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If there is one word in psychiatry guaranteed to create misunderstanding and even fear among lay people it’s psychosis.

Part 9 of 'The mental health workers' guide' begins our exploration of psychosis. You can view the movie files accompanying this series here.

This is partly because of the media’s insistence on confusing psychosis with psychopathy and partly because it’s so unlike most people’s experiences – or at least it appears to be.

Add to this strangeness the various diagnoses that crop up in discussions of psychosis, many of which are equally misunderstood and you have a recipe for confusion that is hard to underestimate.

The word psychosis is just a term we use to describe certain experiences or symptoms. Psychotic symptoms come in three broad groups which are:

• Hallucinations
• Delusions
• Thought disorders

Different diagnoses are made based upon which of these three symptom groups are present, how long they have been an issue for the person and what other types of symptom might also be present.

Perhaps the most well known of the psychotic diagnoses is schizophrenia but there are many others. You may also have heard of other psychotic disorders such as bipolar affective disorder, drug induced psychosis, psychotic depression, puerperal (post natal) psychosis and delirium.

None of these diagnoses automatically means ‘axe wielding murderer’ – that’s just the myth that certain newspapers use to boost their sales. They take relatively rare tragedies and blow them out of all proportion to generate headlines such as

Schizophrenic kills baby in crazed psychotic rampage

What they don’t report are the much more common experiences of people diagnosed with psychotic disorders. After all a headline like

Psychotic woman sits staring at the wall for 15 hours each day

Probably wouldn’t sell many newspapers.

Over the next few episodes we’ll consider the true meaning of psychosis. Remember that psychosis is made up of three types of symptom. These are hallucinations, delusions and thought disorders.

Hallucinations may occur in any sensory modality (e.g., auditory, visual, olfactory, gustatory, and tactile), ‘modality’ just means ‘sense’ but auditory hallucinations are by far the most common. Hallucinations are positive symptoms because they represent something more than the norm. They are an additional experience that most other people don’t share. Think of the ‘plus’ sign you first learned in school. That is also the symbol for positive. Positive symptoms are additions to the norm.

Auditory hallucinations are usually experienced as voices, whether familiar or unfamiliar, that are perceived as different from the person’s own thoughts. This idea is important and we’ll pick up on it later.

Perceived as different from the person’s own thoughts

True hallucinations are different from what most people understand as thoughts. The voice in your head, the internal chatter of thoughts you experience all day long is not an hallucination. Hallucinatory voices are experienced as though they come from a source outside of you. You hear them through your ears – or at least that’s how it seems.

The voices might represent several different entities or just one. They may be nice or nasty and they may talk directly to you or simply talk amongst themselves. Some people hear voices that tell them what to do – these are called command hallucinations.

Interestingly voices often seem to mirror a person’s moods just as your thoughts mirror yours. If you’re feeling happy the voices will tell you positive things. If you’re feeling sad or insecure the voices will tell you how useless you are or how pointless it is trying to achieve anything.

Many people are in no doubt that, however they may seem, hallucinations are their own thoughts. This is extremely significant because it gives them ‘ownership’ of their hallucinations and therefore ‘control’ over them. After all everyone has thoughts they don’t feel particularly proud of or that they wouldn’t be comfortable sharing with others. When considered in this light hallucinations become no more of a problem than any other thought process and equally open to control (admittedly with a bit of training and practice).

For me one of the most interesting aspects of hallucinations is the way that society interprets them. For example daytime television in UK is full of ‘psychic mediums’ who claim to hear voices from beyond the grave. And on the whole society accepts this as somehow more plausible than the experience of the teenager who hears the voice of his late grandparent. We see one of these people as ‘gifted’ and the other as ‘insane’. But is there really any difference?

