Psych and environmental factors in schizophrenia, with Nathan Filer - People Who Read People: A Psychology Podcast

Note: there is an interview transcript towards the bottom of this page.

An interview with Nathan Filer (Twitter @nathanfiler), author of the non-fiction book The Heartland: Finding and Losing Schizophrenia and the fiction book The Shock of the Fall. Both of these books deal with topics of psychosis and, as Nathan refers to it in The Heartland, “so-called schizophrenia.” In The Heartland, Nathan examines the idea that “mad” people may be more similar to us than most of us believe, that perhaps madness is an understandable human response to dealing with various stresses and anxieties. (A transcript is below.)

Nathan and I talk about psychological and environmental factors that can be present in schizophrenia, about the understandable pushback there can be to examining these areas (whether from parents or from sufferers), about the uncertainty around these topics, and about the power of language and the names we give things. I also talk a bit about the mental issues I struggled with as a young man, which included severe anxiety, depression, and involved me dropping out of college mid-semester.

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Transcript

The following is a transcript of this interview. Note that this transcript is not perfect and has some typos and mistakes; if you are able to, the audio is probably the best way to consume this content.

Zach: Thanks so much for coming on, Nathan.

Nathan Filer: Thank you so much for having me, Zach.

Zach: You have an interesting body of work because your work includes an award-winning novel about someone struggling with so-called schizophrenia and you’ve also written a respected nonfiction work about mental illness. And that seems like a pretty rare combination, so I’m curious if you see your goals with both works as accomplishing some of the same things in terms of heightening awareness and empathy for mental struggles?

Nathan Filer: Yeah, it’s often easier as an author to declare what our goals were after the fact. [Nathan laughs] In the moment, I think I’m just trying to write a book that will be readable and that people will enjoy and engage with. But certainly, those two books that I have written the work of fiction, The Shock of the Fall and the subsequent nonfiction work The Heartland, I think they’re very much in conversation with each other and of course they share that common theme of trying to understand people going through a really difficult time, I guess. Fiction felt like the right way to explore some of those questions initially and then nonfiction did.

Zach: Maybe a good place to start also is for me to try to summarize what I see is some of your beliefs about psychosis and so-called schizophrenia, and maybe I’ll state that and then you can correct me where you see I’m stating it wrong.

Nathan Filer: Well, to be honest, Zach, I’m really not sure what my stance is, so I’d love for you to tell me and then I’ll probably just agree. [Zach laughs] If you make me sound sane, reasonable, and erudite, I’m going to agree.

Zach: Sure. One thing I like about you, before I get to that, I like that you come from a very uncertain point of view and I think a lot of these conversations can sound very certain and confident, but I think that the power of your work is talking about the lack of certainty, the doubt we should have about many of these areas. So, I’ll try to summarize this and see what you think. I think you believe that while there may be various genetic or biological factors that make people more likely to enter states of psychosis or so-called schizophrenia, that many of these experiences are understandable ways that a human mind can respond to various kinds of trauma or stress. And while most people who study these areas believe that there is some combination of nature and nurture at work, you believe that we as a society and those in the psychiatry sector tend to focus too much on the biological factors instead of the environmental and human factors, and we are too certain about our very fallible human made categories and believe that these things have negative effects in terms of our ability to help people. Is that a pretty good summary of your thoughts on that area?

Nathan Filer: I’d say yes. Yeah, I think that’s a wrap. I think we’ve got a podcast. [Zach and Nathan laugh]

Zach: Okay, nice talking to you. [laughs] Bye.

Nathan Filer: Yeah, I think that is broadly true and fair. I think ideas and philosophies go in and out of fashion in psychiatry. I mean, I suppose they do in all aspects of medicine to a degree, but it feels especially so in psychiatry where those current decisions or orthodoxies aren’t necessarily led by the science. They can be, I think, by politics a lot as well actually. And so, I think it’s fair what you say there in summarizing my position as being that modern psychiatry is a little bit too focused on what we might call the biomedical model and it’s not paid enough attention in recent years to psychological and environmental. But that is always in shift, it’s always changing, the pendulum swings all the time and we can talk a little bit about why that is and why we are where we are right now, but it’s arguably a little bit too biomedical. And I think that is probably more so in the states where you are than where I am in the UK, actually.

