In tests, 40 per cent of adults and over half of children report “unusual” perceptions or ideas
When I first met Helen she didn’t want to talk to me, or anyone else. She stayed in her room in the ward, sitting alone with her hood up, emerging only for mealtimes. Only after several attempts did she agree to come out for a short walk in the hospital grounds. It took many more walks before she began to talk about her experiences.
Helen was being listened to, continually, by the judges from a TV talent show. Anything she said could be heard by all of them. Sometimes they responded to what they heard by talking to her through the television. No one else could tell they were speaking directly to her, a 13-year-old girl from Edgware, but she knew. It made her feel good. It made her feel special. It also got in the way of things she was supposed to be doing, like school. Helen hadn’t been to school in nearly a year.
Psychosis is an umbrella term for loss of contact from reality. It includes unusual thoughts, such as delusions or paranoia, and unusual sensory experiences, like seeing, hearing or feeling things that others cannot. Schizophrenia refers to the more chronic presence of these features, but they can also form part of mood disorders like depression and bipolar disorder. Psychosis is diagnosed when it interrupts somebody’s life to the extent that they, or those around them, are significantly distressed. It is possible to have one psychotic episode and never have another. It is also possible to experience psychotic-like experiences without distress or impact on everyday functioning. In fact, psychotic-like experiences are much more common in the general population than most people think. Approximately 40 per cent of adults and over half of children in community-based research samples report “unusual” perceptions or ideas when asked. This spectrum of experience is having an increasing impact on the way mental health professionals think about psychosis. Views about psychosis are changing.
Ideas about how to treat psychosis have already changed radically over the years. Although schizophrenia was named in the early 1900s, symptoms were described long before. Historically, treatments were often motivated by fear and lack of understanding. Initial practices of social exclusion and exorcism gave way to Victorian asylums and invasive brain operations. Only in the mid-20th century did anti-psychotic medication become available. Widespread acceptance of evidence for talking therapies has been even more recent. Current treatment of psychosis and schizophrenia no longer has medication as its sole focus, but includes provision of psychological treatments for individuals and their families, as recognised in National Institute for Health and Clinical Excellence guidelines.
Cognitive behavioural therapy (CBT) and family intervention are the currently recommended talking therapies for psychosis. CBT identifies unhelpful thoughts and behaviours and works to discover alternative possibilities. It conceptualises the problem not as the unusual experiences themselves, but the meaning attributed to them and resulting behaviours. So with Helen, instead of getting into a tug-of-war about whether or not the TV judges were listening to our conversations, we thought together about whether this was a good or a bad thing, and what alternative possible ideas there were about what was going on. What did her family and friends think? What did the ward psychiatrist think? How much did she believe each explanation? What would it mean if each explanation were true? It became clear that letting go of the feeling of being watched would be too upsetting for Helen without having some other way of feeling special.
Helen was only 13, but she had experienced a clinically significant psychotic episode. Some children even younger than this report having unusual (or psychotic-like) experiences, which upset them and which impair their everyday life, but not so much that teachers or family might notice. While this is not full-blown psychosis, these experiences are still distressing and functionally unhelpful, and left unchecked, might become a more serious problem. Brand new interventions using CBT to proactively target children with unusual experiences are being used in trials at the Institute of Psychiatry at King’s College London. Results are promising, suggesting that both children and adults can benefit from very early intervention and psychological help. Medical and psychological interventions are already offered for first-episode psychosis, often in young adults or teenagers. This new research suggests that heading off unusual experiences, by providing coping strategies and talking therapies before they become a bigger difficulty, might be the way that future interventions go.
Increasingly, mental health problems are being thought about on a continuum. Public perceptions of psychosis have probably been slower to catch up with this shift than with other diagnoses such as depression. Psychosis fits more with stereotypical ideas of madness, which can be frightening. Distancing people with psychosis removes from them from us and protects us from the possibility that anyone can feel detached from shared reality. Although it may seem easier to identify with and talk about feeling sad than to talk about feeling paranoid, it is likely there is also something there to which we can all relate. The feeling that others are talking about us behind our backs, an odd sense that coincidences happen in a way that benefits us in particular—these are not so far removed from the everyday. Ideas about psychosis are changing as we realise that anomalous does not equal uncommon, for anyone and at any age.
