The New York Times has an article out on the Hearing Voices Movement - ie people with hallucinations and delusions who want this to be treated as normal and okay rather than medicalized. Freddie deBoer has a pretty passionate response here. Other people have differently passionate responses:
I’ve met some Hearing Voices members. My impression is that everyone on every side of this discussion is a good person trying to make the best of a bad situation (except of course New York Times journalists, who are evil people destroying America). Some specific thoughts:
Plenty of people hear voices. Some of these people are your typical homeless schizophrenic, but many aren’t. One of my patients was a successful computer programmer who had near-daily auditory hallucinations. He realized they weren’t real, did his best to ignore them, and got on with his successful life - just like he had been doing for the past twenty years. He was seeing me for unrelated depression.
This guy kept his condition secret from his friends and co-workers. I don’t blame him for this choice at all. But when everybody who can hide it does, we only hear about the people who can’t keep it hidden, who are usually worst-case scenarios. Also (as a bunch of 1980s gay people can tell you) keeping a basic fact about yourself hidden from everyone you know sucks.
I recommended Hearing Voices Movement to this guy. I can’t remember whether he took me up on it or not. But I thought it would be helpful for him to have people he could talk to about his situation who wouldn’t think he was crazy, or try to get him locked up.
People hate admitting that some cases are mild, and others are severe. Especially the kind of people who work at the New York Times
I talked about this a while back in the context of the autism rights movement. Many autistic people live great lives, enjoy the beneficial parts of their condition, and find it annoying or oppressive when psychiatrists keep trying to medicate them. Many other autistic people can’t live outside of institutions and constantly try to chew off their own body parts. A reasonable conclusion might be “the first group seem mild and should be left alone, the second group seem severe and probably need intensive treatment”, but it’s surprisingly hard to convince people of this.
Calling some cases “mild” sounds trivializing. Calling other cases “severe” sounds stigmatizing. Whatever your criteria for a mild case are, there will be someone who fits those criteria, but says the condition ruined their life and you are dismissing their pain. Whatever your criteria for a severe case are, there will be someone who fits those criteria but is thriving and living their best life and accuses you of wanting to imprison them in a hospital 24-7.
And that’s just the activists! We psychiatrists have the same problem from a different direction: we have seen some crazy @#!$. No matter how mild your case is, we’ve seen some case that looked like that at first glance, then slowly descended into a horror movie premise. Our instinct is naturally to round off the person who uses Xanax once a month to the lifetime drug abuser, the mildly depressed housewife to the gory suicide victim, and the occasional voice-hearer to the guy who needs to be in a straitjacket.
Still, some cases are mild and others are severe. People with mild psychosis - like my patient the programmer - probably don’t need to be on really strong medications with severe side effects. They probably just need support. In a perfect world, expert psychiatrists would have a major role in providing that support. In the real world, a lot of these patients expect their psychiatrist to freak out, overmedicate them, and maybe even commit them to a hospital. This being the real world, many of those patients are right. So they look elsewhere.
To a first approximation, communities are good for people in need.
Forming communities is hard. A bunch of atheist groups have tried to form Church, But For Atheists. It usually doesn’t work. People need some kind of unifying factor. Atheism alone is too boring, doesn’t cut it. Race can cut it. Cults prove that sufficiently extreme beliefs can cut it. But most of us don’t have a sufficiently diverse racial identity or sufficiently deep insight into the various incarnations of our thetans, and have to grope around for something else.
Being mildly psychotic is a decent community rallying flag. Are hallucinations real? Probably not, but neither is God, and study after study has shown you will be happier if you go to church. I expect people who go to Hearing Voices Movement meetings are happier too.
One good way to build an community is to unite around persecution. And most chronically mentally ill people have been traumatized by the psychiatric system in some way or another. Sometimes this is specific individuals behaving maliciously or callously. Other times it’s just the normal trauma of being shuffled from institution to institution by a system which isn’t optimizing for preventing you from being stuck on a gurney for twelve hours with nothing to do.
If you want to provide psychiatric care to people who mostly loathe all psychiatric-care-providers, you can do one of two things. First, you can force them - court orders, commitments, guilt, etc. Second, you can signal really really hard that you aren’t like those people.
