Detecting Threat: A Review of ‘Suspicious Minds’

Woman Looking Through Venetian Blinds“Hippocrates is supposed to have said that it is so much more important to know what sort of patient has a disease than what sort of a disease a patient has […] it doesn’t follow that the best or only description of a psychotic illness is a biological one.” —Joel and Ian Gold, Suspicious Minds: How Culture Shapes Madness

What’s almost as scary or threatening as being watched or plotted against by someone? One answer is misperceiving a threat that you are being watched or plotted against by someone. Suspicious Minds: How Culture Shapes Madness (2014) deconstructs narrowly focused biological theories of psychosis and presents evidence for how one’s social experience shapes their pathological responses to stress.

Power siblings Joel Gold, MD, and Ian Gold, PhD, have produced an innovative and engaging book—with both academic rigor and candidly stylized writing—on a topic that is so frequently misunderstood. The clinical concepts are illuminated by exemplary case narratives. Malcom Gladwell’s storytelling prose that combines jargon-free language within complex sociological ideas is similar. Suspicious Minds deduces vast quantities of clinical knowledge and research findings—historic and current—paced by Joel Gold’s stories and interactions with people he formerly treated at Bellevue Hospital in New York. Many of these individuals experienced what Joel and Ian Gold would later refer to as “The Truman Show” delusion.

The grandiose and persecutory delusions experienced by these individuals revolved around the theme of the movie The Truman Show, starring Jim Carrey. The central delusional idea was that the individual was involuntarily being filmed and everyone in their life was an actor for their broadcasted reality television show. This seemingly novel delusion did not exist prior to the film’s conception in 1998. However, as the book explains, this form of delusion has been around since the dawn of time.

The content or details of a delusion are shaped by an individual’s cultural background. If a person is raised in China and experiences grandiose delusions, they might believe they are the disciple of Buddha. Likewise, a grandiose individual from Texas might believe they were a disciple of Jesus (if they were raised within a Christian context). Same form, different content. The book goes on to explain the 12 forms of delusions that remain constant across human cultures (e.g., persecutory, control, guilt, reference, etc.) with differences in prevalence as well as presentation distinctions across different cultural landscapes.

Suspicious Minds also explores the causes of psychosis through a psychosocial perspective. The book goes in-depth to illustrate how childhood adversity (physical and sexual abuse; early childhood loss; being bullied), urban environments, and immigration (i.e., discrimination and status) increase the likelihood of psychotic symptoms.

According to the authors, the consequence of biological explanations for mental health concerns has created an us-versus-other paradigm of care. Those individuals diagnosed with ostensible psychological issues become different from the norm when the emphasis is on physiological make-up and neurotransmitters. Suspicious Minds reframes “mental illness” as pervasive, as well as an ordinary part of our social reality. The book persistently illuminates the gray area between “normal” and “disorder” to the extent that the reader no longer makes the rudimentary comparison; “We all have psychotic and nonpsychotic parts of our mind” (p. 13). One assertion connected to the apparent dichotomy within mental health treatment is that the majority of practicing psychiatrists have never experienced a psychotic episode and they could potentially fear the “psychosis that lurks within us.” The assumption posits a difficulty for clinicians to identify and therefore empathize with clients experiencing psychotic symptoms.

At the heart of Suspicious Minds is a genuine attempt to understand the implicit meaning of extreme beliefs (or delusions) within the context of the individual’s social world. This is counter to mainstream psychiatry’s eradication of psychotic symptoms through medication. In listening to the totality of the client’s experience, “we foster the therapeutic alliance, and stronger alliances yield better therapeutic outcomes. The fact that delusions mean something to our patients is reason enough for them to mean something to us” (p. 228).

Joel Gold—a psychiatrist himself—offers a tactful and impartial critique based on the lack of psychiatric progress in the past 60 years. This includes the absence of biological markers for schizophrenia, little understanding for how antipsychotic medications work, the inadequacy of the Diagnostic and Statistical Manual (DSM) and the overall elusive nature of mental health disorders. He rests his case against psychiatry: “Like murder, it’s hard to prosecute a science of madness without the bodily evidence” (p. 51).

Suspicious Minds attacks reductionist views of mental issues that ignore the social world with literary venom. The strikes are balanced and interspersed throughout, which eventually disables the arguments. According to the authors, the future of psychiatry, or “aspirational psychiatry,” strives to be neuroscience for the perceived security of a more mature discipline. Their cunning agnosticism is refreshing for those parched from dry outdated theories: “Like all research programs, biological psychiatry is a bet. It’s not irrational to take that bet, but it is irrational to believe that it’s a sure thing” (p. 234).

