The stress of everyday life is challenging enough, but imagine living with an additional serious mental health difficulty. Suppose for some reason you became unable to recognise ‘reality’. This experience of ‘loss of reality’ is the characteristic feature of the mental state called ‘psychosis”.
In health we rely upon our sight, our hearing, our taste, our touch and even our sense of smell. We depend upon these senses to faithfully describe our environment. In ‘psychosis’ these senses actually misinform us and this misinformation changes our appreciation of reality. The sensory experiences which arise (so called Hallucinations) can be strange, grandiose, frightening, and even bizarre.
Now try to imagine how your ‘thinking’ would change if your senses misled you in this way. If your experience of ‘being’ was completely contrary to objective reality, your interpretation of the world and your beliefs would inevitably change, (if only in an effort to explain your particular environment). Sensations with no external validity (so called ‘Hallucinations’) and false beliefs unshakably held (so called ‘Delusions’) are typical features of psychosis.
At least 3% of the population will experience a ‘psychosis’ at some stage in their lifetime. For some it is a limited experience that is prompted by an acute brain illness or by substance misuse. For others it is part of an enduring or relapsing mental health disorder such as Temporal Lobe Epilepsy, acquired Brain Injury, Bipolar Mood Disorder or Schizophrenia.
Of course not all unusual sensory experiences are indicative of psychosis. Many people ‘Hear Voices’ and do so without mental health disorder. The Hearing Voices Network is part of an international movement dedicated to the recognition of this fact. Similarly, many people have unusual beliefs which they hold with intensity and despite much objective evidence. These in themselves are not an indication of mental disorder or ‘psychosis’.
Like every mental health diagnosis, the term ‘psychosis’ refers to much more than a set of symptoms. It is a description of an experience which is persistent and pervasive and one that is profoundly disturbing of overall human function. All of which makes it imperative that we try to understand why this condition is still so misunderstood and so neglected.
Surely part of the problem is ‘Stigma’. People who experience mental illness /mental ill health are some of the most marginalised in our society. Psychotic experience is over represented amongst the poor, the young, the homeless and those in prison. All of this goes to increase the prejudice of those who continue to alienate and misunderstand men and women with mental health difficulties. Hostility to those living with psychosis is one of the least acknowledged prejudices. This was illustrated recently by the grotesque statements of the White House Press Secretary Anthony Scaramucci who chose to castigate his Chief of Staff as a ‘F……g Paranoid Schizophrenic’. It was not surprising that the same press secretary subsequently lost his job but sadly his dismissal was not hastened because of his egregious attitude to those with ‘psychosis’.
Another problem for those with severe mental health disorder such as ‘psychosis’ is more understandable. It is ‘fear’. Psychosis is by its nature hard to understand and its content can be as frightening for families and friends, just as it is for those who experience its tormenting phenomena more personally. We need to address this fear with better education and more skills. If the community is to care it needs to be helped to care. This will only be achieved with better education and more support for the best ways to give that care. That is why at St Patrick’s we have been developing educational social media content under the banner of #StillJustMe on Walk In My Shoes. The HSE also has an excellent publication entitled ‘The Journey Together: The Carers Handbook’ available for download.
Perhaps the biggest problem is our collective therapeutic pessimism regarding those with psychosis and other serious mental health disorders. There is a widespread nihilistic belief that people with psychosis cannot really be helped. This is a colossal error. The reality is that ‘Recovery’ from psychosis is possible and modern evidence-based mental health services provide the most effective ways of achieving this. The international data showing that early intervention for psychosis is effective provides compelling proof. There are some important examples of this progress available in Ireland. The benefits have been recognised in peer reviewed research and by service user response. An overview of the national pilot programme for early intervention in psychosis can be seen here.
Unfortunately, the roll out of such early intervention programmes has not kept pace with the evidence or with the need. Mental health services in Ireland for those with psychosis remain patchy, fragmented and far too difficult to access. Isolated areas of best practice do exist but there are huge gaps. This delay in getting treatment is having a detrimental effect on recovery. Shine (Formerly ‘Schizophrenia Ireland’) advocates for services and the rights of people with enduring mental health problems in Ireland including psychosis. One of its equivalent organisations in the UK RethinkMentalIllness puts it well; ‘If your motor car has a breakdown today it is likely that it will be fixed today, but if you or one of your family has a mental breakdown today it is likely to be 18 months before they receive any care’.
This unacceptable situation is impacting on our capacity to deliver the full range of modern effective treatments in the 21st Century. The greatest opportunity for therapeutic benefit today is through early integrated mental health care. That is why we must do something about the unacceptable delays in our mental health service. The recent figures from 2017 (provided by the HSE in response to parliamentary questions) ‘show that 5,954 children aged 17 and under are awaiting a psychology appointment in primary care. Amongst those 1,784 have been waiting more than a year for an appointment’.
Prof Jim Lucey
Prof. Jim Lucey was Medical Director of St Patrick’s Mental Health Services, Dublin, from 2008 to 2019. He is Clinical Professor of Psychiatry at Trinity College Dublin. He has been working for more than 30 years with patients suffering from mental health problems. In addition to medical management, he maintains his clinical practice at St Patrick`s, where he specialises in the assessment, diagnosis and management of Obsessive Compulsive Disorder (OCD) and other anxiety disorders. He gives public lectures and is a regular broadcaster on mental health matters on RTÉ radio, featuring on ‘Today with Sean O’Rourke’.