Patients and Providers Understand Psychosis Differently

A new review examines service-user and mental health professionals’ causal beliefs about psychosis and how those beliefs may affect treatment.


A recent article, published in the journal Psychiatric Services, reviewed the literature on mental health professionals’ causal beliefs about psychosis and examined the differences between their causal beliefs and those of people diagnosed with psychotic disorders. The results showed that mental health professionals are more likely to endorse biogenetic beliefs while people with psychosis are more likely to endorse psychosocial beliefs.

“The purpose of this review was to describe the scope of literature and to map the existing evidence on causal beliefs about psychosis among mental health professionals and people with psychosis,” Rosenthal Oren and her coauthors write.
“Less attention has focused on causal beliefs about psychosis held by mental health professionals, and little is known about possible disagreements between mental health professionals and people with psychosis regarding causal beliefs.”

The modern psy-disciplines have proposed several different understandings of the causes and treatment protocols for psychosis. However, there have been at least six common types of causal beliefs identified in the literature. Causal beliefs are the beliefs regarding the cause of a condition, and they are often understood as part of active attempts to cope with health threats. In fact, a recent systematic review found that the health outcomes of people with psychosis were related to the type of causal beliefs they held.

“Causal beliefs influence emotional responses, coping strategies, and treatment choices,” the authors note. “Among individuals with psychosis, a growing body of literature highlights the potential impact of causal beliefs on adherence behavior and service engagement.”

The six common causal beliefs are as follows:

  1. Biogenetic beliefs emphasize the genetics or heritability of psychosis and primarily focus on pharmacological treatments to address biological abnormalities. Previous studies found this type of belief is associated with higher rates of stigma and medication adherence among people with psychosis.
  2. Psychosocial beliefs take psychological, social, and environmental influences into account for the development of psychosis and utilize more psychosocial interventions to produce changes in cognition, emotions, and behaviors. Previous studies found this type of belief is associated with greater psychotherapy engagement among people with psychosis.
  3. Spiritual-religious beliefs focus on spiritual explanations of psychosis and seek to understand how spirituality and religion are adapted as coping strategies. Previous studies found this type of belief is associated with a longer duration of untreated psychosis.
  4. Substance-related beliefs link the onset of psychosis with substance use and sees drugs and/or alcohol as the reasons for triggering psychosis.
  5. Personal characteristics related to beliefs consider personality and other individual characteristics as contributing factors for the development of psychosis. Previous studies found this type of belief is associated with higher rates of stigma among people with psychosis.
  6. “Psychosis as a part of human experience” refers to beliefs that embrace the idea that the experience of psychosis could be a part of reality—whereby people can have special power beyond current scientific explanations.

This study screened and reviewed 17,029 studies and presented their results based on the final 42 sample articles. They found a clear preference for biogenetic beliefs about psychosis among mental health professionals, whereas the most endorsed causal beliefs for people with psychosis were psychosocial beliefs. However, they also suggested that both mental health professionals and people with psychosis often hold several causal beliefs simultaneously.

“Results suggest that both mental health professionals and people with psychosis often hold complex causal models composed of different types of causal beliefs and that a gap exists in the different sets of causal beliefs held by mental health professionals and by people with psychosis,” the authors write.

Their results showed that different mental health professionals seemed to have different tendencies in endorsing causal beliefs. Among all mental health professionals, including psychiatrists, psychiatric nurses, psychologists, social workers, case managers, occupational therapists, and support workers, psychiatrists were the only group with a higher endorsement of biogenetic belief.

“Those from medical professions were found to hold mostly biogenetic beliefs, whereas those from nonmedical professions, such as psychologists and social workers, were found to hold psychosocial beliefs more often than they held other types of causal beliefs,” the authors note.
“Social-environmental causal beliefs may be associated with positive outcomes, such as higher self-esteem, whereas beliefs related to personal characteristics were found to be frequently associated with negative consequences, such as self-blame, poorer emotional state, and higher levels of anxiety.”

Lastly, the study found that causal beliefs about psychosis varied by nationality for both mental health professionals and people with psychosis. It seemed that people from Western cultures were more likely to endorse biogenetic and psychosocial causal beliefs than people from non-Western cultures, who were more likely to endorse spiritual-religious beliefs than other types of beliefs.

