You needn’t be wrong to be called delusional

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conspiracies, credibility, delusion, delusions, DSM, fixed beliefs, Martha Mitchell effect, mental health issues, paranoia, stigma

You needn’t be wrong to be called delusional

It’s not clear who forcibly sedated her in 1972. It’s not certain that she was admitted to a psychiatric ward in the following year. What’s definite though is that many people thought she was mad as she ranted about conspiracies in the White House during eccentric phone calls to the press. Questions about Martha Beall Mitchell’s sanity were encouraged by the Nixon administration, who consistently briefed against her and probably had her medicated against her will. But ultimately her claims were proven correct when the Watergate scandal broke.

Mitchell was the wife of the US attorney general and saw the planning and cover-up of the Watergate burglaries first-hand. In retrospect, her seemingly paranoid claims made sense and, in her honour, Harvard psychologist Brendan Maher named the Martha Mitchell effect after her to describe the situation where someone is incorrectly diagnosed as delusional but turns out to be right.

But, contrary to popular belief, the relationship between madness and truth is a complex one. They are made out to be strangers but often they are more like distant cousins.

This relationship has recently been acknowledged with the publication of the new version of the psychiatrists’ diagnostic manual (the DSM-5) where one of the most interesting but less noticed changes has been the redefinition of the delusion, a symptom that has long been considered the “basic characteristic of madness”.

Delusions, in the medical sense, are not simply a case of being mistaken, as the everyday use of the term suggests. They are profound and intensely held beliefs that seem barely swayed by evidence to the contrary – even to the point of believing in the bizarre. My heart has been replaced by steam. My thoughts are being stolen by satellites. The government communicates with me through birdsong.

But many delusions are not outlandishly eccentric, they are simply implausible. Consider the scenario where people believe that their neighbours are conspiring against them or that they are the subject of a film star’s secret affections. Occasionally, these beliefs turn out to be true, but this is not a reliable guide to whether someone is delusional or not. This was memorably illustrated by the psychiatrist Andrew Sims, who warned in his psychopathology textbook Symptoms in the Mind that spouses of people with delusions of infidelity may occasionally be driven to infidelity. This romantic betrayal does not suddenly cure their partner of their mental illness.

The general idea is that delusions represent a problem with how you believe – that is, a problem with forming and changing beliefs – not a problem with what you believe. In other words, simply believing something strange or unusual should not be considered a problem but having “stuck” beliefs that are completely impervious to reality suggests something is mentally awry.

On the ground, mental health professionals are often required to decide if someone’s thinking indicates a disturbance in their understanding of the world, and this is where the new DSM-5 definition of a delusion may usher in a quiet revolution in psychiatry. No longer are psychiatrists asked to decide whether the patient has “a false belief based on incorrect inference about external reality that is firmly sustained despite what almost everyone else believes and despite what constitutes incontrovertible and obvious proof or evidence to the contrary”. A wordy and unhelpful definition that has so many logical holes you could drive a herd of unicorns through it.

Instead, the new definition of delusions describes them as fixed beliefs that are unswayed by clear or reasonable contradictory evidence, which are held with great conviction and are likely to share the common themes of psychosis: paranoia, grandiosity, bodily changes and so on. The belief being false is no longer central and this step forward makes it less likely that uncomfortable claims can be dismissed as signs of madness.

And this is where the larger issue lies. As happened with Martha Mitchell, claims against authorities are often dismissed by suggesting that the person has mental health problems.

History is littered with such examples but sadly there are enough contemporary cases to illustrate the point. In a controversy currently rocking Germany, evidence of money-laundering at a big bank has become a huge scandal, not least because it was dismissed as delusional seven years ago when the accuser was diagnosed with mental illness.

Closer to home, when the NHS whistleblower Kay Sheldon reported failings in the Care Quality Commission, the first response was to suggest she had a mental health problem and to commission a psychiatric assessment.

I have no idea whether these people had mental health difficulties but it should have had little bearing on how seriously their concerns were taken. The fact that their claims could be dismissed by allusions to poor mental health is part of the unfortunate stigma that still surrounds the issue. But the stigma goes both ways, and assuming people do not have mental health difficulties because they are correct is the flip side of this.

In the years after Martha Mitchell had been dismissed as delusional, it emerged, contrary to her claims, that she was under the care of her own psychiatrists, drinking heavily and, at times, suicidal. Nixon, for his part, said Watergate would never have happened if it wasn’t for Martha. Both believed that mental illness would undermine her credibility. History, however, came down on the side of truth.

