A new look at psychosis continued...
Tyrrell: I was talking about these ideas at a seminar and a psychologist came up and said, "That's amazing. We've got a psychotic young man at the moment, and he thinks he is a vampire, from a family of vampires, and everyone thinks he's mad. But then I met his family, and they were like vampires! They were the sort of people who took from everybody all around them, all the time. They could drain energy from anyone." The vampire metaphor was totally apt for being in that kind of family. Dreaming in the REM state turns everything into metaphors, but that psychotic young man was doing it in waking reality because of his extremely stressed state.
This is a new idea to you! I can tell, by the look on your face.
Bentall: Well, half new. It's very complicated to address. I certainly agree with you that a lot of psychosis is metaphor. I think that is certainly true of a lot of people's delusional beliefs, for example. To some extent, you might say it is true of hallucinations as well, although I think it's less clear cut.
I suppose one big difference between the kind of approach I'm advocating and the traditional psychiatric approach is that I think psychosis has a meaning. The meaning is distorted in various different ways. I don't think there will ever be a simple explanation of psychosis; you have to look at each type of psychotic experience in turn, and each becomes understandable when you do that.
For instance, hallucinations: surveys show that hallucinations are experienced by people who appear to be otherwise normal and who don't regard themselves as mentally ill. Of the 18,000 participants in the largest study to date, between 11 and 13 per cent reported having had hallucinations at some time in their lives. An important factor in hallucinations is emotional arousal — there are clinical reports of people experiencing hallucinations after particularly stressful times. A British study found that over 13 per cent of recently widowed men and women heard their dead spouse's voice and a Swedish study found that an amazing 71 per cent of bereaved elderly people reported a hallucination or hallucinatory-type experience of their dead partner. Clearly, one cannot confine hallucinations to psychosis. They have a meaning in a particular context.
As for delusions, it has often been suggested that there are similarities between certain religious beliefs and delusional beliefs — no disrespect to religious people intended. For instance, in one study comparing deluded patients, trainee Anglican priests, patients who had recovered from their delusions and non-deluded people, what was marked was the extremely strong need, expressed by the priests and the deluded patients, but not the others, to find meaning in their lives. Then, there are all those accounts of seeing UFOs and being abducted by aliens, which are expressed by quite a high number of otherwise normal-seeming people, particularly in America. Often, in the case of delusions, I've been struck, like you have, by the metaphorical aspect.
Tyrrell: My son Mark is a psychotherapist and he was working recently with someone who appeared perfectly normal until Mark asked him where he lived. He said he lived in Windsor Valley in Brighton, a place that doesn't exist. He actually lived in the roughest part of Brighton, but he was quite a refined person, a sensitive and imaginative person. He had concocted that where he lived was really a secret royal estate and he was a member of the royal family. It was a way he had of coping with his awful life circumstances and surroundings.
Bentall: Sometimes there seems to be a physical reason for a delusion. Elderly people who start going deaf and don't realise it often become quite paranoid. And that makes sense, doesn't it? If people appear to be talking in whispers when in your presence — they must be talking about you. The same sort of thing explains bizarre phenomena like the Capgras delusion, where people think someone close to them is an imposter. Sufferers are fine when talking to that person on the phone, so it must be some difficulty in processing visual information that is the crucial element of this disorder. When we meet someone we know, we recognise them and we also experience a brief emotional response, a feeling of familiarity. This has survival value — is it friend or foe? There are two pathways through the visual cortex involved with recognition: one is concerned with the identification, the other with the familiarity. When Capgras patients are tested, it can be shown that the second pathway is disrupted. They recognise a family member or friend but have no feelings about them. The imposter delusion could be viewed as a way to resolve that dissonance.
Tyrrell: Quite. You also have some interesting things to say, in your book, that could explain thought disorder and incoherent speech, which psychiatrists usually dismiss as symptomatic of the psychosis and having no intrinsic meaning.
Bentall: If you look at thought disorder, it is quite clear that the thoughts are meaningful to patients; the problem is that they are not meaningful to anybody else. The reason for the thought disorder seems to be that they are having some problem communicating their ideas to people, and that happens when they are emotionally aroused. Gillian Haddock and I did a study in which we compared thought-disordered patients' speech when talking about emotionally neutral topics and when talking about the circumstances that led to their admission to hospital. More thought disorder was apparent in the second case. Others have made similar findings.
The story about thought disorder is quite simple really — it's quite fun talking to psychiatrists about this because they are often incredulous, but it appears to be the truth. Vulnerable people are most likely to talk in an incoherent way when they are emotionally aroused, and they are most likely to be emotionally aroused when talking about personal issues. Also, if you take what a thought-disordered person says, wait till they are not so emotionally aroused and then say, "Listen, I couldn't understand any of this. What does it mean?", they can give you a coherent explanation. This has been done.