The authors conclude:

“These possible differences can harm the therapeutic alliance, which is closely linked to treatment adherence and outcomes. Overcoming gaps in causal beliefs requires that mental health professionals become aware of their own causal beliefs and potential gaps so that they can discuss them openly and respectfully with people with psychosis.”
“Such discussion may help people with psychosis integrate their current experiences with their life history, which can facilitate the process of constructing a personally meaningful narrative of self and illness, an important part of the recovery process.”



Rosenthal Oren, R., Roe, D., Hasson-Ohayon, I., Roth, S., Thomas, E. C., & Zisman-Ilani, Y. (2021). Beliefs about the causes of psychosis among persons with psychosis and mental health professionals: a scoping review. Psychiatric services, appi-ps. (Link)


  1. The New York Times just reprinted two articles yesterday under “mental health” from 2019 siding with Big Psychiatry and biogenetic causes of psychosis.

    It’s even worse when your employer sets you up, Putin-style. There is no framework for me to tell my story, be heard, believed or helped withstand inflicted criminal violations of the mental health code and the total destruction criminal psychiatry causes.

    Gina: you are believed by no one who can help you, and it is killing you.

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  2. Now in the professions we DO have what we might call a “guild system.” E.g., professionals are members of a “special interest group” and they have their financial interests. Big Pharma makes it so medical doctors will subscribe to whatever belief fits with the medical profession’s financial interests. However, the psychology profession will also wish to skew things as well to fit their agenda.

    What’s wrong with the psychology profession today, I wonder? My experience of it is that practitioners tend to be from a segment of society that is very non-athletic, unlikely to suffer from ADHD and people who are very verbal and like to talk and who are sedentary as well.

    The profession attracts certain types of people who are part of a certain culture. Oh yes, and they also have this non-scientific sort of attitude and tendency towards vagueness. I also was a scientist and math major and I would describe the whole style of the psychology profession as “non-rigorous.” Which I think is a bit of a cop out.

    A whole section denounces “toxic masculinity” yet, at the same time, they define it vaguely enough so it appears to be the case that they expect the reader to “fill in the blanks” with their own personal biases, including racist ones. They won’t SAY that black Italian Latino or blue collar white men suffer from toxic masculinity, including the macho guy with the tattoos who walks with the swagger. But maybe they expect you to think that, especially if you were not one of those types and perhaps still have bad memories of being called a wuss in the school yard and having the bullies steal your lunch money. Or, at least they are not taking responsibility for how they expect other people to interpret what they say.

    They can argue, as members of a profession that’s a specialty, that they — internally — are not racist and if you get that impression from the things they say about “toxic masculinity,” well that’s just your ignorance and lack of expertise showing. What did YOU major in, in college? Did you even go to college at all? That’s inherently disrespectful, though, if you would claim that your lack of clear communication accessible to the layperson is a result of your superior education and credentials. Conveying an aura of exclusivity.

    When I suffered from really bad PTSD, I found dynamic exercise outdoors mountain climbing to work the best for it, not sitting down and talking to someone in an office. I do think it might have helped even more if I could have done all that outdoor exercise WITH someone else walking with me, mountain climbing with me and talking to me along the way. I’d have recovered way faster.

    Is it not true that, in the soteria project, they did not merely talk to schizophrenics sitting down in offices but went for walks outdoors with them and talked with them as they were going on those walks with them?

    If only they could do further studies and try to contrast the difference. In some cases talk to people sitting down in an office. In other cases, go for walks with them outdoors in nature and see.

    Notice in this study, people who walked OUTDOORS grew brain cells.

    This last article in particular very clearly demonstrates the benefits of outdoor exercise:

    I believe it also matters WHAT sort of outdoor setting you exercise in. I am very intuitive about my own body and I just feel that it has something to do with what you are breathing in outdoors. The olfactory. And that the outdoor environment also makes a difference. Being around a lot of trees, for instance, rather than in the city.

    I also think being around high mountains matters, as well as fast running streams with cold water crashing on lots of rocks.

    The current psychology profession tends to be part of the humanities majors in college which attracts people who are more sedentary and who have trouble getting themselves to exercise even when they want to. I do wonder, though, if indoor gyms might play a role in that. I was personally never able to make exercise a true habit until I combined indoor weight lifting with outdoor exercise as well. I think whatever makes outdoor exercise best for depression also makes it more habit forming as well. And it can make you develop a habit for indoor exercise at the gym.

