By Lynn Nanos author of Breakdown: A Clinician’s Experience in a Broken System of Emergency Psychiatry
As I was selling copies of my book, Breakdown: A Clinician’s Experience in a Broken System of Emergency Psychiatry, at a National Alliance on Mental Illness (NAMI) conference in Albany, NY last month, I had an interesting conversation with someone which reminded me of the dangers of the antipsychiatry movement, which promotes the notion that mental illness doesn’t exist.
A man approached me at my booth and asked me about Breakdown and then shared his experience with bipolar disorder with psychotic features. He emphasized that he’s recovered.
I empathized with his experience and happened to mention “illness.”
Immediately upon hearing this, he interrupted me mid-sentence with “I do not have an illness. I don’t like the use of that word so please don’t use it. I have a condition. I’m not defined by my condition. We need to stop stigmatizing this.”
I thought, “I’m not sure how this conversation will end, but I have to educate this guy. Otherwise, he’ll continue to spread the façade that stigma is an enormous issue and the only way to mitigate it is by not accurately describing what he really has – an illness.”
So, I said to him, “According to several dictionaries, ‘condition’ means ‘illness.’”
His eyes and mouth widened with “What? That can’t be true. Are you sure?”
“I’m sure. Check it out yourself. I’m sure you’re a lot more than your bipolar disorder, but not accurately defining what you have is stigmatizing, not the other way around.”
After a few more minutes of him working through his shock about my challenging him, he eventually said “Thank you for pressing me to change for the better. I’ll look this up.” Smiles and relief.
Earlier this year, I attended the National Alliance on Mental Illness’ national convention in Seattle, WA. The event was kicked off with pomp and circumstance involving a ceremonial military march beside the United States flag on stage before me. As I looked around at a sea of thousands of guests, I couldn’t help but think, “NAMI is huge, important, and powerful.”
Most of the week was filled with lectures and workshops. The “Cognitive Behavioral Therapy (CBT) for Psychosis” workshop I attended reminded me of the benefits of this therapeutic modality for a variety of mental illnesses, but also left me alarmed at some of the messages NAMI has been sending to mostly family members of those with mental illness and some professionals. CBT teaches people to think about, describe, and respond to the environment accurately. It persuades people to behave in healthy ways in response to thoughts. The underlying presumption of CBT is that when either one’s thought, emotion, or behavior changes, the other mental components change.
As I vigorously took notes in the workshop led by psychologists Kate Hardy and Sarah Kopelovich, my review was mixed. Should CBT for psychosis be completely disregarded? No. I’m grateful to the late forensic psychologist Robert Powitzky who extensively directed services for prison inmates, for his educational reminders. He wrote to me, “CBT can have several benefits other than making observable changes in positive and negative symptoms…is often effective for patients with schizophrenia who are stabilized on medication in conjunction with supportive housing.”
CBT for psychosis can be useful, especially once the psychosis has been stabilized and well-managed. The psychologists said that CBT has shown moderate effectiveness in reducing the negative symptoms of schizophrenia – social withdrawal, poverty of speech and thought, apathy, anhedonia, loss of motivation, and inattention to social or cognitive input. I credit the psychologists for pointing out, albeit briefly, that per psychologist Xavior Amador, one of the greatest predictors of successful treatment is awareness into illness. But this was as far as they got regarding insight.
On another note, I confirmed that NAMI was doing two dangerous things: marginalizing those whose psychosis interferes with the ability to engage or benefit from CBT and minimizing mental illness. A mother stood up and said to the psychologists, “All I could think of while watching this was ‘bullshit!’ Employing these techniques was impossible when my son was too agitated and unable to listen because of his psychosis.”
Below is a detailed account of exactly what these psychologists said in the “CBT for Psychosis” workshop accompanied by my impressions.
- Psychosis is a temporary condition. It is usually permanent.
- Everyone is susceptible to psychosis. Not quite. An extremely small percentage of the population is far more susceptible to developing psychosis than others.
- Trauma and stressors make someone more susceptible to becoming psychotic than genetics. False.
- There’s a correlation between creativity and psychosis. I don’t know whether this is true, but I’m not compelled to research it because it seems mostly irrelevant to treatment goals. Even if it were true, how could this possibly be used to help people with psychosis? Should psychiatrists and social workers offer painting materials instead of medication and psychosocial rehabilitation to people suffering from psychosis? Yes, this is a rhetorical question.
- Psychosis is often part of PTSD and can be part of borderline personality disorder. Untrue.
- It’s not helpful to tell the person with schizophrenia, “You need specialized treatment.” Psychosis is a special illness requiring specialized treatment. Treatment providers help their patients by telling them the truth.
- Expect recovery. If you get good treatment, recovery is the norm. Hundreds of NAMI blogs are ridden with happy endings, but everyone with psychosis does not recover. Telling families that recovery is the norm inappropriately sets them up for huge disappointment when good treatment does not work. There are many factors that can interfere with recovery even when the best treatments are tried.
- Intrusive thoughts, which everyone has, can be compared to delusions and hallucinations. Are you stating that psychosis is normal? It sure seems like it.
- CBT inherently normalizes psychosis, because we all have negative thoughts, engage in unhelpful behaviors, and use unhealthy coping strategies. Thus, CBT normalizes psychotic symptoms. Psychosis is normal. The psychologists asked the audience, “How many of you ever felt others were trying to harm you?” There is nothing normal about psychosis!
With all of NAMI’s grandeur and influence, speaking out against its marginalizing those who are most ill and spreading the notion that mental illness is less than important is paramount if we want to alter the status quo. Let’s destigmatize mental illness by defining it accurately. It’s a condition, but more accurately, it’s a brain disease.