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"What was that you said again?" - a new look at psychosis

Ivan Tyrrell and Richard Bentall discuss patient-centred new approaches to the understanding and treatment of psychotic illness.

Tyrrell: You have written a huge book about psychosis, which you manage to make utterly readable and absorbing. There are lots of ideas arising from it that I want to discuss, and I'd like to start with a quote from your book, to set the scene. You are describing the modern psychiatric ward.

"With few exceptions, the psychiatric wards of today are located in general hospitals alongside surgical, medical and other types of services. Admissions to hospital are restricted to those who are floridly disturbed. Discharge back into the community is usually after a matter of weeks by which time, hopefully, the patient's worst symptoms have been controlled by medication.

"Visiting such a ward, one sees patients with a variety of diagnoses aimlessly wandering around. Some talk out loud to their voices or charge around in a manic frenzy. However, on closer scrutiny, the overwhelming impression is one of inactivity and loneliness. Many patients sit in the ward lounge, silently smoking cigarettes, their faces glued to daytime television shows. The nurses, who now wear casual clothes instead of uniforms, spend most of their time in the nursing office, talking only to those patients who are most obviously distressed. The psychiatrists and psychologists are even less in evidence — patients on many wards see their psychiatrists for only a few minutes every week and the psychologists are almost entirely absent, confined by their own choice to outpatient clinics.

"There seems to be a lack of therapeutic contact between the patients and the staff. The patients are simply being 'warehoused' in the hope that their medication will do the trick."

That's a very damning description. As you go on to show, the success of psychiatric treatment today is little better than that achieved in the first decades of the 20th century, before the introduction of modern psychiatric drugs.

Bentall: It was meant to be a damning description. What I argue in my book is that we've been labouring under serious misunderstandings about the nature of madness for more than a century and that only by abolishing these misunderstandings can we hope to improve the lot of some of the most neglected and vulnerable people.

Tyrrell: You say, in effect, that modern psychiatry has been based on two completely erroneous ideas.

Bentall: Yes. The orthodox approach, which I think is so wrong, is based on two false assumptions: first, that madness can be divided into a small number of diseases, for instance schizophrenia and manic depression; second, that the 'symptoms' of madness cannot be understood in terms of the psychology of the person who suffers from them.

The German psychiatrist Emil Kraepelin is really the man who set psychiatry off in this wrong direction — the Kraepelinian paradigm remains almost unchallenged within the mental health professions, even today. It is the organising principle for psychiatric practice and research. It was Kraepelin's idea that psychoses fell into a small number of discoverable types and that these could be independently identified by studying symptoms. Although his ideas were fiercely debated at the time, his system of diagnosis — on the basis of specific symptoms — was embraced by most clinicians.

Tyrrell: Interestingly, hints that the truth might lie elsewhere weren't followed up. For instance, you write about the Swiss psychiatrist, Eugen Bleuler, who took the same basic approach as Kraepelin but refined some of his ideas, and introduced the concept of schizophrenia. In 1867 he took over the psychiatric clinic on an island in the Rhine. When a typhoid epidemic broke out in the village, he recruited some of his patients as nurses. He noted that they performed extremely well, prompting him to suggest that, in a general crisis, mental illness, far from dominating the life of the patients, could retreat into the background.

This is actually a far-reaching insight which we are still struggling to get orthodox psychiatrists and psychodynamic psychotherapists to see today — directing people's attention outwards, off their own problems, helps break the cycle of their illness. Working as nurses gave people a sense of meaning and purpose, self respect, a degree of control, a chance to help others — all things which are crucial to mental health. But, alas, Bleuler didn't make these connections, and what became emphasised in psychiatry was symptom classification.

Bentall: And the system doesn't work. For a categorial system of diagnosis to work, patients must all fit the criteria for a particular diagnosis and not be able to fit the criteria for more than one disease, unless they are very unlucky indeed. That means more and more sub-categories are required, to try to accommodate everybody.

Tyrrell: Could you explain that a bit more?

Bentall: current Diagnostic and Statistical Manual — DSM-IV — there are five subtypes of schizophrenia; two milder forms of psychosis (schizophreniform disorder and brief psychotic disorder); schizo-affective disorder; delusional disorder; shared psychotic disorder; psychotic disorder due to a medical condition; substance-induced psychotic disorder; and, finally, the catch-all "psychotic disorder not otherwise specified"! 
DSM-IV states that patients may not be diagnosed as suffering from schizophrenia if they also meet the criteria for schizoaffective disorder, major depression or mania.