    In any case, I notice the contrast between “biogenetic beliefs” versus “psychosocial beliefs” strikes me as very limited. “Biogenetic beliefs” implies limited reliance on drugs. “Psychosocial beliefs” implies limited reliance on sedentary sit down “talk sessions” with psychologists in indoor offices.

    There is a much larger world out there than those two. You CAN be a rigorous thinker who views certain things as biological and not be one of those psychiatric quack types.

    Meanwhile, as for the whole psychology sphere, I note most relationships involve people DOING activities together, rather than just sitting down and talking. I used to be a member of a grass roots organization where we all worked as a team on a shared goal. Which was outside ourselves.

    Maybe we can call such relationships dynamic relationships? Or dynamic interactions? As opposed to non-dynamic sitting in an office talking purely about cerebral stuff? Where the conversation is supposed to involve only your head and nothing else? As if the head and the brain is just like a separate organ in the body, to be treated separately from everything else?Kind of like how, if you have a heart problem, we just specialize on the heart and leave everything else alone.

    Maybe whatever you might talk about in a “psychotherapy” setting might gell far better if you talked about it with someone in a dynamic setting rather than sedentary sit down setting. Of course, maybe I should also clarify that, probably for me that would really be very important. It might not be as important to others as for me, because everyone is different.

    Even so, it’s important to recognize that diversity. Different people have different needs. Our whole mental health profession, does it truly recognize such diversity or are treatment options geared more towards the structural “needs” of different facets of the mental health profession as a business and an industry?

    Where it is almost as if the profession is saying: “We do what we do, we refuse to stray beyond certain limited boundaries. We will not adjust to you as a patient. You are required to adjust to us. You have to be someone who can be fixed by what we do. And if you need something that is beyond our limited offerings, we will dig our heels into the ground and refuse to budge.”

    I don’t know that you will ever be able to expect more than that from a “profession” like that, of course. Because the economic system is what the economic system is. People need to make money and people need to have lives. There is a certain structure which is compatible only with certain things.

    Long ago, in the past, they used to have witch doctors. Who were somewhat sworn to poverty and lived off the donations of others. And who also, I believe, didn’t have children. There is something of a wisdom to that. You do it for its own sake, which means you believe in it and you care. Rather than, you suddenly have babies and THEY are what motivate you. Whatever is best for them.

    And then, as a psychiatrist, Big Pharma is very willing to come in and help you do whatever is best for your own kids. E.g., make lots of money. The job of the patient is to have it be that whatever fixes their issues is also whatever is best for your own kids. And, if it isn’t, not to complain about it. “Too bad.”

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  3. External or internal causes?

    Premediated psychiatric misinformation has spread everywhere.

    Actress Andie McDowell was interviewed by Terry Gross on NPR regarding her role playing a woman with mental health issues in Netflix’s very popular The Maid.

    Review of Andie McDowell’s character in The Maid: the character’s narcissism seems over-written with a little delusion thrown in to push the mental health angle over simply poor parenting. Paula, mother to The Maid, gets locked up in a psychiatric ward but is released more easily than would happen in real life, at least in Michigan.

    In the interview with Terri Gross, Andie McDowell weaved between internal and external causes for her own mother’s mental health issues, but without acknowledgement she was weaving. The actress, to my ears, appeared confused, like the general public, by popular terms like “misfire” and “chemical imbalance.” McDowell primarily shared that her mother drank and raged, so was treated aggressively by psychiatry against her will, using the tools of the day. Only as an afterthought did McDowell add that her mother was physically abused by her husband in the 1950s, prior to psychaitry, then after 1950s pscyhaitry, the abusive husband left her mother (if I understood correctly). From the actress, I heard a story of a woman, her mother, possibly taken down by external sexism and bad medical care. To her credit, McDowell says the terms schizophrenic and bipolar did not fit the mother she knew. Also to her credit, she was not able to commit her mother to a state insane asylum. The mother cut back her drinking and died of a heart attack soon after not in old age.

    I think people must want to hear more about external causes of mental health problems, but how to rebuild something, psychiatry, that is as strongly insulated as religion?

    How to deal with all the human carnage and greed along the way?

    Knowingly being one of the trampled and discarded is too much to ask.

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