Zach: Yeah. And one thing that’s a bit unclear to me in this area is how much pushback there is against these ideas of talking about the environmental factors and stress as causes because obviously there are many experts who are on the same page as you and you quote some of them in your book, but it’s not clear to me how much pushback there is. For example, are there people in the psychiatry world who would read your book and say you are way off base in focusing on these aspects? Are there people who say schizophrenia is all or mostly a physical malady and it’s wrong to talk about these environmental factors?

Nathan Filer: Yeah. Well, I mean it was the dominant view for probably the best part of the century that schizophrenia was a deteriorating brain disease and I think that’s been pretty fundamentally undermines by the evidence actually. But of course, there are people who would occupy that position and consider these things to be entirely biological and certainly there are people in the other end on the radical critical psychiatry and to perhaps discount the role of our biology or genetics too much completely. I think they are pretty extreme positions and it may just be something of a symptom of our times as these people who hold these more extreme positions often have quite loud voices and maybe we see them on social media or what have you. So, I think a lot of that debate from those two extreme ends is loud, but probably there are loads of people occupying those positions. I think most people do accept and appreciate that when we’re talking about mental illness and we’ll get into [Nathan laughs] what that means in a minute because even that’s controversial, but when we’re talking about this thing generally understood to be mental illness, we’re talking about a kind of distress that probably has its causes both in the biological and the social realms. But we need to be, I think like we need to be careful straight away really and when talking about mental health I think it’s really important that we take a moment to always define some of our terms and make sure that we are talking about the same thing and I think that’s especially so when talking about something as contentious and potentially loaded and upsetting for people as this idea of causes. You mentioned in your when talking about my position, I try and hold on to a position of uncertainty rather than dogmatic declaring something as fact and that’s really important with causes because the science is not at the point where any professional of any stripes can say to an individual what caused them to develop a mental illness or become distressed and those kinds of ways. All we can do really is look at trends, we can look at big trends from big cohorts of people and from that we see not causes but significant correlation and it’s from those correlations that we can be I think pretty certain that there’s a major environmental component to this. That is so to add to probably complicate the picture a bit more, this is partly an issue of professional guilds and what area of healthcare you work in and that you’ve trained in. So, I think there has been in recent years a bit of a, yeah, maybe a bit of a power struggle, a little bit of a tussle I think actually between psychiatry as a medical discipline of psychiatry and psychology which I think too many people maybe assume that one in the same thing, but they are subtly different disciplines actually and tend to acknowledge some of the points made by the other discipline but emphasize their own position.

Zach: And that’s what’s great about your book is the focus on the uncertainty, the focus on the careful language because the language really matters and you talk about that in your book and we’ll talk about that a little bit later, but I’ll segue into a little bit of the controversial area. So, it’s been shown that childhood stresses of various sorts whether that’s sexual assault, or the death of a family member, or being a refugee, or an immigrant, those kinds of stresses increase the chances of having psychotic or schizophrenic experiences and that aspect seems understood and respected even for experts in this area who believe it’s mostly genetic or biological. But then it follows that-

Nathan Filer: And intuitively makes sense, doesn’t it? I think, I mean, for it to be controversial, but I think most people would say, “Well, sure, having horrendous things go on in your life is going to impact on your mental health.” I think that intuitively makes sense, doesn’t it?

Zach: I think the controversial part of it comes to be if we acknowledge that that is true, then it follows that there are other childhood factors that can cause stress like the neglect of parents, the mistreatment of children in ways that don’t rise to the level of abuse, just ways of interacting with children. And I think that’s where the controversial areas seem to arise because parents understandably, don’t want to be told their behavior may play a role in such things or even if there’s no judgment involved, they don’t want to feel that perception of judgment. And you talk about that in your book about the pushback of talking about those kinds of ideas and how the history of that played out because there’s definitely examples where that idea was done in a very irresponsible manner like talking about the idea of the schizophrenogenic mother idea. And can you talk a little bit about that history of that pushback?

Nathan Filer: Sure, yeah, because it is really important and it probably partly explains, possibly more than partly, it significantly explains why we are where we are at the moment with our thinking. So, as I say, I mean, ideas go in and out of fashion in psychiatry as they do in other medical disciplines. But for a long time, psychiatry was really all about that psychological way of thinking of very enamored of the Freudian way of thinking if we look back to the middle of the last century, so between the end of the Second World War in the 1970s, psychiatry was very much about psychotherapy and very much about the role of the family in your mental health. And it was during that period that that invented, as you say, this very bafflingly Freudian and transparently misogynistic notion of the schizophrenogenic mother. And really, mothers could do no right here, you know? They either drove their children to madness by caring for them too much, or not caring for them enough, or caring for them in the wrong ways. And understandably, families didn’t like that, of course, they didn’t and they formed, and it is especially part of the history in of American psychiatry because it was really there that these powerful lobbying groups formed to push back against that. And there were a few other factors then that came together creating a bit of a perfect storm really. So, there were these families going, “No, we don’t really like to being blamed for this. Actually, we’re doing our best.” And then there were these new psychiatric drugs coming on the market from the 1950s, anti-psychotic drugs and so on. And of course, these drug companies had a vested interest in this other narrative around no, this is a biochemical imbalance and the best way to deal with it is using other chemicals. So, they started to fund these lobbying and campaign groups.

