There is now overwhelming evidence that psychological approaches can be very helpful for people who experience psychosis. However, there remains a wide variation in what is available in different places. Even the most successful approaches, such as early intervention and family work, are often not available, and nine out of ten of those who could benefit have no access to CBT. There is a pressing need for all services to come up to the standard of the best and to offer people genuine choices. Perhaps most importantly, we need a culture change in services such that the psychological understanding described in this report informs every conversation and every decision.
(From Understanding Psychosis and Schizophrenia published by the British Psychological Society – page 93)
At the end of the previous post in this sequence, I shared an example from my own experience that confirms the idea that psychosis might be a way of protecting oneself from what one experiences as even greater pain and terror. Here is another example before we move forward.
My experience in 1993 with another client, Ian, who did not want to be shown in full in the video we made at the time, pointed in this same direction (see a previous sequence of posts for a more detailed account). He was an ex-soldier whose traumatic experiences in the army, riding on the back of a difficult childhood and a recent intense and distressing relationship with a woman who had a serious drink problem, had led to a deeply disturbing psychotic experience involving persecutory voices. In many ways he made good progress and for almost a year he kept moving forwards.
It is perhaps worth quoting an extract from a videoed interview with him that exactly explains what for him were key components of the effectiveness of what I call collaborative conversation. In his explanation we find references to the recent reactivating trauma (his abandonment of the woman he was living with and the guilt that ensued), the way that avoidance of the feelings this triggered led to persecuting voices, and how facing the feelings defused the voices.
At the point we pick up on the conversation after a question about how the easing of the voices had helped, he had learnt how to negotiate with the voices to give him breaks from their constant harassment: J. was his care worker where he was living.
I.: Because I’d got time to think about it. And I was thinking about different things, you know? And different things from the past that needed to be talked about. And I could remember things from the past, you know and the thoughts just kept coming into my head of different things. `I must mention that to Pete.’ That’s what I kept thinking.
P.: I know this sounds a very stupid question, but in terms of when you then came and talked about them, what was valuable about just talking about them?
I.: Because it made it real. When I was ill, it didn’t seem real. You know what I mean? My memory didn’t seem real. It was like a dream. And it was as if I’d never done anything. But talking to you reminded me that I’d actually done these things, you know? And that it was memory. And that I’d actually done the things. It was reality.
P.: And how did knowing that it was reality prove so helpful? What did it do?
I.: Well, it proved the voices wrong for a start.
P.: Ah. Why? Were they saying that they were real and your memories weren’t?
I.: Yeh. It proved the voices were wrong. And that my memory was right. And talking to you fetched it out into the open. . . . . .
P.: It sounds as though being able to think about things and about the past or about what’s happening to you now was a very important thing that began to happen.
I.: Yeh. It was very important. Getting in touch with reality. And finding out what things were real. And what things wasn’t real.. . . I needed to think about getting well. And what it was going to be like without the voices. And what it was going to be like without going in and out of hospital all the time. And I needed to think about it. And I couldn’t think about it when the voices were talking to me.
P.: Do you think that when we were talking about things it was only a question of remembering and then realising that the memories were real or were you also doing something else with the memories once you got them remembered?
I.: I was putting ’em in order. I was sorting ’em out. Things from the past that shouldn’t haunt me no longer. That I could put in the past and leave there, you know? I had to talk about ’em. I had to think about ’em. I had to feel about it, yeh. I thought it would never stop, you know. . . It wasn’t easy
J.: You actually hurt a lot, didn’t you?
I.: Yeh. I hurt so much that I thought it wasn’t worth being well, you know? . . .
J.: We tried hard to put the good things in the now, didn’t we? You started to feel them more as well, didn’t you?
J.: Tell me if I’m not getting this right. My belief was that you were feeling all these bad things that hurt. When we went and did something that was pleasant and you realised that you could enjoy that more now it helped you to realise that feelings could be good as well as bad.
I.: Yeh. I thought feeling was all bad. But feeling – like I feel good now – I feel really good now . . . (Pause)
P.: Are you saying that you’ve come to realise – it’s like not being anaesthetised – anaesthetic stops you feeling pain but it also stops you feeling anything else as well – and now it’s like you’re no longer under anaesthetic so you can feel very bad . . .
P.: . . . but you can also feel very good. Is that a price worth paying? Sometimes feeling bad, is that a price worth paying for quite often feeling good?
I.: Yes. ‘Tis a price worth paying. Getting your feelings back is a painful thing, you know? And it really hurts. Makes you cry. But once you done your crying and you’ve realised that that’s real, you know, then you come to terms with it. You can put it in the past without worrying about it.
P.: What do you think is the effect of that on the voices?
I.: Well, they got no worries. So, they leave me alone.
P.: Do you think they fed on the worry and pain and distress you were keeping under?
I.: Yeh. They kept feeding on my suppression, you know? . . . They kept getting worse and worse until it got unreal.
P.: Yeh. There were certain things that you had done that really you felt very bad about, weren’t there?
P.: That you felt really guilty about. In a sense you had never quite faced up to that perhaps? The loss, the grief, the pain, you’d not faced up to. Am I right that these were all different bad feelings you had?
I.: Yeh. I felt bad about L. [his ex-partner] you know? I felt really bad about her. And I thought I’d done her wrong. And that’s why I was ill. The voices fed on it, you know?
P.: Do you think you actually deserved to be ill?
I.: No. Nobody deserves to be ill.
