The Skeptical Psychiatrist – a conversation with Dr Jon Jureidini

Listen to a lively discussion (MC’d by Michelle Tatyzo) featuring Dr Jon Jureidini and Dr Graham Williams talking about the use (or over use) of prescription drugs to manage emotional states. All drugs have side effects, do the benefits of a drug intervention outweigh the costs? Are there alternatives to drugs? Can meditation be a better approach in some situations? Are there situations where meditation doesn’t help? Recorded live at the Lifeflow Studio on Sunday 27 September 2015.

The Skeptical Psychiatrist

Dr Jon Jureidini and Dr. Graham Williams in Conversation

Recorded live at Lifeflow Studio on Sunday 27 September 2015

MC Michelle Tatyzo

 

Introduction:

Michelle: Hello, everybody. Welcome to this wonderful event and thank you all for coming. I know it’s an absolutely beautiful day outside, so not necessarily nice to be inside but this will be a fantastic conversation to make it worth your while.

My name’s Michelle and I’m going to be providing some facilitation today and basically we’re going to have a lovely conversation between Jon and Graham. There’ll be some time for questions at the end a little bit before we move on.

Jon Jureidini is a child psychiatrist at the Women’s and Children’s Hospital, here in Adelaide, where he works with ill and disabled children and their families. He is also trained in philosophy and critical appraisal and psychotherapy. He heads the University of Adelaide’s Critical and Ethical Mental Health Research Group within the Robinson Research Institute, carrying out critical appraisal, meta-research, teaching and advocacy in order to promote safer and more effective and more ethical research and practice in mental health. He also heads the Paediatric Mental Health Training Unit, providing training and support to GPs, allied health professionals, teachers and counsellors in non-pathologizing approaches to primary health care.

Jon learnt most of what he knows about psychiatry growing up in a pub, from being a father, from reading novels and from Michael Leunig’s cartoons. He has also won numerous awards, including the 2006 Margaret Tobin Award for excellence in the provision of services to people with mental illness who need it most.

Graham, as we all know, is the director of the Centre here, amongst many other things.

I was really happy to be asked to facilitate this because I had brief question when I was about 16 or 17. I did some babysitting for some young girls whose father had left their mother and one occasion I came to do my babysitting session and the girls who were usually lovely and bright and bubbly, one of them was a little bit different and I remembered saying to her “Are you O.K?” And she said “Mum took us to the doctor; we were sad and they’ve diagnosed us with depression and I’m on medication.” I remembered thinking “O.K. that’s a little big strange to me.” But I also thought “Well, I’m only 17 and what do I know and I’m probably also depressed so, who knows? (laughter from audience) So, to me that was a really good question about what happens there, so I’m happy to be here and facilitate this conversation and I’ll open it up to you, Graham.

Graham: Thanks a lot, Michelle. I came across Jon on the radio a few years ago – I heard this guy talking who was a psychiatrist and what he was saying was absolutely music to my ears. I couldn’t believe what I was hearing. He was saying that many normal developmental stages in teenage development had been deemed to be disorders. I thought, “Wow, fancy a psychiatrist saying that.” One thing I never forgot that he said was that depression used to mean that you were flat on your back in bed in hospital but now, well, we know what happens now.

It was so refreshing for me to hear a psychiatrist talking in this way and what he said resonated so much with my own experience as a meditation teacher because what I kept finding as people were referred to me, was that people who were told they had very serious mental issues and gradually everyone had given up and thought “well send them to Graham and see what he can do,” like the end of the line. What I kept finding was that these people invariably – in fact without exception – were in touch with their inner lives. They had a gift for what was going on inside of them but these are the people that kept getting into emotional trouble and were liable to diagnoses of mental disorder.

What do I mean by the inner life? Well, it’s all the feelings and inner dialogues and images and visions and emotions and physical sensations, which are part of our minds and bodies – you know that multilayered, sonic, huge multirama film that’s playing in our heads all the time. These people were very much in tune with that, so I found that these people had a gift for this – they were very much in touch with it – and this was what was getting them into trouble. Men and boys who were very much in touch with their feelings were just soldiering on and women and girls who were very clear seeing were trying to be subservient and doing all the things that society said they should be doing and it was actually this; they were denying their own gifts and abilities and trying to be what they weren’t and it was that very thing that was being diagnosed as a problem.

Now the astounding thing was that as soon as they learned meditation the whole thing turned around very quickly as they discovered these gifts and they discovered a way and a tradition which enabled them to express what was most meaningful to them and was taken seriously. So, as our bodies grow in a certain way, as you train your mind, your mind actually opens in certain stages and this is what meditation’s all about –they’re quite defined. So what you discover as you train your mind is that the human mind is the human mind and what it does is what it does. So what often is diagnosed as a mental disorder from my point of view is often actually a normal meditation experience. It’s these people who are open to them that get into trouble. Now I’m just talking from my point of view here, of course.

The problem is this is happening in a world that doesn’t understand it and has no idea about this and is actually afraid of it. Now we’re not afraid of teenagers loving to stretch their bodies and play sport, or taking on intellectual ideas and really testing the limits of those – well emotionally gifted people and people in touch with their inner lives need to do the same thing. They need to expand, they need to stretch, they need to break a few emotional bones to find out how far these limits are. So, no one’s worried about rugby players and footballers having physical injuries and breaking bones – no one’s the slightest bit perturbed by that – and in fact once they turn 18 they’re eligible to be sent off and killed in a war and everyone accepts that. However any teenager who feels the need to stretch and challenge in the quest for testing their emotions, is met with fear and incomprehension and surrounded by a network health professionals who’re determined to keep them wrapped in cotton wool and any deviation from the mythical norm is liable to be diagnosed as a disease and treated with drugs. The problem is that bringing drugs to bear on these sort of experiences is probably the worst thing that can happen because then people are being taught to be afraid of the very things they need to learn to grow. That’s their life.

