Understanding psychosis and schizophrenia - a BPS report

The Division of Clinical Psychology of the British Psychological Society (BPS) just published an interesting and controversial new report entitled "Understanding psychosis and schizophrenia". Despite a wide scope, a long list of collaborators under the drafting and joining hand of Anne Cooke, and clearly positive intentions, I was overall disappointed by elements of radicalism for its own sake, what seems a limited respect for science, and the omission of a historical context.

The authors probably believe passionately that what they are proposing would be a great help to alleviating suffering, to people with psychotic experiences, and to people in distress more generally. Yet, precisely because these are largely professionals, who are familiar with general views (including in other countries) about the topic, they could and should be aware how out-of-line some of their views are and how much they repeat old ideas that were aired in the late 1960s and 1970s, and have never found general acceptance.

So despite my respect for the authors and their good intentions, given that this is a high-profile public document, I will concentrate on what I do not like about the report. The report itself is quite readable, though not, I think, as much as the authors suggest. Whereas they seem to say that they would like to distribute the report to anyone, people with psychotic experiences, carers, the general public, I would not go further than saying that the report should be readable for mental health practitioners.

The famous Mental Elf has published a blog that came out on the day of publication, which is really good and very much worth reading. The main contributions are from Prof Keith Laws, Alex Langford, Samei Huda, and in the comments a substantial, excellent and balanced comment by Dr Vaughan Bell. I assume that readers of this blog are sufficiently interested by the report that they will read the Mental Elf blog, and will avoid most overlap. I try to focus on some topics that concern me, and I believe got less attention by the Mental Elves.

1. The report's usage of words and understanding of psychosis and schizophrenia, a core objective, is inconsistent and insufficiently supported by evidence.

2. It overstates the effectiveness of talking therapies in helping people with psychotic experiences.

3. It appears to be confused about the legal position on refusing treatment in England and Wales.

4. The report's approach, ideas and recommendations are at times positive in general terms, but have many drawbacks as regards their utility for many people with psychotic experiences.

5. The report pays insufficient attention to history and what can be learned from history.

1. The meaning of psychosis, schizophrenia and experiences

The main inconsistency, incoherence even, concerns the report's central topic. The authors do not make clear what their position is. At times (e.g. p.113) they repeat the Laingian mantra that there is no dividing line between psychosis and normality. And they make other statements and quote sources to the effect that psychosis and schizophrenia don't "really" exist. However, as this is a real-life publication and given that in most of the report they talk about "something", they aren't really writing about something that doesn't exist. The authors understand and agree that something happens in the experience of some people. Here they move to a second problematic move - believing that calling something by a different name will make a material difference.

In most of the report they talk about "the experiences", by which they (mostly) appear to mean "psychotic experiences" as many people in mental health would call them (In fact they use "experiences" 298 times, "psychosis" 124 times, and "schizophrenia" 77 times in the text part of the report). My point is that they mount heavy criticism of the terms psychosis and schizophrenia, but believe that if the same human phenomena are relabelled as experiences, this will make a material difference to the world. I am doubtful about this. There is an endless history of doing this (learning disability is a similar example, and has been relabelled many times during the 20th century, especially in Britain), but it does not seem to make a noticeable difference.

This is especially bothersome as they spend much time saying that psychosis and schizophrenia aren't "real". But if they describe the same kind of goings-on as "the experiences", why would the reality of the first two not be the same as the reality of the experiences?

They don't seem to mind the use of more technical expressions. In some specifications of what is or isn't schizophrenia, they are happy to use the words "delusions" and "paranoia", and also use "hallucinations", though for the latter they prefer "hearing voices".

A further problem is that their meaning of "experiences" seems rather variable. At times they appear to say that the experiences can't be defined, and at times they say that the experiences they mean cannot be distinguished from the experiences of people with anxiety, depression, PTSD or personality disorder, or even that "everyone" has these experiences. However, in most of the report they use the word experiences for a range of experiences that many mental health workers would call psychotic or schizophrenic.

The most confusing example of this is on p.89, where it seems to be suggested that flashbacks (as in PTSD) and dissociation may well be the same as psychosis. The authors then make an even more interesting leap, and suggest that the trauma work of authors like Judith Herman, Colin Ross and the van der Hart group (focused on PTSD, complex PTSD and dissociation) means that “psychologists have adapted trauma-focused approaches to therapy in order to help people who experience psychosis”. This seems far-fetched for anyone familiar with this literature, and in any case not related to research evidence. I do not think there is a precedent for people trying to argue that these groups of symptoms or experiences are all the same, or indistinguishable. And this is most definitely not the view of the authors they mention.

