Think You're Crazy? Think Again

A Resource Book for Cognitive Therapy for Psychosis

Anthony P. Morrison, Julia Renton, Paul French, Richard Bentall

• Publisher: Routledge
• Year: 2014
• eBook ISBN: 9781317822165
• Edition: 1
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

Are you troubled by hearing voices or seeing visions that others do not? Do you believe that other people are trying to harm you or control you? Do you feel that something odd is going on that you can't explain or that things are happening around you with a special meaning? Do you worry that other people can read your mind or that thoughts are being put in your head?

Think You're Crazy? Think Again provides an effective step-by-step aid to understanding your problems, making positive changes and promoting recovery. Written by experts in the field, this book will help you to:

• understand how your problems developed and what keeps them going
• use questionnaires and monitoring sheets to identify and track changes in the links between your experiences, how you make sense of these and how you feel and behave
• learn how to change thoughts, feelings and behaviour for the better
• practice skills between sessions using worksheets

Based on clinically proven techniques and filled with examples of how cognitive therapy can help people with distressing psychotic experiences, Think You're Crazy? Think Again will be a valuable resource for people with psychosis.

Chapter 1
What is psychosis?

Calvin is a 26-year-old man. Since the age of 18 he has heard voices that nobody else can hear, often when nobody else is around. Mostly they seem to come from nearby on his left, but sometimes it seems as if they originate from a point just behind his forehead. They can happen at all times of day, but most often in the late afternoon or evening. Sometimes, as many as ten days can pass without him hearing the voices, but at other times they torment him for hours on end. They also vary in loudness and clarity, at times becoming a low mumble that he can hardly make out and at other times speaking as clearly as someone standing right next to him. He has considered various explanations for them. Sometimes he blames them on God or the Devil. At other times (usually after one of his regular meetings with his psychiatrist or community psychiatric nurse) he tries to accept that there is something wrong in his brain, although he never finds this explanation completely convincing. On the advice of his doctor, he has tried to ignore them, but he often finds this impossible. When they are particularly distressing he tries to cope with them by returning to his flat, lying down on his bed, putting on his headphones and listening to loud music.

The voices did not always make him so upset. When they first began, they were actually quite comforting. They spoke to him about the terrible time in his childhood when he had been sexually abused, telling him that he had not been at fault and that he had nothing to be ashamed of. Vaguely aware that this experience was very unusual, he kept it to himself. The voices would appear when he was feeling especially unhappy and would cheer him up. However, everything changed when, aged 22, Calvin had a fight with an employer, who picked on him with racist abuse. Finally snapping after months of torment, Calvin had lashed out and hit him and the employer had called the police. When interviewed, he had (foolishly it now seems) talked openly about the voices for the first time, telling a police surgeon who had been called to the police station to examine him. As a consequence, he was ‘sectioned’ (involuntarily detained in hospital) under Section 22 of the Mental Health Act, and was forced to receive antipsychotic medication for the first time. It had been an awful experience. After he initially refused to take the drugs, the nurses held him down and painfully injected him in his buttock. The incident was very traumatic and had reminded him of some of his earlier experiences, especially the violence and abuse he had suffered when living in a children’s home.

After his stay in hospital, Calvin’s voices became more and more critical. Now they often talk about him negatively, or criticize him directly. He has taken his medication on and off for the past few years. However, due to frequent visits from his community psychiatric nurse (CPN), he has been taking his drugs fairly consistently for the past few months. He has mixed feelings about the treatment, partly because he is not entirely sure that he wants the voices to go away (oddly, he often feels bored and lonely after long periods without them) and also because, when taking the drugs, he feels very lethargic, unmotivated and emotionally flat.

