This week, the British Psychological Society publishes its 180 page report Understanding Psychosis. Like it's 2000 predecessor, it is a polemic game changer, guaranteed to challenge dogma, wobble professional pride and provoke debate on what we can and can't claim about psychosis. Psychotic experiences, like voice hearing and experiencing persistent, unusual beliefs, are framed here as part of a continuum of experience, a normal variation rather than as radically other. Most importantly, it is a report that gives hope - an emphasis that recovery from distressing psychosis is not only possible, but probable. This hope is crucial, for schizophrenia as an idea still sits in the collective conscious as the archetypal terrifying, irrational, out of control mental condition. This potent notion of schizophrenia is one that trumps any other diagnosis, and colonises the heads of those suffering and their relatives. As psychiatric survivor Sally Edwards writes, "I was labelled with all sorts; eating disorders not otherwise specified, major depressive disorder, borderline personality disorder, schizoaffective disorder and eventually schizophrenia... that was the one that knocked the stuffing out of me completely". We read Sally's hopelessness in what this might mean as she continues, "What was the point in fighting if I was going to be suffering from a lifelong brain disease forever?"

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Making Space for the Meaning in Madness*|*Dr Jay Watts

Although it is a waste of time to argue with a paranoid patient about his delusions, he may still be persuaded to keep them to himself, to repress them as far as possible and to forgo the aggressive action they might suggest, in general to conduct his life as if they did not exist.”

This quote from Clinical Psychiatry, a hugely influential textbook in the 1950s and 1960s, epitomises the way in which unusual mental states were generally understood for much of the 20th century. Delusions (such as paranoid thoughts) and hallucinations (hearing voices, for example) were of interest purely as symptoms of psychosis, or what used to be called madness.


Apart from their utility in diagnosis, they were deemed to be meaningless: the incomprehensible effusions of a diseased brain. Or in the jargon: “empty speech acts, whose informational content refers to neither world nor self”. There’s a certain irony here, of course, in experts supposedly dedicated to understanding the way the mind works dismissing certain thoughts as unworthy of attention or explanation.

The medical response to these phenomena, which were considered to be an essentially biological problem, was to eradicate them with powerful antipsychotic drugs. This is not to say that other strategies weren’t attempted: in one revealing experiment in the 1970s, patients in a ward for “paranoid schizophrenics” in Vermont, US, were rewarded with tokens for avoiding “delusional talk”. These tokens could be exchanged for items including “meals, extra dessert, visits to the canteen, cigarettes, time off the ward, time in the TV and game room, time in bedroom between 8am and 9pm, visitors, books and magazines, recreation, dances on other wards.” (It didn’t work: most patients modified their behaviour temporarily, but “changes in a patient’s delusional system and general mental status could not be detected by a psychiatrist”.)

How far we’ve come since those days may be gauged by the arrival on Thursday of Understanding Psychosis and Schizophrenia, a report published by the British Psychological Society. Written by a group of senior clinical psychologists (including one of the authors of this blog), together with people who have themselves heard voices, experienced paranoia or received diagnoses such as psychosis or schizophrenia, the report argues that these sorts of problems can be understood in the same way as other psychological conditions such as anxiety or depression.


“Psychotic” experiences are much more common than used to be believed. Until the 1990s, if you had asked a mental health expert what proportion of the population had paranoid thoughts, for example, they would have answered around 1% – that is, the 1% of the population diagnosed with psychosis. But we now know that around a quarter of people experience regular paranoid thoughts. Just like anxiety and depression, psychotic symptoms exist on a spectrum: many people experience them occasionally and without causing distress; a few people are affected regularly and severely.


What this means is that we need a treatment model for psychosis that doesn’t consist solely of medication. This isn’t to say that the drugs don’t work: for many people they make a positive difference. But for many others the side effects are so unwelcome that they refuse to take the pills.


Moreover, though the precise biological mechanisms are uncertain, we do know that environmental factors – particularly trauma, abuse or deprivation – often play a significant role in psychotic experiences. Research has also found a strong link between psychological processes – the way a person thinks, feels and behaves – and whether they experience delusions and hallucinations. In other words, what happens to people in their lives, and the way they respond, can determine whether or not they experience delusions and hallucinations.


As such, clinicians cannot simply dismiss psychotic experiences as the deranged ramblings (“empty speech acts”) of mentally ill people, but instead must sit down with the individual and try to work out what lies behind their problems.
Research has suggested that cognitive behavioural therapy (CBT) and other psychological therapies – so-called “talking treatments” – can often be beneficial. Indeed the National Institute for Health and Care Excellence (Nice) recommends that they should be made available to everyone diagnosed with psychosis or schizophrenia.


The reality, however, is very different. In a 2012 report – pointedly entitled The Abandoned Illness – the Schizophrenia Commission noted: “We were particularly concerned about the lack of access to CBT and other psychological therapies which are recommended in the Nice guidelines and can be very valuable in helping people deal with the impact of symptoms and in keeping them out of hospital … Only 1 in 10 of those who could benefit get access to true CBT (Cognitive Behavioural Therapy) despite it being recommended by Nice”. NHS figures suggest that in only 3.4% of care spells for psychosis is the patient even given an appointment with a psychologist, let alone a course of treatment.

People with these problems also tend to suffer from severe anxiety, depression and sleep problems, all of which often fuel their psychosis. CBT has a proven track record with these relatively common problems, but again the therapy is rarely used to treat patients experiencing psychosis. (Ironically, in 1952 the first published paper by Aaron Beck – the “father of CBT” – applied a cognitive approach to delusional belief.

For all that, these are relatively early days for CBT as a treatment for psychosis. This kind of therapy isn’t right for everyone. But as we deepen our understanding of the psychological processes involved in these experiences, the treatment we can offer will become much more powerful. The development of CBT for anxiety disorders provides a model: initial efforts produced moderate benefits, but when subsequent theoretical advances were translated into treatment, huge steps forward resulted.


We need to follow a similar process for the treatment of delusions and hallucinations. There’s a lot of work going on right now, including two pilot schemes under the NHS Improving Access to Psychological Therapies scheme, but much more research is needed. Evidence-based talking treatments need to be urgently and thoroughly embedded in the mental health system.

In Understanding Psychosis and Schizophrenia, a patient called David Strange reveals just how much of a difference psychological treatments can make: “In February last year, 10 years since being diagnosed, I finally started psychological therapy treatment … The difference CBT has made is amazing – it has really transformed my life … The only thing I regret is that I didn’t have access to it sooner – it could have prevented a lot of suicide attempts and I wouldn’t have felt so awful for so long.”

Delusions and hallucinations may be the keys that unlock psychosis | Daniel and Jason Freeman | Science | The Guardian