Now I’m not suggesting that the mind doesn’t get diseased – of course it does, the same as our body. It can become completely unbalanced and when that happens of course there needs to be treatment but there’s a long way to go before we get there and it’s in that area that I’m talking. A good emotional shake-up isn’t necessarily a disorder. So it’s generally not known or understood in our culture that there is a proper discipline for experiencing our emotional life and it’s been around for thousands of years and people who come to our courses have heard me rabbit on about this for years. There’s no way in our culture to train our emotions and this is what I searched for in my teenage years. I called it a spiritual discipline, which is what it is, for opening up our deepest feelings. So naturally I found it in meditation, which is why I’m here. In my perfectly normal Buddhist training, I would’ve been diagnosed, if ever I’d gone near a doctor, with chronic fatigue, depression and anxiety just to name a few of the experiences I went through but it never occurred to me to see them as a problem and I trusted my teachers so I wasn’t afraid of it and worked, just went straight through it and learned where all the limits were, to our mind, the same as we take for granted we can do physically and intellectually.

So you discover that there are maps that explore all the different kinds of experiences which your mind is capable of, just as we have maps for exploring the outback of Australia. So, living through these experiences, in a safe environment, with a proper discipline and it takes, like everything, a proper discipline – we take that for granted everywhere else – I discovered our emotional depths and a mental and emotional confidence and a sense of joy and peace which has lasted all my life.

So, here’s Jon – I wanted to talk about this from his point of view. We’ve just been chatting – there’s a lot that we’re on the same page with, there might be areas where we’ll run into a bounce but I want to ask him first off:

“What brought you to swim against the tide of your profession and question the way teenagers are being treated and drugs are being used?”

Jon: Well, I think I’m naturally a sceptical person…

Graham: I agree with that. (laughter)

Jon: …and I tend to spot the blemishes in things. So if I’m looking at a – this is a kind of curse and a privilege really – if I’m looking at a beautiful scene and there’s a bit of litter around, I can only see the litter, I can’t see the beautiful scene. I’m a bit the same with intellectual pursuits as well – I’m quite good at spotting the bullshit that we come across.

I guess one of the formative experiences for me though was a bit shameful really ‘cause I was at a psychiatry conference as a trainee and as there are at psychiatry conferences, shamefully still, the place was just riddled with drug reps giving away gifts. I found myself grabbing a bag and charging around the exhibition hall grabbing golf balls and pens and bits and pieces and I got back to wherever I was sitting and looked at this bag of shame and thought, “I don’t actually play golf, I don’t need these pens, I don’t like any of this stuff in here, why have I greedily run around and picked up all this stuff?” So I guess in a way I had an over-reaction to that, which was to really question the dominance of the pharmaceutical industry in psychiatry. And so I suppose that it’s not just the industry that I’m sceptical about in psychiatry but I guess you asked me where it started and that is where it started. Also when I started psychiatry training, it was regarded as healthy to come into psychiatry training with a dose of anti-psychiatry. You were encouraged to read R.D. Laing and Thomas Szasz and those kinds of things – not to kind of accept at face value everything that was being taught in mainstream medicine. So I think it was a combination of personality, shame and exposure to a sceptical literature.

Graham: I see. You mention R.D. Laing and I actually know of him because my meditation teacher actually knew him – they were friends years and years ago. I think he’s the one who said psychiatry’s a spiritual crisis that you just need to live through. So he took it to the other extreme.

Jon: Yeah. I think you’re kind of tapping into something there about a conflation between two experiences, or two populations. So you have Pat McGorry – for those of you who don’t know, Pat McGorry and Ian Hickie own psychiatry in Australia – and Pat McGorry was quoted extensively in GetUp a couple of years ago saying that there are 700,000 young people locked out of mental health care that they desperately needed. And what is being talked about there, what was being demonstrated there, is this conflation between these two populations. There are indeed 1 or 2% of young people who do need people like me in their life, sadly, who have a very severe level of disturbance of some sort and whether that’s socially determined, or a brain disease or whatever – you can argue the toss about – but they are severely disturbed and need medicine in the broader sense, not necessarily drugs.

But there are at any time, in any year, there are 20 or 25% of young people who experience a degree of distress, which is sufficient to be disruptive in their life. And what Pat McGorry and others do is they group those two populations together and seem to be suggesting that what the 1 or 2% need the 20% need. In fact there’s no evidence that those 20% are going to benefit from what I can offer, any more or as much as what you can offer, or nothing at all even, just natural recovery and growth. We don’t have enough trust in young people and in ourselves as parents, I think, to see these experiences through and that’s not in any way to diminish the dangerousness of these experiences. I don’t hold that some of my colleagues do, I don’t hold with the view that mostly what psychiatry is doing is labelling normal as pathological. It is doing that to an extent but more importantly it’s really important to acknowledge that those people who are being mislabelled in psychiatry are most often distressed and severely distressed and possibly that might lead to suicide or drug addition or other dangerous behaviours. But the fact that it’s got dangers associated with it doesn’t make it psychiatric and doesn’t make it medical.