To many users of psychiatric services, their families and the mental health professionals who look after them, Calvin’s experiences will seem very familiar. Despite this familiarity, they may also seem baffling evidence of a mind that has lost touch with reality. It is quite common for people who experience voices to feel threatened by them, and frightened that they are on a slippery slope that can only end in complete insanity. Indeed, Calvin has at times wondered whether he is slowly deteriorating and has compared himself to an elderly uncle who, some years ago, he watched slowly drift into dementia and eventually die. Calvin’s friends and relatives are also frightened about what will happen to him in the future. His mother, in particular, is worried that he may become violent and uncontrollable; she regularly watches the television news and has seen many reports of psychiatric patients attacking other people, sometimes even murdering complete strangers.

The psychiatric staff who have looked after Calvin over the years have not always been helpful in this respect. Several of the psychiatrists he has seen have told him that he suffers from ‘schizophrenia’, and another has told him that he has a ‘paranoid psychosis’, but they have neglected to explain what these terms mean. The fact that the different psychiatrists do not seem to have been in complete agreement with each other has fuelled his doubts about the treatment they have offered him. To make matters more confusing, Calvin is aware that other people who have been given the same diagnoses seem to have problems that are quite different to his.

Cath is a 41-year-old woman with two grown-up children, and has been in contact with psychiatric services for more than half her lifetime. Her difficulties began 22 years ago, just after the birth of her first child, Steven, when she started to believe that social services were spying on her. Fearing that they planned to take her son away from her, she refused to leave her house. Eventually, her fear receded and two years later she gave birth to a second child, her daughter Claire.

Following the second birth, all of Cath’s fears returned and became more severe than ever. Convinced that social workers were spying on her through her windows, and even watching her through her television set, she closed her curtains and refused to go outside, in case her children were snatched away from her. She even refused to answer the telephone. When a district nurse came to check on the children and was refused entry to the house, a psychiatrist was called out and Cath was eventually admitted to a psychiatric ward. Not surprisingly, perhaps, this experience only reinforced Cath’s fears, and no amount of reassurance from her husband (who was able to look after the children on his own) or the nurses on the ward seemed to help.

Cath’s difficulties have continued over the years and she now believes that the police are working with the local social services department to plan her prosecution. She believes that they let themselves into her house on the rare occasions that she goes out, and rearranges items such as ornaments and small pieces of furniture in order to remind her that they are watching her. On the few occasions that she does go out, Cath keeps her head down, looks at the pavement and counts in her head, in order to prevent police officers and social workers from reading her mind.

After more than two decades of these difficulties, Cath’s relationship with her husband is at an all time low. He frequently reminds her that she was an inadequate mother and that he had to carry the burden of raising the children. He also tells her that she should be very grateful to him for marrying her in the first place (the marriage took place in a hurry, following the discovery that Cath was pregnant). As if to confirm his low opinion of her, Steven and Claire make very little attempt to hide how difficult they find it to see her, and visit at most once a month, despite the fact that they live in the same town.

Like Calvin, Cath has received various diagnoses, including ‘puerperal psychosis’ (the diagnosis she was given just after Steven was born), ‘psychotic depression’ and ‘paranoid schizophrenia’. She is even less persuaded than Calvin that the psychiatric staff really understand what has happened to her, and the lack of a convincing explanation of her difficulties has encouraged her continuing belief that she is the victim of some kind of conspiracy.

What Is Psychosis?

Many labels (for example ‘schizophrenia’, ‘paranoia’ and ‘psychosis’) have been used to describe the kinds of problems suffered by Calvin, Cath and the millions of other people in the world who are like them. One problem for many people who receive psychiatric care is that there is no readily accessible source of information from which they can obtain an explanation of these terms, or an account of what they might expect from their psychiatric treatment. Although there are some useful sites on the internet, most are difficult to read and different sites sometimes seem to contradict each other. There are very few books available that provide clearly presented information about mental illness. If they are lucky, patients may find a psychiatrist, psychologist or psychiatric nurse who will spend some time talking to them about their experiences, but overstretched psychiatric services do not always provide this kind of help. This is one reason why we have written this book.