And then there was a third factor and I don’t know whether it possibly goes into a bit too much detail for your podcast, but you’d be the judge of that, of course, but psychiatry also in the 1970s was in a bit of a embarrassed position of a few studies had come out that were demonstrating that it really wasn’t very good at diagnostics that was very poor reliability to psychiatrists who’d seen the same patient, just sometimes mere moments apart, would arrive at different diagnoses. There was the famous or infamous depending on your position, rose on hand experiments and you may be familiar with that. So, this was this researcher who got himself deliberately incarcerated in mental health wards along with his fellow researchers claiming to have some psychotic symptoms. But the moment they were accepted on the ward, they no longer said they had any of those symptoms. They acted completely sane for want of a better word and they were all kept in hospital for a really long time and couldn’t get out, yeah. So, this idea of being so sane and being in the same place and probably around this time as well there’s one fellow who the cuckoo’s nest came out. There was a lot of stuff going on and psychiatry was in a really embarrassed position. And the way it tried to deal with this poor reliability problem, poor diagnosis problem was to create much clearer diagnostic rules. It categorized mental distress in ways that had never really been done before, certainly not to the same extent and it led to this a document a very famous document in the history of psychiatry called the Diagnostic and Statistical Manual Volume Three. There have been a couple of other versions of version three sorry, they’ve been a couple of other versions before but one that came out in I think 1980 was the one that really changed everything and started to say no these mental disorders can be categorized and we will arrive at a diagnosis, only one patient shows these exact symptoms for this exact amount of time and started to make it look unfair or a lot more scientific.

So, all of these things came together, the DSM, the categorization, the family groups, the drug companies and it came together and it pushed that pendulum so far in the other direction to the point that we really stopped talking at all about this. There’s a shameful sort of hung over perhaps of that schizophrenogenic mother as well so that have been completely discredited and so we’ve just stopped talking about environmental causes at all and that’s the position now that we’re trying to come back to from around the 1980s.

Zach: And as you point out in your book too another factor in this too is just the fact that trying to examine the environmental causes would require so much effort and it’s much easier to think about treating it purely biologically just from resources and finance because even theoretically, if you believe that someone suffering from so-called schizophrenia could benefit from long-term talk therapy and such, that’s a huge expenditure of resources compared to giving medicine.

Nathan Filer: Yeah, that’s an interesting position. I mean, I think many listeners would still find it fairly extraordinary there are questions about your childhood so rarely asked for the most unwell people in hospitals so we know, I mean I can give you some gut-wrenching statistics really from the UK, we know that one of our charities institutions over here that looks at cruelty to children, the NSPCC, we know that about one in 20 children suffer abuse in childhood. And I mean that alone is just horrendous to think about, isn’t it? That’s more than one child in every classroom. And we know that between half and three quarters of psychiatric inpatients have suffered childhood abuse and yet the majority of psychiatric inpatients are never asked about that and the group that are least likely to be asked are people with those more devastating psychotic disorders such as schizophrenia and that might impart be as I say part of that just that horrible shameful hangover from the schizophrenogenic mother that psychiatry is just failing like that some territory that they don’t want to go there.

Zach: Right, yeah. And it’s understandable even without that history, I mean it’s understandable in the sense that there is naturally pushback against, it makes sense that parents don’t want to examine those aspects sometimes because it’s tough feeling like there’s aspects of the environment you’ve created for a child playing a role in this stuff, so it doesn’t make sense even just at that level that there are these pushbacks. And I want to get your take on this because it seems to me a big part of trying to make progress in this area is the power of language because in order to talk about these things and to make progress on these factors, you would have to talk about these things in a way that doesn’t communicate responsibility blame, so there has to be a way of talking about it in terms of like look there are environmental factors and if these theoretically played a role in your child’s of how they developed it, it doesn’t mean it’s your fault because at the end of the day, we’re very complex creatures and being human is stressful and we all have our ways of coping with the world and we all just face so many challenges so I’m talking about in these more empathetic ways.

