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Understanding Psychosis and Schizophrenia

What are the psychological and social processes that contribute to psychosis?

What is schizophrenia? Well first and foremost it’s simply a label. It’s a name given to a diverse set of symptoms that includes hearing voices, feeling paranoid, or seeming out of touch with reality. However, the term ‘schizophrenia’ is also a mental health diagnostic category, and this is where our conceptions of this term start to get confused. Even as a diagnostic category – it is still defined by a set of symptoms – not by its causes (because we don’t yet have a good picture of what the causes are). So, as soon as someone is given a “diagnosis” of schizophrenia there is the immediate temptation to think it represents an underlying cause that ‘explains’ the symptoms – for example, how often do we hear the phrase “she is hearing voices because she has schizophrenia”. That is simply re-describing the symptoms – not explaining them!

What is also important – and misleading – about having ‘schizophrenia’ as a diagnostic category is that it implies a medical model of the symptoms. It implies that people who have these symptoms are “ill”, that there is a biological dysfunction of some kind underlying the symptoms, and that the best form of treatment would be a medical one involving medication. And perhaps most important for our conception of psychotic symptoms – conceptualizing schizophrenia as an ‘illness’ in this way misleadingly implies that the best way of understanding psychotic symptoms is through medical and biological research, to the detriment of psychological research and psychological understanding of the individual.

This month, the British Psychological Society Division of Clinical Psychology has published a report that attempts to highlight some of the misconceptions that surround psychotic symptoms. The important points that the report makes are:

  • Hearing voices or feeling paranoid are not symptoms of illness, but are commonly experienced by most people, and these experiences can be exacerbated by trauma, abuse or deprivation.
  • It is a myth that people who do hear voices or feel paranoid are generally violent.
  • While many people with psychotic symptoms find that antipsychotic medication helps to make their experiences less frequent, intense or distressing, there is little or no evidence that this medication corrects any underlying biological abnormality.
  • A majority of research on psychotic symptoms is medical, biological or genetic, and this is often at the expense of the development of psychological models of psychosis. Much more attention needs to be directed at the psychological and social processes that contribute to the development of experiences such as hearing voices and feeling paranoid.
  • With these facts in mind, mental health services should not insist that people with such symptoms view themselves as ‘ill’. Many people in such circumstances see their symptoms as aspects of their personality and identity and need psychological help to understand these experiences, to discover how their experiences might have developed, and need help to manage them.

The report also notes that there is a real need to invest in prevention programs – concentrating on treating existing problems is like “mopping the floor while the tap is still running”.

We really do need to develop conceptualizations of psychosis in psychological terms, to develop psychological models of these experiences (and not just rely on biological or genetic models), and to pursue the quest for effective psychological interventions that can address these experiences and help the individual to understand them. None of this will happen unless (1) the general public have a better understanding of how common the experiences of hearing voices and feeling paranoid are (something that should help to reduce the stigma associated with these experiences), (2) funding bodies understand the significance and relevance of promoting research on psychological models of these experiences, and (3) mental health services develop and provide effective psychological therapies for these experiences.