This is the second part of MIA’s coverage of the British Psychological Society’s recent report challenging the current paradigm for the diagnosis and treatment of psychosis.
The authors of the report expand upon the traumatic and sociopolitical factors underlying presentations of psychosis and “schizophrenia” and call for new ways of understanding these experiences.
“It is vital that mental health workers are open to different ways of understanding experiences, and do not insist that people see their difficulties in terms of an illness,” the authors write. “This simple change will have a profound and transformative effect on our mental health services.”
The authors warn against conceptualizing voice hearing and other “unusual” experiences as indications of an unwanted “brain disease.” Most notably because this view uniformly pathologizes an otherwise heterogeneous experience that some find non-distressing and conducive to their lifestyle. Furthermore, they argue that these approaches privilege internal explanations for distress in a way that conceals the effects of trauma and structural violence.
They cite compelling evidence that mental health problems, and distressing experiences often labeled as “psychosis,” can be reactions to stressful life events, such as poverty, abuse, and different forms of trauma. Survivors of child abuse, for example, may hear voices resembling their former abuser. One review found that between one-half to three-quarters of individuals in psychiatric inpatient units were victims of childhood physical or sexual abuse.
Alongside flashbacks, intrusive images, and dissociation, hearing voices might similarly arise as a natural response in the aftermath of trauma. Refugees, for example, may hear voices or have visions related to personal experiences. The authors write:
“It is becoming clear that there is much more overlap than was previously thought between these trauma-related experiences and those that have been thought of as psychosis.” They even cite some sources which argue that there is no distinction, and that “psychosis” need not exist as a separate label.
One voice-hearer shares the following:
“I thought I was bad because the voices called me all sorts of names. Later I realised that the voices were related to the physical abuse because they have the characteristics of those that abused me. Then I noticed that the voices became more or less intrusive depending on the situation I was in. They became bad when there were conflicts in the house. So they were a kind of mirror of my living situation.”
An individual with experiences of paranoia offers the following recounting of their history:
“When I was a child we lived on an all-white road. Nobody was friendly to us and, as luck would have it, our next-door neighbour was a member of the National Front and he kept throwing abuse over the garden wall at us… It was really horrible, horrible stuff. And when you were growing up as a child, you think that’s how the outside world sees you. You are not going to have pride in yourself and you actually fear the world around you. I can see where that has had a knock-on effect on my experience of paranoia.”
Results from one study, cited in the report, appear to support the notion that experiencing multiple forms of childhood trauma makes one susceptible to “psychosis” in the same way that smoking puts one at risk for lung cancer.
Poverty, homeless, unemployment, and low education have been identified by the World Health Organization (WHO) as social determinants of mental health problems. Other studies have identified experiences of discrimination and institutional racism as factors influencing the development of “unusual” or “paranoid beliefs.”
The authors draw an important distinction between racist individuals and systemic racism, noting that the latter operates pervasively and insidiously in ways that permeate myriad aspects of individual well-being Dr. Suman Fernando connects the excessive labeling of “schizophrenia” to “excessive stop and search, prison, and school exclusion.”
At times, institutional racism manifests in policies which have blatantly targeted people of color. Dr. Johnathan Metzl calls attention to the specific diagnostic term “negro schizophrenia” used in the 1960s to label those taking part in the Civil Rights Movement with “protest psychosis.” In some cases, members of certain communities that have experienced collective trauma have reported hearing voices reminiscent of their historical persecution.
“Because I taught African and Caribbean culture, the transatlantic slave trade was a big part of my remit and I went into it a little bit too deeply. And then all of sudden something unlocked in me. I started hearing my ancestors. I could hear them crying and I could feel their pain. All my female ancestors, I could feel them and I could feel all their children. I could hear them on their voyage and I could feel all these people coming to me through all my reading. It started to affect me and that was a problem.”
Studies further demonstrate that Black service users are more likely to be stereotyped as violent, receive poorer quality services, and be forcibly medicated or locked up. Some scholars describe this pattern to result in a “circle of fear” in which people of color are more likely to experience distress because of racist policies, suffer from poor services and then avoid seeking help when experiencing distress.
These different complicating factors demonstrate the underlying complexity that gives rise to experiences recast as “schizophrenia.” The purpose of this report is to challenge how service providers have developed their beliefs and conclusions about “psychosis,” urging them to reconsider their approach.
Some individuals find voice hearing and experiences of this ilk to be distressing and disabling. While certain forms of professional support can be helpful, the authors point out that one’s network of friends, community, and social support is fundamental to their wellbeing. Formulating interventions with this in mind is an important step to improving services.