It seems to me that mediums, channellers, voice-hearing priests and the patient in your local acute ward who talks to the aliens all occupy one of three possible categories:

1.       They are psychotic;

2.       They are genuinely in touch with something outside of normal understanding;

3.       They are lying.

Of course, different people will have different opinions based upon their particular preferences and bias but that’s not really the point. If we call any one of these experiences psychotic we must also acknowledge that there is just as much (or as little) evidence to say the same about the rest. This is equally true if we decide that they are deceitful or even that they truly are ‘gifted’.

There’s an interesting cultural (and even subcultural) perspective here. For example, some African cultures are much more likely to accept voice hearing in a religious context than more traditional Western churchgoers might.

I have a friend who used to work in Glastonbury in Somerset. For those who don’t know Glastonbury,  it is a town where ‘New Age’ devotees and a range of spiritual practitioners from ‘rebirthing’ to ‘primal scream’ therapists rub shoulders with dowsers, spiritual healers and even, occasionally, traditional clergy. There you will find people who will sell you ‘colour therapy’ sessions and help you to learn from your past lives and there is no shortage of people who will offer to talk to a range of divine entities on your behalf – for a small ‘donation’, of course.

According to my friend the definition of psychotic in that particular part of Somerset is radically different from the definition used in the rest of the UK. Believing yourself to be the reincarnation of a medieval knight is quite acceptable, as is communing with angels, long dead ancestors and even (in some isolated cases) psychiatrists.

With all these cultural influences to take into consideration it becomes extremely difficult to say what is and what is not an hallucination in any ‘medical’ sense when so many people claim otherwise. I know an ordained priest who has told me on more than one occasion about her conversations both with God and Satan (the latter being a less than welcome intruder into her life). She is adamant that these conversations happened – or at least she was the last time we discussed it. I have a rather different perspective on the whole affair but then I would, I’m an atheist.

But who cares what I might think?

However, if you are interested in what I think then keep listening and I’ll tell you.

I think that my opinion should be less important to the person experiencing hallucinations than their own ability to deal with them.

If they choose to believe in conversations with some ill-defined spirit and that helps them to cope then so be it.

Who cares what I might think?

After all if TV mediums like Derek Acorah or the late Doris Stokes can find a place in the world then so can anyone else. What interests me is not imposing my own interpretation of someone’s experiences but in helping them to function with whatever explanation they choose. To that end I might talk with them about their interpretation but it remains their interpretation that matters, not mine.

After all, many of the chief religious and political figures across the world achieved their status precisely because of experiences such as these. However let’s not get too carried away ‘normalising’ psychosis and hallucniations. It’s true that many people cope very well but others do not. The majority of voice-hearers we see in social care settings are very likely to be in the distressed camp – otherwise we probably wouldn’t be working with them. These people are not the much feted psychic mediums and spiritual healers of the world. They are the struggling individuals who have not found a way to integrate their experiences into society’s acceptable mainstream and we would do them a great disservice by pretending otherwise.

Distressed voice-hearers may well need our help and it’s up to us to try so far as we are able to provide that help as part of the larger multi disciplinary team.

Treatments and interventions for hallucinations vary. The traditional medical approach is to try to remove them altogether using medication. Unfortunately, although medication can work extremely well for some people, it isn’t always effective. Sometimes all antipsychotic medications do is dampen down a person’s thinking and energy levels until they lose all quality of life. For others the medications cause severe side effects that are extremely difficult to cope with and in some cases are irreversible.

Yet medication has its place and can work wonders. It’s always worth considering antipsychotics but if they don’t ‘do the trick’ – if they don’t solve the problem that doesn’t mean that there are no other options.

As we have seen, many people function extremely well with their hallucinations – sometimes because of their hallucinations. As we shall see later some people achieve great things precisely because they hear voices or see visions. These people have a lot to teach us about how to help the people in our care.

For example, it’s not the fact that you hear voices or see visions that is the problem. It’s the way you think about those voices and visions that matters. Marius Romme and Sondra Escher founded the ‘Hearing Voices’ network decades ago to help people learn how to understand and deal with their voices constructively. There are many techniques that can be used with genuinely remarkable results. We’ll consider some of these as the series progresses.