Descent into psychosis can happen all at once, like a fog bank blowing in. It can lap in slowly, like the tide, so as not to be noticeable. It can be short lived and not return, or be chronic and degenerative. Psychotic does not mean deranged, it does not mean evil, it does not mean bad. It is not having many selves, it is not Dr. Jekyll and Mr. Hyde. It is a loss and a fracture of reality—and of self.
In this article I attempt to define psychosis as a clinical manifestation, discuss how it is commonly seen and misunderstood in the culture, and explore the ways that psychosis can be re-conceptualized from a clinical framework to an extreme but understandable part of the human experience. As I do this, it is not my intention to diminish the suffering and the very real need for treatment of these symptoms. I ask the reader to consider that these concepts can co-exist, that there is a way a psychotic mind isn’t so far at all from the tendencies of a typical mind—that it is understandable, and also that symptoms can be so distressing and disruptive that medical, social, and psychotherapeutic support are needed for the individual and their family. In explaining and normalizing, I don’t profess to be an expert or the end all be all authority on the matter, but I do think it is a complex and important subject to speak to and that it afflicts many people’s lives. Lastly I offer suggestions and inquire into ways people with lived experience and their allies can address the isolation and stigma that can come with experiencing this condition.
Psychosis is composed of some or all of the following symptoms:
1) Delusions: Persistent false beliefs, for example, “people on the street can read my mind” or “I am dead”.
2) Hallucinations: False sensory experiences that can affect any sensory system: sight, smell, touch, taste, or hearing, for example, hearing voices or seeing visions.
3) Thought Disorder: Disruption in thinking and formulating speech, for example speaking tangentially or haltingly.
4) Negative Symptoms: The absence of behaviors that would otherwise be present, for example, blunted expression and monosyllabic speech.
Psychosis often emerges, unjustly, in early adulthood at a time when young adults go through changes in identity, in physicality, in cognition and often in location (moving for college or work). It emerges when youth are the most impulsive, headstrong, and often don’t have an adult’s sense of responsibility or esteem. Yet the symptoms take chronic care, tenacity, tenderness, and patience to stabilize and recover from.
In this developmental time of fragile identity, there can be a drift towards self-stigma, self-hate, and isolation — a feeling as if one is not enough, is the “other”. The media can tend towards a whitewashing of psychotic manifestations into stock characters who are all the time mumbling and unhinged. It can be challenging for young adults not to internalize these messages. How difficult it can be, then, to muster the energy for self-care and the maintenance of social connections one needs to manage a difficult illness. Tendencies towards attacking the self and isolating can be potentiated by the way that our society relates to and spins narratives of the psychotic experience. Listening to mainstream thought, psychosis seems only unintelligible and threatening.
Ironically and despite media messaging, people with all types of mental illness account for only 3-5% of violent acts[1],and people with psychosis are much more likely to be the victim of a crime than its perpetrator. In addition, people with psychosis are not rare—they are found all around us as they are 1-4 % of the population[2]
Some people live well despite psychosis. Those who are able and lucky enough to manage their illness have families, work and socialize[3] People observing from the outside wouldn’t know that sometimes at work, when symptoms flare, the person experiencing them is ignoring delusions and voices that are disruptive and sticky. They are coping in the same way some with depression or anxiety do, by trying to let go of or challenge their negative thoughts/voices, self-soothing, or calling a friend, family member or treatment provider.
Not only can people with psychosis appear and often feel well and be integrated into society, psychotic symptoms themselves are not divorced from the human experience. They are part of the spectrum of human consciousness, integrated into the human experience.
To explore how these symptoms are an extension of the machinations of the typical mind, let’s begin to break down and tease apart the positive symptoms of psychosis. Positive symptoms are those that add to the experiences of a person, as opposed to negative symptoms, which take away experiences. The two positive symptoms of psychosis are hallucinations and delusions.
Hallucinations, one of the hallmarks of psychosis, are not just experienced by those with psychosis, they are said to be experienced by up to 10% of the population, and this number increases to 75% when talking about one- off or nominal experiences[4]. Many of us can have an unusual sensory experience, hearing our voice being called when no one is there or seeing a shadow at night. Most people’s minds will compare the voice or shadow to all their past experiences of reality and then dismiss these experiences as not real and be able to move on. This skill is referred to in clinical practice as “reality testing”.
In the clinical literature, the lack of ability to reality test is the crux of what defines a psychotic disorder[5]. In psychotic disorders, the mind does not know what to dismiss. It cannot compare an aberrant experience with past non-aberrant experiences and conclude that the aberrant one is not credible. In experiencing voices, visions and delusional beliefs, a person’s reality testing can be impaired a lot, a little or not at all. Belief in the veracity of hallucinations and delusions exists on a spectrum; it is not an on off switch. When psychotic illness gets better it is often experienced by the person as a scary or disruptive belief and/or hallucination becoming less “real” and easy to dismiss. When the illness gets worse the belief and/or hallucination becomes more “real” and it can become all consuming.
The Hearing Voices Network, an advocacy and community building group for people who experience voices and see visions, for people with all levels of reality testing, states, “People of all ages and backgrounds can hear voices at some point in their life, for many different reasons. Whilst some are distressed by their experiences, people can – and do – find ways of living with them.” And people do. Learning to strengthen, by practice and assistance, one’s ability to reality test is one of the many skills used in working effectively with psychotic symptoms.