Graham: This is what made music to my ears. The point I was making is when it comes to our physical lives, no one’s the slightest bit worried about teenagers putting themselves in danger, to a certain extent. Personally I wouldn’t go near a rugby field or a football field – it’s far too dangerous – but emotionally I was prepared to do absolutely everything. I can remember my parents were terrified, really terrified. But I totally agree with you, danger’s not necessarily a bad thing and that, I think, from my point of view, is the big point I’m making because to grow we need to test boundaries. Our culture is so frightened of this emotional level and I wondered if you have any views as to why.

Jon: Well, partly it was concern about explaining away very significant distress in young people – the idea that it was just adolescent turmoil – and people rightly reacted against that because they thought that the distress the young people were experiencing wasn’t being taken seriously and sort of reacted in another way to say “Well let’s treat distress in adolescents exactly the same as we would at any phase in life. And of course adolescents, by definition, are immature and if you’re displaying emotionally immature behaviour at the age of 15 – 25 that’s very different from displaying the same emotionally immature behaviour at the age of 35 – 45. So what makes sense to pathologize… I still feel uncomfortable about it but you know you can kind of see that there are things that you might regard as being out of the normal in adults that aren’t in teenagers. I think it’s a very real phenomenon, a very important phase for many of us to go through – not everybody by any means – but for many of us to go through a kind of developmental breakdown at some point in our life where we just kind of… I don’t know, there are a thousand different ways of describing it – a spiritual crisis, or any number of ways – but we go through some state where we regress to some extent. Or we – these words are never quite adequate for what the experience is – and then we grow as a result of that experience.

I think people got angry and anxious because what they saw was people getting sick, getting schizophrenia, or some other horrible condition and that not being taken seriously and the young people not being cared for. So in the process of sort of compensating for that I think we lost the capacity to tolerate ordinary madness in young people rather than worrying madness and how to tell the difference. It’s not easy to tell the difference between them.

Graham: Oh, thanks for that, I think that’s a wonderful point and to make that distinction of course, is a very fine one. Just coming from the Buddhist tradition they’re quite ruthless in a way and as I taught I realised they could afford to be because they had a whole structure and a whole culture, which supported this but what you did if you went into training there is whatever you experienced was just left alone. You went through the whole experience. Now of course there’s been total chaos as that has been transplanted into the West and then I can see on top of that you’ve got the attitude – like from my father’s generation – well just get on with it.

Jon: That’s what I get tarred with you see. People don’t like what I say and they interpret what I’m saying as “If you’re depressed, it’s your fault, get up, get on with it, you’ll be fine.” Which is not at all what I’m saying but that’s what people like to characterise it as.

Graham: O.K. so what you’re making is the point that now everything’s just gone to the other extreme which of course it tends to do, doesn’t it?

Jon: The other thing you’re talking about that I’d like to pick up on is this notion of

saturated experience, or completed experience or whatever – that we’re so incapable of offering our children these days. The culture and the technology and everything makes it pretty difficult for kids to get bored and that, combined with this ridiculous idea that we should be able to take 4 year olds to the supermarket and they not have tantrums. Whereas it would be much healthier to either not go to the supermarket, or if you are going to go to the supermarket with a 4 year old and have a tantrum then let them have the tantrum because you’re the person who’s put them in the wrong place and you need to tolerate their level of distress until you are able to help them to readjust to that situation.

We ‘re always interrupting what kids are doing and I think that is sitting in the background of the difficulties that our teenagers are having. They have the expectation that things are going to be fixed – if they feel bad, somebody’s going to make it better. We have this kind of slogan that it’s much more important to be good at feelings than it is to feel good but the society says the opposite. The society says that you should feel good. I’m always showing images of that air conditioning advertisement: ‘22 degrees all year round.’ As though that’s a good thing? Why would you want it to be 22 degrees all year round? Today’s fantastic because it’s 22 degrees but if you don’t have days when it’s 42 or 2 how are you supposed to properly appreciate when it’s 22?

Graham: Totally! I thoroughly agree. You mentioned the word ‘boredom’ and of course that’s not on the radar anymore but there are two quotes I love to give around boredom. One is a very famous old Tibetan teacher who said: “If you’re not bored you’re not meditating.” So it hasn’t begun until you’ve got bored. And then a quote from Goethe, the German poet around Beethoven’s time, who said he was casting around ready to commit suicide, looking for a knife, or a rope and then he said: “Oh, then, oh boredom, you came to my rescue; mother of the muses.” Which I’ve always used because it’s a fantastic quote because boredom of course is the bedrock of all human creativity and everything we’ve done. I totally agree with you, people are getting terrified of it and being trained to be frightened of it and not allowed to experience it.

Jon: Hmm.

 Graham: Yeah. Thank you for that one. I wondered too what your experiences have been over the years of working, in your profession – what kinds of things you found and discovered in your experiences you’ve had with clients?

