Psychiatry at war with itself (I)

Psychiatry is at war with itself. The battlefield is the forthcoming publication of the DSM 5 - the latest version of the diagnostic manual that defines mental illnesses for the industry. At stake is the authority of psychiatry, and our society’s whole approach to the mind and mental illness. This is the first part of a three-part piece.
My friend Nick and I took LSD together for the first time when we were 15. A year later, while he was tripping on his own in London, Nick had a psychotic episode in which he thought he was in Hell, and the police who came and arrested him for disorderly conduct were really devils come to drag him down. He was put into a mental institution and given antipsychotic drugs, while I carried on taking recreational drugs in the outside world.
Then the drugs caught up with me too. I had a bad trip when I was 18, and another when I was 19, and the experiences left me traumatized. The trauma came back to haunt me when I was at university, in the form of panic attacks, social anxiety, and depression. This lasted for a few years, until finally I discovered that I was suffering from some form of post-traumatic stress disorder together with social anxiety, and that these conditions were treatable with cognitive behavioural therapy. So I did a course in CBT and, to a large extent, I recovered.
Then one day, when I was walking down the Kings Road in London, I happened to bump into Nick. I hadn’t seen him for about five years, and felt bad about never visiting him in the mental institution. He’d been out for a few years, he told me, and was studying at art college. We swapped war stories from our various experiences with mental illness, and rekindled our friendship.
Unfortunately, Nick then had another psychotic episode, after he left art college. I remember him coming to meet me in a cafe, and as soon as he walked through the door it was obvious he was in a different place. His lips were quivering, the pores on his face had opened like he was in a fever, his eyes were staring. He told me he was going away, and wished me ‘peace’. I rang his parents afterwards, worried, and discovered he’d stopped taking his medication and had been institutionalized again.
This time, I went to visit him in the psychiatric hospital - a grotty place off the Vauxhall Bridge Road. He was in the high security ward. I sat in a room with dirty yellow walls, in which a radio blared mindlessly, underpaid Nigerian staff prowled moodily, and disturbed inmates paced like deranged lions in a zoo. Then Nick appeared at the door - six foot two with a big Biblical beard, and those staring, suspicious eyes. He came up, stood looking at me for a bit, then said ‘Why hast thou come here, Satan?’ ‘I’m not Satan, Nick. It’s me. Jules.’ He paused. ‘Know that I am the angel of the Lord’, he said, holding up two fingers like Jesus. ‘Now be gone.’ So I went.
This went on for a few visits. But, gradually, he became a bit less suspicious, a bit less haughty and aloof. He stopped called me Satan, which was good. I tried to relate to him, to see his delusions as manifestations of emotions. When he was being haughty and defensive, calling me a demon and so on, he was basically expressing fear of an external threat to his autonomy. I told him I knew that he must be afraid, but it was OK, I wasn’t a threat. At the end of that meeting, he said ‘I am scared of you, Jules’. I felt like it was a breakthrough - beneath the haughty Messiah complex, a simple admission of fear.
Then the doctor changed his medication, and his condition improved very quickly. The feverish delusions and grandiose Messiah complex went away, anyway, and Nick was released back into the community. But the core beliefs that underlined the schizophrenia remained: Nick still believed, very firmly, that he had been singled out by demonic forces who were bent on dragging his soul to Hell. This was the way he interpreted his hallucinations. He told me: ‘If you’d seen a man with red eyes sitting staring at you, you’d believe in demons too.’ He was simply believing the evidence of his own eyes, as we all do. And he also heard voices, quoting the Bible, telling him how to live. He interpreted these voices as being the voices of angels, giving him celestial orders. Should he ignore the evidence of his senses?
We’d go to the pub of an evening, and I would talk about how CBT had helped me overcome PTSD and social anxiety. Nick very much recognized my description of social anxiety - he also had paranoia, moments of acute self-consciousness, low self-esteem, feelings of being socially exposed and threatened. There were aspects of our mental illnesses that we had in common. I thought CBT might help him too, and tried to get him to test out his beliefs, to get out of his comfort zone, to face his fears. I think I saw him not just as a friend, but as a challenge, I’m embarrassed to say. If CBT could make me better, couldn’t it make him better too?
The problem was, Nick’s core paranoid schizophrenic beliefs were very entrenched, and very good at defending themselves. Nick had a stark choice of two ways in which to interpret reality.