If psychosis is a rational response to abuse, let’s talk about it

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abuse, cbt, culture, diagnosis, hearing voices, medication, paranoia, psychological support, psychosis, schizophrenia, trauma

If psychosis is a rational response to abuse, let’s talk about it

There is something of a sea change in the way we understand experiences that have traditionally been labelled as psychotic. In our culture at least, experiences such as hearing voices or seeing visions have long been viewed by the medical establishment as unequivocal symptoms of mental illness. Treatment has tended to focus on the suppression of such “symptoms” using antipsychotic medication.

Research (often funded by drugs companies) has been largely concerned with the brain as a physical organ, rather than with the person within whose head it is housed, or indeed with their life experience. And, because of the presumption that psychotic symptoms are the preserve of mentally ill people, estimates of the numbers affected have been based on the numbers who have received a particular diagnosis.

But a report published last week by the British Psychological Society’s division of clinical psychology, challenges many of these assumptions.Understanding Psychosis and Schizophrenia presents a compelling case for trying to understand psychotic experiences as opposed to merely categorising them. It argues that such experiences can be understood from a psychological perspective, in the same way as other thoughts and feelings, rather than being placed on the other side of an artificial sick/healthy divide.

And, indeed, they appear to be much more common than is frequently supposed. According to the report, up to 10% of the population has heard a voice speaking when nobody was there and almost one in three holds beliefs that might be considered paranoid. Two in three people who had heard voices or seen visions did not seek help because they were untroubled by them. And, of course, there is huge diversity in the way such experiences are understood and valued in different cultures.

For those who find their experiences unwelcome and disturbing (and they can be extremely disturbing; I don’t think anyone questions that) the range of help on offer is decidedly limited. Despite the National Institute for Health and Care Excellence recommending that everyone with a diagnosis of schizophrenia is offered cognitive behaviour therapy(CBT), only one in 10 has access to it. Treatment by medication alone, forcibly if needed, is the norm.

It is widely accepted that early life experience, trauma, abuse and deprivation greatly increase the risk of developing psychosis. Indeed,research suggests that experiencing multiple childhood traumas gives approximately the same risk of developing psychosis as smoking does for developing lung cancer.

Many people object to the psychotic label because they consider their experiences a natural reaction to the abuse they have suffered, and even a vital survival tool. What they want above all is space and time to talk about their experiences and to make sense of them. It is shocking how few are given this opportunity.

Of course, psychological approaches to helping those with psychosis will not suit everyone. There are those for whom a diagnosis can come as a welcome relief. Many people find medication helpful, as treatment on its own or alongside talking therapies.

In fact, one of the most persuasive messages of the report is that people should be allowed to understand their experience in their own way, without professionals insisting on a particular interpretation.

It is a highly collaborative approach and fitting that at least a quarter of those who contributed to the report have lived experience of psychosis. Their opinions and experiences are as varied as you would expect with any group of individuals but together they comprise an enormously powerful and vivid testimony to the full range of human experience and to the many and varied ways in which we can help each other to make sense of it.

Schizophrenia: the most misunderstood mental illness?

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diagnosis, discrimination, fear, help, media, mental health issues, paranoia, psychosis, recovery, schizophrenia, shame, silence, stereotypes, stigma

Schizophrenia: the most misunderstood mental illness?

Let’s face it, when most people think about schizophrenia, those thoughts don’t tend to be overly positive. That’s not just a hunch. When my charity, Rethink Mental Illness, Googled the phrase ‘schizophrenics should…’ when researching a potential campaign, we were so distressed by the results, we decided to drop the idea completely. I won’t go into details, but what we found confirmed our worst suspicions.

Schizophrenia affects over 220,000 people in England and is possibly the most stigmatised and misunderstood of all mental illnesses. While mental health stigma is decreasing overall, thanks in large part to the Time to Change anti stigma campaign which we run with Mind, people with schizophrenia are still feared and demonised.

Over 60 per cent of people with mental health problems say the stigma and discrimination they face is so bad, that it’s worse than the symptoms of the illness itself. Stigma ruins lives. It means people end up suffering alone, afraid to tell friends, family and colleagues about what they’re going through. This silence encourages feelings of shame and can ultimately deter people from getting help.