Nathan Filer: Yeah. No, I hear you and I think you’re exactly right. We need to be able to have those as non-judgmental conversations. And yeah, that’s difficult because people in those positions, if you’ve got children and your children or teenage children or whatever, and someone you love is becoming really, really poorly, you’re going to be in a just a heightened difficult state anyway, aren’t you? So, I mean, it might not [Nathan laughs] that might not be the time to have those conversations. And really, what we’ve got to look at is, how do we move forward with this? How do we help? How do we live with this? But you’re right that it doesn’t need to be or the evidence seems to suggest that it doesn’t need to necessarily be the extreme childhood trauma abuse that we might all intuitively feel, of course, that could lead to poor mental health, it can be really surprising things. So apparently, I think there’s a couple of studies that have shown that even something as seemingly innocuous as moving school a couple of times in adolescence can double your chances of having psychosis or schizophrenia. We need to be careful then when we say because you say double your chances and that sounds absolutely huge. But of course, all that really does. It potentially increases it from 1% to 2% chance so you’re still not saying that if you move school, you’re definitely going to get unwell, but-

Zach: It’s difficult to talk about because if they can feel judgmental even if the intent is not judgmental, and one thing that stands out to me is it seems like there’s power to talking about the chance element of these things because theoretically, somebody who develops so-called schizophrenia in a normal seeming household, maybe a different person in that exact same situation wouldn’t develop schizophrenia, it means that there’s chance elements here and there’s ways of being, there’s ways that the environment can affect us, there’s ways that our genetics can affect us that lead to these things and it doesn’t mean anyone’s to blame necessarily, but talking about it in that way might allow us to examine the factors and talk about it without it being perceived as judgmental, basically. And it’s all about language really.

Nathan Filer: You’re exactly right. And all that point of two people in the same household might go into very different directions even though stance ostensibly have the same upbringing. I mean, I suppose that’s something to wrestle with there as well. But yeah, it is worth pointing out that though we know that there’s very strong correlation with adverse childhood events, is still the case that the majority of the people who’ve been with very difficult childhoods do not go on to become mentally unwell or if they do to go on to have the same symptoms and arrive with the same diagnosis. And this is, I think, where our genetics and so on really comes into it. So what setting is someone in one direction or another, I think that will be influenced by the risk factors or protective factors of our genes.

Zach: Right, I think for a lot of these things, it’s recognizing the role of basically chaotic, all these chaotic complex factors interacting. For example, my own mental struggles and when I dropped out of college involved me smoking a lot of weed and that’s been shown to be associated with panic and anxiety and depersonalization and then the so-called schizophrenia and psychosis stuff to it, there’s a link there. But my point is just that maybe I wouldn’t have had those problems, I wouldn’t have gone down that path if a few things hadn’t aligned, if I hadn’t smoked weed, for example, or whatever. But basically, just acknowledging that there can be many factors. And just because some things happen, doesn’t mean they necessarily had to happen that way, but it still means we can examine the factors and how they played a role.

Nathan Filer: Sure, yeah. And we can’t I think for things as complex as the human mind and certainly, this psychiatric labels like schizophrenia which describes so many thoughts, feelings and behaviors, such a range of symptoms, I don’t think we can, we just cannot talk about single causes. You can’t with your genes either, as I use that term, we are talking about risk factors or protective factors, not a clear causal link. I think that the cannabis one is really interesting because yeah, there certainly is strong correlation there between certain sorts of cannabis and psychosis so detachment from reality. And there have been some pretty compelling studies around that one study, a robust study arriving at the conclusion that the number of first presentation psychosis in South London can be reduced by about 25% if this particular type of cannabis, we call it skunk, I don’t know whether you call it skunk there or another term, but this high concentration THC cannabis were removed, that would reduce [Nathan laughs] our first presentation psychosis by really quite a lot. But there’s an interesting other data that came out of that which is it seems that there’s other more natural strains of cannabis. So, these kinds that have not been genetically modified to increase this THC ingredient. These are more natural strains which have more of something called CBD cannabinoidiol, yeah, which is very fashionable now in health food shops and stuff, isn’t it? It’s cannabinoidiol, it seems that has an anti-psychotic protective factor.

Zach: Right, it has a mediating influence on the THC or something, yeah.

Nathan Filer: It seems to be. That’s leading to some research now as to whether CBD could have anti-psychotic properties in its own line, so the picture is never simple.

