Insider knowledge: A psychologist consumer’s perspective on psychological interventions for psychotic illnesses

Hoa Pham MAPS is a counselling psychologist who works in the tertiary education sector. She was diagnosed with schizophrenia in 2003 and has had three psychotic episodes since that time.

“My mind is playing at pick-up sticks. Somehow I have to piece it all together and make the structure stable. Somehow sort out the lived experiences from the hallucinations. All of my perceptions are suspect, what is most vivid to me cannot be depended on to be the most true.”

Insight is conventionally seen as the essential cognitive component of a psychotic illness that makes it manageable. So what happens when insight is lacking? Often clients know there is something wrong but are unable to describe what it is in clinical language. The labels of schizophrenia and bipolar disorder are still full of stigma and misunderstanding. This article describes a cognitive framework in which to view the positive and negative symptoms of these disorders which may or may not require the client to internalise a DSM-IV diagnosis. The different stages and approaches to helping clients manage psychotic illnesses are presented, including issues associated with diagnosis, the externalising of positive symptoms, and use of an acceptance and commitment framework to empower a person living with a psychotic illness. These insights are intended to provide one person’s ‘insider’ perspective on the effectiveness of interventions that may be offered by psychologists and how they can be of most assistance in empowering their clients who have psychotic illnesses. What I have written here is what I have found useful, keeping in mind that each client’s experience of psychosis is different.

Handling the diagnosis issue

I was not given the diagnosis of schizophrenia until a few months after my first psychotic episode, which was complicated by depression and made the initial diagnosis one of schizoaffective disorder. Eight years later, after a post-partum psychosis and a manic episode, I was told I had bipolar disorder. I was relieved when I went to a presentation by UK clinical psychologist and author Professor Richard Bentall, where I was informed that most clients have an average of four different diagnoses over the course of their psychotic illnesses. Illnesses change over time, and psychotic illnesses are mostly episodic with periods of wellness and remission in between. This information from a clinician is an essential part of the psychoeducation that should take place for the client. It provides knowledge and understanding of the illness which can empower the client. It helps to provide a form of ‘narrative’ hindsight for the client, striving to make patterns and to make sense of his or her world.

By the time the client has reached a psychologist he or she may have already been provided with a label to explain the presenting symptoms. However, if there has been no other contact with mental health professionals, care needs to be taken. Often open-ended questions about the nature of what is bothering the client can elicit a series of positive and negative psychotic symptoms. Though it is tempting to do so, the psychologist should try to not label the disorder. Although some clients find it is a relief to have a label, others will find it a burden. In any case, if the client is experiencing psychosis a cross referral to a psychiatrist is required. Introducing this concept may involve some gentle steering regarding the nature of the client’s illness and the nature of the health professional who has been recommended. Sometimes it is helpful to tell the client that his or her experiences are outside the norm, and that there are professionals who are used to dealing with the experiences that the client is going through.

What about the client who already has a diagnosis? An important step is asking how he or she feels about the diagnosis and the meaning of this in his or her life. This questioning will elicit any conflict about the diagnosis and the attitude to subsequent treatment. If medication compliance is a problem it is important to know what is behind this – for instance there may be some psychoeducation that could clear up a misunderstanding about treatment. Asking what symptoms are being experienced and how the illness manifests is another way of finding out and empathising with the client about what his or her experiences actually are. Sometimes the diagnosis that has been provided is short-hand for the psychiatrist to communicate with other health professionals, and given the overlap between schizophrenia and bipolar with psychotic features, care needs to be taken to not make assumptions based on the labels the client is carrying. It is always helpful for the psychologist to make contact with other treating health professionals involved in the client’s care.

Assistance to manage psychotic symptoms

The cognitive side of experiencing hallucinations, delusions, paranoia and other positive symptoms has been explored by many authors. What I will focus on here is the cognitive aspect of managing these symptoms using psychological techniques such as externalisation. Helping the client to sort out what is real and what is a symptom of the psychotic illness can be one of the biggest challenges but can also bring significant relief to the client.

When the client has insight, the symptoms can be externalised as being part of the illness and not real. When the client does not have insight, somehow it needs to be communicated that what he or she is experiencing is not part of the norm. This can be achieved by emphasising the scary aspect of hallucinations and paranoia and the client can be assisted to gently reality check the experiences. Clients may be in denial that there is something wrong, because to doubt one’s senses is probably the biggest cognitive jump of all to make. This is extremely important for treating psychologists to appreciate.

There are instances where a client may have only one positive symptom such as hearing voices, and care needs to be taken here not to too quickly make assumptions. There is an argument that people who only have this symptom are not mentally ill. In fact, there is a group in Holland that meet and concentrate on hearing voices and do not have any association with being mentally ill (for more information see Bentall (2004), Madness explained: Psychosis and human nature).

There are also cultural considerations in helping clients to manage auditory hallucinations, since for some cultures the voices may be those of the deceased or of loved ones and not be a hallucination at all. These possible cultural aspects are very important to understand. For example, my grandmother had survived the Vietnam/American war, and she frequently talked to my grandfather who was deceased. My brother and I decided that talking to Grandpa was all right. After all, they had nine sons together and were by each other’s side every day for decades. When she talked about Grandpa she was fine. However, there were other flashbacks that weren’t so fine and she did need help.

When there are delusions that are associated with violent compulsions it is especially important to establish with the client that these compulsions are not from the client’s ‘self’ but are the result of the psychotic illness. The experience of violent thoughts is among the most frightening for someone with a psychotic illness. Even if a diagnosis of the illness has not been established, the compulsions can still be externalised if there is part of the client that objects to the compulsions and is fearful. The psychologist needs to carefully tease this out, and needs to tread with care to know whether referral for forensic attention is required.

The power of acceptance and commitment therapy

I have found acceptance and commitment therapy (ACT) to be a useful model for mid- to long-term treatment of psychotic illness. ACT is a psychological intervention that teaches clients to accept unavoidable events and emotions, and focus on actions towards valued goals.

Identifying that there is an internal observer and that the psychotic illness is separate from oneself is very useful. To imagine that psychotic thoughts and manifestations are just temporary like clouds passing over the sky or leaves down a stream can make the symptoms feel less frightening. To separate diagnosis and labels from oneself and defuse these notions by separating the self from them can be liberating and powerful. Then to emphasise one’s values and core beliefs in order to reframe one’s life, rather than just being determined by the limits of the psychotic illness, is an empowering process.

Conclusion

Cognitive reframing of psychotic illnesses can be an important step in the recovery process from such illnesses. Liberating the self from positive and negative psychotic symptoms and the use of psychoeducation to empower the client can greatly assist in the acceptance of the symptoms if not the illness wholesale. Along with the possible use of medication, cognitive approaches to managing psychotic illness can reduce the likelihood of relapse and at the very least prepare the client to better manage a relapse if it does occur. The key is for treating psychologists to use their skills and cognitive interventions to find the balance between: (1) gradually assisting the client to internalise an understanding of his or her illness to enable power through knowledge; and (2) empowering the client by externalising the psychotic symptoms from the sense of self. This is a delicate balance that requires skills, care and compassion.

With thanks to Dr Brett Wilson and Alister Air for helping me to keep well.