Jon: One thing is how difficult it is to do therapy – to actually be present in therapy with a patient, or a family. I achieve that fully, shamefully infrequently. I’m either not being sufficiently curious, or sufficiently empathic, or accepting of what I’m being told and I drift off and wish I was out walking in the bush rather than sitting in an office. So I guess learning how… and how fundamental that is to the pursuit. The relationship is what it’s all about. The relationship is what makes a difference. Our specific treatments, our particular style of therapy, the drugs we use, contribute much less to our healing capacity than do our relationships with our patients. But that’s not to say that you can just do this work by being a nice person and sitting with people because I think unless you’ve some kind of theoretical underpinning to what you’re doing… and you know my rubbish is just as rubbish as your rubbish, that doesn’t really matter as long as it’s internally consistent and it’s not, frankly, wrong, then it doesn’t really matter much to me, as long as we are rigorous about what we’re doing. One of the things I think is an enemy to good work in therapy is eclecticism when it amounts to just casting around for clever ideas from wherever you can get them and joining them all together without serious… You know unless you’ve got to the point in understanding a theoretical approach where you can feel critical of it and doubt it and struggle with it and hate it and all those kinds of things, then I don’t think you’ve internalised it enough to be able to put it to use.

Graham: Ah, look we’re totally on the same page here, ‘cause so much in the meditation world it’s… I think Ken Wilber called it ‘boomeritus,’ which is “whatever I do is right and I’m going to do it my way” and not realising that – exactly as you said – to really get to grips with any discipline or any understanding, you have to stay in the same place and battle it through, even if it’s not stacking up which, as you’re saying, enhances your critical faculties and gives you something to work against.

Well thanks for that one. I’ve got one more and then we can open it all up. I just wondered what you thought about this thing I said of… I know you’re not an experienced meditator or anything like that and it’s not part of your territory but wondering what you thought about what I said about the possibility of what would be normal meditation experiences being diagnosed as disorders because they’re just not within the context of our culture and being totally misunderstood?

Jon: Yeah. Look I think if you’re distressed and you come to somebody like me and you are having the kind of experiences that could be read in different ways, that’s dangerous to tell me about that because I’m trained to see that as a manifestation of pathology…

Graham: I see.

Jon: …and not trained to see it in the way that you would be trained to see it. It seems to me that what we might broadly describe as crazy experiences that we have, there’s a group of crazy experiences that many of us have, perhaps mostly infrequently throughout our life, without it meaning that there’s anything wrong with us. There’s a smaller number of experiences that it’s quite unusual to have unless you are suffering from what we might describe as a psychiatric illness like schizophrenia. And we’re not very good at distinguishing between those two families of experiences and there’s an overlap anyway amongst them, I think.

What tends to happen is that if you’re experiencing a lot of distress and you’re having some of these, what you might describe as meditation experiences and you talk about that to your psychiatrist, then the psychiatrist is likely to be skewed towards interpreting your experience as psychosis rather than depression or anxiety or something else. And so you might end up then being channelled down a pathway which can be very dangerous to be going down. I do think that there is a big overlap between what you’re describing – I don’t fully understand it – but what you’re describing as meditation experiences and what would be seen as psychiatric symptoms but I don’t think they’re absolutely the same thing. I think that there are some… I’m not confident about this but my guess is that there are some psychiatric experiences that actually, in and on of themselves, are quite pathological and manifesting some kind of brain dysfunction. But there’s a whole pile of experiences that get grouped with them in psychiatry, which actually could be quite benign.

Graham: O.K. Oh, thanks very much for that ‘cause that does tally with my experiences. As I’ve said over the years I’ve seen many people and for the bulk of them… I think of one particular example of someone who was diagnosed with bipolar disorder, which meant they would be on – is it Lithium usually? – or some drug for the rest of their lives and they were interested in learning to meditate, so they were prepared to take it on. This is what I find too, if people aren’t prepared to work at it well, of course, there’s nothing I, or the tradition can do, so it does mean taking on a discipline. But they did and worked themselves right out of it and have learned to manage the whole thing themselves. The drugs just went and haven’t had to look at them ever since.

Jon: That would, in and of itself, mean that the person didn’t have bipolar disorder because there’s an assumption that the way in which you deal with major psychiatric disorders is with drugs and that if you get better without drugs then you didn’t have the disorder in the first place. And there’s no real evidence to support that – when you look at the population of people with schizophrenia and you look at the outcomes, 10, 20 years after they first present, the people who’ve taken less drugs have actually done better than the people who’ve taken more drugs. Now you’ve got to allow for the fact that the most severely affected people are more likely to have been put on drugs, but even after you correct for that, you find that you’re better off in the long term, not being on drugs.

We know that people in small scale societies who don’t have access to the best of western medical care, actually do better with schizophrenia than people who live in our society. Again, there are other reasons about it other than medication load, but that’s one plausible explanation. So the fact that meditation helps somebody to live with and get better from bipolar disorder, doesn’t, to me, mean they didn’t have bipolar disorder. They might not have, you know, on average I reckon probably half the people who are diagnosed with psychiatric conditions don’t have them but nevertheless the fact that somebody gets better without conventional medical treatment, or does better with… I’ve got a patient who I’ve been seeing for years who has been significantly helped by being ‘born again’ and functions better as a result of that. I would see that, from my position of bias, being born again as being diminished – in terms of your autonomy and your access to all of the good things of life. But for her, being born again is a lot better than being crazy. So there’s no kind of neat correspondence between medication and illness.

Graham: O.K. Thanks. So what I’m hearing is there’s a big overlap but I would agree once there is a point where you can go over the edge. I’ve seen that with people (who) have come and it’s obvious that it’s gone too far for me to do any… for it to really… because they need to be in a position where they can take on some work and start to work with it. I have worked with psychiatrists with people who’ve been on drugs and the meditation’s helped them but I certainly would never have recommended them to come off the drugs. I find it very interesting that you’ve said that on the whole most people would probably do better without the drugs in the first place, if I’ve heard you correctly.

