Pro and Con: The British Psychological Society Report on Psychosis

The original etymologies and current usages of the words "psychosis" and "neurosis" are confusingly topsy-turvy.

"Psychosis" literally means a disease of the soul or mind, but for more than 100 years this term has been used to describe only the severest forms of mental disorders, those that have at least partial causality in neurological (brain) malfunction.

"Neurosis" literally means a disease of the nerves, but for more than 200 years this term has been used to describe a grab bag of mostly milder mental disorders more clearly related to psychology (the mind) or to social pressures than to any neurological disease.

Recently there has been considerable controversy and confusion around how the word "psychosis" should be used, if indeed it should be used at all.

The British Psychological Society's Division of Clinical Psychology recently issued a report, "Understanding Psychosis and Schizophrenia [Why people sometimes hear voices, believe things that others find strange, or appear out of touch with reality . . .  and what can help]." Edited by Anne Cooke, the report presents a psychological perspective on these experiences and questions the way we think about mental illness.

Anne will support the report, and I will critique it. Anne writes:

Our report has two main aims. Firstly, it is intended as a resource for people who have the experiences we think of as psychosis, and for their families. Secondly, we hope it will lead to significant change not only in mental health services, but also in wider society.

Our dream is that our report will contribute to a sea change in attitudes so that rather than facing prejudice, fear and discrimination, people who have these experiences will find those around them accepting, open-minded and willing to help.

The report has been written by a group of eminent clinical psychologists drawn from eight universities and the UK National Health Service, together with people who have themselves experienced psychosis.

It provides an accessible overview of the current state of knowledge, and its conclusions have profound implications both for the way we understand "mental illness" and for the future of mental health services.

Many people believe that schizophrenia is a frightening brain disease that makes people unpredictable and potentially violent, and can only be controlled by medication. However the report summarises recent research that suggests this view is false. Rather:The problems we think of as "psychosis"-hearing voices, believing things that others find strange, or appearing out of touch with reality-can be understood in the same way as other psychological problems such as anxiety or shyness.They are often a reaction to trauma or adversity of some kind which impacts on the way we experience and interpret the world.They rarely lead to violence.No one can tell for sure what has caused a particular person's problems. The only way is to sit down with them and try and work it out.Services should not insist that people see themselves as ill. Some prefer to think of their problems as, for example, an aspect of their personality which sometimes gets them into trouble but which they would not want to be without.We need to invest much more in prevention by attending to inequality and child maltreatment. Concentrating resources only on treating existing problems is like mopping the floor while the tap is still running.

The finding that psychosis can be understood in the same way as other psychological problems such as anxiety is one of the most important of recent years, and services need to change accordingly. In the past we have often seen drugs as the most important form of treatment. Whilst they have a place, we now need to concentrate on helping each person to make sense of their experiences and find the support that works for them.

Thanks, Anne. I welcome your effort to clarify and destigmatize the confusing term "psychosis." I also heartily agree that it is crucial to attend to the psychological and emotional meaning of all experiences and understand the social context in which they occur.

But I do worry that your report creates its own set of unintended problems and may inadvertently perpetuate rather than dispel confusion and stigma, especially for those who have the most severely impairing of psychotic experiences.

The fundamental problem is that the report uses the term "psychosis" far too loosely and nonspecifically, lumping together very distinct situations that are better understood once they are teased apart diagnostically.

I can think of at least six distinct current usages of the word "psychosis," each of which has a quite significantly different implication regarding severity, chronicity, clinical significance, causality, and treatment:

• "Psychosis" is often misleadingly misused to describe anyone who occasionally experiences hallucinations. This overlooks the fact that 10 percent of the general public reports having had a hallucination, and 20 percent reports having had a direct encounter with an angel or devil. We forget that some of the greatest leaders in history-including shamans, saints, artists, writers, and the founders of most religions-have hallucinated. If this loose usage of "psychosis" had been applied in the 15th century, Joan of Arc would been sidelined in a hospital and medicated instead of leading the French army to victory. Not every unusual experience is evidence of a mental disorder. "Psychosis" should be reserved only for those who are unable to reality-test the hallucination and also display significant distress and impairment in interpersonal and vocational functioning.
• Brief psychosis is considered a mental disorder, but it is just a transient one with excellent prognosis and no reason to expect long-term impairment. The symptoms emerge suddenly in response to stress and usually disappear just as suddenly (especially if the stress is removed), often never to reappear. This is common in many cultures, and I have seen it fairly often in college students away from home for the first time, in travelers in strange lands, and in people who have had something terrible happen to them. Antipsychotic medicine is needed only briefly, if at all.
• Psychosis may be caused by intoxication or withdrawal from alcohol, a medication, or a street drug. The symptoms usually go away promptly once the person is detoxed and as long as they stay off whatever they were taking. Antipsychotic medicine is again needed only briefly, if at all.
• Psychoses arising from medical or neurological diseases often get better if and when the disease gets better. Antipsychotic medicine may be necessary in the short run, or if the illness is irreversible, but is often overused, particularly with the elderly in understaffed nursing homes, where it has the dreadful impact of reducing life expectancy.
• Psychosis can occur (usually episodically) as part of bipolar and major depressive disorder, usually requiring short-term antipsychotic treatment, but continued long-term use is often not necessary.
• Psychosis can occur as a primary, often debilitating and chronic feature in schizophrenia and delusional disorder. Misfiring nerve cells play a central causative role, although psychological factors, stress, and social supports are certainly important in determining onset, recurrence, and treatment. Antipsychotic medication is almost always necessary in the acute stages and may be necessary for the long haul to prevent severe and chronic dysfunction. And lack of available treatment and adequate housing are responsible for 600,000 of the severely ill in the U.S. being trapped in prison or homeless. These are the people I worry about most, because they suffer the most and tend (as in the report) to be lost in the shuffle and neglected.