Similarly, the criteria for bipolar disorder specify that the patient's symptoms shouldn't be better accounted for by schizoaffective disorder and must not be imposed on schizophrenia, schizophreniform disorder, delusional disorder or other psychotic disorders. But what researchers found when they tested the criteria was that 60 per cent of people who had met the criteria for one disorder had also met the criteria for at least one other at some time. They concluded that suffering from one disorder put people at greater risk of suffering from another.

Strangely, they didn't discuss the possibility that their findings might reflect the inadequacies of the neo-Kraepelinian system! The most likely explanation for the strong associations observed between schizophrenia, depression and mania is that these diagnoses do not describe separate disorders. 

Tyrrell: Absolutely! One of the central planks of your book is that the problems involved in categorising and 'explaining' schizophrenia and manic depression and so forth disappear if we look at the circumstances behind, and meaning of, people's psychotic experiences. We need to listen to what they have to say about it themselves, and accept that there isn't such a huge divide between people who have psychotic experiences, such as hearing voices or delusions, and those who don't.

Bentall: You can't consider the brain in isolation from the social world and the experiences people have. You can't treat psychotic disorders without addressing patients' psychological and social needs.

Tyrrell: Indeed. That's what the human givens approach is all about.

Bentall: I would say that psychotic complaints invariably reflect concerns about the self or relationships with other people. Psychotically depressed people, for example, often believe that they are inadequate or guilty of imaginary misdeeds. Manic patients often feel they are superior to others and are capable of achievements that will amaze the world.

The delusional beliefs usually attributed to schizophrenia are particularly redolent with social themes: patients rarely profess bizarre ideas about animals or objects; they believe they themselves are being persecuted or denied recognition for some imaginary achievement or that they are adored by a particular celebrity or their doctor. The voices that psychotic people hear are often critical voices, telling them that they are worthless or they are doing something incorrectly. Michael Musalek, a psychiatrist at the University of Vienna, has suggested that psychotic symptoms reflect the core existential dilemmas experienced by ordinary people, and that really resonates with me.

Tyrrell: You provide lots of evidence to show the importance of social stresses and family stresses, which cause anxiety and depression, in the lead up to psychotic breakdown. And yet this has been so ignored by conventional psychiatry. I think that, if society were better able, psychotherapeutically, to deal with depression, anxiety disorders and trauma, we would have far fewer psychotic breakdowns in the first place, because — as you show in your book — it is almost like a continuum.

Bentall: I think that's true.That comes out in the latest trial that we are doing, that we've just got the data for. This is a pilot study of using cognitive behavioural therapy (CBT) to prevent psychosis. We identified 60 people who are at ultra-high risk of psychotic breakdown because they are showing attenuated psychotic symptoms. Half of them were offered CBT and were monitored at monthly intervals to see how their symptoms developed. The other half were simply monitored without any psychological intervention.

We asked the treated patients to come up with a problem they wanted to work on, and, for the majority, the problems have concerned relationships with other people or mood problems. We had pre-set criteria for transition to psychosis and our initial results showed a significant difference between the groups in terms of reduction in numbers of people who became psychotic over a one-year follow-up period. Interestingly, we also found that the treated patients' doctors were less likely to prescribe neuroleptic medication. 

Tyrrell: Presumably, those who had the CBT, and were helped to think about relationships or other problems in a less negative or self-deprecating way, were the less likely to become psychotic?

Bentall: That's right. It was a relatively small study and we don't know what will happen in two years' time. We are currently discussing with the Medical Research Council the possibility of a bigger version.

Tyrrell: You make the point, and I couldn't agree with you more, that psychotic phenomena are, above all, emotional phenomena. This is something we are always saying when talking about depression. People who are depressed seem flat but internally they are highly emotionally aroused. Similarly, you describe the case of a man diagnosed with schizophrenia where two doctors, two social workers and a psychologist who all knew him well described him as quite severely blunted in his emotions. But his diary, which his mother had, showed he was full of emotion — he talked about feeling pity and love and hurt and being cowardly and misunderstood and so forth.