Jon: No. When you look back on people who have survived with minimal drugs over the years, they’ve done better. What happens in the first acute phase… So when you think about it psychiatric drugs are not specific treatments for anything. We label one group of drugs antipsychotics, we label another group of drugs anti-depressants and the implication is that’s a bit like antibiotics – antibiotics just means kills bugs. So antipsychotic should mean kills psychosis, and antidepressant should mean kills depression, or cures depression. But that relationship is not there – it’s completely a product of marketing.

So what we have are what are called psychotropic drugs. So a psychotropic drug is any drug that has an effect on your psychological functioning. Alcohol is a psychotropic drug, marijuana is, Seroquel, Prozac – all of those drugs are all psychotropic drugs – and most of those drugs have a relatively predictable pattern of effects on people. So you know that, if you think about alcohol, which is probably the psychotropic drug that most people are familiar with – you can kind of predict what the effect of alcohol is going to be on people. Some people have idiosyncratic responses to alcohol but most people will respond to alcohol in a pretty predictable kind of way. Well it’s the same with what we call antidepressants and antipsychotics. Take antipsychotics as an example – they are emotionally and cognitively numbing drugs and so we can predict that that’s what they’ll do with people.

When should we use emotional and cognitively numbing drugs? Well, only when people’s emotions and cognitions are so disturbed that being numbed is preferable to not being numbed. And when you’re ragingly psychotic that’s an example of that situation. And so a good prescribing decision would be to say, “I have this person with this pattern of symptoms. I have this drug which has this predictable effects. When I look at those predictable effects and match them with this person, is it likely that the benefits of this drug are going to outweigh the harms?” If it is likely, then a good prescribing decision would be to give that person the drug. If it’s not likely, then we shouldn’t.

The problem for we doctors in making that assessment is that, for a whole range of reasons, we’re not very good at noticing, collecting and analysing the harms that drugs do. And so we’re much more familiar with the benefits than we are with the harms and so sometimes we make the decision to give somebody a drug because we can predict that the match will result in benefits but we don’t take enough account of the harms that go with that. That’s one of the reasons why we make bad prescribing decisions.

Graham: Thank you very much. That’s a very wise point. I’d just like to point out that the same thing happens with meditation too of course, especially in the mindfulness field where it’s actually been advertised that mindfulness does no harm. The psychologist Michael Yatco in America has said anything that can do good, can do harm…

Jon: Yes, absolutely.

Graham: …so it’s not true. And it is true, it can in the wrong hands, in the wrong way, it can be harmful. So, my side of the fence is just as bad at that as yours.

Well, at that point shall we open it all up?

Michelle: I had a little bit of a question while you were talking. I think you’ve made some interesting comments about, I think you said, at certain points in our lives a breakdown might be a bit necessary for our growth. So tying all this together I wonder… we’re really talking a bit about confusion over life experiences in some way. We’re not maybe so comfortable with the unpleasant things that are happening to our mind and body, as we are pleasant things that are happening to our mind and body. So, I wonder are we… How do you both view that idea about how we’re handling pleasant and unpleasant feelings and do you think that’s part of the problem. I also had a question “Does positive psychology link in here anywhere to help that sort of stuff, or is that more negative?

Jon: I’m the number one paid up member of the anti Seligman club. I think positive psychology is an absolute blight. One of the reasons why I think it’s terrible is that when asked about “Your ideas sound fine at St Peter’s College but what about in disadvantaged areas?” Seligman is quoted as saying – and I wasn’t there so perhaps I shouldn’t quote him – but he’s quoted as saying: “I don’t do disadvantage.” What we systematically ignore are the social determinates of health – physical and mental. Every major work/report that happens in medicine these days, starts off in the first couple of paragraphs talking about the social determinates of health – poverty, bad food, bad living circumstances – all that kind of stuff and then proceeds to ignore it for the rest of the document when it comes to the results.

The idea that you can optimise your way out of being abused and disadvantaged is shameful, I think. I have, probably correctly, been accused of being an emotional Calvinist because I think that we need to experience suffering. Not for the sake of it, I don’t want people to be hurt when they don’t need to be hurt but if something hurtful happens in your life, you’ve got to sit with the pain to a certain extent. If you don’t do that, then you’re diminished as a result of that.

Michelle: What do you think about that, Graham?

Graham: Yeah, I come from the same point of view. I have to admit I hate the whole happiness movement in my territory for the same reason because it gives such a skewed view of life. Whether we like it or not, life does involve pain, it does involve suffering and I think if we try to – exactly as you were saying – if we try to bolster ourselves against it and pretend it’s not there, we actually end up making it more painful because we become afraid of the very things that are going to cause us to grow. It’s only when you get a shock, it’s when you experience something that conflicts with how you think things should go, that it causes you to question, it causes you to open your mind a little and it causes you to step back and say “Well, what is happening here?”

On that basis I would say it’s cruel to throw people into those experiences deliberately which a lot of weekend sessions do – you can throw people into all sorts of things. They used to describe it as psychically dissecting people and then leaving them on the floor and saying “Well, put yourself back together again.” Now I think that is totally cruel, so if you’re going to – like in my territory – lead someone to these kind of experiences which open the mind, you need to provide a solid basis of calm and a solid foundation to work from. So I come from that point of view. It needs resources to be able to face pain and suffering and I don’t think our society gives them properly.