As regards their specific criticism of DSM-5, from which they quote the complete criteria for schizophrenia, the authors don't seem to have drawn the consequences from this text as it stands. The DSM diagnosis of schizophrenia is only made when other symptoms than hearing voices alone are present. And DSM only diagnoses schizophrenia when a certain set of symptoms lasts for more than 6 months, and is combined with real problems in living - "level of functioning in one or more major areas, such as work, interpersonal relations, or self-care, is markedly below the level achieved prior to the onset of the [problems]". The report writes that many people have "the experiences" without suffering from them or having any distress - but if there's no distress, this would disqualify them from a DSM diagnosis of schizophrenia. This takes most of the wind out of the sails of section 4.

In some places the authors are attacking positions that are not really held on any scale, except perhaps in popular media and press. E.g., there are few if any serious attempts of mental health practitioners to say that diagnoses are "the only way" of looking at a person's experiences, or that diagnoses are "the most helpful way". A way, yes! But no more. (Section 3.5)

As part of their critique of the diagnostic categories in DSM (and ICD) the authors announce their preferred alternative as a new "formulation" approach, but fail to mention that this does not exist, and has nowhere been worked out operationally. Not in Britain; not in other countries. (Section 3.6)

2. The effectiveness of talking therapies

This is very well treated in Prof. Keith Laws part of the Mental Elf blog about the report, so I will be short here.

I am surprised about the report's treatment of the relevant NICE guideline (the NICE Guideline on psychosis and schizophrenia in adults; CG178). It mentions the guideline a number of times, but the authors manage through selective description and even quotation (e.g. p.87 and p.92) to leave the impression that the Guideline recommends CBT for all people with a schizophrenia diagnosis, and is open-minded and flexible about anti-psychotic drugs. The Guideline is quite clear, in sections 1.3.4 and 1.4.2 about treatment recommendations, that it expects antipsychotics to be offered to everyone with an acute psychotic episode or a diagnosis of schizophrenia, as well as CBT. The guideline specifies: "Advise people who want to try psychological interventions alone that these are more effective when delivered in conjunction with antipsychotic medication" (section 1.3.4.2) This advice is not mentioned in the report. Neither is the NICE guideline's recommendation to consider art therapy as an option for people with schizophrenia.

3. The right to refuse treatment

In sections 13.2 and 13.3 it is stated that the current attitude in NHS and social services is that “the ‘patient’ role is to obey the ‘advice’”. However, as far as I am aware, English law, NHS guidelines for doctors and medical and social work training seem to be consistent and clear on this point. As shown by decisions of the General Medical Council and the website NHS Choices, any adult with mental capacity has the right to refuse any form of treatment. And the Mental Capacity Act starts by saying that every adult is presumed to have capacity. (Section 13.4 is written as if this is not the case). There are indeed people who get drugs administered involuntarily, but this happens in a minority of well-defined situations, and is more related to behaviour than to diagnosis. At least this is my understanding.

4. What is helpful for people with psychotic experiences?

The report's discussion about antipsychotics is well reviewed in the Mental Elf blog.

The report seems misleading in its attack on the biological side of psychotic experiences. They partly attack positions that are not held by any professionals about the separation between mind and body or separating nature from nurture. Do the authors think human experiences can take place in the mind or in the soul (à la Descartes) without anything physical / biological changing in the body? Do they believe that antipsychotics do not affect dopamine receptors? Do they believe that the concept of illness implies an "underlying biological abnormality"? It is not made clear. In my view they suggest that they are on to something novel and important, but what they say either does not make sense, or has been known since the early parts of the 20th century.

5. The history of the ideas in the report.

At times I felt like being in a time warp, having returned to the late 1960s, when I first read exactly the same ideas as in the report from the pen of RD Laing and David Cooper. For some reason the authors pretend that their ideas are novel, by the odd reference to "recent research". But I don't believe there is are any major general ideas in the report (with the exception of course of the discussion of NICE guidelines and specific results of CBT trials) that was not already around in 1970. And the strange thing is that this isn't mentioned. In particular any reference to R D Laing (1927-1989) is missing.

Equally concerning is that on the matter of talking therapies for schizophrenia, a central concern of the report, the authors write as if this is a new idea, based on new evidence deriving from the last 10 to 15 years. In my view this distorts the historical picture. Psychotherapists have tried to use psychotherapy to work with people with psychotic experiences since the start of psychotherapy around 1900. There is an enormous tradition, with voluminous literature, of these attempts. Authors that should at a minimum have been mentioned would be Sullivan, Binswanger, Searles, G Bateson and the MRI, Arieti, Prouty, Esterson and Laing. Moreover, since 1945 there have been countless psychoanalytically oriented therapists working with psychotic clients. Much of this has been unsuccessful, perhaps at times misguided, but there has been much to be learned from the attempts. Also, family therapy, which is recommended by the authors, has been substantially informed by the pioneering work of Bateson and Esterson / Laing.

Overall, as stated, I was disappointed by the report, and believe it may do more damage than good by its biases, in particular its methodological weaknesses and the examples it sets of supposedly easy "common sense" reasoning that is not linked to research evidence or to verifiable solid sources.