Psychotic complaints invariably reflect concerns about the self or relationships with other people.

Bentall: Yes, just because people aren't emotionally expressive, it doesn't mean they are not having emotions. In fact, flat affect, as it is called, is one of the severe side effects of neuroleptic medication, so it could even largely be down to that, not the illness at all.

Tyrrell: That brings me on to my next point. Neuroleptics.

Bentall: What's striking about the story of the neuroleptics is that, in terms of efficacy in their effect on the so-called positive symptoms of schizophrenia (hallucinations and delusions), there has been no real improvement since the discovery of chlorpromazine, the first neuroleptic to be used on psychotic patients. There is no evidence that the new 'atypical' neuroleptics that are available today, and that have been pushed by drug companies at a huge expense to the British taxpayer, are any more effective than the older drugs.

Neuroleptics do have an effect on positive symptoms, and I believe that's been proven, given the amount of trial evidence available. But they have many negative effects, which are also well understood. The old fashioned, so-called typical, neuroleptics, for example, produce side effects that are really dreadful: the patients have parkinsonian symptoms; they have a terrible inner sense of restlessness and depression; they get muscle dystonias, which are muscle spasms. In some cases they get tardive dyskinesia — pronounced involuntary movements of, for instance, the tongue, the lips and mouth, which can be very debilitating to people.

And these drugs also appear to have an extremely negative effect on people's motivation, so that patients taking them often have what's been described as a neuroleptic-induced deficit syndrome. So, although users may experience fewer positive symptoms, they're also less able to achieve things in their lives.

Now, the new, or atypical, neuroleptics are being touted as much better because they don't produce these side effects, but the truth is that they produce lots of other side effects. For example, if you take a drug like olanzapine, which is probably the most widely used neuroleptic in this country at the moment, massive weight gain is a serious problem. At least 50 per cent of people have sexual dysfunction and there is also a high risk of diabetes, so these drugs have pretty nasty side effects.

Tyrrell: Clearly, any benefits need to be balanced against all those side effects.

Bentall: Ah, but you also have to take into account that maybe a third of patients don't get any benefits at all; they don't get a reduction in positive symptoms, although they are still given the drugs and so still get the horrible side effects.

Tyrrell: So why do they keep on being prescribed the drugs?

Bentall: Psychiatrists tend to think the drugs are the only thing there are, therefore they must be prescribed, even if the patient is not getting any obvious benefit. I think patients should be asked if they want to take these drugs. The benefits and the side effects should be explained, and, if they do want to take them, they should be given a low-dose typical neuroleptic like chlorpromazine for three months. At the end of that time, a detailed account should be taken of the costs and benefits, and then the patients should decide if they want to continue or to try another drug. If the costs seem to be outweighing the benefits, then it makes sense to try another drug. If that doesn't work after another three months, it makes sense to try an atypical neuroleptic. If that doesn't work, then step four is to give up on the drugs. But that never happens.

You find, in Britain, that probably under five per cent of psychotic patients are not given neuroleptic drugs and they're usually people who have been labelled as non-compliant: the people who have the guts to say firmly that they don't want to go down that route. And they're treated in a very pejorative way by the psychiatric establishment because of that. If taking a drug were based on an analysis of cost and benefits, you'd probably find just 50 per cent of patients would be on neuroleptic drugs.

Tyrrell: That's scandalous!

Bentall: There is also a bit of a scandal about the dosage of these drugs that are used. I think everybody in psychiatry knows about it and I’ve heard it discussed at conferences, but in a strangely detached way, as if this issue isn't really having an impact on patients' lives. The evidence is that you get no benefit whatsoever from doses above about 300mg per day of a chlorpromazine equivalent, and that's easy to work out for each of the main neuroleptics. If you go above that level, you get a massive increase in side effects but no added clinical benefit. And yet, it is still very common to find patients who are on much higher doses than that. We did a study of patients in the North West recently, which included recording their neuroleptic medication, and out of 200-odd patients we found that the median dose was about 600mg a day of chlorpromazine — in other words, double what the evidence says is the optimum dose. And there are plenty of people around who are taking more than a gram a day of chlorpromazine equivalent. 
So there are people literally being poisoned by their psychiatrists. Of course, the paradox is that, by overprescribing medication in this way, psychiatrists actually deprive patients of benefits that they might otherwise get from the treatment.

