The Division of Clinical Psychology of the BPS has just published a guide to understanding psychosis, aimed at young people and their supporters. I was quite struck by how the document was written. So, in this blogpost, I want to offer a brief critique of it.

For me, the bewilderment with the document started with the definitions on the second page. For example, here is the definition of delusions:

Holding strong beliefs that others around you don’t share. Some people call these beliefs delusions.

The definition is quite crafty as it pretends not to be a definition. The sentence only describes something. Except the second sentence turns the description into a definition. But also here the problems don’t end. This is because it’s a definition only for some people.

There is strange tension in these two sentences. Readers are offered information which the document undermines. It’s hard to think that the authors refer to themselves as ‘some people’, so the text serves as a distancing device from a particular stance. But that makes it hardly a text that offers to give information for decision making. There is a subtle (or not so subtle) value attached to at least one perspective and I must admit that I find it irritating. The text becomes disingenuous.

But what I find truly extraordinary is the use of the phrase ‘some people’.  On the surface of it, the sentence is completely truthful. Yes, only some people call the beliefs in question delusions. Some others, for example, don’t know the word, yet others reject such a conceptualisation altogether. And yet, I find the definition, shall I say cautiously, dishonest.

First of all, the use of ‘some people’ suggests that the point of view adopted in the definitions is like many others. John doesn’t like the definition, but Joanne does. As it happens, both John and Joanne have friends who  mostly agree with them. Occasionally, they come to each other’s houses and debate their respective opinions. This is, for me, what the definition implies. And yet, that’s actually not true.

And here we come to the second point. The implication that definition is just an alternative on a par with others is not true because the ‘some people’ in the definition include institutional medicine, including psychiatry and psychology. That’s quite significant ‘some people’.

I have no trouble arguing against, say, psychiatry or psychology, I’ve done it many times. But, for pity’s sake, let’s not pretend that the voice of institutional medicine, like it or not, has the same weight and significance as John’s and Joanne’s. Or indeed, the admittedly relatively small group of (critical) psychologists who authored the original long document together with those who agree with it, come hell or high water.

Moreover, before you think that I am overstating the institutional bit here, let me remind you that the author list of the long Understanding Psychosis document sports 13 names with the title ‘professor’ in front of them. It seems so important to have the professors’ names as such that the titles are not abbreviated to ‘Prof.’ (even though the 6 doctoral titles were). These titles are used for the obvious reason of claiming authority in the field (the document was not written by any odd John or Joanne), with all the institutional paraphernalia it implies. In other words, the authors are very keen to claim their Bourdieuan symbolic capital. And yet, somehow, they the document doesn’t mention that minute fact that ‘some people’ who find the definitions useful are the thousands and thousands of psychiatrists and psychologists the world over. This is a sleight of hand to say the least.

A reservation is needed here. I am not claiming at all that the authors of the short introduction aim to mislead their target audience. In fact, I am fairly certain they’re not. The text is submerged in a particular set of discursive practices that allows it to have the form it has. Unfortunately, I think that it shows the conflict in the psy-disciplines, but that’s for another post. In any case, what I write here is only an analysis of the text and not of the authors, their minds, intent or any such thing. I leave such deliberations to psy-people.

Anyway, as I was pondering the phrase ‘some people’, I noticed that the definitions were not the only place in the text where the phrase was used. So, I started looking for it. Here is the list of the uses of the phrase, there are 16 of them.

1. Some people use the word psychosis to describe these experiences.
2. Yes, these experiences can sometimes be very distressing and, if they go on for a long time some people find it helpful to see them as an illness.

3. Hearing voices when there is no-one there — or seeing, tasting, smelling or feeling things that other people don’t. Some people call these experiences hallucinations.
4. Holding strong beliefs that others around you don’t share. Some people call these beliefs delusions.

