Introduction

More than 70 percent of the people who enter intensive care for mental illness return home to their families, and almost always need further care. This means that over 10 million people are living in households with someone who is in one stage or another of attempting to recover. Those in this position find themselves alone, with few professional services available, and with very little advice. Certainly, they have not been given the accumulated wisdom about how to care for themselves and their family during and following a psychological catastrophe. This situation has led to increasing frustration and suffering by patients and their families, who have long relied solely on systems of professional psychiatric service. But there is just no "system," mental health or otherwise, that can deal with the scope of this problem. It is a situation of increasing urgency. In this day and age, when the world is proliferating with armies of dispossessed and homeless people, it is important to learn about the nature of "recovery" and, if need be, how one's own home can become a household for recovery.

The desperate condition of the world of mental health care is already common knowledge. This is especially true in the care and treatment of people in extreme states of mind, psychosis and the so-called chronic mentally ill. This care is confounded by opposing views, personal outrage, resentment, and staggering social challenges. The suffering of the millions of people in extreme mental states has understandably led their families and their doctors to become dependent on the ever-proliferating medication designs intended to effect a "biological cure."

An almost exclusive focus of interest on the biological and chemical origins of mental derangement has developed over the past twenty years. Government and private funding have become devoted to the so-called medical model, leaving other areas of clinical study in danger of atrophy. This arises out of a fascination with high-technology research in brain mechanics and a total trust that someday it will solve the problem of mental illness and discover the chemistry of mental health. Once again, the solution is just around the laboratory corner.

It is now popularly believed that an authoritative scientific judgment on this enigmatic illness will soon appear, making any great effort at individual or social treatment futile and impractical. Hardly even considered anymore is the simple notion that psychosis might be one of the unfortunate permutations and conditions of being human; rather than the comforting notion that psychosis is only a rare disease, psychosis may be the natural consequence of the way anyone has lived. Perhaps the medicalization of insanity has created for all of us a false sense of security. The fact is that people have lost control of their minds and they become psychotic at any age, from infancy to the moments before death. Believing that psychosis begins and ends with idiosyncrasies of the brain nullifies it as a human tragedy, and contributes to the steadily deteriorating conditions of care that today face almost all of the chronic mentally ill.

Current care has reached such a level of confusion and competition that the overuse of multiple medications is commonplace, and along with that has come the health-consuming battle against their enfeebling side effects: bodily dysfunctions, lethargy, distance from others, clouded concentration, loss of interest, and what is called "the boredom." Electroconvulsive therapy has become fashionable to the degree that some major teaching hospitals are delivering it as the primary treatment for severe neurotic depressions. It is now used on over thirty thousand patients a year. And there is a renewed interest in the use of psychosurgery based almost exclusively on the argument of cost-effectiveness.

The outrageous predictions of Ivan Illich in Medical Nemesis: The Expropriation of Health have already come true. That is, with such wholesale and gullible acceptance of the "medical model," people have abandoned all the traditional wisdom of caring for themselves or other ill persons. The healing professionals as well have become ignorant of the skills to be learned and practiced in order to care for their own mental health properly. What has been called the "industrialization of mental health" is almost complete: Timeless healing wisdom and simple common sense are now called "anachronistic"—outmoded and no longer useful in the modern era. But the "modern era" of treatment is already a grim sociological case history. All modern treatment facilities are bound by three powerful conditions that restrain and govern the therapy of people who need intensive care: cost-effectiveness, insurance regulations, and the fear of malpractice allegations. These three conditions guarantee a continuation of the unquestioned yet very false belief in the virtues of treating many people in one place, with its resulting "asylum mentality." These conditions have always justified a wide variety of therapeutic aggressions ("furor therapeuticus," as the elder clinicians used to call it). Most modern treatment situations, without realizing it, promote a fear of the intimate relationships that are so precious and vital to the recovery from madness.

Almost as distressing as the ill effects of modern mental treatment is that the training for people working with patients who are in extreme mental states has been grossly neglected. Those in charge of training also seem to be waiting for a biological key to be discovered. While they wait, there is a continual stream of indictments from many who have been treated in our hospitals and asylums—of inattention, neglect, and violation. The study of mind and its functions has virtually ceased within medical, psychiatric, and most psychological curricula. Training in the psychotherapy of highly disturbed people, or in the disciplines of interpersonal healing in general, is becoming increasingly rare in academic realms—already, nearly all the chairmen of psychiatry departments are biochemists or geneticists. From where will the training come that allows one to overcome the fear and helplessness one experiences in confronting a mind that has become psychotic?