Tyrrell: That's outrageous. And the only beneficiaries are the drug companies.

Bentall: Yes, they are beneficiaries. I give a lecture every year to our Masters students — we have a Masters in research methods and I give a lecture every year called "The science and politics of clinical trials" — and I say at the beginning that, if they don't feel less comfortable going to their doctor after this lecture, they've not been listening! I have lots of case studies of ways in which randomised controlled trials are subverted to give misleading results. So, for example, in the case of a newer atypical neuro-
leptic versus a typical neuroleptic, most trials have compared the new drug with an irrationally high dose of the old one, and they find that the atypical neuroleptics have a much better side-effect profile. Well, of course they do, because they have been compared to a toxic dose of the typical neuroleptics! I can't think that drug companies don't know what they've been doing, so it's a way of making a compound look good by comparing it to a wrong dose of a traditional one.

Tyrrell: Neuroleptics are supposed to be anti-psychotic but they don't address the psychosis at all, do they? Don't they just calm people down? 

Bentall: Well, I don't think that's actually quite true; I think they are to some extent anti-psychotic. As I've said, in some patients, they have a very strong anti-hallucination and anti-delusion effect. But they also have quite a profound effect in calming manic patients down, which is a good thing because, if you've ever seen someone in a manic episode, it's pretty frightening. It's pretty frightening for them and it's also pretty frightening for everybody else around them.

It's important with psychiatric drugs not to throw the baby out with the bath water. There should be some people on anti-psychotic drugs, a lot fewer than are actually on them, and most of those who are on them should be on a lower dose. I would like to see the rational prescribing of psychiatric drugs. They are dangerous tools that have some benefits, if used carefully. But they're not used carefully.

Tyrrell: There's been some debate, particularly in America, I think, about whether psychologists should prescribe psychiatric drugs. 

Bentall: I would welcome having a prescription pad. Most of my time is spent on research projects but I see patients one day a week, and it would be wonderful to be able to say, "I'll deal with the whole package, the medication as well as the psychological treatment". Equally important, it would give me un-prescribing rights. Then it would be possible to deliver a treatment for patients that actually matches their needs.

TyrrellCould you talk about your research on brief therapy interventions with psychotic patients?

Bentall: I've been involved in some randomised controlled trials for psychological treatment, which I think are methodologically extremely sound, compared to most drug trials. One of the major ones that I have been working on is the SoCRATES study (Study of Cognitive-Realignment Therapy in Early Schizophrenia), in which the principal investigator is Shon Lewis who, interestingly enough, is a psychiatrist. This is a large study of about 360 patients, 80 per cent of whom were having their first episode of psychosis, the rest their second episode. They were randomly assigned to three conditions: a brief CBT intervention, supportive counselling or treatment as usual — go to hospital and get pumped full of drugs. 

TyrrellCounselling comes in many different models. I assume you are talking about the person-centred, so-called Rogerian model when you say supportive counselling?

Bentall: Rogerian, that's right. The therapy window was very, very short, just five weeks, and the study was extremely arduous to carry out. We had a team of three psychiatrists to do the follow-ups, who were blind to the treatment that the patients had received. They managed to follow up on 75 per cent of patients over 18 months, which in itself was quite an achievement, because it's a fairly itinerant population. The outcome of the study was, I suppose, in some ways a little disappointing. We had a significant benefit from both types of therapy and there was a greater benefit 
from CBT but, while it was better being in psychological therapy than not, the clinical benefits were on average not as great as we would have liked. 

We got a strong centre effect — there were three centres where the therapy took place. In one centre, there was almost no benefit from therapy; in another there was a very strong therapy effect; and the third fell in between. I guess that suggests that skill of the therapist is important — although we did supervise the therapists, who had the required level of competence on a cognitive therapy scale.

I think another interesting part of the data was that the supportive counselling group did quite well; the CBT group did better, but the supportive counselling group did quite well. Now, I've heard cynics, extreme advocates of biological psychiatry, describe this sort of counselling treatment as placebo control, but I don't think that is the right way to think about this. I think the simple story is that treating people with respect and being warm and human is quite important! The fact that supportive counselling did have this effect is a chilling reflection on the quality of routine care. I'm not saying supportive counselling doesn't require some skill, because it does, but it is an intervention that should be possible to deliver on a mass scale. So, it is striking that the treatment-as-usual patients were not getting that kind of support.