Someone who knows first hand how damaging this stigma can be is 33 year-old Erica Camus*, who was sacked from her job as a university lecturer, after her bosses found out about her schizophrenia diagnosis, which she’d kept hidden from them.

Erica was completely stunned. “It was an awful feeling. The dean said that if I’d been open about my illness at the start, I’d have still got the job. But I don’t believe him. To me, it was blatant discrimination.”

She says that since then, she’s become even more cautious about being open. “I’ve discussed it with lots of people who’re in a similar position, but I still don’t know what the best way is. My strategy now is to avoid telling people unless it’s comes up, although it can be very hard to keep under wraps.”

Dr Joseph Hayes, Clinical fellow in Psychiatry at UCL says negative perceptions of schizophrenia can have a direct impact on patients. “Some people definitely do internalise the shame associated with it. For someone already suffering from paranoia, to feel that people around you perceive you as strange or dangerous can compound things.

“I think part of the problem is that most people who have never experienced psychosis, find it hard to imagine what it’s like. Most of us can relate to depression and anxiety, but a lot of us struggle to empathise with people affected by schizophrenia.”

Another problem is that when schizophrenia is mentioned in the media or portrayed on screen, it’s almost always linked to violence. We see press headlines about ‘schizo’ murderers and fictional characters in film or on TV are often no better. Too often, characters with mental illness are the sinister baddies waiting in the shadows, they’re the ones you’re supposed to be frightened of, not empathise with. This is particularly worrying in light of research by Time to Change, which found that people develop their understanding of mental illness from films, more than any other type of media.

These skewed representations of mental illness have created a false association between schizophrenia and violence in the public imagination. In reality, violence is not a symptom of the illness and those affected are much more likely to be the victim of a crime than the perpetrator.

We never hear from the silent majority, who are quietly getting on with their lives and pose no threat to anyone. We also never hear about people who are able to manage their symptoms and live normal and happy lives.

That’s why working on the Finding Mike campaign, in which mental health campaigner Jonny Benjamin set up a nationwide search to find the stranger who talked him out of taking his own life on Waterloo bridge, was such an incredible experience. Jonny, who has schizophrenia, wanted to thank the man who had saved him and tell him how much his life had changed for the better since that day.

The search captured the public imagination in a way we never could have predicted. Soon #Findmike was trending all over the world and Jonny was making headlines. For me, the best thing about it was seeing a media story about someone with schizophrenia that wasn’t linked to violence and contained a message of hope and recovery. Jonny is living proof that things can get better, no matter how bleak they may seem. This is all too rare.

As the campaign grew bigger by the day, I accompanied Jonny on an endless trail of media interviews. What I found most fascinating about this process was how so many of the journalists and presenters we met, were visibly shocked that this young, handsome, articulate and all-round lovely man in front of them, could possibly have schizophrenia.

Several told Jonny that he ‘didn’t look like a schizophrenic’. One admitted that his mental image of someone with schizophrenia was ‘a man running about with an axe’. It was especially worrying to hear this from journalists, the very people who help shape public understanding of mental illness.

Many of the journalists also suggested that through the campaign, Jonny has become a kind of ‘poster boy’ for schizophrenia and in a way, I think he has.

Jonny has mixed feelings about the label. “I hope that by going public with my story, I’ve got the message out there that it is possible to live with schizophrenia and manage it. It’s not easy, it’s an ongoing battle, but it is possible. But I’m aware that I’m one of the lucky ones. I’ve been given access to the tools I need like CBT, but that’s not most people’s experience. Because of our underfunded mental health system, most people don’t get that kind of support. I can’t possibly represent everyone affected, but I hope I’ve challenged some stereotypes.”

As Jonny rightly says, one person cannot possibly represent such a diverse group of people. Schizophrenia is a very broad diagnosis and each individual experience of the illness is unique. Some people will have one or two episodes and go on make a full recovery, while others will live with the illness for the rest of their lives. Some people are able to work and be independent and others will need a lot of support. Some people reject the diagnosis altogether.

What we really need is a much more varied and nuanced depiction of mental illness in the media that reflects the true diversity of people’s experiences.

What I hope Jonny has managed to do is start a new conversation about schizophrenia. I hope he has made people think twice about their preconceptions of ‘schizophrenics’. And most importantly, I hope he has helped pave the way for many more ‘poster boys’ and girls to have their voices heard too.

For more information, visit Rethink Mental Illness

*Name has been changed