Zach: The weed aspect too, I think, to the things you talk about in your book and the things I’ve thought about in my life with my experiences is our struggles can have an underlying logical cause and it’s possible for these various forms of stress whether that’s like a weed aided semi psychotic experiences or whether that’s trauma of other sorts, these things can lead us to experiences that make a certain sense. For example, when I was having my extreme anxiety and dropped out of college and smoking a lot of weed, the marijuana led me to some dark mental pathways but in hindsight, those pathways made a lot of sense because I felt very isolated and a lot of my struggles had a narrative, they could be put in a narrative framework of I felt very isolated and an existential level isolation is a very stressful thing. And that’s some of the stuff you talk about in your book too trying to put these because it can seem from the outside like, oh, that’s a biological thing. That’s something that someone very different from me is experiencing. But I think at the end of the day, we all have the capacity to go down these mental pathways, environment given the right experience and depending on our upbringing and such, too. But yeah, I think there’s a lot to examining the logical reasons behind the reason people are going down these dark pathways.

Nathan Filer: Yeah, I couldn’t agree more. And I think there’s a story in there, isn’t there? People are living, we live our life and we’re living a story and I think that within some of those maybe unusual thoughts that we have on like becoming what some people would call mentally ill or contained within that within a delusion, for example, inherent to that is a narrative, is a story. The brain is telling itself a story in order to try and make sense of uncertainty, isn’t it? And I think this is one of the reasons why I’m drawn to that way of thinking about mental health rather than more binary, well, this is just madness so we just need to get rid of the madness and just say delusion is something that are either present or absent and we should get rid of them. I’m much more interested in the content. And I don’t know whether that is a part as well, I’m a storyteller, this is the area that I work in so of course, I am, but I think we all should be and certainly I think that our mental health professional should be interested in people “psychotic thoughts” as well as unpsychotic ones because they’re all part of that person’s story, aren’t they?

Zach: Yeah. And getting to that narrative aspect, I mean, that overlap between fiction and nonfiction. I’ve often thought there’s so much to our self-narratives, our narratives of the world, that are operating under the surface of our consciousness. So-called “healthy” ways of navigating the world represent the culmination of all these sorts of unexamined, unknown narratives about our own lives, about the world. As a pretty functional person myself, at this moment in time anyway, I have various narratives about myself. Like: I’m capable of future enjoyment of life. I am a functional entity. Or other people are mostly similar to myself and can be understood by me. Or even: other people are just as real as me. And all of these unspoken aspects of our self-narrative, of our world view, we take those for granted mostly, because they’re things that were built by our childhood experiences and that we don’t really question or ever think about or don’t know how to confront consciously. But I think what happens with people with mental struggles is that those things are not a given. In fact, they can malfunction in various ways. And there’s probably common experiences about life that lead people’s self-narratives or world narratives to malfunction in pretty common ways and in various categories of ways. But I’m curious what you think about those ideas? I haven’t seen much in that area and I’m curious if you have seen resources that talk about those unspoken narratives.

Nathan Filer: Well, I was just fascinated to hear you say all of that, really. I have to say I think you articulated it so well and that makes me want to come back and listen to this podcast just to hear you say that again. [Nathan and Zach laugh] So yeah, I mean, in some ways, I suppose, your understanding of these things; your guess is as good as mine, but it’s extremely a complex area, isn’t it? But in terms of like, what we hold as certain and what we don’t question and how that makes us mentally robust, I think we can turn our attention again to some of those children who perhaps had considerably less certainty in childhood. When you’re not even sure that the people that protect you are going to look after you, of course, that’s going to introduce a lot more noise into the system, isn’t it, of what we can actually rely on and what we’re not so sure of. But yeah, I mean, I’m not sure I’ve gotten much more to say than that, Zach. I think you said it very well by yourself.

Zach: Yeah, those are the things that really interest me because I’ve spent a good amount of time thinking about my own experiences and reading a lot on this subject. And I think it’s interesting just thinking about the unexamined assumptions that we make about the world as functioning mentally healthy people, these unexamined under the hood assumptions. And for example, there’s different ways you can have stress in childhood. Like if you’re neglected, if no one pays attention to you, then that impacts your ability to be an independent entity, you’re lacking in your ability to define yourself as a separate person so that leads to a slew of problems in itself, too. But yeah, definitely a whole interesting subject that’s-

Nathan Filer: What we still need to be careful to do, of course, is even if something like that, if the narrative of that feels very neat, we need to be careful not to arrive at that assumption. So therefore, that explains everything because then we’re falling into the same trap that others have done.