Tyrrell: That all fits in with our ideas. I worked with a psychotic patient who showed all the REM state signs I mentioned before, and I talked to Joe about it. I had only worked with a handful of psychotic patients over the years — I'd mainly worked with anxiety and depression and trauma. But I thought — and to me it was a new idea, I didn't know it wasn't — suppose psychosis is the dreaming process gone awry: the REM state wrongly activated during waking consciousness because of a huge build up of stress. We thought, if that were true, the literature should show that psychotic breakdowns are preceded by considerable emotional arousal, in the form of anxiety, stress and depression—
Bentall: —Which they are.
Tyrrell: I have to go back a bit here, to explain all this. You may know that fetuses in the womb and newborn babies of species that are born immature spend a lot of time in REM sleep. It has been pretty firmly shown that this is the time when instinctive behaviours are programmed into us — not just us but animals too. We end up with broad templates to which we attempt to match our experiences in the outside world — recognising the importance of a nipple-shaped object, for milk, in the case of babies, or twig-like objects as suitable for nest building, in the case of birds, for instance. We look for something that's 'like' something we've been programmed to seek out. So the REM state operates, in effect, through metaphor.
But the mystery is, why do we carry on needing REM sleep, even when we are adults? Joe's research findings showed that, in dreams, in the REM state, we act out metaphorically the emotionally arousing concerns from the previous day that are still bothering us — the ones that haven't been expressed and discharged. He made the case that dreams serve to reduce the burden of emotional arousal on the brain, freeing it up to deal with the concerns of the following day. People who are depressed are constantly worrying and introspecting, and so they need much more REM sleep in order to discharge all of that arousal.
We know that anxious and depressed people dream far more than non-depressed people; that's been known for 30 or 40 years. We also know that's why depressed people always wake up tired and find it difficult to orientate themselves.
Bentall: That's not the conventional view of the relationship between depression and fatigue. The conventional view is that there is a disruption of circadian rhythm.
Tyrrell: Is it?
Bentall: David Healy, a psychiatrist at the University of Wales College of Medicine, has argued that stressful life events often disrupt normal routines and, when this disruption is severe enough, the consequence can be a form of chronic circadian dysrhythmia, in which our biological rhythms are persistently out of synch with the demands of daily living. It's like a permanent jetlag. That explains the sleep disturbance — there would probably be disruption of REM sleep — and the fatigue. In fact, Healy even argues that circadian dysrhythmia is the primary cause of depression. When people suffer persistent fatigue and the kind of subtle cognitive deficits that follow from disrupted sleep, they start failing to cope with their work and their social relationships, and then start blaming themselves for that, and that's how depression gets going.
Tyrrell: That idea doesn't ring true to me at all — for many reasons. It doesn't, for example, explain why depressed people dream more than non-depressed people, or why people under no especial stress can get depressed. He is saying that the effect is the cause, which is not the case.
We have a different suggestion. As I said, we know depressed people have more REM sleep — that's documented. Also documented is the discovery by sleep researchers that, if REM sleep is prevented, severe depression lifts — but it returns when REM sleep is allowed again. ECT causes REM sleep deprivation, and that of course can lift depression. And most antidepressants reduce REM sleep. So clearly reduction in REM sleep leads to a reduction in depression.
Before REM sleep starts, there is a massive firing of the orientation response, known as the PGO wave, which, when we're awake, alerts us to novel stimuli — it's part of the fight or flight mechanism, as you know. Hundreds of studies show this mechanism is hyperactivated in depressed people, and it is linked with dreaming. Now, if the orientation response is firing off all night, that is likely to be exhausting. In just the same way, research shows that watching television, with all its modern techniques of quick zooming in and out and jump cuts and successive visual and sound shocks, also keeps the orientation response firing excessively, and people end up exhausted. So that, we suggest, is why depressed people wake up next day, feeling so lacking in motivation and tired.
When you stop depressed people worrying, the depression lifts. That's the basis of effective therapy — to shift people's focus off their emotions and get them to focus outwards.
Bentall: Intriguing. But I can't comment, as I don't know enough about that. I'd be happy to read something on it, though.
Tyrrell: We can certainly provide that. Well, when we started getting interested in the REM state and psychosis, we thought it might be a continuation of the stressed state that anxious and depressed people get into, which makes them dream more. And that's what we found when we started reading various books, and your book particularly makes it really clear. There's the idea in your book — and in what you've said today — that psychosis is almost on a continuum. The only bit that is missing, for us, is the extra bit of knowledge about the dreaming state. That is the reason human givens therapists are known for getting people out of depression quickly. Amongst other things, this connection to excessive dreaming is a wonderful thing to tell patients. The worst bit about depression is waking up in the morning, after being in bed for hours asleep — people may have taken a long time to get off to sleep because of the worries going round in their head — and feeling so tired and unmotivated and even worse than before they went to sleep. All that is explained by the fact that they have been dreaming excessively. And then you can give them a perfectly logical reason for the need, whatever happens, to stop worrying. You've got to get them active, you've got to get them doing things.