It might help if we begin by noting that the different labels that mental health professionals use when talking about their patients’ difficulties have evolved historically, as different psychiatrists and psychologists have struggled to find ways of describing their patients’ symptoms. Therefore, when mental health professionals use different terms – for example, when one nurse talks about a patient suffering from ‘psychosis’ and the other talks about the same patient suffering from ‘schizophrenia’ – there is usually no disagreement meant. One professional simply prefers to use a different term than the other. It is therefore important not to get too worried about the words used when psychiatrists, psychologists and nurses talk about their patients (although professionals may disagree about the causes of patients’ difficulties, as we will discuss later in the book).

The broadest term used to describe the kinds of problems experienced by Calvin and Cath is psychosis (or ‘psychotic disorder’). Psychosis simply means, roughly, a type of problem in which the patient appears to be, at least to some degree, out of touch with reality. The patient may be judged to be out of touch with reality because he or she has unusual perceptions (for example, hearing voices, as in the case of Calvin) and/or because he or she has beliefs that seem strange and unjustified to other people (most often, the terrifying belief that there is some kind of malevolent conspiracy afoot, as in the case of Cath). Patients with psychosis may also suffer from other emotional difficulties (for example, they may have difficulty coping with the demands of life, or may be very depressed). They also commonly experience changes in the way that they perceive themselves and the world around them, becoming preoccupied with unusual ideas and may withdraw as a result. However, it is the unusual experiences and beliefs that usually lead the patient to be described as psychotic.

At this point it will be useful to introduce two words that mental health professionals use to describe the main symptoms of psychosis. Calvin experienced voices of people who were not actually present. This type of experience, which (we will see later on) is surprisingly common, is known as a hallucination. The most common type of hallucination is auditory-verbal, like Calvin’s. However, less commonly people also experience visual hallucinations (seeing things that are not really there, as in the case of a young man who believed that he could see the Devil), tactile hallucinations (for example, the sense of being touched when no one else is present) and olfactory hallucinations (smells that no one else can detect).

The term delusion is used by psychiatrists and psychologists to describe beliefs that are strongly held, even in the face of significant evidence against it, and which appear unbelievable or even bizarre and ridiculous to nearly everyone else. The most common type of delusion is paranoid or persecutory. People with these kinds of beliefs, for example Cath, fear that there is some kind of conspiracy against them. However, other kinds of unusual beliefs also lead people to seek psychiatric help; for example, they may believe that they have supernatural powers or enormous wealth (causing them to do things that they later regret) or feel that they are guilty of impossible crimes. An important point that we would like to make here is that, in general, people do not pick unusual beliefs out of the blue. Usually, people who have beliefs that seem bizarre or implausible to other people have good reasons for holding those beliefs. Of course, this is not to say that those beliefs accurately reflect what is happening.

Does Diagnosis Matter?

Although there is general agreement amongst mental health professionals about the broad term ‘psychosis’, matters become a bit more complicated when more specific diagnostic labels are used. Despite attempts by psychiatrists and psychologists to define diagnoses precisely (for example, by writing manuals that try to define the symptoms associated with each diagnosis), there remains disagreement about how many different kinds of psychiatric disorders there are, and how they should be labelled.

One term that is often used to describe psychotic conditions is schizophrenia. Usually, the person who is diagnosed as suffering from schizophrenia has hallucinations and/or delusions, but also has other difficulties. For example, he or she may lack motivation, feel emotionally flat and may avoid contact with other people as much as possible. He or she may also have difficulty speaking clearly, especially when emotionally distressed. Although people diagnosed as suffering from schizophrenia are often very unhappy, this diagnosis is usually not given when the main problem is experienced by the person is one of mood (feelings).

If mood problems are predominant, the terms manic depression or bipolar disorder are often used (these terms mean the same thing). People who receive these diagnoses may have periods of extreme depression, and also periods of feeling manic (excessively high, but also irritated and panicky). However, people who are diagnosed as suffering from manic depression/bipolar disorder may also have psychotic experiences (hallucinations and delusions), especially when manic.

Because many people experience a mixture of difficulties that appear to be neither clearly schizophrenic nor clearly manic depressive, and because some psychiatrists and psychologists doubt whether these are really separate conditions, the diagnosis of schizoaffective disorder is often used when patients have both persisting psychotic symptoms and also persisting problems of mood.