Zach: Exactly. You can examine these factors while still saying like, “Well, we don’t know everything.” And there’s obviously also big genetic and biological components to this, too. I think what the strength of examining the things that you examine your book is not to say that they’re the only reason, it’s to say if we’re going to solve this, if we’re going to help solve it, then maybe we need to think about the way that the environment or someone’s way of being is putting stress on someone even if it’s not the only cause or far from the only cause, yeah.

Nathan Filer: Also, just to pick up a bit more on your point there that those real questioning those really big existential ideas which seems like it feed into some of your experience. I certainly can speak for whether you see more of that thinking in people who become psychotically unwell, I don’t know, but certainly, from my experience of working in mental health and being working in that area, something that anecdotally I think I’ve seen is that lots of people who become very unwell in that way are very sensitive people. And I mean by that like sensitive to the world around them, sensitive to interpersonal relationships, they feel things very deeply, they pick up on small signals from people, and it’s important then to stress that, of course, being a sensitive person, that can be a really good thing, can’t it? I mean, you would expect, wouldn’t you, that somebody you would hope that a doctor or a nurse working in mental health would be a sensitive person. So, what leads you then into becoming an unwell person well, that’s going to be circumstances. Yeah.

Zach: Yeah, then there’s some theories, biological theories of so-called schizophrenia that talk about sensory gating malfunctions like people who are prone to that show more activation when presented with various sensory input. I don’t know what the science is on that these days, but I know that there was something that they looked in to when they-

Nathan Filer: Sure. And of course, for every study that tells you one thing, there’s another study that [Nathan laughs] tells you something else. And it is, I mean, it is a bit of a problem as well. I think within the neuroscience, I mean, I think the genetics like that’s a pretty robust position really and that these genetic studies often have like huge cohorts of people, hundreds of thousands of people. You compare that to neuroscience where they might have eight students and it’s not a convenient sample from the university that they put in a fMRI machine and then wonder why there’s poor replicability in these studies. I think, partly there’s just problems that are with the study design. And I think that this thing may be very attractive to people that the answers are there to be found by the neuroscientists, they’re really clever and they understand the brain and so we don’t need to worry about it because they’re on top of it. But what we’re coming to accept now and the scientists coming to accept is they’re really not all over it. [Nathan laughs] There’s a lot of questions and a lot of uncertainty still.

Zach: Right, exactly. Yeah. Yeah, I wanted to take a moment to plug a book that I found was very wise and meaningful in these areas. So, besides Nathan’s book which… By the way, what’s the name of your book? I should mention that here.

Nathan Filer: Yeah, yeah. So, I’ve got a couple of course. So, the hardback of it was The Heartland. The paperback is This Book Will Change Your Mind About Mental Health. My novel is The Shock of the Fall. But I don’t know Zach how available any of these books are in States. I did an event for a charity in the States just the other week and that issue came up then. But maybe some of your listeners would like to listen to my podcast, so maybe you could point them in the direction of that.

Zach: Yeah, your books are definitely on Amazon. Your novel had another name though, didn’t it?

Nathan Filer: Yeah, it’s had a couple of… [Nathan and Zach laugh] All my books get renamed.

Zach: Yeah, I was going to say you have a lot of names for your books and I’m confused. [Nathan and Zach laugh]

Nathan Filer: It looks like I’ve got about four books. And actually, The Shock of the Fall was published in about 30 countries and they each came up with a different name. So, it looks like I’ve done loads.

Zach: It’s a good cover, good disguise. [Nathan laughs] Yeah, it looks impressive.

Nathan Filer: Yeah, yeah. But the podcast when it goes out hopefully in the summer will be called Why Do I Feel. That’s a podcast looking at human emotions and stories.

Zach: Looking forward to that. But yeah, and getting back to the, I was going to mention Irvin Yalom’s book which is Existential Psychotherapy which is just a fantastic book and it talks about existential psychology ideas, he didn’t come up with it, but the idea behind that field of thinking is that there’s these basic facts about our existence as thinking beings that are big contributors to our mental anxieties and stresses, for example, the fact that we have to deal with fear of death is one big stress, the fact that we all at some level deal with fears of isolation because we’re both separate from other people alone in our minds and yet we want to commune with others to make contact and so there’s that tension between isolation and merging with others. But anyway, just a great book, yeah.

