Monday, January 17, 2011

De-escalating worry

“The more people became shocked and worried about him, the more withdrawn he got,” Ms. Castle said.       
This quote about Jared Loughner is from the NY Times. It is a huge indictment of the way people in a mental health crisis are treated, before they seek help and even after seeking help. While I would like to think that medical help will alleviate the shock and worry attitude directed to the person, unfortunately, medical intervention usually exacerbates it. Shock and worry is an example of high expressed emotion and is studies show it leads to people doing less well. High expressed emotion (and its opposite, low expressed emotion) is a term that few parents are familiar with.

If we view the person as weird, sick, creepy, we hinder the person's integration back into society. I have written many times on my blog about how the doctors in our case used language and body gestures that escalated my worry about my son, which I, of course, projected right back onto him. I can only imagine how Chris must have felt getting a double dose of worry.

Actually, I know how Chris felt. The more my husband and I projected worry and concern, the more nervous and isolated he got. His last relapse taught us a huge lesson in this regard. We decided to leave him largely to himself, safe to do and think what he wanted to in the comfort of our home, free to speak or not to speak, free to fail a course, free of our daily cheerful inquiries about his state of mind. Positive concern is still concern, so we backed off talking glowingly about his future prospects. We say very little. Chris is thriving under this approach. He still has a way to go in his rebuilding project, but he's getting there.

The medical profession and its friend Pharma, has made schizophrenia a very high expressed emotion condition. They tell us it is the "most serious mental illness." I didn't know any better at the time and I took them at their word. Being "the most serious mental illness" implies that medical professionals, the people in white coats, are the best people to handle psychosis. The medical professionals, of course, administer drugs, which immediately ups the ante and makes schizophrenia a "very, very serious mental illness."

Everybody agrees that mental health care needs a huge overhaul. I can't think of a better way to express the basis for any treatment philosophy and practice than repeat the quote from the top of this page.

“The more people became shocked and worried about him, the more withdrawn he got.”

You can also interpret the quote as one of scale, meaning "the more people" who Loughner shocked and worried, the worse it got for him. For me, this is a clear call to de-escalate a mental health crisis as soon as possible by creating an environment of optimism within a small circle of caring. I have heard that the Open Dialogue Program in Finland does this well. Any large scale attempt to do the same generally falls victim to over-professionalization, almost by definition engendering a climate of fear and worry.


  1. Rossa,

    If I had to define the mental health system in one word, it would ironically be "manic".

    The mental health system has not learned how to take deep breaths, how to take things a moment at at time.

    It moves too fast. It moves too powerfully. And most of the time, it moves in the wrong direction.

    Dr. Joseph Mercola says that conventional psychiatric treatment is like trying to kill a mosquito with a cannon ball.

    I agree.

    Duane Sherry

  2. Jared Loughner is not mentally ill, he is evil and chose to do evil. If a person is psychotic, they do not know what reality is. They don`t know what time and day it is, what social expectations/rules are (then how to follow them), how to pay for items such as food and transport.
    Jared Loughner knew where to be, when to be there, how to get there, wear clothing , bring the loaded gun, and so on.
    Like people have the choice to be good, and for example help people in Haiti after the earthquake, people also have the choice to be evil if they have freedom.

    If you, a psychiatrist, or God forced everyone to be good, there would be no freewill.

  3. Excellent post Rossa. I agree with you and Duane.

    However, as for just sending Jared Loughner out to a farm in Finland, let's say, the night before or two nights before the massacre, I'm just not there. I am not yet convinced that all people who have psychotic breaks are prone to violence, even if left untreated. What I'm trying to say is that I think we can't lump everyone in together. And of course the next logical question is, well how do you know?


  4. Rossa,

    You wrote:

    "We decided to leave him largely to himself, safe to do and think what he wanted to in the comfort of our home, free to speak or not to speak, free to fail a course, free of our daily cheerful inquiries about his state of mind."

    Your son is fortunate to have you in his life!

    It sounds like you are doing everything possible to make his recovery successful.

    I wish there were more parents like you.