Tyrrell: The patients hadn't been put on drugs, presumably.

Bentall: They were on drugs. It just wasn't possible, for political reasons, to do a trial without drugs.

TyrrellWas that because drug companies were financing the—

Bentall: —No, no, it is just that you can't persuade NHS psychiatrists not to give patients drugs. But, also, a reasonable question to ask is, "Does the therapy produce added benefit above the drug treatment?" To which the answer is yes. As we had a very short therapy, it was quite amazing that we did have these effects after 18 months. 

Tyrrell: Some people might wonder what is involved when you are using cognitive behavioural techniques with psychotic patients, who are effectively out of touch with normal reality.

Bentall: Well, I think that's a myth, really. I say to students that there is always an island of rationality in the maddest of patients.

TyrrellAbsolutely! I quite agree. One thing I was struck by, though, when I looked in the index of your book, was that there was nothing much in it about the REM state, the rapid eye movement stage of sleep that is associated with most dreaming. J. Allan Hobson, professor of psychiatry at Harvard and one of the greatest sleep researchers, said in his book, The Chemistry of Conscious States, "If we can unveil the root cause of dreaming, we will have found the genesis of psychosis. Dreaming is not a model of psychosis, it is psychosis." What do you know about that?

Bentall: It's an old idea. It goes back to Jung, who described the psychotic patient as a dreamer awake. I'm not convinced by that!

Tyrrell: Well, my colleague, psychotherapist Joe Griffin, has put forward a theory that does appear to explain dreaming, and we are becoming more and more aware of a connection between dreaming and psychosis. We've worked with a few psychotic people — we’ve filmed working with them — and we notice many signs in their behaviour that could be explained by their being in the REM state while they are awake. For instance, you very often see rapid eye movement while they are talking. They are dissociated. The equivalent, in the REM state, of the catatonia seen in schizophrenia is that, when you are dreaming, you're paralysed. People with schizophrenia are reported to feel less pain. In dreaming, you don't experience pain, which is why the hypnotic state, which is also a REM state, is used for operations. I myself had an operation under hypnosis when I was 15, so I know that works! People hear voices —

Bentall: —You know there have been newer explanations for that, looking at the relationship between hemispheric activation and—

Tyrrell—Yes, the right hemisphere is massively active. When people hear voices, the speech centres are activated, and that can be seen on brain scans.

Bentall: It's the left frontal areas in particular.

TyrrellBut the point is that, when people are psychotic, they think the voices are alien, outside of themselves. What we think might be happening is this: the dream state, it is known, is the province of the right hemisphere and people aren't usually capable of left hemisphere thought when they 
are dreaming, because they are locked into the metaphorical script of the dream. But if they are dreaming whilst awake, so to speak, there is still going to be some left hemisphere activity. Perhaps the only way the right hemisphere, which is dominant at the time, can make sense of these left brain thoughts is to create the metaphor of hearing voices. There is no language but metaphor for that part of the brain to use. So these voices become aliens, spies or strange influences from beyond, or from the government, and so on. 

People totally believe in the reality of dreams when dreaming them, however crazy — you could be flying or talking to animals and in the dream it is totally real. It is only when you wake up that you think, "My God, I've had a really weird dream". But you believe in the reality at the time, in just the same way that psychotic people believe in their reality. But, because the dream has broken out of the REM state theatre, if you like, and it is now invading their waking reality, they will believe that with the same intensity that they believe in a dream. They can't make the distinction of knowing what's a dream and what isn't. Psychotic people don't say, "God, I've had an amazing dream".

Bentall: No, they don't. 

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.

There are people literally being poisoned by psychiatrists, given drugs at double what the evidence shows is the optimum dose.

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 let’s 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.

 

PROFESSOR RICHARD BENTALL holds the Chair in experimental clinical psychology at the University of Manchester. "Madness Explained" is published by Allen Lane.

IVAN TYRRELL is a psychotherapist, writer and lecturer who, with JOE GRIFFIN, developed the human givens approach.

 

"Human Givens Journal" Volume 10 - No. 3: 2003

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