Nathan Filer: Do you remember that when we first met on the Twitter? You recommended that book to me and I bought it. I hung on your every word and I bought that book and it arrived, and then I saw the size of it. [Zach laughs] I could barely pick it up. I was like, “Do you know what? I’m going to read that one later.”

Zach: My wife took a year to read it, [Nathan laughs] yeah, but she loved it I’ll say. Also, my wife read it and she agreed with me that it was like getting months or years of therapy like I don’t want to overstate it, but I think the ideas are that powerful and I also think I’m shocked that there’s not a more, I’ve looked around and I can’t find a more accessible way to I mean, I think for anybody, I thought about it myself trying to put these ideas in a more accessible format because I just think the ideas are so powerful and I’ve even reached out to Dr. Yalom and he was, unfortunately, when I talked to him about having him on the podcast, his wife had just passed away so it was bad timing. But I just think these ideas are so powerful and I think that you would really enjoy them because they deal with things that you can relate to that you talk about in your book the fact that these are the struggles that people are going through are very understandable in a way or at least they can be put in understandable narratives. Not to say that it explains every element of them, but I think even for my own mental struggles, I can very much relate to the fact that when I was a kid or from the outside, my struggles might have look like, “Oh, you’re going crazy. These ideas don’t make any sense.” But thinking about it more as I have over the years, they actually do make a lot of sense. They make sense in the sense that they were about fears of isolation, they were about fears of meaningless, they were about fears of me not being able to be a functioning person in the world, and these are all understandable aspects of being human. I was just confronted with them head on whether that was through factors in my upbringing, whether that was me smoking a lot of weed, whatever it was, I had to face these fears in some way, these various stresses. And I think what happens to a lot of people is that they get in those situations and it seems like they’re going crazy because we don’t talk about these problems as a society when I think we should be. These are things that everybody should be talking about like the fact that it’s very weird to be a human and to deal with this existence, there’s a lot of stressful things about this existence that we tend to take for granted and not talk about. But yeah, I just think you’d love the book basically.

Nathan Filer: Well, I think you’re exactly right and it raises some interesting questions as well, doesn’t it, about maybe what we mean by recovery and again, that you can go into different models because you think of this medical model of recovery as a complete remission of what you might call clinical symptoms. But for some people, of course, that doesn’t wash when you’ve had such an extraordinary change in your mental state and been forced to confront some of these ideas and things about yourself, well then recovery might not be a return to where you were before. It might be as you’re describing a sort of attribution of meaning to those things and understanding what that meant and growing from that.

Zach: And it’s also tough to talk about these things too because we were talking about parents feeling judged, I mean, someone going through so-called schizophrenia psychosis can feel judged by even bringing up the idea that these things might be understood, there’s that kind of pushback, too. For example, I have a friend that I talked to recently and she had had a psychotic break in the middle of her life and we talked about the things that led up to that and it can be perceived as judgmental and that can be demeaning in itself to say, like, oh, examine why this happened to you, and so, there is that pushback, too. So, it gets back to the way we talk about these things because we have to find a way to talk about them in ways that are not judgmental because the fact that I got over whatever thing, not to compare my stuff to other people’s stuff because mine was not that extreme, everyone’s different, but the fact that I maybe had better results than other people who went through similar things, it’s not a reflection on my strength or my abilities, it’s just a reflection of chaotic things that were happening and that maybe my genetics were slightly different or maybe I had some slightly better environmental stuff that helped me through. It’s not about judgment or assigning responsibility. So, I think it comes back to the careful language of talking about these things often are not in our control, but it’s tough to talk about, yeah.

Nathan Filer: Oh, I agree. My silence is a poignant agree.

Zach: Sorry. Yeah, [Nathan laughs] I get nervous on the podcast. I think I lose people.

Nathan Filer: No, wait, you didn’t lose me at all. I completely concur.

Zach: I do have one thing I was just curious about was writing your novel and then writing your nonfiction work, did anyone scoff at you because you were first a novelist? I can imagine that happening, but I’m curious if people were like, oh, he’s a novelist. He’s looking for clean narratives or something like that.