Consumer groups made up of former mental patients disagree with each other about treatment procedures. But even they tend to be united in their opposition to those who endorse all the popular medical theories of incurable brain dysfunction. Wherever you look, in fact, there is disagreement, frustration, and rivalry about psychiatric treatment, and many people feel that the current situation is approaching hopelessness.

But at the same time, it is not the whole story—there is evidence for another point of view. There is a wisdom within the history of caring for insane people that is not well known, yet contains the freshness and simplicity needed to meet the current crisis.

It is from this wisdom that Recovering Sanity draws its inspiration and offers a different perspective on the nature of psychosis and its treatment. In spite of the bewildering and discouraging biases that determine current treatment, something inspiring and hopeful can still be pointed to by refocusing attention on the inner or personal reality of insanity and the fundamental mental functions that propagate it. One needs to learn directly from intimate relationships with people in psychosis about the abysmal struggle taking place within psychotic turmoil itself. It would be a misunderstanding to see this refocusing as associated with what is popularly called "antipsychiatry." But it does stem from a long psychiatric tradition that is definitely not in vogue. Perhaps it has never been in vogue. It is a tradition that has always taken many risks in the pursuit of alternative treatments for mental illness.

Motivation toward an alternative, more natural, and homelike treatment is a long and venerable tradition within psychiatry itself. At one point in his career, in the late 1800s, the great Swiss psychiatrist Eugen Bleuler (the founder of the concept of "schizophrenia") lived with his psychotic patients for twelve years: He farmed, cooked, ate, chopped wood, and shared his life with them in an experimental healing community that he founded at the old monastery at Rhineau. At around the same time, William James took a young man from the state asylum to live and recuperate within his own family. Bruno Bettelheim did the same with two autistic children.

It is in such settings that one can hear the truth and learn from people who are in psychosis: about the bewitchment and seduction of psychotic mind, and about the effort and discipline required for recovery. But the world of mental health appears to have totally ignored or forgotten what our patients have told us, and continue to tell us, about psychosis and other extreme states of mind. That is, whatever the trigger to that state might be, the experience must still be related to at its subtle stirrings, during the midst of psychological anarchy, and during the fragile process of awakening. One must work directly and precisely with ongoing and seemingly bizarre mental and physical events. Failure to do so drives one deeper into madness.

However, recovery, not reform, is the fundamental issue of this book. First and foremost it is written from the point of view that authentic recovery from psychosis is possible.

Moments of natural recovery, "islands of clarity" as I have come to call them, happen all the time within the experience of psychosis; not only can these be recognized and acknowledged, they need to be protected. Ultimately this book is about perceiving and nurturing islands of clarity, for in this way full recovery from psychosis has been accomplished and will continue to occur without aggressive or physically intrusive methods of treatment. Yet the possibility of anyone fully recovering from psychosis is generally doubted anddisputed, and there is still a reluctance to develop noninvasive methods—as if to say there is no continuity between psychosis and sanity, that we can ignore our own minds and the frightening potential for insanity in all of us.

Some years ago I wrote to Professor Manfred Bleuler, a dean of international psychiatry who for twenty-seven years assumed his father's seat as director of the Burghölzli Hospital in Zürich (renowned for Carl Jung), and shared with him some of my own concerns and dilemmas in treating people in psychosis. I was as troubled as I am now at our culture's failure to assist these people. He answered like an opening hand.

In response to descriptions of the treatment work I was doing, he wrote:

May I mention some particular points in regard to which I found your presentation particularly excellent: the importance of the 'history of sanity' is rarely mentioned in the psychotherapeutic literature. As far as I know you are the first who describes it in such a convincing way. It plays also a great role in my psychiatric work. The need to become free from the prejudice that a person who has become insane will always be so, is extremely urgent and you are formulating it very well. I have been much attacked within the last years as I have seen and described the recovery of many schizophrenics who had been severely sick for long periods. The critic of my teaching and my experience consists in the following opinion: 'A schizophrenic patient can never recover—if you imagine to have seen recoveries of schizophrenic patients the reason is: you have made the wrong diagnosis.' In my opinion this criticism is unrealistic and is harmful to our patients. I am glad to know that you fight with me against this criticism.

It is in this spirit that I hope to present the view of recovery, and to give patients and those around them who are able to give care the means to recognize the actual sequence of events in becoming insane and likewise the sequence of events that occur during natural recovery. For example, it is terribly important to become aware of the spiritual dimension of the psychotic ordeal and how closely related it is to actual bodily experiences. Such insights into how psychotic suffering is created may bring treasured moments of clarity and relaxation. In short, this book is meant to provide to those who have suffered in psychosis and may do so again, to their families, psychiatrists, or others who work with them, a practical knowledge of the ways and means of handling and protecting themselves and of improving their conditions in the different stages of illness and recovery.