This is a cut and paste of the usual fare here. I collect these pieces, in anticipation of the disappearing. I have to say reading it scared me, not because of what it says, but that it needs to be said at all. These are new times.
Mind over medicine
Mental health professionals should look beyond the medicalisation of psychosis and recognise the relevance of traumatic life events, writes Dr Warren Larkin
You mean they don’t? Why not? Did they ever? Why did they stop? How’s that working out? Aren’t these good questions? Why not? How come few will answer or even form them, every dadgum time I find a piece of current commentary that favors traumatic causation of mental illness, they just gloss over the big picture, but do manage to make the standard “not to blame parents” disclaimer and that too is decontextualized. When did we blame mothers? What happened then? Why did we stop? Can we go back now please?
I want to do the happy dance, I really do. But these anemic, politically correct and socially disengaged apologies for experience don’t go far enough and purport to be all illuminating and cutting edge and shit. Tell you with a straight face that CBT is good for your soul. Maybe we’re just starting, maybe they need to catch up. Maybe I should stick with blogs if I could find them. Seriously, is there a theoretician in the house? I’m raving mad. Back to the thing:
The word “schizophrenia” has different meanings for different people, most of them negative. Being diagnosed as schizophrenic leads to fear, hopelessness and stigma for many.
Others reject the concept and the psychiatric system that pathologises them, instead preferring to try to make sense of their experiences in a more personal way, seeking the support of user-led groups such as the Hearing Voices Network.
Some biologically oriented psychiatrists and drugs giants continue to promote the notion of schizophrenia as a degenerative brain disease with a strong genetic component. Mental health professionals and service users and their families are told psychosis has something to do with dopamine – a brain chemical – and that drugs can treat this biological abnormality.
Conversely, many psychologists researching and working therapeutically with people who experience psychosis now prefer not to use the unscientific term “schizophrenia” at all. They prefer instead to research and work with the specific psychotic experiences that people describe commonly, such as hearing voices, paranoid thinking, unusual or distressing beliefs and disorganised thinking.
Psychological treatments are based on the assumption that mental distress can be understood and that psychotic experiences are meaningful and understandable in the light of a person’s life experience. There is also a strong body of evidence to support the effectiveness of cognitive behavioural therapy (CBT), in the treatment of schizophrenia, and the National Institute for Clinical Excellence (Nice) has issued guidance to NHS trusts stating that CBT and family interventions should be offered to all service users and their families and carers.
Around one third of patients taking anti-psychotic medication obtain no therapeutic benefits at any dose. Drug treatments certainly can provide symptomatic relief for some people, but distressing side-effects, such as weight gain and sexual dysfunction, are still common and, on balance, some service users conclude that the costs outweigh the benefits. Approximately half the people prescribed these drugs stop taking them, largely because of the adverse effects.
Those whose symptoms are well controlled by medication still face many obstacles on the road to recovery. For many people, an important element of recovery is about making sense of what happened to them.
There is now a considerable body of evidence that points to a link between traumatic life events and the development of psychosis. For too long this sort of research has been discouraged by an overemphasis on neurons and genes. Fear of “family blaming” has also contributed to decades of silence on this issue.
Two facts are important here. Firstly, all families do the best they can and, if parents are struggling in their parenting, it is important that the difficulties, abusive or otherwise, are identified so that help can be offered to the family as a whole. Secondly, much abuse – particularly sexual abuse – takes place outside the family.
A recent review of more than 70 studies by a group of leading academics found that, overall, 69% of female patients diagnosed psychotic reported either physical or sexual abuse in childhood, with the figure being 59% for male patients. In addition, several sophisticated large-scale studies have concluded that child abuse is a causal factor for psychotic experiences (Jansenn et al 2004; Bebbington et al 2004; Whitfield et al 2005).
Moreover, studies have confirmed specific causal relationships between abuse and hallucinations. For example, a survey of 17,337 Californians found that after controlling for substance abuse, gender, race and education, those with the greatest number of adverse childhood experiences were 4.7 times more likely to have experienced hallucinations.
While abusive and other traumatic experiences aren’t reported by everyone who experiences psychosis, mental health professionals need to be routinely trained to ask about this, to respond appropriately and to offer information about the treatment options including psychological therapies.
There are clearly complex and multiple interactions between trauma and psychosis. It is exciting to see researchers from both biological and psychological disciplines joining forces to discover the specific mechanisms by which childhood abuse and other traumatic experiences lead to psychosis.
It is possible that the consequences of traumatisation convey a vulnerability to psychosis. Negative beliefs about the self, the world and other people that arise as a consequence of trauma are common in those experiencing psychosis. Paranoid thinking has been demonstrated to be common in those who have been traumatised, and many studies have observed that traumatic experiences are often reflected in the content of hallucinations and delusions.
Psychotic experiences appear to be regarded by many people as normal and do not necessarily lead to distress or disability. Research has shown that psychotic experiences are essentially normal phenomena that occur on a continuum in the general population. However, traumatic life experience may be the factor that differentiates those who become psychiatric patients and those who do not.
Although the medicalisation of pyschosis continues to dominate in mental health care, psychosocial research and the theoretical models that are being developed from it allow psychological therapists and those who experience psychosis to develop a shared understanding of psychotic phenomena, in a way that not only guides the therapy process but also offers a compassionate perspective and hope for recovery.
Dr Warren Larkin is an NHS consultant clinical psychologist and author of the book Trauma and Psychosis: New directions for theory and therapy, published by Routledge.