This section solidified the subtle argument against a narrow biological explanation of psychosis. Humans use a cognitive system to notify social threats and inform defenses. This solidification of the book’s themes is a radical deviation from dated psychiatric rhetoric on psychosis. Unfortunately, this section spanned less than two pages and left me feeling similar to when an otherwise great movie ends abruptly. I look forward to the sequel.

The Suspicion System is their inventive theory for the manifestation of delusions. This is not a system found within those who are thought to be mentally disturbed or carry a diagnosis of schizophrenia. This is an inherent biological system shared by all of us humans.

The Suspicion System is their inventive theory for the manifestation of delusions. This is not a system found within those who are thought to be mentally disturbed or carry a diagnosis of schizophrenia. This is an inherent biological system shared by all of us humans. Those that are prone to psychotic symptoms produce errors in this system and these thoughts are not appropriately influenced by the “reflective system.” With heightened awareness of the status quo, the authors believe that “culture shapes madness” and that this notion “does not fit the particular spirit of the times” (p. 12)

Suspicious Minds caters to students and professionals from both academic and clinical reference points. The past and present reflections on individuals’ experiences juxtapose the themes of the text. The normalization of client symptoms is echoed throughout: “Their problems, while experienced in unusual ways, are not so different from our own.” Suspicious Minds has a place among intellectual book clubs, medical school libraries, and numerous places in between (e.g., social work and psychology curricula). The text includes graphs and pictures to supplement the narrative along with a thorough index, bibliography, and notes.

In a concise and scrupulous manner, Suspicious Minds tackles the interplay of stress and operations of the mind within the social world. The history and theory are objectively scrutinized to create a dynamically stimulating read. These ideas are enough to make the most indoctrinated psychiatrist a little suspicious.

© Copyright 2015 GoodTherapy.org. All rights reserved. Permission to publish granted by Andrew Archer, LICSW, therapist in Mankato, Minnesota

The preceding article was solely written by the author named above. Any views and opinions expressed are not necessarily shared by GoodTherapy.org. Questions or concerns about the preceding article can be directed to the author or posted as a comment below.

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  • James B

    James B

    April 22nd, 2015 at 1:27 PM

    Yeah I don’t know what would be worse. Actually knowing that there is someone who is following you or living with that threat of what you think but is not real at all.

  • Olin

    Olin

    April 22nd, 2015 at 3:25 PM

    I will admit that this is the first time that my own eyes have been opened to the possibility that there is more to psychoses then just nature. There is a part of this that can be created and nurtured if you will by the environment in which we are raised. I never have stopped to think that there is any other contributing actor than this illness other than just that’s the way that you are born. But it’s not all about only that. There are so many other factors that can come into play when you are dealing with someone who lives with this illness.

  • Harrison

    Harrison

    April 23rd, 2015 at 8:44 AM

    I think that my sister suffers from this- she is always convinced that there is someone out to get her.

  • Andrew Archer

    Andrew Archer

    April 23rd, 2015 at 12:50 PM

    Perceived threat tends to be just as damaging over the long run. It taxes the central nervous system, because of the constant over-activation or fear of threat. In my opinion, “psychosis” is an exaggerated form of what all humans experience (e.g., anxiety, fear, worry, dread etc.). The cause of our anxiety–and how we manage it–is culturally influenced and predicated on levels of trauma.

  • Jean

    Jean

    April 25th, 2015 at 11:51 AM

    Would it be too simplistic to believe that much of what ails us as adults, whether full blown mental illness or not, stems form so many of the experiences and things that happened to us over time and especially as we were children?
    the more I see and hear I understand so much more clearly how those childhood experiences that we have are so strong in creating the person that we become, and with that in mind it really is frightening just how much so many children have to endure and then the things that they must have to do to overcome many of them.

  • Andrew Archer

    Andrew Archer

    April 25th, 2015 at 6:46 PM

    Jean: I think yours is an extremely valid and often overlooked point. Our very first attachments (or the lack thereof), set the stage for how we manage the stress in the world, give/receive love and how we fundamentally come to understand relationships. Our brains change based on social interaction/nurturing.

    We are social beings, in a social world. The resilient ability to stay afloat has less to do with how many waves hit us, but rather the number of resources we have access to. Fortunately, the plasticity of our brain allows us to learn ways to develop these resources. In “Suspicious Minds” they describe a study (that I am butchering here) with rats and how pups who were reared by high-licking mothers grew up to be less stressed as adults than those raised by low-licking mothers. However, you can switch the pups who had low-licking mothers and place them with the more nurturing mother and the effects are changed.

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