Schizophrenia Daily News Blog

Editorial: Daniel Fisher Workshop

A Review of a Dan Fisher Workshop

An editorial by MARVIN ROSS

Dr. Daniel Fisher, a psychiatrist who suffers from schizophrenia and who heads the National Empowerment Center, told the audience at his recovery workshop in Hamilton, Ontario that when he first entered psychiatry he found that his ideas ran counter to the newly emerging physiological theories of mental illness. “They were all jumping on the brain and I was jumping off” he said.

While science has made considerable progress in defining the changes in the brain of people with serious mental illness, Fisher continues to espouse controversial views to the point where a number of participants at the Hamilton workshop that I talked to were angered. One family member told me that she could hardly wait to get out she was so outraged by his comments that serious mental illness is an emotional problem and that people do not hear voices they just have loud thoughts.

Others expressed concern about his anti medication bias and one senior psychiatric hospital administrator said that while not agreeing with him it is important to hear other views. While defending the rights of people to present their opinions, I am concerned that Dr. Fisher gives the wrong message and that can be dangerous. Much of what he talks about is “touchy feely” unscientific new age platitudes combined with some common sense and a message that serious mental illness is not physiological. His answers to questions that I posed are at the end of this editorial and are very revealing. Dr. Fisher, as you will see, considers me to be overly simplistic.

How often have we heard someone with severe depression being told to “snap out of it”? Asking the question or expecting the depressed individual to cure their own depression implies that it is not a disease but a personal failure. You can’t “snap out of” a broken leg or an occluded blood vessel. But, Dr. Fisher seems to think that you can overcome what he calls a severe emotional distress (SED) that is precipitated by trauma or loss. When an individual suffers this SED, they often are taken over by the mental health system and labeled as severely mentally ill.

He further discounts the medical model by stating “the present mental health care system is based on an illness model in which an expert defines the problem as primarily a defective chemical mechanism in the patient’s brain that needs to be repaired by the expert. This model reduces symptoms but interferes with the person’s taking an active role in recovery.” In that same paper, he states “all of us can achieve self control of symptoms to varying degrees….” And “genuine healing comes from within by an activation of our own healing powers”.

This is from a paper he had published in 1994 in Hospital and Community Psychiatry that he handed out at his workshop as if we have not made numerous advances in the past 10 years. First, serious mental illness is just that – an illness of the brain. One needs to look at the many imaging studies of the brains of people having a first episode psychosis compared to normal controls to realize that.

Dr. Fuller Torey has an excellent paper in which he reviews 65 studies of individuals with schizophrenia who had never been treated with medications that indicate significant abnormalities in brain structure.

How can you achieve self-control of symptoms when the symptoms are caused by circumstances beyond your control like abnormalities of the brain? You can’t. That is like telling someone with epilepsy that they can will away their seizures.

These notions are the same as those in cancer where it is suggested that you can control your cancer and its spread through imaging, visualization, laughter, prayer, biofeedback, and other similar modalities. I could not find any studies in the medical literature that support this. A few years ago, I did an article on group therapy and its ability to help ameliorate the symptoms of advanced cancer and help to prolong life.

I did a group interview with women who were dying of advanced metastatic breast cancer but who were part of a study to see if group support might help their symptoms and prolong life. All of the women expressed intense dislike for the proponents of the visualization treatment. They all said that the implication is that their failure to control their cancer and get better is their fault. It is not. They were very ill and they were going to die and it was not because they did not want to live or they were not visualizing hard enough. But, the consequence of this New Age concept of will your way to better health is to demean their suffering and their incredible strength.

The same goes for serious mental illnesses like schizophrenia. Dr. Fisher may not need meds for whatever reason but most do. When I asked him why people experience a return of symptoms when they go off meds, he said that it might be because they were not far enough along in their recovery process (see Q and A below). What balderdash! What does that mean?

I can give him all sorts of examples as most can of the return of symptoms that are so bad that people have committed suicide as a consequence. But, here is an example of someone who was recovered. A man with schizophrenia who took his meds, worked full time at a career, was married and was enjoying his retirement and his many hobbies. The doctors decreased his anti-psychotics and his symptoms came back and he had to be hospitalized until the increased dosage kicked in.