A number of peer support options exist both separate from and integrated within mental health services. Some are informal and naturally occurring, others are service user run, and others involve paying providers for more formal peer support.
The “service user and survivor” movement serves as a supportive community featuring a forum designed for individuals to reflect on their experiences and share their perspectives. This has resulted in a growing literature that offers unique views of “psychotic” experiences, touching on the dehumanizing nature of some mental health services, and portraying a link between “madness,” creativity, and spirituality.
Self-help and mutual support methods are also becoming increasingly popular, particularly for individuals with marginalized identities to receive support that is culturally appropriate. Black services users have formed self-help groups, as have LGBT individuals and women. Collective approaches such as this function to combat isolation and to bolster feelings of solidarity between members.
The Hearing Voices Network (HVN) is an internationally active network of self-help groups “based on the idea that different people have different ideas about the nature and causes of their experiences.” The report goes on to describe community development approaches and “recovery colleges: an educational approach to offering help,” as additional options for support, and the report ultimately concludes with list of resources, websites, and services.
The authors stress the importance of people receiving desired care and support in a timely manner. For some, this might involve support with basic needs such as housing, money, and food. Although most people who have experienced “psychosis” want to work, they are severely underemployed which can have added costs to their finding value, support, and meaning in their lives more generally.
Emotional support, and interventions that can enhance organization and motivation in one’s life can be especially appreciated, leading the authors to identify the need for creative responses to individual needs. Yet, current legislation allows people to be kept in hospitals against their will, where they are often forcibly administered medication.This has not effectively resulted in preventing admissions.
“There is an argument that by keeping people against their will in wards which are often unpleasant and sometimes frightening, and where often the only help on offer is medication with distressing side effects, we are failing to uphold the basic ethical principle of ‘reciprocity’, namely that ‘where society imposes an obligation on an individual to comply with a programme of treatment or care, it should impose a parallel obligation on the health and social care authorities to provide safe and appropriate services, including on-going care following discharge from compulsion.’”
The comprehensive and compelling critiques offered in this report provide considerable room for reformation at multiple levels of services. First, they encourage moving beyond the “medical model” and offering services that replace paternalism with radical collaboration, involving a privileging of service user perspectives, and a general acceptance of views outside of an “illness model.”
Automatic prescribing of antipsychotic drugs needs to be stopped, they write, and instead, service providers need to start to support individuals’ right to be informed, to choose, and to have a clear sense of expectations. They call for a reexamination of the justification supporting the use of compulsion and forced medication, pointing out that these services are inherently discriminatory.
Finally, research efforts must reflect these changes by redirecting “the search for biomedical abnormalities” toward understanding “the events and circumstances of people’s lives” and how they affect people. Thus, services will not simply provide standardized care, but collaborative interventions tailored to individual circumstances. To do this, they argue, service providers, particularly those leading talk therapy, must be willing to listen, to accept, to fully be themselves with the client to facilitate interpersonal healing, and to receive the needed support and training that enables them to do this.
One voice-hearer shares what they found they needed once they learned the meaning behind their experiences:
“What I would ultimately learn was that each voice was closely related to aspects of myself and that each of them carried overwhelming emotions that I’d never had an opportunity to process and resolve – memories of sexual trauma and abuse, of shame, anger, loss, and low self-worth. The voices took the place of this pain and gave words to it. And possibly one of the greatest revelations was when I realised that the most hostile, aggressive voices actually represented the parts of me that had been hurt the most profoundly – and as such, it was these voices that needed to be shown the greatest compassion and care.”
The report calls for a fundamental shift in the field to enact these critical changes, particularly in recognizing the ways in which oppression begets the suffering often categorized as psychopathology.
“There is no ‘us and them’, people who are ‘normal’ and people who are different because they are ‘mentally ill’. We’re all in this together and we need to take care of each other. If we are serious about preventing distressing ‘psychosis’ we need to tackle deprivation, abuse and inequality.”
Part 1 of MIA’s coverage of this report (published Monday, October 15h) can be accessed here: https://www.madinamerica.com/2017/10/psychologists-push-new-approach-psychosis-part-1/
Cooke, A., Basset, T., Bentall, R., Boyle, M., Cupitt, C., Dillon, J., … & Kinderman, P. (2017). Understanding psychosis and schizophrenia, Revised version. London: British Psychological Society, Division of Clinical Psychology. (Full Text)