A lot of things about the Hearing Voices Movement are cringe. There’s a lot of talk about how your “nonconsensus reality” is okay, how everything is real in some sense, and how if you saw an angel or whatever then that’s so beautiful and you must be a deeply spiritual person.
I think these claims are false, but that’s exactly the point: they’re the sorts of things no self-respecting psychiatrist would ever say. Which means they’re good signals that the Movement isn’t just another branch of the psychiatric establishment. Which means that chronically mentally ill people can actually feel safe there and go listen to them. This is a load-bearing part of their treatment model and their community-building model, and GK Chesterton would like to have a word with you before you tear it down.
(Alcoholics Anonymous makes an interesting comparison: they’re solving this problem in their own way, by being more conservative and unforgiving than the psychiatric establishment would like. Hearing Voices is more liberal and accepting than the establishment, but the key point is not landing in the exact same place.)
Imagine that you go to the top of a Himalayan peak, take some obscure Ecuadorian psychedelic, sink deep into meditation, and have the most profound experience of your life. You see God approaching in the form of an arrow of pure light, which splits open your head and then blossoms like a flower, and this makes you realize that your whole childhood was [and so on in this vein].
You try to explain this to someone, and before you even get three words out, they tell you that you’re crazy and God doesn’t exist and you need to take risperidone 2 mg daily until they tell you to stop.
This is probably the right response, and if someone had been willing to do this to the original hippies we might have saved ourselves several decades of weird art and dumb politics. But from the inside, it feels kind of harsh. I’ve occasionally had experiences like this, and although “students are most earnestly warned against attributing objective reality or philosophic validity to any of them”, you kind of want someone to at least let you finish your trip report before telling you that you’re bad and invalid and need a neurotransmitter balance that doesn’t suck.
I don’t know whether there’s something to be gained from picking over experiences like these, but it’s natural and human to want to do it. Generations of Freudians made good livings by flattering their patients’ preconceptions that their dreams had to mean something. As a psychiatrist, I try not to engage with patients about the meanings of their hallucinations, because my words carry some sort of scientific authority and Science very much does not have an opinion on this. But somebody ought to do it, and “let mildly psychotic people do it for each other” seems like a good solution.
Actually, this is an important point. The Hearing Voices Movement makes a specific clinical claim: trying to reason with or even befriend your voices works better than trying to repress them.
Is it true? Most of the psychotic people I’ve talked to say no, at least not trivially on first inspection. Most voices can’t be reasoned with. They don’t have agendas, they don’t talk back or bargain.
But the psyche tends to behave how people expect it to behave. If all the people you consider friends and authorities in your social group say that voices talk back and negotiate, might voices talk back and negotiate? The entire western occult tradition says yes. I’m only half joking here; the history of hermeticism suggests that if you give borderline-psychotic people a really strong assumption that the techniques they’re using will produce hallucinations with certain results, they’ll get what they signed up for.
Or what about Internal Family Systems? This is a kind of woo-y type of therapy where the therapist says “imagine that your anger is talking to you, what does it say?” and then the patient tries to have this imaginary conversation. Sometimes their anger says something insightful like “I am just trying to protect you from being hurt again” and then the patient and their anger reconcile and the patient becomes less angry. I was never able to get the hang of this myself, but some people swear by it. Psychosis seems like a good starting point here - instead of saying “Imagine your anger could talk”, you can start with “You know that voice you hear all the time which keeps telling you to kill everyone? Let’s start by assuming it’s your anger”. I expect that some of the people for whom IFS works will find this works too.
So am I saying “voices aren’t really intelligent and agentic, but if you put someone in a weird cultural situation, their voices will start acting that way”? Sort of. But a better framing might be “in the weird cultural situation of 21st century scientific psychiatry, nobody expects voices to be intelligent and agentic, and they aren’t. In some other weird cultural situation, who knows?”
Is all of this mealy-mouthed and post-modernist and denying the existence of ground-level truth? Sort of, but “your subjective experience of your psyche is culturally relative” is a weaker and more defensible claim than “reality is culturally relative”, and one with a lot of support - see eg Julian Jaynes and Ethan Watters for more.