Jon: Yeah and I think you raise an important point because there are times when you need to keep a stiff upper lip and put things out of your mind and get on with it. My favourite psychiatrist ever is William Rivers, who worked with shell-shocked people in the First World War. What they would do with these officers… he was working with officers who came to Craiglockhart in Edinburgh and they would come very disturbed with mostly horrible images and memories from what was happening on the front. As British officers they had been taught to keep a stiff upper lip and keep it out of their mind and that was failing. It worked during the day and then they’d lie down to sleep at night and as their consciousness receded they’d just be flooded with horrible images. What Rivers and his colleagues did was to say “O.K. so you need to give the pain the attention, but not all day.” So they would create a safe environment in which the soldiers could have a couple of hours – or, I don’t know how long it would be, hours, minutes, some time in the morning with their therapist where they would actually focus on the terrible things that had happened but for the rest of the day they tried to make them as comfortable and looked after as possible in order that they would provide just what you’re talking about – that kind of security from which you can address those bad feelings.

Graham: Oh, good. You’ve mentioned the word attention, so I’d just like to put in a plug here – that is really the correct definition of mindfulness. That’s what it actually means, it’s just to pay attention to something and so what you’re describing there is classical mindfulness training – is provide a secure foundation in which you can then turn around and pay attention to whatever the disturbance is and allow it to open up, or not, as the case may be.

Back to you Michelle.

Michelle: Well, we are running out of time so perhaps I might ask one quick question and then open it up to the audience, if there’s any questions.

You’re kind of leading into talking about that people might need to be a little bit sort of nurtured to be able to, or have a space to be able to experience some of those negative feelings and things that are going on in their lives. Jon, I read an interview where you said “one of the most ethically admiral things a therapist can do is nothing and you talked about watchful waiting.” Is that this sort of thing?

And Graham I think some of that maybe mirrors the meditation approach. Is that what you meant about allowing space for those things to happen?

Jon: Yeah but also for us as doctors to be… we always want to do something to fix it and there’s a really good saying in medicine, which is: “Don’t just do something, stand there.”

Graham: Can I tell you the meditation one? The meditation one is: “Don’t do something, sit there.”

Jon: It is much easier to do something than not to, or it comes more naturally to us and we’re trained to behave in that way. There are situations in which you can’t just stand there. Like when there’s violence or whatever, we sometimes have to be much more in an advocacy role than a therapeutic role. But once you’ve established the safe ground on which to do therapy… you could accuse me of kind of talking of a therapeutic approach that ignores the social determinants of health. What I’m talking about is not of much use to someone who’s currently the victim of domestic violence or child abuse. Those things have to be dealt with first. So, we’re always assuming that we’re dealing with people and circumstances where the pain is something that’s happened and isn’t continuing to happen. Whenever it’s continuing to happen we have to shift our focus to stopping it from happening.

Graham: Yeah. I agree with that. I always point out with students and clients that you’ve got to look at things in order. So the first thing is the physical situation and that’s personally and what the persons in and that needs to be dealt with first before you can start to go near the emotional or the mental. So I just want to concur that I’m totally in accord with that too, from my point of view.

Michelle: Would anyone like to ask a question and particularly in relation to the content that you’ve heard here.

Q: (paraphrased) Could Jon explain boredom and the difference between a normal teenager who might experience boredom and a person say in a detention centre who might be experiencing boredom?

Jon: I think the latter case is an experience of deprivation and not of boredom. Boredom is when you’ve got what you need and you’ve got the opportunity to be doing things but nothing actually feels right to do at that time. So you have to recreate yourself, I suppose, from that bedrock that Graham was talking about a little while ago. I think the kind of sensory and emotional deprivation is a very different experience from healthy boredom.

Graham: I totally agree with that. You mentioned the word creative –you’ve probably heard of Otto Rank? He was one of Freud’s circle, who broke away from Freud and he said something that fascinated me when I heard it because it tied in with what I said at the beginning, that all neurosis is a symptom of an Artiste Manqué, a failed artist, which is someone who hasn’t been able to creatively – like you’re saying – to have the ability to, or opportunity to, create from the conflict, or in this case the boredom that they are facing. I totally agree, that’s totally different from someone in a detention centre total, who’s – I think the word’s correct – who’s just in a state of total deprivation.

Q: (Paraphrased) In schools what can be done to help prevent the onset of mental illness, particularly with rising numbers of mental illness?

Jon: I have to say that schools are the most important institutions in our society and teachers are the most important people in our society.

Graham: Can I just give a clap to that? (Audience applause)

Jon: And it’s shameful that you need more marks to get into a commerce degree than to get into teaching because we don’t value teaching enough in our society. Teachers and schools are the best antidote for mental health problems and you don’t have to do anything, except be a good teacher… because the same curriculum that develops kids cognitively, develops their imagination, which is what enables them to overcome adversity and do all of the things that they need to do.  So the less teachers think about mental illness and whether the kid’s got depression, or anxiety, or an eating disorder and the more they think about them as children who need to learn and they can help to learn, the better. So it’s actually just getting on with the vitally important job of being a teacher.

Graham: Can I add to that because I actually trained as a schoolteacher in my nefarious youth, among other things. I’ll never forget… they had all this teacher’s training stuff and we had to write an essay about what you needed as a teacher and I think I wrote a paragraph saying that what a teacher needs is to be passionate about what they’re teaching and to love it and to really care about communicating it and I totally failed the essay. That’s where I stood back then and that is where I still stand, so I totally agree with you 100% on this. If teachers really care about kids and care about their subject, the kids will pick up on it. I believe that that’s what starts to give direction and a lot of – from my point of view – mental disorder comes from a lack of direction, is that constant confusion about where to go. Where are the limits of will ‘cause teenagers are constantly testing will. Where are the limits of emotion?

