VOL: 98, ISSUE: 39, PAGE NO: 40
Jacqueline Freeman, RMN, is staff nurse, Lambeth early onset (LEO) unit, Lambeth Hospital, South London and Maudsley NHS Trust
The phenomenon known as psychosis is part of several serious mental illnesses, including schizophrenia and bipolar affective disorder. Characteristic symptoms such as hallucinations, delusions and paranoia present great difficulties for patients and their families and friends. People who become psychotic rationalise their experiences in idiosyncratic ways.
Continuum of experience
The first or only episode of psychosis is most likely to occur between the ages of 18 and 28. A psychotic experience is bizarre by definition, presenting people with unusual sensations and thoughts. They are likely to feel set apart from their family and peers so they may have the perception of being specially chosen or persecuted. There is no typical reaction. They may feel anxious, depressed or enlightened.
One way for families, carers or friends to understand the illness is by thinking of experiences on a continuum from ‘normality’ to ‘psychosis’. Anyone has the potential to move along this continuum. Sensory deprivation, sleep deprivation or drug use can induce psychotic states in otherwise mentally healthy individuals. People commonly experience psychotic-type experiences in everyday life, such as hearing their names called when nobody has done so or believing that they are being followed when there is no evidence of this. It could be argued that strongly held religious or political beliefs are akin to delusions as they are difficult to change.
Accepting that experiences are on a health-illness continuum provides a realistic picture of psychosis as a transitory and essentially human experience. Such acceptance can engender hope, which is itself a healing commodity (Nunn, 1996).
Making sense of experiences
People who are caught in a psychotic world may not accept this view. The most natural reaction when faced with an alternative experience of reality is to try to make sense of it using personal resources, such as past experiences, culture or one’s personal view of life. This explains why people who hear voices telling them what to do may attribute these voices to a higher power. Yet this reinforces the voice’s authority and the individual’s powerlessness against it.
Another example is people who feel they are being watched and then notice when a police car or a man in black is near. Their experiences reinforce their inner beliefs.
Cognitive and behavioural therapies aim to modify the individual’s beliefs, thoughts and behaviour in psychosis. The therapist works collaboratively with the patient to unravel the fabric of his or her psychosis. There is strong evidence that this approach helps people to make sense of their experiences (Drury et al, 1996; Kuipers et al, 1998). This therapy is built on a trusting relationship, the lack of which can be a serious obstacle to such therapeutic work.
Trust and alliance
Nobody appreciates being told that they are mentally ill, that they have misunderstood what has been going on and that they need to return to consensual reality. It is insulting and incredible for most of us to imagine being given a psychiatric diagnosis such as schizophrenia. Moreover, some people prefer their psychotic world or have invested a lot of time and emotion in it. Gaining the trust of people who are believed to be psychotic demands great skill and sensitivity. This translates into listening to their story, ‘getting inside their world’ and acknowledging why they hold particular beliefs. Incarceration in hospital and enforced medication rarely foster trust or mutual respect.
Listening to psychotic people’s stories can reveal how they have made sense of unusual experiences. Gentle challenges such as ‘how can this be? or ’how do you know?’ can prompt reflection on recent events. Discussing a key assumption they have made can uncover alternative hypotheses. People who believe that their home is bugged because the telephone has stopped working could be asked whether they have called an engineer. In this way a ‘wrong turning’ in a person’s thinking can be identified in a non-threatening manner.
Psychosis is usually treated with antipsychotic medication if it persists for more than a few days. Nurses do not prescribe such medication but administer it, presenting a potential threat to the therapeutic alliance if people are not willing to take drugs. Basic trust between patients and nurses aids the taking of medication. It can also help if the patient has some influence over the dosage or start date. Discussion of the pros and cons of medication is essential.
It is far better for patients to make an informed choice to take medication than to be coerced. ‘Compliance’ with medication suggests submission to an authority. ‘Alliance’ or ‘concordance’ suggest partnership and power-sharing.
Research suggests that two-thirds of people recover completely from psychosis, although half of these experience further episodes (Shepherd et al, 1989). As people recover and regain some of their familiar sense of self, their engagement with professionals should improve.
Sooner or later, people who have experienced psychosis seek to make sense of the experience. Nurses have a key role to play in helping them to do so. If psychiatric services have been involved in patients’ care it is possible that a ‘medical’ or illness model will be proposed to them, with which they will be invited to agree. The nurse’s role at this time is to help people appreciate where medication and biochemistry fit into their explanation of the psychosis. But the medical model is not necessarily the ‘right’ model and psychosocial explanations of health and illness may be more palatable and appropriate.
People may choose to contain or integrate a psychotic experience into their life experience (McGlashan, 1989). Containing the experience is a way of rejecting it and choosing not to derive any benefit from it. This is more likely if patients believe that they have a stigmatising condition but have little influence over its manifestation, apart from by taking medication. People who choose to contain their experiences may be more likely to relapse as they have not sought to understand and control the psychosis.
The integration of psychosis into one’s persona is more challenging and perhaps more healthy. The psychotic experience is implicitly validated and people may learn to guard against later episodes by examining and being aware of the warning signs of relapse. There is no shame or stigma. Psychosis is seen as part of a continuum.
Stress and vulnerability
Some contemporary thinkers believe that psychosis is a result of an interaction between the components of underlying vulnerability and environmental stress. Individual vulnerability may be represented by a genetic disposition.
The risk of developing psychosis increases in proportion to the closeness of the biological relationship to a family member with a psychotic disorder (Gottesman, 1991). Exposure to viral infections around birth and delivery complications can increase vulnerability (Geddes et al, 1999). A severely disturbed family environment may also make people more vulnerable (Tienari et al, 1994).
Everyone has the potential to become psychotic. Environmental stress plays a key role, whether or not there is a vulnerability. Many people cite stress as the trigger of their psychotic episode. Acute stress may be generated by life events or crises, such as leaving home, starting college or taking drugs. Life events viewed as stressful by the individual may act as triggers (Norman and Malla, 1993).
A person’s living circumstances may be a chronic source of environmental stress. Living in a city or being a second generation immigrant may be stress factors, while the emotional atmosphere at home can influence whether an individual lapses into psychosis (Bebbington and Kuipers, 1994). Critical comments, hostility and emotional over-involvement are known to be instrumental in promoting a relapse or the first onset.
A model of stress and vulnerability can be applied to a person’s circumstances and used to generate an individual explanatory framework to answer the question: ‘Why me?’ Such a model can also be used to help people navigate their way through psychosis, integrating the experience and recognising triggers and protective buffers against further episodes. When research is applied to an individual’s situation it can be empowering. A realistic exploration of psychosis can be devastating and there is a proportionately high risk of suicide among young people diagnosed as psychotic (Appleby, 1999). Sensitivity, support and the provision of emotional space for reflection are crucial when nursing people who are recovering.
Any person’s experience of psychosis is deeply powerful and generates a search for personal meaning. Although sometimes inexplicable to others, an episode may begin to be demystified using a continuum model. Several complementary approaches may be used to treat and resolve a psychotic episode, notably medication, cognitive behavioural therapies and education.
For any therapeutic approach to be effective, a baseline of trust and respect is necessary. A stress-vulnerability model can be used to help a person and his or her family or friends make sense of why they became psychotic and how they can prevent it in the future. An approach that empowers and respects the individual is paramount to recovery.