One of Freddie’s big complaints about Hearing Voices - and about a lot of mental health advocacy groups - is that they’re doing the Special Snowflake thing too hard. They think that having a mental illness makes them quirky and substitutes for a personality.
In Freddie’s defense, they are definitely doing this.
You can think of this in a condescending way, something like: yeah, but you can see why, right? A lot of people with mental illness aren’t very functional. I don’t mean “need to be in an institution” dysfunctional, I mean “barely holding on to their dead-end job and struggling to pay rent” dysfunctional. People need personal mythologies. “I am a guy who works a McJob and is bad at it, and that is all I am” isn’t going to cut it psychologically. “I am a guy who works a McJob by day, but my hallucinations give me a higher level of insight into the problems of the world than all these people who are superficially more successful than I am” is just healthier, as long as it doesn’t get taken to a grandiose extreme.
The non-condescending version is that everyone is in this situation. The Hearing Voices people pat themselves on the back because they have interesting hallucinations and are more creative than everyone else. Freddie pats himself on the back because he has an uncompromising commitment to taking his psychiatric problems seriously, warts and all, and not glossing over the negative aspects. I pat myself on the back because I’m balanced and reasonable and empathetic to both sides. It’s really hard not to do the special snowflake thing in some way or other. Prudence consists of doing it in ways that don’t step on other people’s toes, wildly contradict reality, or make society worse off.
Since we’re on the topic of Special Snowflakes, a point only tangentially related to mental health.
Right now, our society demands you be a Special Snowflake. Women who aren’t quirky enough are “basic bitches”, men who aren’t quirky enough are “yet another straight white dude”. Just today, I read some dating advice saying that single men need to develop unusual hobbies or interests, because (it asked, in all seriousness) why would a woman want to date someone who doesn’t “stand out”?
Someone on Twitter complained that boring people go to medical school because if you’re a doctor you don’t need to have a personality. Edward Teach complains that people get into sexual fetishes as a replacement for a personality. I’ve even heard someone complain that boring people take up rock-climbing as a personality substitute: it is (they say) the minimum viable quirky pastime. Nobody wants to be caught admitting that their only hobbies are reading and video games, and maybe rock climbing is enough to avoid being relegated to the great mass of boring people. The complainer was arguing that we shouldn’t let these people get away that easily. They need to be quirkier!
A friend read an article once about someone who moved to China for several years to learn to cook rare varieties of tofu. She became insanely jealous; she doesn’t especially like China or tofu, but she felt that if she’d done something like that, she could bank enough quirkiness points that she’d never have to cultivate another hobby again.
In this kind of environment, of course mentally ill people will exploit their illness for quirkiness points! We place such unreasonable quirkiness demands on everybody that you have to take any advantage you can get!
I’m guilty of this myself. I think I’m an interesting person in certain ways. But those ways tend to be things like “I wrote a blog that was condemned by the New York Times”, and “I’m in a group which many people consider a cult” - not the right type of quirky for job interviews. So when I got the inevitable “tell me about yourself and how you’re different from all our other applicants” question, I talked about how I’d struggled with obsessive-compulsive disorder. Which is true. It wasn’t a very interesting struggle, and it didn’t particularly shape my subsequent personality. But I’d never admit that to an admissions officer.
And on one level it’s definitely true that mankind will not be free until the last admissions officer is strangled with the entrails of the last New York Times journalist. But in another sense, we do this to ourselves. We demand quirkiness from our friends, our romantic partners, even our family members. I can’t tell you how many times my mother tried to convince me it was bad that I just sat inside and read all day, and that maybe if I took up rock-climbing or whatever I would be more “well-rounded”. We can stop at any time. We can admit that you don’t need a “personality” beyond being responsible and compassionate. That if you’re good at your job and support your friends, you don’t also need to move to China and study rare varieties of tofu.
But if you do insist on unusual experiences as the measure of a valid person, then there will always be a pressure to exaggerate how unusual your experience is. Everyone will either rock-climb or cultivate a personality disorder, those are the two options. And lots of people are afraid of heights.
