Making Space for the Meaning in Madness
This week, the British Psychological Society publishes its 180 page reportUnderstanding 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?"
Understanding Psychosis destabilises such hope-crushing ideas that schizophrenia is a brain disease. How? Firstly, the report takes seriously the main biological theories, weighing up the evidence base before concluding that there is no proven biological abnormality associated with schizophrenia. This does not mean that medication will not help some, we read, but that its efficacy is overplayed, as is an implication the tranquillisation effects of the drugs is specific to psychosis; they may also cause long term side effects that can be damaging, and are no more effective than cognitive behavioural therapy for psychosis. The authors then proceed to argue that schizophrenia has no validity as a construct, has poor nosological reliability between different diagnosing professionals, and little utility in determining which treatment may help. This is not a new argument, yet drug companies like Eli Lilly remain able to state as if it were fact on their websites: "schizophrenia is a ... neurological disorder, believed to be caused by a biochemical imbalance in the brain", and get away with it. Unlike other critical publications, Understanding Psychosis may just make the crucial difference in shifting such discourse as it engages and deconstructs over a hundred years of evidence to prove such assertions are simply bad science. This decluttering of the stereotypes about what psychosis is in everyday language allows one thing to emerge - the importance of actually listening to sufferers to find the meaning within madness. It insists we ask: why this, why now, why you.
One of the biggest effects of conceptualizing schizophrenia as an illness is that it short-circuits such interest. Taking symptoms as signs of illness rather than as disguised attempts at communication has meant that, scandalously, we are only now realising the robust links between psychotic experiences and traumas such as childhood sexual abuse. Past experiences are often a little more metaphorically disguised in psychosis, only coming to light when they can be thought about in a caring, safe space. Think, here, of the voice hearer who realizes that the male voice that ceaselessly bullies him uses the same words and the same rhythms of speech as an abuser. Or the black youngster convinced people are looking at him who suddenly connects this with the "oh so subtle ways white folk hold their bags a little closer" when he passes. By labelling experiences as symptoms of an illness, we foreclose the possibility that they are telling us something of the sufferer's experience of the world, something that needs to be explored to foster the conditions for healing.
Psychological therapies, as Understanding Psychosis argues, can be crucial safe spaces to search for meaning, but so can activist community organizations such as the Hearing Voices Network, where voice hearers sit together with others who may have found ways of coping with their voices or, indeed, experience them, as Sally came too, as "great friends and advisers". Normalizing voice hearing in this way - up to 10% will hear a voice talking to us when no-one is there after all - reduces our anxiety about them. This is crucial as it's anxiety which tends to make such experiences distressing rather than counting as part of normal difference. It is a benign cultural script, for example, that can allowevangelical Christians to experience voice hearing in a less distressing way than psychiatric patients.
So will people listen to Understanding Psychosis? Well, the last time psychologists came up fighting against diagnosis, they were seen as getting stuck in a turf war with psychiatry. I have no doubt the report will spark fresh controversy about whether formulation is better than diagnosis, or whether CBT for Psychosis is really equivalent to medication. Big words like 'science' and 'trials' and 'risk' and 'facts' will be banded about, often hiding the professionals' vested issues (money, power, jobs, position). Yet the reiterated chorus of the report is that some ways of understanding can be useful for some people, yes, but no one profession holds absolute knowledge to assert what psychosis is and isn't. For me, Understanding Psychosis is a game changer not because it wins any particular argument, but because by decluttering headspace from false facts, we make space for individuals to find their own meaning, to be able to direct the cast of professionals, relatives and others who aim to help, to claim agency. This is a quite different phenomenological experience to being bulldozed into one reading of what a symptom means by would be experts.
Rather than make the reader anxious about the limits of knowledge, such an approach makes space for wonder at the often ingenious coping skills, attitudes and challenges to psychiatry that service users have come up with.Understanding Psychosis is bubbling over with quotes from those who have been hurt by psychiatry, helped by it, or never engaged with it - and they inspire. This emphasis on multiple voices, and attending especially to the voices of those most subjugated, parallels the supremely effective 'Open Dialogue' treatment founded in Finland. In this approach, when someone first experiences psychosis, family, neighbours, staff, and anyone else involved meet together within twenty four hours of a crisis to make room for as many different ways of understanding what is going on as possible. Crucially, all participants are trained to have a questioning approach to their own ideas, and the positions from which they speak. So a psychiatrist might offer suggestions about medication but locate his ideas in his medical background, acknowledging that his frame of reference is not unproblematic given there is no proof schizophrenia exists. A psychologist might suggest therapy as an option, but explicitly say that she is aware that there are ways of dealing with anguish that the family might have from their life experiences or cultural grouping which could be far more beneficial. This allows the sufferer to claim expertise, to have space to think about the meaning of what is going on for them, to not be stuck as a passive recipient of a storyline about 'schizophrenia' that may have little relevance for them. Understanding Psychosis is - in effect - Open Dialogue in action, for it deconstructs ideas of what is known to give space to the unheard voice of the sufferer and their symptom to speak.
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