What is “psychosis” and who decides who is “psychotic”?
December 12, 2006What is “schizophrenia?”
January 15, 2007(Note, this is a very old post, and at least many of the problems reported with the EAST program no longer exist, as they have been open to making some changes. This post however does still describe problems that exist with many suppposedly “progressive” programs which really still follow an excessively narrow and inaccurate “medical model.”)
The following exerpt is part of an email I wrote to Kathy Savicki, the director of an early intervention in psychosis program in Oregon called EAST. (You can find out more about EAST by checking out www.eastcommunity.org.) While this program can be praised for at least bringing up the issue of recovery, it also apparently suffers from very serious flaws due to the way it pushed a biological explanation for psychosis – both common sense and research tell us that when people believe their mental problems are biological, they feel less able to do anything about them. Since empowerment is a key factor in recovery, and since biological theories are highly speculative, then biological theories should never be presented as fact. “I found some things about your program that I liked very much, but also some apparent problems which I would like to discuss with you. Since you have taken a forward looking approach in being involved in new programs, I am hoping you are open to hearing different and probably controversial ideas, even if critical of some aspects of your program!
I was pleased to see the many references to cognitive therapy for psychosis, which I practice and teach. I was the person who applied for and then lobbied to get cognitive therapy for schizophrenia and other psychotic disorders accepted by the state of Oregon as an evidence based practice. The state originally rejected this application on the basis of their belief that cognitive therapy for psychosis was already included within another evidence based practice called “Illness Management and Recovery” which attempted to combine psychoeducation based on the medical model of psychosis with cognitive therapy. I successfully argued (with help from Kingdon and Turkington in the UK) that cognitive therapy for psychosis cannot be successfully combined with “medical model” psychoeducation, since they are incompatible models.
So, while I am happy to see the references on your website to cognitive therapy for psychosis, it also seems to me that there has been an attempt to combine it with a medical model psychoeducational approach incompatible with cognitive therapy. I will try to explain what I mean.
One problem has to do with the way psychosis is explained. The EAST site never lists trauma as a possible contributing factor to psychosis, and in the FAQ section even asserts that “Multiple personality disorder” refers to a dissociative disorder in which people respond to severe trauma through fragmenting their personality. Schizophrenia is a biologically based information processing disorder.” This suggests a belief in a clear line between something like dissociation which is caused by trauma, and the psychosis in schizophrenia caused by “biology.” Yet, if you read “Cognitive Therapy of Schizophrenia” by Kingdon and Turkington, you will find that using a formulation that refers to the role of trauma, if present, is standard in such therapy. This rests on a strong research based background about the role of trauma in apparently causing psychosis in many cases; I’m attaching an article titled “Childhood trauma, psychosis and schizophrenia: a literature review with theoretical and clinical implications” for your review in reference to this.
The distinction your site makes between dissociation and psychosis also seems to lack a solid basis. This issue is discussed in another article I am attaching titled “Are psychotic symptoms traumatic in origin and dissociative in kind?”
I think this issue of the role of trauma is critical, because it has powerful implications for recovery. As a case example, a friend of mine, who is now on the Human Rights Commission in Eugene, spent years in state mental hospitals with a diagnosis of paranoid schizophrenia. He credits the turning point in his recovery as when he began to be able to relate his own confusion to the confusing and traumatic things that had happened to him in his life, and he began to be able to make sense of his story and his experiences. Many of my clients also have traumatic backgrounds, and many of their apparently “psychotic symptoms” clearly relate to the difficult experiences in their past. It seems to me that if we are to ever help them make sense of what is going on in their brains, we will have to address this.
I also noticed that the EAST site claims that psychosis is known to be the result of a “chemical imbalance.” I understand there are some theories to that effect, but shouldn’t these be introduced as theories rather than fact? As I understand it, evidence for a distinct chemical imbalance is quite weak or lacking entirely. (I’m including a copy of a few pages from Richard Bentall’s book “Madness Explained” that summarizes some of the findings regarding dopamine.) Or is there conclusive evidence about some kind of chemical imbalance that I haven’t heard of? I like the stated emphasis on the EAST website about the importance of having frank and honest discussions about medications with people, but to keep them honest, I think it is important to refrain from introducing any conjectures as fact.
I also noticed an apparent assertion that sleep deprivation should only be considered to be a cause for psychosis if the psychosis clears up when the person gets enough sleep, and drugs should only be considered a cause if it clears up reasonably soon after the drug use is discontinued. This explanation seems to contradict the practice in cognitive therapy of looking at causation in a complex way and of identifying predisposing, precipitating, and perpetuating factors in the causation of psychosis. According to the latter approach, sleep deprivation may have precipitated the psychosis, but it may then be perpetuated by things like a catastrophic interpretation of the psychotic symptoms, withdrawal of social support, coping attempts that inadvertently make things worse, and other factors. Tracing out the chain of events and interpretations that keep psychosis going is a key part of cognitive therapy, but your website seems to discourage anyone from doing this (again, in preference to a “biochemical imbalance” model.)
Finally, I noticed some surprising limitations in the stated purposes of cognitive therapy as listed within a pdf file on the site. Just as cognitive therapy for depression attempts to eliminate the symptoms of depression, cognitive therapy for psychosis attempts to eliminate the symptoms of psychosis. That is, if the person appears to have a delusion, cognitive therapy attempts to change the belief, etc. Research into cognitive therapy for psychosis shows it is often effective in reducing such symptoms. Yet the goals stated for cognitive therapy for the EAST program seemed to be more about adjusting to having the illness, and failed to mention any possibility of symptom reduction. I found that odd, and it suggested to me that your program has not yet taken a real cognitive approach, and is still relying too much on the medical model.
I have noticed that therapists who believe that a particular symptom is strictly “biological” or “biochemical” tend to give up on attempting to do psychological work with a person to change that symptom. I have noticed as well that consumers who subscribe to such beliefs are also more hopeless about changing them through any route other than medications (which are often not effective or only partially effective anyway, leaving the client at a dead end.) A recent review article describes the way medical model beliefs tend to actually increase stigma as well as hopelessness, and I think should be must reading for anyone interested in cognitive therapy and the role of beliefs in relationship to schizophrenia and psychosis, as well as for anyone interested in the reduction of stigma. I’m attaching that article as well.
I know a lot of what I’ve written here may appear very controversial, but I hope it has also caught your interest and you will look into it further. I would appreciate the opportunity to discuss some of these issues with you and/or some members of your staff. I look forward to hearing from you.”
Anyone who wants a copy of the articles mentioned in this post should email me at ronunger @efn.org (note that my actual email address doesn’t have a space, I inserted that here just so programs that try to harvest email addresses from websites will be frustrated. So delete the space before you send me an email!)
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Ron Unger
Ron Unger is a therapist and educator specializing in cognitive behavioral therapy for psychosis, with a special interest in the relationship between trauma, psychosis, and spirituality.
