joel_gold's picture
Psychiatrist; Clinical Associate Professor of Psychiatry, NYU School of Medicine; Coauthor (with Ian Gold), Suspicious Minds
The Thin Line Between Mental Illness And Mental Health

It is discomfiting for many to contemplate this fact. To assuage our minds, we imagine a nice thick wall between Us, the "Well," and Them, the "Mad."

In one episode of The Simpsons, Homer is psychiatrically hospitalized by mistake. His hand is stamped "Insane." When his psychiatrists come to believe he is not and release him, they stamp his hand "Not Insane." But sanity is not binary; it is a spectrum on which we all lie. Overt madness might be hard to miss, but what is its opposite? There is clear evidence that large numbers of people who have no psychiatric diagnosis and are not in need of psychiatric treatment experience symptoms of psychosis, notably hallucinations and delusions.

A study published this year in JAMA Psychiatry surveyed over 30,000 adults from nineteen countries and found that 5 percent of them had heard voices at least once in their life. The majority of these people never developed "full-blown" psychosis of the type observed in a person with, say, schizophrenia. An older study reported that a full 17 percent of the general "non-clinical" population had experienced psychosis at some point.

It gets even more slippery when taking into account that it isn’t always clear if an experience is psychotic or not. Why is it that someone who believes that the US government is aware of alien abductions of Americans is not deemed delusional, or merely a conspiracy theorist, and yet someone who believes that he himself has been abducted by aliens likely will be considered delusional?

The psychosis continuum is not simply a fascinating concept; it has important clinical ramifications. Unfortunately, that is news to many mental health practitioners. It is easy to see the neurobiological parallels between antidepressant medication improving mood, anxiolytic medication reducing panic, and antipsychotic medication ameliorating hallucinations. But ask a psychiatrist about providing psychotherapy to people suffering from these symptoms and, again, the wall comes up. At least here, in New York City, many people with depression and anxiety seek relief in therapy. Very few of those with psychosis are afforded its benefits, despite the fact that therapy works in treating psychotic symptoms. And here is where the lede has been buried.

Cognitive behavioral therapy (CBT)—one of the most practiced forms of therapy—while commonly applied to mood, anxiety, and a host of other psychiatric disorders, also works with psychosis. This might seem to be inherently contradictory. By definition, a delusion is held tenaciously, despite evidence to the contrary. You aren’t supposed to be able to talk someone out of a delusion. If you could, it wouldn’t be a delusion, right? Surprisingly, this is not the case.

And here we return to our thin line. Early on in CBTp, the therapist "normalizes" the psychotic experiences of the patient—perhaps going so far as to offer his own strange experiences—thereby reducing stigma and forging a strong therapeutic bond with the patient, who is encouraged to see himself not as "less than" his doctor, but further along the spectrum (the continuum model). The patient is then educated as to how stressors like child abuse or cannabis use can interact with preexisting genetic risk factors and is encouraged to reflect on the impact his life experiences might have on his symptoms (the vulnerability-stress model). Finally, the therapist reviews an Activating event, the patient’s Belief about that event, and the Consequences of holding that belief (ABC model). Over time the clinician gently challenges it and, ultimately, patient and doctor together reevaluate the belief. CBTp can be applied to hallucinations as well as to delusions.

CBTp has about the same therapeutic benefit as the older antipsychotic medication chlorpromazine (Thorazine) and the newer antipsychotic olanzapine (Zyprexa). This does not mean, of course, that people shouldn’t take antipsychotic medication when appropriate. They certainly should. The reality, however, is that many do not, and it’s not hard to understand why. These medications, while often life-saving (for the record, I have prescribed antipsychotics thousands of times), unfortunately often have adverse effects. Impaired insight (the ability to reflect on one’s inner experiences and to recognize that one is ill) is also a significant impediment to medication adherence.

Here, CBTp can have several ancillary benefits. First, the therapy can improve insight and thereby adherence. Second, if a patient refuses to take medication but is willing to engage in CBTp, he is going to do better than with no treatment at all. Finally, people receiving CBTp might ultimately require lower doses of antipsychotic medication, diminishing its toxicity and, again, increasing adherence.

The utility of CBTp shouldn’t be news, as evidence of its efficacy has been replicated over and again, but it remains so, sadly even in the mental health community, especially in the United States. While CBTp is a first-line treatment for psychosis in the UK, you would be hard-pressed to find a psychiatrist in the US who could describe how it is practiced. Good luck finding a mental health practitioner who is trained to do it. But the good news is that the news is spreading. However slowly, more clinicians are being made aware, are being trained, and are practicing CBTp. More practitioners will become available to more patients who will then receive better care (optimally, along with other well-established, psychosocial interventions like family therapy and supported employment), and we will see improved medical outcomes.

If this news sticks—and I think it will—it will have a great humanizing effect in the way society views people suffering from psychosis. After all, while there are psychotic aspects in all of our minds, it is assuredly just as true that there are healthy parts of even the most stricken of minds.