I’m not sure how Dr. Fisher would account for that but I think of the comments made in a presentation by Dr. Robert Zipursky of the Centre for Addiction and Mental Health in Toronto. Dr. Zipurski said about 80% of patients will relapse within the first five years if they stop taking their medications. But, even if they are in remission, they should stay on indefinitely because of the cumulative damage each psychotic episode inflicts. "Recovery from relapse may take a long time and it is uncertain," he said. Scientists, he added, still don't know if someone can remain well for five or 10 years without medication, and the risk of not recovering from a relapse is too great. "If you've spent a year or two getting someone well and watching them rebuild their lives . . . to watch them get sick again is not something you would wish on anyone,"

Questions Dr. Fisher:

Q. Some people define recovery as being off all medications. You have said that you are not opposed to using medications as one tool in a person’s recovery journey. I have not been able to find your 7 steps to recovery on your website. Does your definition of recovery include not being on medication?

A. We do not define recovery as being off all medication. After all there are many people who take a variety of psychiatric medications but were not labeled mentally ill because there (sic) life was not interrupted by the experience. No, we say that when a person has recovered medication is one tool among many freely chosen by the individual.

Q. One psychiatrist that I talked to stated that your pro recovery position suggests that there are people who are anti recovery. He found that offensive as his goal for his patients is to help them recover. Could you comment on that?

A. I do not believe any psychiatrists are anti recovery, however many do remove hope by saying the person will remain mentally ill their entire life.

Q You say that taking medication should be informed and voluntary. Where do you stand on committal and treatment for people who are so psychotic that they cannot make an informed decision?

A. Except under emergency conditions of a very acute nature, for a person in a hospital, where there is a risk of harm, I am opposed to forced medication. Even under those conditions I think it should be called chemical restraint as it is called for persons with developmental delay

Q. You have said that you are off medications and that you know many people who are. One psychiatrist told me that 25 years ago, the diagnostic criteria for schizophrenia was much broader in North America than in Europe and that some people may have been diagnosed at that time who would not have been today since the North American criteria and now much tighter. It is not possible that some of the people who were diagnosed when you were might have been misdiagnosed?

A. I am tired of hearing that I was misdiagnosed. I still would have met the criteria of schizophrenia

Q. I have seen some very impressive imagings of the brain of people who were having a first psychotic episode and were unmedicated. There were significant differences between those images and normal controls. When these psychotic patients were treated with medications, you could see a significant change in the brain images that were now much closer to the brain images of the normal controls. Does this not suggest that schizophrenia is a neurobiological problem?

A. Our biology is not our destiny. Our brains change over time as we learn new behaviors and patterns of thought. This has been shown with all nervous systems.

Q. If it is then how can anyone go off medication? Is that not like suggesting that someone with epilepsy can go off medication and remain well?

A. Therefore one can have a severe mental illness, and change over time to the extent that medication is no longer necessary.

Q. Researchers are also finding genetic links to schizophrenia. Does this not also imply a physiological cause?

A. It may imply a genetic factor but not the cause. These conditions are very complex and involve a variety of factors. It is not helpful to focus so exclusively on only one factor and say it is the cause.

Q. I know of a number of people who attempt to go off medication and start to become psychotic again. How would you explain this in your recovery model?

A. Perhaps they went off too quickly. There is a rebound effect. Perhaps they were not far enough along in their recovery.

Q.. You told Medscape in an interview in January that you tell people going through a psychotic episode that: “this is not a permanent condition and that other people have recovered.” Does that not suggest that you do not believe schizophrenia to be a physiological condition?

A. There is no contradiction between saying these are not permanent conditions and my saying that there is a physiological factor. That factor can be changed over time. As I said there is good evidence that our brains change over time with new learning.

Here are Dr. Fisher’s unsolicited comments about my questions:

Overall it appears you have misunderstood my position. The world is not nearly as black and white as you make it seem. There is (sic) mostly shades of grey, in fact mostly grey matter. It is true I emphasize that people can recover and in many cases even completely recover. Our definition is on our website on the home page, right side. However, you must recall that I am a psychiatrist and I prescribe medications. I am not opposed to medication I just feel it is overemphasized