Mind over medicine

Mental health professionals should look beyond the medicalisation of
psychosis and recognise the relevance of traumatic life events, writes Dr
Warren Larkin

Warren Larkin
Friday May 11, 2007

SocietyGuardian.co.uk

The word "schizophrenia" has different meanings for different people, most
of them negative. Being diagnosed as schizophrenic leads to fear,
hopelessness and stigma for many.
Others reject the concept and the psychiatric system that pathologises them,
instead preferring to try to make sense of their experiences in a more
personal way, seeking the support of user-led groups such as the Hearing
Voices Network.

Some biologically oriented psychiatrists and drugs giants continue to
promote the notion of schizophrenia as a degenerative brain disease with a
strong genetic component. Mental health professionals and service users and
their families are told psychosis has something to do with dopamine - a
brain chemical - and that drugs can treat this biological abnormality.

Conversely, many psychologists researching and working therapeutically with
people who experience psychosis now prefer not to use the unscientific term
"schizophrenia" at all. They prefer instead to research and work with the
specific psychotic experiences that people describe commonly, such as
hearing voices, paranoid thinking, unusual or distressing beliefs and
disorganised thinking.

Psychological treatments are based on the assumption that mental distress
can be understood and that psychotic experiences are meaningful and
understandable in the light of a person's life experience. There is also a
strong body of evidence to support the effectiveness of cognitive
behavioural therapy (CBT), in the treatment of schizophrenia, and the
National Institute for Clinical Excellence (Nice) has issued guidance to NHS
trusts stating that CBT and family interventions should be offered to all
service users and their families and carers.

Around one third of patients taking anti-psychotic medication obtain no
therapeutic benefits at any dose. Drug treatments certainly can provide
symptomatic relief for some people, but distressing side-effects, such as
weight gain and sexual dysfunction, are still common and, on balance, some
service users conclude that the costs outweigh the benefits. Approximately
half the people prescribed these drugs stop taking them, largely because of
the adverse effects.

Those whose symptoms are well controlled by medication still face many
obstacles on the road to recovery. For many people, an important element of
recovery is about making sense of what happened to them.

There is now a considerable body of evidence that points to a link between
traumatic life events and the development of psychosis. For too long this
sort of research has been discouraged by an overemphasis on neurons and
genes. Fear of "family blaming" has also contributed to decades of silence
on this issue.

Two facts are important here. Firstly, all families do the best they can
and, if parents are struggling in their parenting, it is important that the
difficulties, abusive or otherwise, are identified so that help can be
offered to the family as a whole. Secondly, much abuse - particularly sexual
abuse - takes place outside the family.

A recent review of more than 70 studies by a group of leading academics
found that, overall, 69% of female patients diagnosed psychotic reported
either physical or sexual abuse in childhood, with the figure being 59% for
male patients. In addition, several sophisticated large-scale studies have
concluded that child abuse is a causal factor for psychotic experiences
(Jansenn et al 2004; Bebbington et al 2004; Whitfield et al 2005).

Moreover, studies have confirmed specific causal relationships between abuse
and hallucinations. For example, a survey of 17,337 Californians found that
after controlling for substance abuse, gender, race and education, those
with the greatest number of adverse childhood experiences were 4.7 times
more likely to have experienced hallucinations.

While abusive and other traumatic experiences aren't reported by everyone
who experiences psychosis, mental health professionals need to be routinely
trained to ask about this, to respond appropriately and to offer information
about the treatment options including psychological therapies.

There are clearly complex and multiple interactions between trauma and
psychosis. It is exciting to see researchers from both biological and
psychological disciplines joining forces to discover the specific mechanisms
by which childhood abuse and other traumatic experiences lead to psychosis.

It is possible that the consequences of traumatisation convey a
vulnerability to psychosis. Negative beliefs about the self, the world and
other people that arise as a consequence of trauma are common in those
experiencing psychosis. Paranoid thinking has been demonstrated to be common
in those who have been traumatised, and many studies have observed that
traumatic experiences are often reflected in the content of hallucinations
and delusions.

Psychotic experiences appear to be regarded by many people as normal and do
not necessarily lead to distress or disability. Research has shown that
psychotic experiences are essentially normal phenomena that occur on a
continuum in the general population. However, traumatic life experience may
be the factor that differentiates those who become psychiatric patients and
those who do not.

Although the medicalisation of pyschosis continues to dominate in mental
health care, psychosocial research and the theoretical models that are being
developed from it allow psychological therapists and those who experience
psychosis to develop a shared understanding of psychotic phenomena, in a way
that not only guides the therapy process but also offers a compassionate
perspective and hope for recovery.

Dr Warren Larkin is an NHS consultant clinical psychologist and author of
the book Trauma and Psychosis: New directions for theory and therapy,
published by Routledge.

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