The term paranoia is typically used when the person has paranoid or persecutory beliefs, and no other psychotic experiences. Many psychiatrists today prefer to use the term delusional disorder in these circumstances. To make matters slightly more confusing, people are sometimes diagnosed as suffering from paranoid schizophrenia if they have many symptoms, but paranoid fears are the most severe.

The important point for both patients and their friends and relatives to bear in mind is that diagnoses matter much less in psychiatry than in general medicine. Psychiatric diagnoses such as ‘schizophrenia’ and ‘paranoia’ do not describe completely different illnesses in the same way that ‘cardiac arrest’ and ‘diabetes’ do. Because of the disagreements that exist about diagnostic boundaries, and because patients’ difficulties may change over time, it is quite common for people to be given one diagnosis at one point in time and, when another doctor comes along some months or years afterwards, a second or even third diagnosis later on.

For this reason, when helping people with psychosis, psychiatrists, psychologists and nurses should try to assess and understand the unique combination of problems experienced by each patient. Taking this approach, it is easier to understand the origins of patients’ problems and, hopefully, to devise interventions that meet their needs [1].

Chapter 2
Are my experiences abnormal?

In this chapter we will explain how psychotic experiences can be thought of as occurring on a continuum (range) with normal, healthy functioning [2]. We will show that there is not a clear dividing line between ‘sanity’ and psychiatric disorder. This observation is important because it establishes that people with psychiatric difficulties are not very different from everyone else. In fact, as we will see in later chapters, many of the difficulties experienced by people suffering from psychiatric problems can be seen as extreme variations of characteristics to which we are all prone.

As we discovered in the previous chapter, Calvin is a 26-year-old man who has heard voices since he was 18. These voices began as a positive experience, offering him support and advice. The voices started to become negative after Calvin was detained in hospital when he was 22. He was injected with medication against his wishes and he now recounts that the voices became critical and negative following this incident. At that time he was told for the first time that he suffered from schizophrenia.

How Common are Psychiatric Diagnoses Like Schizophrenia?

As discussed earlier, Calvin and Cath both have diagnoses of schizophrenia. Many people with similar experiences are given this or similar diagnoses by their doctors. According to conventional medical opinion, schizophrenia is one of the most common psychotic disorders, with approximately 1% of the population suffering from this disorder at some point in their lives. This means that, in the United Kingdom alone, about 600,000 people will have a diagnosis of schizophrenia (the figure for the USA is just under 3 million). Similar rates apply to other psychotic disorders – bipolar disorder (or manic depression) affects up to 2% of the population (so over 1 million people in the UK or about 6 million in the USA) and schizoaffective disorder affects roughly 0.5% (about 300,000 people in the UK, about 1.5 million in the USA). With other psychotic disorders, such as psychotic depression and delusional disorder, this means that well over 2 million people in the UK will be affected by a psychotic condition that leads them to seek help from mental health services.

How Common Is It to Hear Voices?

Calvin was walking down the road last week and heard a voice saying ‘He shouldn’t be allowed out. Someone should get him’. When he looked around, there was nobody there. Yesterday, he was watching television and heard a voice telling him that the newsreader was talking about him. He changed channel to watch Top of the Pops, and the voice said ‘They’re singing about you now’.

The experience that Calvin has of hearing voices when nobody is around (or at least when nobody seems to be saying the words that he is hearing) is actually quite common. Sometimes the things said appear t...

Table of contents

• Cover
• Title
• Copyright
• Dedications
• Contents
• Acknowledgements and an introductory note
• 1 What is psychosis?
• 2 Are my experiences abnormal?
• 3 Will I be like this forever?
• 4 What' s happening to me?
• 5 Evaluating your thoughts
• 6 Evaluating your thoughts by changing your behaviour
• 7 Helpful and unhelpful ways of coping
• 8 Feeling good about yourself
• 9 Staying well
• 10 Using medication
• 11 Recovery
• 12 Who can help?
• References
• Appendix
• Index