If sick men fared just as well eating and drinking and living exactly as healthy men do…there would be little need for the science [of medicine].—Hippocrates
The 180-page report by the British Psychological Society (BPS), “Understanding Psychosis and Schizophrenia,” released November 27, 2014, is clearly a well-intended document.1 According to the Executive Summary, the report concludes:
“. . . hearing voices or feeling paranoid are common experiences which can often be a reaction to trauma, abuse or deprivation; there is no clear dividing line between ‘psychosis’ and other thoughts, feelings and beliefs; for many people, though not all, experiences such as hearing voices or feeling paranoid are short-lived . . . [and] more generally, it is vital that services offer people the chance to talk in detail about their experiences and to make sense of what has happened to them."
I doubt that many psychiatrists would disagree with the general thrust of these claims, or with some of the report’s “feel good” generalities, such as “. . . each individual is unique and the only way to find out what will help a particular person is to explore their particular situation with them, and then support them to try things.” And, despite a decidedly jaundiced view of both psychiatric diagnosis and antipsychotic medication, the report acknowledges that “. . . many people find that ‘antipsychotic’ medication helps to make the experiences less frequent, intense or distressing.” Finally, to its credit, the report stresses that we “need to invest in prevention by taking measures to reduce abuse, deprivation and inequality.”
Unfortunately, the report also contains numerous straw-man arguments that I will not try to rebut here; for example, the notion that the term “schizophrenia” necessarily refers to a “brain disease.” On the contrary: the term “schizophrenia” is correctly applied to a generalized and pervasive condition of the person,* with dysfunctional manifestations in the cognitive, sensory, emotional, and behavioral realms. To be sure: schizophrenia is often associated with neuropathology, but that is neither necessary nor sufficient for the diagnosis, as the DSM-5 criteria make clear.
Moreover, some of the assumptions in the BPS report sound like caricatures of what knowledgeable psychiatrists actually believe or assert; for example, the report states, “It is often assumed that there is a straightforward dividing line between ‘mental health’ and ‘mental illness’ (normality and abnormality) and that discrete, identified disease processes (for example ‘schizophrenia’) are responsible for experiences such as hearing voices.” [Sec. 3.1]
I wish the report’s authors had specified who, exactly, “often assumes” such simplistic nonsense, since psychiatrists surely do not. Here, for example, is a quote from the DSM-5’s Introduction:
“The boundaries between normality and pathology vary across cultures for specific types of behaviors. Thresholds of tolerance for specific symptoms or behaviors differ across cultures, social settings and families. Hence the level at which an experience becomes problematic or pathological will differ . . . [Moreover] although some mental disorders may have well-defined boundaries around symptom clusters, scientific evidence now places many, if not most, disorders on a spectrum with closely related disorders that have shared symptoms, shared genetic and environmental risk factors and possibly shared neural substrates.”
But in my view, the most serious failure of the BPS report is in the area where one might expect psychologists to excel; ie, in understanding the phenomenology of psychotic states and illnesses like schizophrenia. (The philosophical meaning of phenomenology denotes “the study of structures of consciousness as experienced from the first-person point of view”—Stanford Encyclopedia of Philosophy). Understanding the phenomenology of psychosis entails understanding how most persons see themselves and the world, when they experience putative psychotic symptoms, such as delusions of persecution, the belief that their thoughts are being controlled by an outside force, etc.
What is lamentably missing from the BPS report is any deep understanding of the psychic suffering occasioned by severe and enduring psychotic states, including but not limited to schizophrenia. Indeed, I believe the BPS’s attempt to “normalize” psychosis winds up trivializing the immense psychic pain and agony experienced by many persons diagnosed with schizophrenia and related disorders of reality perception.
For example, the report asserts, “Many of us hear voices occasionally, or have fears or beliefs that those around us do not share.” Well, yes—but this shallow and superficial description of the psychotic experience does scant justice to the nightmarish reality of severe psychotic states. It is a bit like saying to someone with advanced cancer, “Many of us experience very rapid cell growth occasionally, or have lumps or tumors that others do not have.”
Yes, the BPS report gives a perfunctory nod to the fact that, “Experiences such as hearing voices are real experiences for the person having them, and can lead to very real distress.” [3.4.1] But “distress” hardly captures the inner world of those with severe forms of psychotic illnesses. Terms like “agony,” “torment,” and “anguish” would be much closer to the mark, for many patients with severe psychotic illnesses.
1. Cooke A (Editor). Understanding Psychosis and Schizophrenia. British Psychological Society. https://www.bps.org.uk/system/files/user-files/Division%20of%20Clinical%20Psychology/public/understanding_psychosis_-_final_19th_nov_2014.pdf. Accessed December 22, 2014.
2. Arieti S. Interpretation of Schizophrenia, 2nd ed. New York: Basic Books; 1974.
3. Bowie CR, Harvey PD:.Cognitive deficits and functional outcome in schizophrenia. Neuropsychiatr Dis Treat. 2006;2:531–536.
4. Frances A. Pro and Con: The British Psychological Society Report on Psychosis. Psychiatric Times. December 19, 2014. http://www.psychiatrictimes.com/blogs/couch-crisis/pro-and-con-british-psychological-society-report-psychosis. Accessed December 22, 2014.
5. Saykin AJ, Shtasel DL, Gur RE, et al. Neuropsychological deficits in neuroleptic naive patients with first-episode schizophrenia. Arch Gen Psychiatry. 1994;51:124–131.
6. Pies RW. On myths and countermyths: more on Szaszian fallacies. Arch Gen Psychiatry. 1979;36:139-144.