I think there’s a difference between psychotic people exploring their psychosis, among themselves, in ways that serve their psychological needs, and the New York Times running an article about it where you’re supposed to conclude that they’re right and good and the stupid square psychiatric establishment who want them to take medication are just dumb and out of touch.
I’ve been following the conflict between pro-transgender activists who want to celebrate transgender people and fight stigma against them, vs. anti-transgender activists who want to prevent a bunch of kids from hearing that being trans is cool and so transitioning. This is a really sensitive issue but I am going to do my best to talk about it, and I’m sorry for probably offending both sides.
My starting point for any discussion of this, which I feel like it’s really hard for a well-informed and well-intentioned person to disagree with, is that at least some large subset of transgender people aren’t consciously faking it. That is, they genuinely have the experience of feeling like they are the other gender, they’ll be absolutely utterly miserable if forced to live life as their birth gender, and telling them “no, just snap out of it” will not work, at all. I think it’s hard to know transgender people closely without coming to this conclusion, unless you have some kind of really galaxy-brained take beyond my ability to even imagine .
So what’s left for the people who believe transgender is a “social contagion” or about “special snowflakeness”? If I had to steelman their position it would be something like: there’s some switch that can be flipped by social pressure and wanting to look cool. Once the switch is flipped, you’re transgender in some pretty real way: you’re not faking it, and you’ll be miserable until you’re allowed to gender transition. Still, being transgender makes people worse off on net, so society should try to avoid flipping that switch.
(if you read this blog often, you might notice similarities to my theory of anorexia: yes, lots of people start dieting because they want to be a ballerina or something, but the extreme dieting seems to flip a switch, the switch turns it biological, and you can’t make anorexics go back to healthy eating just by convincing them not to want to be a ballerina anymore)
If this were true, a maximally compassionate policy would involve both trying to support people who are already transgender, and trying to prevent the switch from being flipped in people who aren’t transgender yet. I’ve never heard anyone explicitly advocate this policy, probably because it’s really hard to get right - the harder you try to avoid talking about it in front of impressionable young minds, the more you risk stigmatizing existing transgender people, and vice versa. There’s enough bad blood around this issue that I’m sure neither side would trust the other to respect a compromise like this. Probably they would be right not to trust them. Still, when I try to figure out how I personally should behave, I give some weight to considerations like these.
This is also how I feel about hearing voices. Is hearing voices socially contagious? My guess is slightly. The DSM says that you can’t diagnose a psychotic disorder if someone’s in a cultural context when they’re expected and encouraged to hear voices - which sure does sound like the experts think cultural context can affect whether you hear voices or not. Born again Christians are constantly having what would normally get classified as psychotic experiences - I have asked a bunch of evangelicals who say “God told me to X” whether they actually heard God in a, you know, hearing God type way, and they usually say yes. Again, read your Jaynes. It feels prudent not to tell everyone that hearing voices is totally normal and cool.
I don’t feel like the Hearing Voices Movement is doing this, exactly. They just sit around being an accepting place for people who already have this experience and problem. I do think New York Times articles about how cool and accepting and normal they are - and how much better they are than boring people who just take their medications - probably don’t do anyone any favors.
The article talks about peer mental health counselors - people with a mental illness who try to help others with the same condition.
Some peer mental health counselors are among the best and most compassionate people I know. This is difficult and low-paid work, performed by people who may be struggling themselves, and yet they do amazing jobs and probably save a lot of lives in situations I can barely imagine having to operate in.
Other peer mental health counselors suck. The arrogance of a doctor who’s read a lot of textbooks and journal articles about a condition can’t hold a candle to the arrogance of a peer who has overcome the condition themselves and thinks that means they know the One True Standardized Way everyone has to do this.
Also, “overcome the condition” can be sort of a stretch goal for these people. I still remember a patient who asked me if I could cure his anxiety within a week. I told him absolutely not - medications take a few weeks to even kick in, and managing anxiety can be a lifelong process - and why did he need a cure in a week anyway? He said he was an inspirational speaker on the topic “How I Overcame My Anxiety”, and he had a speech scheduled next week, but was too anxious to work on it. I think about this person often.
The worst failure mode is people who handled (or “handled”) their condition without medication, believe everyone else should be able to do this too, and pressure other patients to stay away from meds - make them feel like they’re giving in to the evil psychiatric establishment if they even consider a pill. The New York Times piece reads like it was written by one of these people.
