The British Psychological Society’s Division of Clinical Psychology has recently released a report on 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.
I read it with interest as it’s written by a group of clinical psychologists from several universities and NHS trusts, together with people who have experienced psychosis. It gives an overview of the current state of knowledge, with conclusions that have implications for the way we understand mental illness and the future of mental health services.
It’s true that many people believe that schizophrenia is a brain disease that makes people unpredictable and potentially violent, and can only be controlled by medication. However, the report suggests this view is false.
Instead it finds that the problems we think of as ‘psychosis’ can be understood in the same way as other psychological problems such as anxiety. Thinking of them as an illness is only one perception, and not shared by everyone or all cultures. That they are often partly or fully a reaction to the things that can happen in our lives – such as abuse or racism.
I broadly welcome the report. It is right that many psychotic problems occur in a wider range of people, and that they can respond to psychological approaches such as cognitive behaviour therapy. One of my own first publications (back in 1973) was on the development of a cognitive approach to therapy for paranoid delusional beliefs. This psychological approach to psychosis is not yet widely recognized, and it deserves to be. Nevertheless, I have two caveats.
First, I remain somewhat more supportive of the disease approach to psychosis which the report says is not the only way of understanding psychosis. Indeed, it isn’t, but it suggests a kind of relativism that has given up on trying to establish when and why it may be useful.
I see this as a scientific matter that is amenable to research. For example, there may be significant difference between those who have a complex set of psychotic experiences from those who have just one. I also see pharmacological and psychological treatments as compatible and I suggest that some people benefit from both. If that is the case, we need a broad, integrative model of psychosis that can find room under one roof for biological, social and psychological aspects.
I would also like to see a more explicit emphasis on spiritual aspects of psychosis, within such a broad-spectrum approach. As people like Isabel Clarke have pointed out, there are striking analogies between psychotic and spiritual experiences.
Religious content is a significant feature of many psychotic experiences, and there may be common causal pathways in how they arise. I suggest that it can be helpful, in at least some cases, to take the spiritual aspects of psychotic experiences seriously, to see psychosis as in part a ‘spiritual emergency’, and to enter into sympathetic conversation about the spiritual aspects of the experience.