Then there are delusions. These false beliefs generally emerge as people develop stories to explain what is happening to them, and why. Sometimes these delusional stories can be bizarre, or unlikely to happen, like thinking one is a werewolf (clinical lycanthropy), they are not always. Sometimes people believe perfectly common things, that another loves them fiercely for instance, or is cheating on them, or that there is a gas leak poisoning them. Only in this case those beliefs are false. However, even when the stories are bizarre, it is not just people with psychosis who have bizarre thoughts.
There also exists a spectrum of accepted non-psychotic non-rational beliefs. Some mainstream beliefs on this spectrum are ghosts, superstitions, horoscopes, predicting the future etc. For some these beliefs are comforting, for others they seriously interfere with people’s lives. There may not be a way to demarcate beliefs from delusions per se, except that beliefs are held by community and culture whereas delusions are held idiosyncratically[6].
When someone is psychotic and unable to reality test, beliefs are developed and held firmly because they explain in some way what is happening in the person’s world. This includes why they are experiencing hallucinations, thought disorder, and/or negative symptoms. For example, if someone is seeing ghosts (hallucinations) cannot hold onto their thoughts (thought disorder), and is not experiencing emotional range (negative symptom), they may come up with a story that they are dead (Cottard’s Delusion). This search for narrative and flow is the tendency of human minds– we were assigning and absorbing the meanings of singular and collective experiences at prehistoric gatherings around fires, while writing epic creation myths and collecting and documenting fairy tales. We do this still while writing memoirs and binge watching and posting comments about newly streaming shows.
The hearing voices network states of its constituency, “We do not exist inside a bubble. Whatever their origin, voices (and I would argue other hallucinations and delusions as well) are linked to our relational, social, cultural, spiritual, historical and political worlds.” Psychotic symptoms are often not so opaque that some meaning or linkage to consensus reality cannot be forged.
Delusional beliefs can come from somewhere outside a person as well, the themes are often found swirling in the cultural milieu. Before TV and radio, no one thought they were on a reality show (Truman Show Delusion). Before worries about aeronautics, airplanes and space shuttles, there were no delusions about flying saucers.
What is happening in a family or a culture can show up as illnesses in the minds of the vulnerable. And so, what does it mean to be “crazy” in this society? Surely one of the meanings is to experience deeply the traumas the culture tries to disown and deny—the end of the world, the terror of one’s death, the vulnerability of one lone person against a powerful society.
It may be in part because of this phenomenon, that the psychotic experience has been so deeply “othered”, pushed away, sectioned off from the accepted forms of human experience—perhaps because it is too painful, too prescient, too scary to collectively bear. It seems the fear and stigma from our cultural shadow has been laid down heavy onto people with psychosis, who suffer from this cultural bifurcation between the “sane” and the “insane”, between what is acceptable to think and what is not. The separation is most unfortunate, but its persistence is not inevitable.
How do we, then, as people with psychosis, as family, as allies and treatment providers of people with psychosis, after understanding more fully the place of psychotic experiences within humanity, heal the split and free ourselves, our loved ones, our clients from the burden of the “othered” category?
The Disability Rights Community has advocated for drawing power and meaning from disability. The Community asks us to notice how differences make us all unique and to honor those unique experiences. What is the meaning of our own minds and souls? Where is our strength and standpoint wisdom? How can we give back? how can we connect? how can we heal? Where will our paths take us?
What fights stigma can also be, in part, the relationships we build that connect us to each other. Perhaps as we steer our own ships intentionally forward our paths will take us toward connection with others, to community, to art and creativity, to work, to faith, to family, towards pride in our ability to persist and towards our values and desires.
In the end we are all just people, psychotic or not. When we belong to a community like the Painted Brain, in person or on line, to a club, a team or family, when we have connections that give us a sense of belonging, it can be profound and it can be healing.
Belonging
can reduce stress, promote health and wellbeing, be transformative and create
deep meaning. It can help us accept ourselves just as we are. In those moments when we are able to accept all
parts of us, when we can feel accepted by others, we may find a way to breathe
a sigh of relief, heed a call to advocate for change or simply enjoy the opportunity
to be authentically ourselves.
[1] Mental Health Myths and Facts. (2017, August 29). Retrieved February 19, 2020, from https://www.mentalhealth.gov/basics/mental-health-myths-facts
[2] Perälä, J. (2007, January 1). Lifetime Prevalence of Psychotic and Bipolar I Disorders in a General Population. Retrieved February 19, 2020, from https://jamanetwork.com/journals/jamapsychiatry/fullarticle/209973
[3] Cohen, A. N., Hamilton, A. B., Saks, E. R., Glover, D. L., Glynn, S. M., Brekke, J. S., … Strauss AL. (2016, November 15). How Occupationally High-Achieving Individuals With a Diagnosis of Schizophrenia Manage Their Symptoms. Retrieved from https://ps.psychiatryonline.org/doi/full/10.1176/appi.ps.201600031
[4] Welcome. (n.d.). Retrieved February 19, 2020, from http://www.hearing-voices.org/
[5] Kleiger, J. H., & Khadivi, A. (2015). Assessing psychosis: a clinicians guide.
[6] Steel, C. (2013). Cbt for schizophrenia: evidence-based interventions and future directions. Chichester: Wiley-Blackwell.