The anti-diagnosis bias of the British Psychological Society results in a report that misleadingly lumps together all these very different usages of "psychosis," thus losing crucial prognostic and treatment precision.

The report makes broad statements about the role of medication and psychosocial interventions in psychosis that are essentially meaningless because most certainly there is no one size that fits all. Each usage should be considered separately, because each calls out for a different response.

The report's pro-psychosocial bias is useful in pointing out that psychosocial contributors and treatments are important for all the groups and are too often ignored by practitioners who follow a narrow medical model. But the lumping obscures the fact that psychosocial factors are much more central in some groups than in others.

In parallel, the report's anti-medication bias is helpful in pointing out that antipsychotics are often prescribed when not indicated, or prescribed for longer or in higher doses than needed. But the lumping obscures the fact that in some of the groups, medication will be essential, but not in others.

Let's do a quick overview:

• Group 1 may require no treatment at all, only reassurance and normalization.
• Group 2 will usually require brief psychosocial and medication treatment.
• In groups 3 and 4 psychotic symptoms are secondary, usually transient, and treatment will focus on the primary substance or medical problem.
• In group 5 psychotic symptoms accompany mood episodes and usually disappear when the episode is successfully treated.
• Group 6 will need antipsychotics for acute episodes and to reduce the risk of relapse, though continued long-term use in stable individuals is more controversial and subject to individual choice once the risks and benefits are laid out.

Antipsychotics certainly are being overused but are often useful in the short run in all but group 1 and are often the safest bet even for the long term in group 6.

The report's strong stance for patient empowerment and against psychiatric coercion made great sense 50 years ago, when hundreds of thousands of people were confined against their will in snake-pit psychiatric hospitals. It seems quaint and misdirected now, when the most frequent, longest-lasting, and most horribly degrading loss of empowerment comes not from coercive psychiatry but from being imprisoned or homeless-the real threat for the severely ill in the U.S. and increasingly in the UK.

So the basic problem with the report is its unitary, nondiagnostic approach to psychosis and consequent broad-brush recommendations that work very well for some people in some situations but can be disastrous if followed for others in different circumstances. The report's optimistic emphasis on psychosocial causation and treatment is perfectly appropriate for some people with psychosis and perfectly inappropriate for others. Emphasizing the positives of psychotic experiences seems terribly out of place when it comes to those most impaired by them, who are rotting in jail or on the street because they had no access to treatment and services. Emphasizing empowerment to avoid psychiatric coercion seems out of place for someone with severe symptoms and terrible judgment, who will very likely have a disastrous fate without it.

The people with lived experience most opposed to psychiatric diagnosis, medication, and coercion are those who have been harmed by it and have done well without it. Their vocal opposition to medication and involuntary treatment is extremely useful to the extent that it helps highlight and curtail current massive medication overuse and unnecessary restriction of patient choice. But their happy experience without treatment does not generalize to those who are most ill, who need medication to avoid a much worse outcome. I fear the report may have the unintended negative consequence of persuading people who need treatment to avoid it.

Let's not offer broad and misleading generalizations and focus instead on what's best for each person. Strong ideological differences often fade when common-sense people discuss the real-life situations. Thanks again, Anne, for stimulating this discussion.

Anne's final comment:

Thank you Allen. I agree completely that a one-size-fits-all approach is unhelpful, and that is absolutely not what our report advocates. Neither do we necessarily advocate using the term psychosis. It only appears in the title to indicate that the report is about those experiences which sometimes attract such labels. People need to be able to google our report when they are told "you have psychosis"! We suggest using people's own "plain English" descriptions of their experiences, for example "hearing voices." Whereas you appear to be suggesting that people with "real" mental illnesses can be separated from others, we are suggesting something rather different-that for every single one of us, our experiences and their combination of interacting "causes" are different. For some of us our biological makeup plays a significant role but for many of us the events and circumstances of our lives are more important. We can never know with any certainty all the causes of someone's problems. The only way to work out what might be going on, and what might help, is to sit down with each person and listen. You are raising the issue of classification-the question of how meaningful or useful it is to classify experiences into different categories for various purposes, the provision of help being one. I suspect that is a bigger debate than we have space for here, but one which I look forward to having!