    My best,


  5. Mark, I don't agree that Loughner is evil. What he did was clearly wrong and tragic, and he will be horrified with the realization of what he did when he is no longer psychotic. I also think that people who are psychotic can go through the motions of daily living. He also knew how to get up in the morning and go to class, even when he was psychotic. He w2as also observed while doing this as being psychotic. Some people kill when they are acutely psychotic because they actually think they are saving sonmeone's life from daemonic forces. There is a scene in A Beautiful Mind where Nash's wife begins to suspect that Nash will harm their child. I can't remember how it resolved itself, but many people live in terror of what their relatives may do when they are acutely psychotic. It is fortunate that in most cases it never goes this far. There is also a 1955 film starring James Mason entitled Bigger Than Life, about a man who goes psychotic on cortisone and threatens to sacrifice his son, because, like Abraham, because he believes he is obeying God's command. Is the psychotic relative evil? I don't think so. I think their "illness" has not been effectively addressed.

  6. Hi, Bham,
    The Tuscon case shows us the worst case scenario of what can result from untreated psychosis. I hate to use my son as an example, because he is the kindest, most gentle person I know, and he abhors violence, but I also know that when he was deteriorating at one point, he was getting more frustrated and angry. Had we let it go any further, had we shunned him or made it worse for him, violence may have been the outcome. He was already beginning to direct it towards himself. It would have been completely out of character for him to hurt others, but it could have happened. When it gets to that point, you are probably right about Open Dialogue. I suspect that most, if not all facilities, wouldn't take someone so far gone unless they are on medication.

  7. "he will be horrified with the realization of what he did when he is no longer psychotic"

    "In 2007, Loughner was heavily into marijuana and mushrooms, and was arrested for possession. Evidence from 2007 indicates that he was falling, if not already fallen over, the deep end, asking bizarre questions of Giffords at a political event in Tucson." found on the internet

    Loughner is/was a drug abuser. Mixing up his drug abuse (drugs he voluntarily took) with (involuntary) mental illness is bull.

  8. Well, I suppose you might know better than me, but I am not all that high about rushing in to diagnose him with psychosis or mental illness or whatever. Yes, it does look at some point like he had a psychotic break. But, we don't know for sure. And, there is just so much we don't know. Presumably the thinking is that once he "comes to," and I think many of us are expecting him to do something like that, wake up or something, then he will just break down in tears realizing the horror that he has committed. As this line of thinking goes, once he receives some kind of medication (and I'm not against that at this point), he will rest, calm down or whatever then he'll realize what he's done. That's the thinking. But I don't see that happening. It's possible that's because he is refusing medication, I don't know. But I'm just not so sure that the script so many see in their heads will truly play out to form.

    There is another scenario that's being put out there these days, and that is a profile of the assassin or would-be assassin. NPR did a piece on it, and I've seen it one or two other places. I'm not sure that the paranoid schizophrenia diagnosis factors in at all.


  9. Rossa,
    This post is right on target! I find the less that I project any emotions or express any concerns about my son's care or condition, the better he does, and the happier he seems. Worry, concern, indeed any thing that can possibly be perceived as a recognition that there is something missing or not what it could or should be causes him distress.

    He has in the last 4 days blossomed once again.
    The night before his first good day, he listened to a meditation CD while going to sleep. The next morning when he woke up, he took a shower--no cue or prompt. He has every day since taken better care of his hygiene, and for the the first time since his hospital stay, been able to do a multi step task without assistance, and without forgetting what he is doing.

    This improvement also coincides with a lowering in the dosage on two of the meds which were increased when he was hospitalized.

    I do express my confidence in his decisions, and assure him that he knows more than anyone--including mom--what he needs.

  10. Things are sounding good, Becky. Keep doing what you are doing.

  11. The Tuscon case is the poster child for what not to do/how not to handle psychosis. It's an extreme example of what happens when help is delayed. The script for Loughner has been written. He will receive the death penalty or life imprisonment. He will never get out of prison, not matter how much he improves. I can't really comment on the marijuana use other than it is typical of teens and adults alike. Heavy cigarette smoking is also a way of trying to escape psychosis. Dr. Abram Hoffer referred to drugs and alcohol as a coping mechanism for trying to stave off the hallucinations.


I am no longer approving comments. All I ask is that you be respectful of others and refrain from using profanity.