Jon: Yeah and I think one of the things that schools talk about is mental health literacy and I think there are at least two components: one is emotional literacy, which is fabulous; the more kids can understand feelings in themselves and other people, the better. The other is medical literacy; knowing what depression is and what anxiety is and I think that’s counterproductive because what is being done in schools in the name of mental health literacy in that part of it, is teaching kids how to be sick – teaching kids to see their distress as being a manifestation of some kind of illness. It’s attractive isn’t it? We talked before about harms and benefits. Labels are a fantastic example of something that has a harm and a benefit to it. Being able to make sense of your experience by giving it a label and saying, “Now I get why I’m the way I am because I’ve got Asperger’s, or whatever. That makes you feel part of a club – you’ve got what feels like an explanation – but what we don’t realise is, or what we don’t pay enough attention to are the costs of having that label, both in terms of diminished autonomy and also in terms of not being treated as a whole person and all those kinds of things.

So I think mental health literacy in the sense of teaching kids and teaching teachers to make diagnoses – nobody would say that’s what they’re doing but that’s essentially what it amounts to. I think that’s really dangerous. Emotional literacy on the other hand – can’t get enough of it but it should be part of the curriculum. Where do you learn about feelings? You learn that from hearing stories – telling, being told, writing, reading, fiction, or non-fiction but real stories about people.

Q: (Paraphrased) Is the problem of over-diagnoses and over treatment related to not having a thorough enough check-list to use before prescribing?

Jon: You’re never going to be able to do it with a checklist.  I’ve never seen a case of ADHD. I’ve had lots of people come to me with a diagnosis of ADHD but by the time we’ve finished talking, we’ve always got a better explanation for what’s going on. The better explanation might be “dunno” but it’s better than ADHD. So what we have to strive to do as psychiatrists is to make sense of the person’s experience, to make meaning out of the experience. People come to us with what, on the face of it, are pretty meaningless… that’s kind of one of the things they’re often complaining about – it’s all meaningless. But they engage in meaningless behaviours like drug use, or aggressive behaviour, or whatever. We’ve got to try and make sense of that. When we do make sense of it, the response to it becomes pretty common sense. It might be really difficult to implement but it’s kind of obvious what you need to do.

So if a kid comes to me with a behaviour problem and it turns out his parents are fighting and what would be ideal would be if he could come to me and say; “Look my parents fight all the time and I can’t bear it, can you help me?” But most kids can’t do that, so, this particular kid’s behaving badly. It’s kind of obvious what needs to be done. It might be impossible to do it but what needs to be done is that the parental relationship needs to be sorted out and ADHD disappears off the table completely.

Q: (Paraphrased) How do you identify is someone is psychotic. How do you identify who needs help and who doesn’t?

Jon: I think anyone who presents as psychotic needs help of some kind. That kind of belongs, I guess, mostly in our territory if somebody has lost touch with reality. But there are a range of different explanations for that – the most common one being related to taking psychotropic drugs but ones you by on the street, rather than ones you get from somebody like me. Once you stop taking those drugs, often the psychosis disappears, so you might deal with it like that. But there are other cases in which the person does appear to have some kind of brain disorder and sometimes using emotionally and cognitively numbing drugs plays an important part in dealing with that brain disorder.

So, the skill has to be telling the difference between somebody who can be dealt with one way, or somebody who can be dealt with the other and having an open mind to the fact that we might have got it wrong. So every intervention that we offer – and again I think this might be quite similar to meditation – every intervention that we offer ,ideally it’ll result in an improvement in the person’s state of well-being. But if it doesn’t, it’ll tell us something. The process of what we’re offering the person not being helpful for them in terms of making them feel better, might be quite helpful in terms of understanding what’s going on. So if the intervention’s failed, the way in which it’s failed, or being curious about why it’s failed, often informs us about where we go from there.

Graham: I’d just like to make a comment that I think you know far more about meditation than you realise. There’s two things I’d just like to summarise: is that once you name something, that’s what you get. Well, that’s one of the key things in meditation and so one of the things you’re learning with meditation, is to just give up those names and stay with the experience. And that ties in with what you just said that it’s an ongoing process; that you’re not trying to finish, or fix something, you’re constantly working and adjusting and learning from that experience, as much as helping. So they’re two key elements of the whole meditation training, so thanks for that.

Q:  (Paraphrased) Did Jon have any pivotal experiences as a teen that led him into this path?

Jon: I was a shit. (laughter) I was bullied when I started high school and I bullied other people in turn but I didn’t make any real connection between what was happening to me and you know I sort of accidentally went into psychiatry – at a conscious level – in that I started doing physician’s training and hated it and ran in to an old boss I’d had when I’d done a psychiatry term and got talking to him and he said; “Why don’t you come and do psychiatry?” At a conscious level it wasn’t… but I’m sure on all kinds of other levels it was influenced by a range of experiences that I had – perhaps my parents dying when I was in my twenties?

