw people with mental illness as the lowest of the low. Galton saw eugenics as a new religion, one in which followers would be kind enough to stop these “defective stock” from breeding: “What Nature does blindly, slowly and ruthlessly, man may do providently, quickly, and kindly” (qtd. in Whitaker, 2002, p. 44).  As a result of the Eugenics movement in America, it became illegal for people with mental illness to marry, and thousands of people were sterilized under the guise of humanitarian therapy. Other countries followed suit. Madison Grant, a wealthy New York lawyer who founded the American Eugenics Society, went one step further by calling for complete “obliteration… of worthless types” in his book The Passing of the Great Race (qtd. in Whitaker, 2002, p. 65). Adolf Hitler wrote Grant a fan letter, telling him the book was his Bible (Whitaker, 2002). American Eugenicists continued to toy with the idea of mass murdering people with mental illness, but Hitler beat them to it, gassing more than 70,000 patients, and then proceeding to eliminate others considered devoid of value (Whitaker, 2002). When the horrors of the Holocaust were exposed, the general public was horrified, and Eugenics in America came to a screeching halt. 
One prominent Eugenicist was German psychiatrist Emil Kraepelin (Engstrom, 2007).  Kraepelin is famous for discovering a new way of classifying mental illness. Instead of looking primarily at major symptoms, as his predecessors had, Kraepelin grouped symptoms into patterns, or syndromes. He is credited with differentiating between manic depression (his definition now encompasses a range of mood disorders including bipolar disorder and major depression) and dementia praecox. In 1908, psychiatrist Eugen Bleuler replaced the term dementia praecox with the word schizophrenia. Because some of his patients improved rather than deteriorated, Bleuler recognized that the disease was not a dementia. Schizophrenia, which translates roughly to "splitting of the mind," refers to the separation of function between personality, thinking, memory and perception that Bleuler found to be characteristic of the disorder. Even more optimistic than Bleuler was his lesser-known son Manfred, also a psychiatrist. In a 1974 study, M. Bleuler found that many more people with schizophrenia recover or make significant improvement than his father suggested, even without medication. Manfred has suggested that his father was overly pessimisstic because he did not follow patients after they left the hospital. 
While Kraepelin and the elder Bleuler were laying the foundation for our modern system of diagnosis, Sigmund Freud was developing the theory of psychoanalysis. Therapy had been practiced in various forms over the ages, but Freud is considered to be the father of modern psychology. Anna Freud, Alfred Adler, Carl Jung, Otto Rank, Erik Erikson and others built upon Freud's theories, establishing psychodynamic therapy. Behavior therapy developed in the 1920s, followed by existentialism and Carl Rogers' person-centered therapy. In the 1950s, Albert Ellis and Aaron T. Beck independently developed two very similar approached to cognitive therapy, which in the 1970s were lumped together with behavioral therapy under the heading Cognitive Behavioral Therapy. Today there are perhaps hundreds of approaches to talk therapy, including ecopsychology, somatic psychology, contemplative psychotherapy, postmodern approaches, feminist therapy, and liberation psychology. 
As modern psychotherapy emerged, the field of psychiatry was changing as well. In the 1930s, four treatments were widely used: insulin coma therapy, metrazol convulsive therapy, electroshock and lobotomy. All of these therapies worked by damaging the brain, rendering the patient incapacitated and sometimes dead. The idea was not to alleviate the subjective pain that patients experienced, but to make patients easier to manage. Journalist Robert Whitaker (2002) points out that this same concern guided the invention of psychiatric medication, when Thorazine went from pesticide to tranquilizer or “chemical lobotomy” in the early 1950s and was later re-labeled, for marketing reasons, as “anti-schizophrenic.” Thorazine was followed by more anti-psychotics, including atypicals, as well as anti-depressants and mood stabilizers.
In 1948, Albert Deutsch published The Shame of the States, exposing conditions in the asylums. Thirteen years later, sociologist Erving Goffman published Asylums: Essays on the Social Situation of Mental Patients and Other Inmates, which described how institutionalization socializes people into "good patients," a demoralizing process which encourages chronicity in mental illness. In part as a result of these books, advocacy organizations were fighting for reform and for less restrictive environments. Meanwhile, funding for asylums was decreasing, and psychiatric medications may have allowed more people to live in the community of their choice. These factors converged and led to the closing of many hospitals in the mid-1960s, a movement known as deinstitutionalization. Many people with mental illness were able to live in the community for the first time as a result, but many others became homeless or ended up in jail.
Also in the 1960s, the consumer/survivor/ex-patient (C/S/X) movement began to hit the ground running. People with mental illness have published their own accounts of illness and treatment throughout history; those in English extend back as far as 1436 (Hornstein, 2011).  In America, early patient advocates included Dorothea Dix, Elizabeth Packard, and Clifford Beers. In the 1960s and early 70s, consumers and survivors began to organize, inspired by movements for Civil Rights, Women’s Rights, Gay Rights and Physical Disabilities Rights, and it was this inspiration that formed the foundation of the movement we have today (Zinman and Bluebird, 2011). C/S/X groups include MindFreedom, Intervoice, the National Mental Health Self-Help Clearinghouse and the National Empowerment Center. The C/S/X movement led to the development of the peer specialist profession and other patient-controlled alternatives to the mental health system. It has also inspired the recovery movement, a range of philosophies that share the idea that people with mental illness can move forward with their lives after a diagnosis of mental illness. 
Concluding Thoughts: The World and the Future
This paper has not examined recent treatment of mental illness outside of America and its primary influences, but people continue to grapple with mental illness around the world. In 1969, the World Health Organization set out to examine just how far ahead of the rest of the world developed nations were. Instead they found out (in two separate long-term studies) that complete recovery from schizophrenia is approximately twice as common in developing countries as it is in developed countries, concluding that "being in a developed country was a strong predictor of not attaining a complete remission" (Jablensky, et al, 1992, p. 88). Such results prompt the question: what are we (developed countries) doing wrong? Whitaker (2002; 2010) says research shows that although psychiatric medication can help calm symptoms in the short term, it actually encourages chronicity of illness in the long term. Dan Fisher, director of The National Empowerment Center and a psychiatrist who has himself recovered completely from schizophrenia, believes that the answer lies partly in differing social responses: developing countries respond to mental illness by reconnecting with people and reintegrating them back into the community, while developed countries respond with "ceremonies of segregation and isolation, which is really what our hospitalization process is" (Medscape, 2005). 
Though largely ignored by today’s mental health system, the WHO studies and others (including but not limited to M. Bleuler’s 1974 study) raise important questions about the efficacy of our modern treatment of mental illness. There is much to be learned from examining our past and finding what has worked and what hasn’t. Each person and illness is different, so we must consider psychological, spiritual and biological factors rather than assuming the answer lies in only one idea- or in only one civilization or time period. If we all work together, making a special effort to include the historically ignored voices of consumers and survivors, we can improve and refine methods of treating and coping with mental illness.  
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