Nathan Filer: If people have made that criticism, and of course, they may have done, they’ve not made it directly to me. [Zach laughs] So, I’ve been happy with the response and I think that most readers, including readers in the various professions, have seen that really am attempting here to just ask the questions, to listen to people’s stories, to not false my own opinion, but partly because I don’t have a very strong opinion about these things. I did enter the writing of that book very much as a student really rather than trying to be a teacher. Possibly where I’ve received a little bit more criticism or where people question my position was on the novel actually and I think that’s because I worked in mental health, I was a mental health nurse, but I was writing that novel from the position of a mental health service user, a patient, somebody who was really very unwell in a way that I had not been. And I think that does raise interesting and relevant questions more so today probably than when I published it around appropriation and who has the right to write what. I mean, my personal position with that was in that novel, I wasn’t trying to tell everybody’s story, I was telling one fictional character story. It drew a lot actually from my own childhood as well. But of course, I had to do a lot of imagining with that. And I think that’s what novelists should do. I think that was part of an exercise in empathy to imagine ourself into someone else’s experience and spend time with that as we ask our readers to do by reading the book, but of course, we do that as an author as well. And I think I’ve made that point really that I think mental healthcare and writing a novel and reading a novel all share that one thing in common that to do them well they require a good deal of empathy. But certainly, I think for some readers and maybe readers who maybe had a very challenging time with psychiatry perhaps they’ve been very unhappy with their experiences of psychiatric treatment and so on, I think for some of those people, the fact that I was a mental health nurse is always going to be problematic and of course, I respect that. Of course, I do.

Zach: Yeah, sometimes I think the benefit of art is that it’s educating us in empathy. If you had to give a practical quality to a lot of art, it is allowing us to see the world through other eyes in various ways. Even art that doesn’t seem like it’s giving you a lot of intellectual philosophy or intellectual point of view, it still often is giving you a different perspective on the world, which is related to empathy.

Nathan Filer: Absolutely. And I think that’s absolutely central to fiction.

Zach: That’s the connection there with both of your works there, yeah, is increasing empathy and I was-

Nathan Filer: And with the second that which is very much story land if I tell the stories of five individuals who live with or lived with or very close to a diagnosis of schizophrenia, that book is entirely led by those stories so they’re not case studies. They make up more than 50% of the book which is quite unusual in mental health nonfiction which would often be quite I think ideas led and then case studies would be included to illustrate those ideas, but it did feel important to me. Well, that just wasn’t the route that I took. I listened to the stories, told their stories as best I could which comes with a huge amount of responsibility. I mean [Nathan laughs] writing fiction is difficult for any number of reasons, [Zach laughs] but writing this kind of nonfiction came with a great burden of responsibility. I was being trusted with these people’s stories to hear them and to share them, but that was the process for me to be with those stories and then see where those stories lead in terms of exploring the ideas that came up from them.

Zach: Yeah, and it’s such a fraught area as you discuss in your book. And yeah, it’s a great book, I thought it was fantastic. It’s also great to hear that you didn’t get much pushback for the nonfiction book which is one of my things I was curious about was like how much pushback is there to these ideas and the fact that I looking for reviews of your book, I couldn’t find much in the way of criticism of it and the fact that you have multiple experts.

Nathan Filer: It’s because I sat so firmly on the fence, Zach. [Nathan laughs] If I had gone in one position or the other, I’m sure I would have got a lot more. [Nathan laughs]

Zach: But even just the fact that talking about the environmental factors as potential causes even just that discussion because I’ve been uncertain like how that is perceived and I think reading the experts quoted in your book and reading other resources and reading reviews of your book, I’ve gotten a better understanding that most experts on the subject whether psychiatry or psychology or are in the middle of somewhere where it’s like obviously there’s genetic biological factors and also obviously there are environmental factors which may seem obvious to people in that area, but I think is not that too obvious to people who might just read a handful of things. Yeah, so this has been great. Thanks so much for coming on. It’s been a real honor and I wish you luck with everything else you’re working on including the podcast.

Nathan Filer: Thank you so much. It’s been an absolute pleasure, thank you.

Zach: This has been an interview with Nathan Filer about so-called schizophrenia and about his book The Heartland: Finding and Losing Schizophrenia. You can follow Nathan on Twitter @nathanfiler. This has been the People Who Read People podcast with me, Zach Elwood. You can follow me on Twitter @apokerplayer. You can learn more about this podcast @readingpokertells.video. If you enjoy this podcast, please know that I make no money from it, in fact, it’s a pretty big expenditure of time and energy for me. So, if you want to do me a big favor, please share word of it on social media and give it a rating on iTunes. This is a labor of love for me, everybody’s got a podcast these days as you probably know and it’s pretty hard to gain listeners when you’re competing with the big podcasts that have so much advertising money behind them. This is not to complain. I love talking to all these interesting people and getting to ask questions that are otherwise hard for me to find answers for. Okay, thanks for listening.

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