Bentall: Yes, that makes sense to me.
Tyrrell: You've got to get them solving their problems, improving their relationships, etc. And they buy into that and very often snap out of depression almost overnight.
It was taking this insight about what causes depression a stage further that produced our explanation for psychosis. You talked earlier about psychotic complaints invariably being concerned with the self or one's relationships with other people. It's like being in a trance state of self absorption — which is what depression is, too, except at a less intense level. The REM state is the deepest trance state there is, and psychosis, we suggest, is a deep, waking trance.
You'll remember you said in your book, "The main problem in psychiatry is not one of personnel or resources but one of ideas". You are so absolutely right. There is a desperate need for new ideas in this whole field, because nothing really has changed in a long, long time. That came across vividly to me in your book. I think that, by putting the psychotic patient's experience first, you've done an amazing service, because you are not denying the reality of what they are going through.
Bentall: No. I hope that my approach is very patient oriented. But, as regards what you've said, my mind is a bit of a buzz. I'll have to read more before I can respond.
Tyrrell: Yes, you can see we are just flying a kite here. But it seems to hang together to us. We would really like to connect up with people doing work in this area because—
Bentall: —You're not a research outfit.
Tyrrell: We're not a research outfit in the way you are at all. We research organising ideas. But, amazingly, we've just been offered financial and practical help to set up a teaching hospital where we would be able to do research. The interest has come from people very interested in mental health, who think our approach worth supporting. The project is in the early stages at the moment but it arose from an appeal in Human Givens, making the case for a hospital or centre where people with less debilitating illnesses could be treated as outpatients, and people with psychoses could be treated as inpatients, on completely different lines from conventional psychiatric hospitals.
There was a place set up by the Quaker, William Tuke, in the late 1700s, as a retreat for people. It was based on the philosophy that psychotic patients needed kind, caring, non-judgemental people around to ensure they ate properly and got up at regular times and dressed properly and did ordinary, everyday necessary things such as gardening or cleaning — activities which, we would say, strengthen the left hemisphere and get people in touch with reality as much as possible, and calm their emotions down.
Bentall: Yes, I know about that. It was the Retreat in York. It is still there today, but it is run on conventional lines now. Someone else tried the same sort of thing in the 1970s — an American psychiatrist called Loren Mosher created the Soteria Project in California. He compared that sort of compassionate treatment to conventional psychiatric admissions and, at two-year follow-up, patients who went through the Soteria Project were doing at least as well as patients going through conventional psychiatry, and in some ways better. What was remarkable was that most didn't have neuroleptic treatment at all. That project, I think, badly needs to be replicated, and it's my dream project, by the way, for which I think there is about a two per cent possibility of getting funded in my lifetime.
Tyrrell: Well, that's what we want to do in this human givens hospital.
Bentall: If you ever get the funds to do that, I'll certainly be willing to come along and act as a scientific adviser or something.
Tyrrell: Can I hold you to that?
Bentall: Yes! As I said earlier, we got some significant effects from our therapy techniques in the SoCRATES study but not as large as we'd have liked. And that's enough for some people to write them off. There's this prejudice that either psychological techniques work or they don't, and people find it very difficult to think of psychological techniques as evolving. Imagine if drug companies said, "We've got an effect from our drugs but it
is not as large as we'd like, so letŐs give up!" It's ridiculous, isn't it?
Tyrrell: Yes, you said something like that in your book and it really made me laugh.
Bentall: So, we're at the beginning, really. There are plenty of opportunities to think about the kind of ideas that you have suggested, and plenty of opportunities to improve on what we have achieved so far in our trials.
Tyrrell: I think so, too. Thank you for the huge contribution to this effort that you have made with your book. I recommend our readers to read it.
© Richard Bentall and HG Publishing (2003)
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This article first appeared in Volume 10, No, 3 (2003) of the Human Givens journal.
PROFESSOR RICHARD BENTALL holds the Chair in experimental clinical psychology at the University of Manchester.
Madness Explained is published by Allen Lane at £25.00.
IVAN TYRRELL is a psychotherapist, writer and lecturer who, with JOE GRIFFIN, developed the human givens approach.
> You can find out more about psychosis and the new thinking on its causes at the following Human Givens College events:
From stress to psychosis: How to prevent people having breakdowns (one-day course)
Understanding and treating psychotic disorders (one-day course)
> The HGI ONLINE REGISTER of human givens practitioners, lists all fully qualified human givens therapists in private practice.
> More information, including all references, can be found in the following books, both by Joe Griffin and Ivan Tyrrell
Dreaming Reality: How dreaming keeps us sane or can drive us mad
Human Givens: A new approach to emotional health and clear thinking
> Read more about schizophrenia here
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> For a range of useful related publications including the above CD, visit:
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> Read more about schizophrenia here