For the last two years I have been on a journey, trying to find a way to help someone who is dear to me deal with psychosis. I began this journey with great faith in the experts in the field of mental health. I have long accepted the standard explanation that serious mental illnesses, such as schizophrenia and severe depression, are genetic brain diseases. According to this explanation, the person afflicted has a broken brain with a chemical imbalance. The proposed solution is the correct medication that will restore the imbalance in the brain and ameliorate, if not completely relieve, the symptoms. Some supportive therapy may be helpful, but in this biological model of severe mental distress the true remedy is psychiatric medication. In this era of brain research, a complete understanding of these brain diseases is promised to be right around the corner.
There is a problem with this expert view of severe mental illness. The treatment appears to be making people sicker. The number of people disabled by mental illness has risen dramatically in developed countries. According to the Social Security Administration which tracks disability payments, it has nearly tripled in the United States between 1987 and 2007 (Social Security Administration Annual Statistical Reports, 1987-2007).
The medical journalist Robert Whitaker has written a remarkable book, Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs and the Astonishing Rise of Mental Illness in America (2011). The book is a devastating scientific critique of the popularly received “expert” view of severe mental illness and the efficacy of psychiatric medication. Whitaker presents research he has collected from a variety of sources that show higher rates of recovery for the era prior to the introduction of psychiatric medicines and for parts of the world where Western style psychiatric services are not available, and he makes the case that the long term use of psychiatric medicines turn an acute illness into a chronic disability with a life span twenty years shorter than the norm.
The book is highly controversial and hotly contested by mainstream psychiatry. I find it compelling. It is entirely plausible to me that experts who profess (with great confidence) simple solutions to complex problems are as likely to make things worse. I think I have been watching this happen in the Church for most of my more than thirty years of ordained ministry. One of the perquisites of serving on a seminary faculty, which I did for eight years, is that you get to do a lot of supply work. I served a series of small struggling parishes with a common story of decades of decline. Often the parish story included the arrival of a young, keen priest who was called because of their expertise in church growth and parish renewal. Often the story included intervention by the diocese and its team of consultants. I was actually one of these consultants in three different dioceses. Each of these parishes had had the benefit of a series of experts applying the latest knowledge to the problem of congregational vitality and church growth, and the result of each intervention had been a new wave of defections from the parish. Interventions that were supposed to build parishes in fact accumulated to hasten their decline. Interventions that were supposed to generate spiritual renewal left parishes divided and diminished.
But back to the world of mental health. As confidence in the biological model has begun to wane a new movement is taking hold in the world of therapy. There is a new confidence in talking. The best outcomes for the treatment of psychosis in the developed world are in western Finland. Here the local mental health agency has created an approach called Open Dialogue. The easiest way to get a sense of this approach is to view this documentary on Youtube. In this approach, medicines are used sparingly, if at all, and for relatively short periods. Martin Buber’s I/Thou thinking and the writing of Russian literary theorist and philosopher Mikhail Bakhtin on the nature of dialogue are more important for understanding and relieving psychosis than biology. In this view the person suffering from a psychosis has lost their voice and is stuck in monologue. The psychosis expresses the inexpressible, and the treatment is a profound listening which aims to help the person recover their authentic voice and rebuild their social network. If the therapist is to be any help, he or she must get out of the expert position and learn to tolerate uncertainty. The therapist must also abandon the detachment of the expert and engage with the patient and their family on a human-to-human level. If real dialogue can be developed, genuinely new things can emerge. In the exchange of monologues, nothing new can happen.
What would it mean to put away the image (idol?) of the clergy as expert, to abandon the one up and detached position of the person with the privileged knowledge and the proven solutions? I am not talking about abdicating the proper authority of Holy Orders, which I think has in fact been diminished by this flirtation with expertise. But what would it mean to replace the exchange of monologues with genuine dialogue? At the least we would not make it worse. Perhaps something new could happen.
“You know that the great men of the gentiles lord it over one another, but it shall not be so among you.”
The featured image is “Dr. Karl Menninger, the psychiatrist’s psychiatrist” (1969) by J. Dawson and was uploaded to Flickr by the Topeka Library. It is licensed under Creative Commons.