How common is psychosis
Psychosis is not uncommon. In fact, around one in every 200 adult Australians will be diagnosed with schizophrenia, schizoaffective disorder or bipolar affective disorder in their lifetime. Common psychosis symptoms include false irrational beliefs (delusions), experiencing things that aren’t there (hallucinations), disordered thinking and behaviour.
Impact of psychosis
If you have a diagnosis of a psychotic illness you are probably doing it tough. Locally, an Australian survey of people experiencing psychosis found they were worse off financially, find it harder to get and keep a job, have more medical issues.
Contribution of childhood abuse and neglect
Not everyone who experiences psychosis symptoms, were exposed to childhood abuse and neglect, however a lot have. For instance, surveys of Australians with a psychosis related diagnosis have found that three-quarters reported exposure to any childhood trauma. Furthermore, over half reported emotional abuse and nearly a quarter reported childhood physical abuse and a quarter childhood reported sexual abuse. In addition, nearly a half reported emotional neglect and nearly a half reported physical neglect. Unsurprisingly, individuals who have experienced childhood abuse or neglect have an increased likelihood of psychical and mental health issues.
Alcohol and other drugs
Psychosis symptoms can be debilitating and exhausting. Consequently, it is not surprising that a national survey found around half of Australian’s who experience these symptoms form a dependence on alcohol or drugs at some stage in their lifetime. Unfortunately, people who experience psychosis symptoms are more likely to be sensitive to the side-effects of drug use. This means relatively low level drug use can result in you ending up in hospital diagnosed with drug induced psychosis.
Psychological treatment for psychosis
Anti-psychotic medication is commonly prescribed to people experiencing psychosis symptoms. However, the reality is that medications do not work for everyone, many stop taking their medications, and re-hospitalisation is common. Fortunately, psychotherapy, including modern forms of cognitive therapy such as ACT, have been shown to be helpful.
Groups such as the Hearing Voices Network point to the evidence that 70% of voice hearers can identify a traumatic life event that triggered their voices. Similarly, they encourage voice hearers to talk about their voices and what they mean as a way to reduce anxiety and isolation. For example, the Maastricht Approach is a structured way of exploring the life experiences that may have lead to the hearing of voices, the possible meaning of those voices, current coping strategies and current supports. Similarly, a modified Maastricht approach is used for people who experience paranoia. I am Registered as a Licensed Maastricht Alternative Approach Practitioner and a Member of the International Association of Maastricht Alternative Approach Practitioners. If you are experiencing psychosis symptoms, I would encourage you to engage in a non-stigmatising and collaborative approach to making sense of your current experiences. As a psychologist who is trained in the Maastricht Approach, as well as modern cognitive behavioural therapies, I would welcome the opportunity to continue your recovery journey toward a values-based life.
People experiencing schizophrenia or psychosis often have significant trauma histories. EMDR has been found to be a safe and feasible intervention for people with psychosis can be helpful in reducing distress associated with traumatic memories.
What is ACTp?
ACTp is ACT for psychosis, a treatment focused on managing the distress and disability associated with persisting psychotic symptoms. Furthermore, ACTp has been shown to achieve change specifically by increasing psychological flexibility. In addition, ACTp helps by increasing openness and awareness of psychosis symptoms, and a willingness to take valued action, despite the presence of psychosis experiences.
For example, a systematic review of ACT for psychosis shows that ACT can help reduce re-hospitalisation rates. In addition, ACTp has an impact on the psychological inflexibility of people experiencing psychosis and is beneficial for people with either first episode or enduring psychosis.
What is the Maastricht Approach?
The Maastricht approach was developed by Marius Romme and researcher Sandra Escher and emphasises accepting and making sense of voices and paranoid thoughts. Part of the Maastricht approach is the Maastricht Interview which enables individuals to explore their own experience and create some emotional distance from the voices and paranoid thoughts. In addition, the Maastricht Approach involves the development of a report that summarises the interview and proposes an approach including recommended treatment that will able individuals to change their relationship to their voices and paranoid thoughts and gain a greater sense of mastery.
The Maastricht Interview for Voice Hearers covers:
• The nature of the experience (how the voice hearer experiences their voices)
• Characteristics of the voices (for each voice, exploring their name, gender, age, tone of voice, frequency, hierarchy)
• Personal history of voice hearing – the circumstances when each voice first appeared or changed or disappeared
• Voice triggers
• What the voices say – exact sentences
• Explanations for the origin of the voices – places, situations and emotions that trigger the voices
• Impact of the voices on the voice hearer’s life
• Balance of the relationship – can you converse with the voices, do they listen to you, is there respect
• Coping strategies: cognitive (using your mind), behavioural (doing things), physiological (actions to get a physical reaction like drugs, yoga)
• Experiences in childhood such as trauma, abuse or neglect
• Treatment history such as previous therapy
• Social network – who is important in your life, have you told them about your voices, do they support you.
The pace of the interview is matched to the individual. For example, some individuals may never have spoken about the events that contributed to the emergence of their voices and thoughts. The Maastricht Interview is typically conducted over 4 to 5 sessions. However the pace of the interview is highly individual
Psychosis and depression – I’ve got both – What treatments help?
A 2015 study “Acceptance and Commitment Therapy for depression following psychosis” explored the effectiveness of ACT as a intervention for people experiencing clinically significant depression following a psychotic episode. In the study, participants were randomly assigned to either an 10-session ACT intervention tailored for psychosis or given Treatment-As-Usual. In the study participants who received ACT for psychosis intervention, compared to those who received Treatment-As-Usual, were 15 times more likely to achieve clinically significant decreases in depression scores.
To be included, patients required a diagnosis of a:
• psychotic disorder (i.e.,schizophrenia, schizoaffective disorder, schizophreniform disorder, delusional disorder, brief psychotic disorder, psychotic disorder NOS), or
• bipolar disorder with psychotic features, or
• depressive disorder with psychotic symptoms.
The participants in the study were:
• no longer acutely unwell – few had clinically significant levels of:-
◦ “Positive Symptoms” – problematic thoughts (delusions) or hallucinations or
◦ “Negative Symptoms” – severe reduction in emotional expressiveness (blunted affect) or emotional withdrawal and
• clinically significant levels of depression.
What was the ACT for Psychosis Intervention?
The ACT for psychosis intervention incorporated the following themes:
1. distinguishing between different types of experience: internal experience vs. 5-sense experience;
2. recognising how we get caught up struggling to move away from suffering;
3. moving towards our values;
4. getting distance between us and our ‘life stories’;
5. exploring how trying to control difficult mental experiences can be part of the problem rather than the solution;
6. noticing that we can notice: focusing on the context in which mental experiences occur rather on the content of these experiences; and
7. exploring worry thoughts associated with psychosis
This study builds on other studies that explores:
• ACT’s effectiveness for individuals with psychosis in inpatient and community settings
• group based ACT for psychosis,
• compassion focused interventions,
• the emergence and persistence of delusional beliefs, and
• the role of early attachment in the development of paranoid thinking,
My voices tell me to kill myself and harm others. How can psychotherapy help?
At a biological level, harsh voices are connected to the brain’s threat system. For many, as personal stress levels increase, so too does the so does the intensity of the voices and consequently the distress experienced by the individual. For voice hearers, Compassion Focused Therapy can help by improving emotional regulation skills and applying these skills to cultivate a sense of safeness which deactivates the threat system.