The British Psychological Society (BPS) has stated that ‘clients and the general public are negatively affected by the continued and continuous medicalisation of their natural and normal responses to their experiences; responses which undoubtedly have distressing consequences … but which do not reflect illnesses so much as normal individual variation… This misses the relational context of problems and the undeniable social causation of many such problems’. The BPS Division of Clinical Psychology (DCP) has explicitly criticised the current systems of psychiatric diagnosis such as DSM–5 and ICD–10. It has suggested that we need ‘a paradigm shift in relation to the experiences that these diagnoses refer to, towards a conceptual system not based on a ‘disease’ model’.
(From Understanding Psychosis and Schizophrenia published by the BPS – page 28)
What has this to do with EMS?
EMS stands for Everybody Means Something. My work as a clinical psychologist was with people who were experiencing what our culture calls a psychosis. When I started work in the NHS most people felt that these experiences were meaningless. I disagreed. I found myself using those three words as a kind of mantra to remind myself of my conviction. It was a no-brainer to use them as the title for my blog.
Various experiences reinforced my scepticism about the medical model with its prevailing assumption that such experiences are largely biologically determined. I came increasingly to believe it was significantly incomplete, possibly seriously flawed.
Before I move onto psychosis in particular there is a story from my earlier experiences in clinical psychology, which served to reinforce my scepticism and which clearly illustrates how this default assumption can operate as a potentially damaging blinker.
Laura had been given a diagnosis of endogenous depression, ie one that was not explicable in terms of her life situation. She used to believe that her parents were more or less perfect. The work we were doing became very stuck and seemed to be going nowhere.
We had plateaued on bleak and distressing terrain, more tolerable than her previous habitat but too unwelcoming to live on comfortably for the rest of her life, and yet with no detectable path towards more hospitable ground.
Frustrated by the protracted lack of movement, I began to see discharge as a very attractive option. I discussed this with my peer supervision group. We decided that I should continue with the processes of exploration but make sure that I did not continue my habit of stepping in relatively early to rescue her in sessions from her frequent experiences of intense distress. I continued to see her, having agreed with Laura that I would allow her to sink right into the “heart of darkness” in order to explore it more fully and understand it more clearly. The very next session, when we first put this plan into action, after I had left her alone in her silence for something like half an hour, Laura came to a powerful realisation at the heart of a very intense darkness. She said: “I think my mother threw me away even before I was born.”
This paved the way for deeper and more fruitful explorations of the reality of her childhood, the nature of which I will come back to later in this sequence of posts.
Since I started this blog almost eight years ago now, my interests have ranged widely across many topics, and psychosis has only featured in a relatively small number of posts. Decluttering has triggered me back into my fascination with ‘psychosis’ as the recent posts on out-of-the-ordinary-experiences illustrates.
When I trawled through my backlog of journals I found no other article dealing with that topic. On the web as a whole my most important find is a book edited by Isabel Clarke titled Spirituality & Psychosis which touches on it in places. I will need to buy a copy of that and read it carefully before I can even begin to comment, but the Chapter headings and their authors on the Google version certainly whetted my appetite. How could I resist a book dealing with two of my favourite obessions?
I have found a few other titles on related themes via the British Psychological Society website and it is on three key papers from among those that I wish to focus now.
We’re on a Continuum
Bethany L. Leonhardt et al, right from the beginning of their article arguing that psychosis is understandable as a human experience (page 36), ask us to regard the symptoms of psychosis ‘as part an active meaning-making process, regardless of whether or not that meaning is adaptive.’
They explore how the use of literature, particularly novels, can help those who work with people who are having psychotic experiences tune into their predicament more empathetically. As a result of their use of this method, they offer some interesting perspectives.
For example, (page 47) they ‘suggest that exposure to novels and related literary genres may help prevent therapists from surrendering to the view that psychosis is not understandable as anything other than a collection of abstract symptoms or from infantilizing patients by offering of paternalistic direction or protection from life demands.’
As we have seen in the previous sequence on out-of-the-ordinary experiences (OOEs), the attitudes of others has a powerful effect upon how well or how badly a person is able to deal with their bizarre and often frightening experiences. An assumption that what people have experienced is meaningless is at best patronising and at worst confrontational and undermining. One of my own early observations was that most of the clients I saw were expecting me to dismiss everything they were saying, either by ignoring it, refusing to discuss it in any way that resembles their own terms or by frankly rubbishing and pathologising it. They seemed both surprised and relieved when I did my best to engage with them in an attempt to understand it, which is of course not the same as endorsing everything they told me as objectively true. It was though a way of taking what they said seriously and respectfully. For a fuller explanation of my approach click on the posts listed below.
On the occasions where I was unable to sustain this at a sufficiently high level I risked damaging the relationship. I can remember one such occasion. A client was convinced that the devil was plotting against him and kept bringing forward the evidence he thought proved it. My approach clearly aroused his suspicions as to my beliefs about the devil, and he repeatedly pushed me to disclose what my own beliefs were. After several repetitions of this over a number of sessions I concluded that my holding back was blocking further progress. I made the mistake of letting him know that I thought that the devil had no objective existence but was a metaphor to explain evil. He discontinued therapy at that point.
In retrospect I realised that I could have given a more authentic response from a deeper level of my thinking and stated that, while for practical purposes in my own life I did not operate on the assumption that the devil existed, I had to admit that there was no way I could dogmatically state or absolutely prove that he didn’t: agnosticism on that point would have been a better and perhaps more honest answer. Though I may have failed this client, I learnt something very helpful for future interactions.
Equally importantly, Leonhardt et (ibid) ‘acknowledge that our views largely draw on the idea that psychosis can be understood as existing along the continuum of human experience. Our use of novels and related literary genres indeed seems predicated on the idea that individuals experiencing psychosis are not inherently different from anyone else, and that some of the strangest and most bewildering experiences can be made sense of while reading literature and engaging in other reflective activities.’
This ability to find ways of empathically recognising that psychosis is a point on a dimension we all share in some way is a key requirement of a true understanding of what psychosis is in my view.
Next time I will explore the role of trauma in the formation of psychosis.
An Approach to Psychosis (1/6): Mind-Work & Trust
An Approach to Psychosis (2/6): Surfaces & Depths
An Approach to Psychosis (3/6): Complicating Factors
An Approach to Psychosis (4/6): The Mind-Work Process (a)
An Approach to Psychosis (5/6): The Mind-Work Process (b)
An Approach to Psychosis (6/6): Fitting It All Together
 The article was published in the American Journal of Psychotherapy, Vol. 69, No. 1, 2015.