To show us the limits of what can be done, and how psychosis can seem preferable to raw reality, it was then that we discovered that there were two anniversary effects that triggered a resurgence of the hostile voices: these related to two traumatic army experiences whose pain and guilt he was never able re-experience and integrate, preferring instead for the voices to get worse at that time of year. We realised that the guilt at what he felt he had done to his ex-partner, the trigger to the hospital admission that led to my involvement, had been reactivating an earlier and far deeper sense of guilt. An increase in the intensity of the voices was in this case the lesser of two evils for him, even though it risked relapse and consequent hospitalisation sometimes.
It was experiences like these that convinced me that the medical model had to be complemented, or maybe even superceded, in some way.
In explaining his model, Shields, whose work I examined earlier in this sequence, is not discounting the role of biology (ibid):
However, this hypothesis does not view these psychological processes as operating independently of biological factors; these psychological and existential factors work closely with the structural or functional integrity of the brain in producing psychotic episodes.
He is singing from the same hymn sheet as Bethany L. Leonhardt et al in arguing that there is a continuum (page 146):
. . . psychotic symptoms exist on a continuum even in healthy individuals (Stefanis et al., 2002). This, too, seems to be explicable if psychosis is a way to cope with existential distress – as psychosis would be quantitatively, rather than qualitatively, different from normal. . . .
They go on to make a particularly subtle but potentially crucial point (pages 146-7:
This hypothesis can explain another aspect of psychosis: psychotic individuals do not choose realistic explanations for their experiences (Freeman et al., 2004). If the explanations chosen by psychotic individuals were more realistic, then the problem of reality would continue to intrude on an individual that cannot deal with reality.
This possibility paves the way towards explaining why some people with psychotic experiences are desperate to be helped to get rid of them while others work hard to hold onto them against every attempt to persuade them otherwise (page 147):
Psychotic breaks that do not entirely allow psychotic individuals to avoid dealing with the issues that prompted their psychosis would leave these individuals no way to avoid reality – though they desire to. Therefore, individuals in this state would want to rid themselves of reality and their experience however necessary – if their psychosis is, indeed, an attempted escape from an unbearable reality. Alternatively, for psychotic breaks that do truly allow individuals to avoid dealing with the issues that prompted their psychosis, these individuals would cling to their psychosis with certainty, as their psychosis is what permits them to cope with the crushing distress that prompted their episode.
The implications of this would explain why the drugs prescribed prove to have a positive effect of any kind at all (page 150):
This paper’s hypothesis – that psychosis might function as a mechanism for coping with existential distress – explains the efficacy of antipsychotic drugs by their ability to help a patient avoid existentially distressing issues. . . . . After a lengthy review of the evidence for and against the dopamine hypothesis, one psychiatrist proposed that antipsychotics primarily work not by modifying dopamine but instead by inducing neurocognitive suppression, which diminishes the severity of psychotic symptoms (Moncrieff, 2009).
This leads to another disturbing conclusion (page 151):
However, if the hypothesis outlined herein is true, the nature of the antipsychotic cure is temporary rather than permanent; the individual still has not dealt with the issues that prompted their psychotic break. This temporary nature may explain why antipsychotics increase the chronicity of psychosis: antipsychotics are simply another measure in avoiding the same issues that need resolved.
Shields recognises that his hypothesis is not without its weaknesses (page 152):
[One] limitation of this hypothesis is that many individuals undergo existential crises without having a psychotic break. However, it may be that individuals who do not have a psychotic break do not attempt to avoid the existential issues they are facing; instead, they may accept these issues or deal with them. Again, though, this is speculation, and it does not easily lead to predictions for further research. A final possible limitation of this hypothesis is that it implicitly assumes that psychosis is a unitary phenomenon, potentially manifest in differing ways, but some argue that a single concept of psychosis ought to be abandoned for a pentagonal model (Os & Kapur, 2009; White, Harvey, Opler, & Lindenmayer, 1997).
What for me is of compelling interest in the arguments these papers put forward has two aspects.
The first is that they all seek to confirm in one way or the other that psychosis is a meaningful response to experience.
The second follows on from that. If psychosis is a meaningful response to experience, then it needs to be explored in the light of that experience if the person is to move on. Shields favours some form of existential therapy but admits that he lacks the evidence to support his preference. The study he would like to see run has not happened yet (page 153):
In a randomized trial of treatment for psychotic individuals, those treated with existential psychotherapy – especially a type of existential psychotherapy that provides an ontological ground for the resolution of existential issues, such as the one provided by Bretherton (2006) – should have significantly better outcomes than those treated with biological methods.
I also am drawn to existential therapy, and it influenced my own approach, not least because of the emphasis it places upon developing the capacity to think about one’s thinking (metacognition), something widely recognised as a problem for people with psychotic experiences.
I am aware as well that there is a great deal of scepticism about the efficacy of Cognitive Behaviour Therapy for schizophrenia, partly because its implementation has been half-hearted, to put it mildly, but also because it may not be the optimal response in every case. I am not convinced by any one-size-fits-all model.
I need to explore all this more deeply still, but I know what I feel is likely to be the case.
These writers are right, despite all caveats. Psychosis is a response to extreme experience that cries out to be worked with in a way that helps the person come to terms with what for them is unendurable.
I know from my own experience that this is not going to be easy. Some people would choose not to go down that road at all, just as there are those who would rather take painkillers forever than begin to use exercise to help their bodies heal. But I also know that if our society and its institutions gave far more support than they do to this model (in fact they all too often rubbish it at least implicitly) far more people would be empowered to use it and leave the real and imagined terrors of the psychotic state behind.
I also recognise that more needs to be done to fashion and test the best psychotherapeutic approach to these issues. But that is no reason for failing to do anything on a larger scale to remedy this deficiency.
 I may have been missing the crucial point that links suppression of painful feeling with increasing loss of contact with reality and the ascendancy of the voices. This pertains to the difficulty he had explaining what the point of talking about memories was.