Graham: Well, I can talk about my experiences – I had definite experiences. Well, I did a year’s medicine actually and hated it and failed, so I never went back. Being an artist and doing music, what I see over and over and I virtually say this to all my students “If you’re an artist, you’ve got to have Asperger’s and you have to be Obsessive Compulsive. That describes an artist, so treat it as fun and stop worrying about it. Also I discovered in my teens, I actually… looking back now and it came through in the retreats I was doing in meditation – is that I did go into very deep inner states which were very like depression and I enjoyed exploring them. I would lie on my bed reading Thomas Mann – I don’t know how many have tried to plough there way through Thomas Mann’s work – it’s about as depressing as you can get and it really probes those states of mind. I got to the point of suicide – I didn’t realise until afterwards. When you look at the lives of artists, you find that they all virtually go through these experiences – it’s what I mean by pushing the limits and finding out where they were. I know if my parents had died in my twenties, I’d be pretty knocked around. I think it would certainly bring up some very big questions.

It’s interesting that you were bullied at school because that is a typical symptom of someone who I was talking about who has a gift for their inner life, is that they don’t fit with their peers and they have those kind of experiences. A lot of my students who are brilliant at this work, have gone through those same experiences of being bullied at school.

Q: (Paraphrased) How much movement, or how much can the system bend to look at the levels of people’s lives in order to take a more holistic approach and might this approach be more cost effective in the long term?

Jon: Once somebody comes into our system, we don’t tend to say: “You don’t need to be here” because there’s always something that you can feel like, or mostly something you feel like, you can do, to be helpful. Individual cases… it doesn’t really work, I don’t think, to think about medicine at the level of individual cases. What we’ve got to do is take a public health perspective and think about where we should be investing our resources for the benefit of most people. So thinking about children with difficult behaviour, I’d be wanting to come at it from a completely different perspective that wasn’t medicalising. I’d be wanting to see it as an educational challenge for example. How can we modify our educational system so that we respond better to and find a place for people who behave badly in classrooms? That might involve interventions that are informed by occupational therapists, or a whole range of professional contributions to that. Out of that certain individuals will emerge where it’s not making sense and things aren’t going right, or the meaning isn’t coming out of that – in that case you may need to refer off for expert assessment. But I think we’ve got to get away from the idea that labelling the challenging behaviour, or the person’s challenging experience, is the first step towards making sense of it and helping with it.

Often when you find out what’s going on, like the parents fighting – which I make no apology for using that example because it’s a common thing that I see. Often people know that’s what’s been going on but they just haven’t really given it enough emphasis, weight.

Graham: In family therapy, you always would look at the whole situation and someone is going to be a scapegoat, someone is going to play out the symptoms of what’s going on in the family – and I assume this is what you are talking about – and respond to it and react to it. So quite often what appears to be an individual problem, isn’t.

Jon:  It’s not just within the family. Bad behaviour should be thought of as the first approximation of what’s going on when children, young people, are behaving badly, is not that they’re sick or bad but they’re protesting about something. It’s their clumsy way of telling us that things aren’t right in their lives. The great paediatrician Donald Winnicott said, “delinquency is a sign of hope.” I kind of understood that at a cognitive level, on an intellectual level, that we know from just animal experiments, when you torture animals – which is what Seligman did in his first career – they’ll initially get very aroused and protest and then they’ll give up. I knew intellectually what Winnicott was on about but it didn’t really mean anything to me viscerally until I worked in immigration detention and you would find that young men in particular coming into immigration detention, would initially make the best of a bad lot – they’d play soccer, learn English, do the things that were available to do in the detention centre. Then after a few weeks, or months, or longer, of that, they’d start to protest and they’d often protest in very destructive ways – sewing their lips together, being aggressive and hostile – very unpleasant things.

That’s the point at which mental health services would be called in and they’d say you’ve got to do something about this person, they’re sick. What would characteristically happen would be, after months or even years of that we’d be told “Oh, you don’t have to worry about Abdul anymore he’s OK now.” What you’d find out was that he was spending 18 hours a day in bed and basically had given up. When men who were got out of detention in that second phase, they did well but the ones who got to the third phase, on average, they did very badly because they’d given up. So I think we need to see behaviour that we don’t like in young people as communication, as protest, as an expression of hope – like we would with a baby. When we see a baby getting angry, we naturally, instinctively, respond: “that baby needs something from us.” Whereas when we see an angry adolescent we want to discipline them or push them away or whatever and that’s just the wrong approach to take.

Graham: I think it takes us back to that same point of testing limits and boundaries again, doesn’t it? I think the best thing an adult can give is the example that they’re not frightened of that. I think that so much that goes wrong is that we as adults are often frightened of these behaviours. And so we’re teaching the kids that this behaviour is stronger than we are and than the world is and it’s therefore so important instead of showing it’s just something you go through – you’re testing the boundary, great. Let’s not be so afraid of it.

Jon:  That’s pivotal I think. That’s our role as parents and as therapists is to tolerate uncertainty and fear and contain that. Not be dismissive of it but to actually not be bullied by it into doing things that aren’t in our children’s best interest.

Graham: We teach in the meditation tradition that the greatest gift anyone can give anyone else is the gift of no fear. And of course this means knowing ourselves, doesn’t it, to a certain extent.

Jon:  Doing this kind of work in psychiatry is challenging and we’ve set up this new research group within the University of Adelaide called the Critical and Ethical Mental Health Research Group and we’re very pleased to have come kind of into the academy, to actually be kind of in the mainstream, saying some of these things that until now we’ve been able to say from the outside. If any of you think that what we’re doing is worthwhile and think that it would be worth supporting, there’s a little tab on our Critical and Ethical Mental Health homepage in the University of Adelaide which enables you to make donations towards our work.

Michelle: It’s been a wonderful discussion – I thank you both.