1) The doctors were right, and he was suffering from paranoid schizophrenia. 2) The voices were right, and he was engaged in a holy war with demons.
Now if he chose to believe option (1), and he was wrong, he could go to Hell. He was risking his soul. And, if option (1) was right, that meant he was a mentally sick person, unemployed, without many prospects, condemned to live as a low status person on the fringes of society. If he chose to believe option (2), and obey his voices, then at least his soul was not in eternal peril. And, in the world of option (2), he was high status - he was chosen by God and Satan, a human battleground between warring celestial forces. And all the doctors, and the outside world, they were either ignorant, or involved in some Satanic plot against him.
So, in some ways, it was rational to go with option (2). It seemed to have more of a pay-off, at least in the short-term. Unfortunately, though, if he believed option (2), it also meant that Nick was condemning himself to be completely alone, in his own private cosmic drama, separated from the rest of the human race. And it meant he would not make any progress in the real world - in terms of getting a job, making friends, potentially finding a partner, and generally making a life for himself.
I tried to get him to question his core beliefs, to challenge the absolute omnipotent authority of the voices. But the difficulty with this was, the voices were very good at defending themselves. They spoke the language of Christianity. And the main consolation Nick had in life was Christianity. He didn't have much going his way in this world, but he did have the belief that somehow his trials in this world meant something in the next world. And when I tried to get him to challenge the voices, it seemed to him that I was challenging Christianity, trying to tempt him from the path of righteousness, like Satan. What would usually happen is that Nick would say ‘well, I’m a Christian’, or he would say ‘let’s not talk about it anymore’, and that would be the end of it. He didn’t really want to question his beliefs.
The problem, it seemed to me, was that changing your mind takes a lot of energy. And Nick didn’t have a lot of energy. In fact, the medication he was on seemed to take all his energy away. He didn’t read, he didn’t listen to much music, or take much interest in the outside world. He had access to the internet, but showed no interest in researching schizophrenia or joining support networks like Hearing Voices. The closest he came to actually testing out his core beliefs was when he went to speak to a priest, to see if the peculiar and idiosyncratic commands that the voices gave him were in any way orthodox Christian beliefs. He came away thinking the priest was a demon. The parasite of his illness was a genius at defending itself and perpetuating its own existence.
Gradually, I wondered if CBT was really any help in schizophrenia, or if it was purely a physical or neurological condition that destroyed the mind’s ability to reason. If so, then hoping that a schizophrenic would be able to challenge their own beliefs and think their way out of the labyrinth of mental illness was perhaps unfair. On this theory, you shouldn't expect a schizophrenic to have any capacity for reason or autonomy.
But I knew that some schizophrenics did get better, and did manage to think rationally about their voices and hallucinations, and to challenge their authority, through CBT. They managed to go on and build lives for themselves, and to re-join the community of autonomous adults. But this takes a bravery and a humility - to accept that you might be suffering from a mental illness, and that you're not, in fact, the saviour of the world - although you could be a great help to other people going through similar experiences. So you could, actually, help save people from hell.
Nick, meanwhile, seemed to be treading water. He was smoking more and more dope, becoming incoherent. Then, last December, he was re-sectioned, back into that dingy psychiatric institution, where he spent last Christmas. He hadn’t had a psychotic episode. In fact, he was highly indignant at being sectioned - after all, he hadn’t ever been violent, so why was he being deprived of his liberty? He blamed his parents, he blamed the staff, he blamed the psychiatrists. He could actually be quite funny, railing against his psychiatrist: ‘He’s a pseudo-scientist, a criminal, and possibly a latent homosexual. You should expose him, Jules, write a story about it!’
I had some sympathy with his plight. But a brief stint in the mental institution might do him good, I figured. His dope smoking was out of control, and now he was off the dope, he seemed to be mentally sharper and more coherent. The problem was, he couldn’t stand the staff or the psychiatrists, and was very rude to them. Why, I often asked him, didn’t he just try and be polite to them? Just play by the rules, otherwise they would never let him out. After all, he’d been in the institution over a year - he’s still in there now - and there was no sign of them letting him go free. ‘I don’t think I’ll ever get out’, he told me. ‘I think they’ll keep me here forever.’
I thought he was being irrational, overdramatic. But then I read about the ‘Rosenhan experiments’ where sane medical students checked themselves into mental institutions, saying they heard voices, and then behaved perfectly politely and reasonably for the duration of their stay. The psychiatrists who observed them were convinced they were mentally ill, not one of the pseudo-patients were detected, and some were confined for several months. I also started to believe him about the staff and psychiatrists being rude and heavy-handed. It may have been part of the NHS, but unlike other parts of the NHS, the people there were in there against their will. It was a prison as much as a hospital, with all the power dynamics of a prison.
One thing is clear: the treatment isn’t working. Nick has now been in the psychiatric ward for over a year, and he has started to lose faith that he will ever be released. If anything, he is getting worse. He has become increasingly withdrawn, suspicious and rude. He clearly has no sort of therapeutic alliance with his psychiatrist. I think he sees the psychiatrist for about 15 minutes a week. He is not given CBT. Just the drugs, and a small glass of water. He has no say in who treats him or what he is treated with. He feels he is locked inside a system of arbitrary power and incompetent pseudo-scientific diagnoses, and he doesn’t think he will ever get out. I hope he is wrong.

The second part of this piece, published on Monday, will look at the crisis in psychiatric diagnoses and treatments prompted by the new DSM 5 manual.