How can mental health professionals open their minds to psychosis?

Researchers at the Universities of Birmingham, York and Melbourne say that by understanding the intricacies of feelings, attitudes, and experiences which are interlinked with delusions, clinicians will be better able to build trust and genuine engagement with patients.

In a new study, published today (4 May 2022) in The Lancet Psychiatry, researchers collated and reviewed first-hand accounts of the experience of delusions from patients with psychosis in mental health settings. In their review, the team used a new methodological approach informed by philosophy to combine and synthesis all the available qualitative evidence. The team then developed a new model to better understand how delusions emerge and are shaped by different contexts from multiple levels of explanation.

The authors examined the experiences of more than 370 patients, described in 24 different scientific studies and found a number of themes that were common across all the studies.

For most participants, for example, delusions were not just a symptom of illness or an irrational belief. Delusions often were the most compelling way that the person could make sense of their life, in the context of a radical alteration of reality and intense emotions. While the experience could be hostile, sparking fear or panic, individuals could also experience awe or wonder, or deep meaning in their delusions.

When reality is altered in this way, individuals can struggle to make sense of their own identity, experiencing self-doubt or a loss of control or, conversely, the feeling that they are someone special, or with a unique purpose. In the latter case, the delusional experience seemed to provide a sense of coherence, purpose and belonging at a time of intense life stress and can therefore be interpreted as temporarily adaptive or beneficial.

“These experiences are complex and nuanced,” said lead author Dr Rosa Ritunnano, consultant psychiatrist and researcher at the University of Birmingham’s Institute for Mental Health and the University of Melbourne. “When we train clinicians in treating psychosis, we need to ensure they are going beyond ‘correcting’ a dysfunction or ‘curing’ a symptom. Instead, by trying to understand how the delusion is shaped by the patient’s emotions, life experiences and socio-cultural contexts, we can devise treatment and support that is more relevant to the individual.”

The approach has particular resonance for situations in which a patient may be detained without their consent with the aim of protecting themselves from harm. The number of patients detained in this way has been steadily rising for several years, with particular ethnic groups and those with learning disabilities being particularly impacted in this process.

“One of the main issues is that all too often, the patient’s voice is lost within the process of trying to help them,” says Dr Clara Humpston, one of the senior authors on the paper. “Carers, clinicians and family members all have a challenging task in learning how to listen. That means accepting that there may not be a shared view of reality, but the patient’s experience is still true and valid, and ought not to be silenced.”