I don’t have that much to say about the piece itself, beyond begging you to keep my Cheat Sheet For Reading Popular Media Articles About Psychiatry handy whenever you open a newspaper, but I do think it’s worth talking about the WHO angle.
A lot of the article’s anti-doctor anti-med propaganda relies on a WHO report, Guidance on community mental health services: Promoting person-centred and rights-based approaches. It writes:
Last June, the World Health Organization published a 300-page directive on the human rights of mental-health clients — and despite the mammoth bureaucracy from which it emerged, it is a revolutionary manifesto on the subject of severe psychiatric disorders. It challenges biological psychiatry’s authority, its expertise and insight about the psyche. And it calls for an end to all involuntary or coercive treatment and to the dominance of the pharmaceutical approach that is foremost in mental health care across conditions, including psychosis, bipolar disorder, depression and a host of other diagnoses. Psychiatry’s problematic drugs, the W.H.O. maintains, must no longer be an unquestioned mainstay.
This guidance is part of a WHO program to get together a lot of patients rights advocates who say drugs suck and psychiatry is bad, they all write a report together saying that drugs suck and psychiatry is bad, and then the WHO marks off on a checklist that they have respectfully listened to the people who think drugs suck and psychiatry is bad.
For example, if you look at the report, the first person credited as a “key international expert” whose opinion it relies upon is Celia Brown, whose biography describes her as:
Celia Brown is a psychiatric [abuse] survivor and leader in the movement for human rights in mental health. Celia has served on the Mind Freedom International board for several years, including as MFI president…Celia is shown here speaking at an MFI protest directly in front of the American Psychiatric Association Annual Meeting
I’m glad people like this exist; they keep the rest of us honest. But if you get together a hundred people like this, they will say the kinds of things that people like this say. And if you make it into a glossy report and stick the WHO logo on it, then there will be a glossy WHO report that says the sorts of things that people like this say. That’s fine and I believe everyone should be allowed to make a PDF if they so desire, but the New York Times seems to be trying to use this to suggest that clinicians or experts or someone whose opinion you should care about is admitting that drugs don’t work and treatment is bad, and this suggestion is false.
Please, please just use the cheat sheet.
The usual human and humane provisions - food, shelter, counseling, acceptance, support, friendship - make a big difference. Not just in depression. Even in things like psychosis that you’d expect are way too biological to affect through fuzzy things like that. There are a lot of people who are psychotic under stress but do well in an ideal environment. There are a lot of other people who will be psychotic no matter what you do, but depending on environment their psychosis can be benign and compatible with a happy life, vs. violent and uncontrollable.
But these things don’t work infinitely well, and sometimes you need the meds.
(The meds also don’t work infinitely well, but the interaction between medication and psychosocial support is complicated. There’s usually some dose of medication that will make a patient stop doing dangerous and disruptive things, but this dose might not leave them very happy or able to do anything at all. This forms a difficult and ethically-questionable tradeoff - how do you balance the patient’s own comfort with the comfort of the people around him who don’t want him being disruptive? Part of the role of psychosocial support is to give the patient an environment where people are willing to tolerate the occasional weird or disruptive thing, so that the compromise point on this tradeoff is more compassionate to the patient’s needs.)
People like to paint psychiatrists as close-minded monomaniacs who think medication is the only possible solution to everything. This is true of some, but an insult to others; contra what Johann Hari thinks, the biopsychosocial model isn’t exactly a closely-guarded secret.
But the opposite of this are the people who think psychosocial interventions and acceptance are the only possible solution for anything and trash talk the meds every chance they get.
My guiding star has always been patient choice - except in the rare situations where the legal system officially takes this away to protect other people. That means having opportunities for patients to do things other than take drugs. It also means not trying to scare patients away from the drugs or misinforming people with NYT-quality drivel.
I think there’s room for the Hearing Voices movement and things like it in the mental health tent - as long as they don’t try to kick other people out of the tent and say their way is the one-size-fits-all solution for everyone.
In Partial, Grudging Defense Of The Hearing Voices Movement