5. Some people find having a diagnosis helpful and others don’t.
6. Some people find it helpful to see their problems as an illness, particularly if their experiences are very distressing and disabling.
7. Whilst some people’s psychotic experiences are distressing and disabling,
8. some people feel OK about theirs or even welcome them.
9. Some people feel it’s a bit of both – they see positives to their experiences but also find aspects of them
10. For some people, the voices they hear are related to this inner voice.
11. Some people prefer more informal support from friends, family or mental health workers – or some of the excellent self-help groups set up by other people who hear voices or experience paranoia.
12. Some people find medication helpful and others don’t – it really is a case of ‘suck (or swallow!) it and see’.
13. Some people use medication only at particular times, for example when the experiences are particularly intense or feel overwhelming.
14. Some people also find them helpful afterwards, or even long-term, to make the experiences feel more manageable.
15. While not everyone will experience unwanted effects from neuroleptic medication, for some people they can be quite severe.
16. As with psychological therapies, some people benefit from taking medication and others don’t.

When reading these sentences, I was struck again by the sleight of hand in the use of the phrase’. Let’s briefly consider the potential identity of ‘some people’. The first sentence is quite ambiguous and probably the largest in its scope. It’s probably this one time ‘some people’ could refer to anyone using the term, in other words, both professionals and, shall I say, lay users, by which I mean both patients and those around them, carers, family, friends etc. But in the next sentence (statement 2), ‘some people’ changes its identity and refers to patients (possibly also those around them, but it’s not clear). This identity is then picked up again in statement 5 and continues till statement 16.

In between them, in statements 3 and 4, ‘some people’ is likely to be used primarily in reference to institutional medicine and psychology. After all, it is particularly those people that are in need of such definitions. Yes, no doubt, some ‘lay users’ will also avail themselves of the term, definitions, however, are primarily for nosological and clinical use.

And here is my problem. We have two major identities (I am ignoring statement 1 now as it’s ambivalent) of ‘some people’: one is the lay people, the other is the professionals. And yet, nothing in the text suggests that the phrase is used in such two, admittedly very distinct, meanings. Moreover, by putting statements 3 and 4 between the uses of the phrase in the other meaning, you might read statements 3 and 4 also as referring to patients and those around them. This not only hides the information about common medical/psychological use of the term ‘delusion’, but also undermines it by pretending it’s nothing particularly different from what John and Joanne do.

And I have a problem with it. In my view, a BPS guide should be much more forthcoming with the information who exactly is referred to. Moreover, all the statements put the views of ‘some people’, i.e. medicine as a whole and those of John and Joanne, as if on an equilibrium. Is it really an equilibrium?  Do as many people find diagnosis useful as those with the opposite view? Do as many people reject the notion of delusion as those who accept it? This is what the text suggests and I don’t buy it.

Once again, I find a text with which I should have much sympathy way too problematic. Why does it conceal? Why does it imply things which are at the very least tendentious, partisan, not to say manipulatory and deceiving? Is it really so necessary to propagate the critical stance by resorting to linguistic tricks? Is your position so weak that full-on honesty is not possible? I am beyond disappointed.

Before I finish, I would like to point to another word I was interested in. I looked at the pronoun ‘we’ – the most manipulative of words. The authors start by using ‘we’ in reference to themselves. For example:

• We are delighted to introduce you to our booklet.
• We want you to know enough to decide for yourself how you understand your own experiences

A bit later, however, the document says:

• Often these experiences happen at times of a lot of stress and when we feel strong emotions, for example worry, anxiety, fear, depression or feeling overwhelmed by events.
• Many of us get a bit confused when we’re emotionally stressed.

Who is ‘we’ in the latter two statements? Who the hell is it?! Is it you, the authors? Or is it all of us, including me and my neighbours? I really would like to know, because it is the identity of the pronoun that will determine its function in the text. You see, it really bothers me that if ‘we’ is used in this ambiguous, nebulous, ‘we’re all in it together’ way, it probably serves as a fairly clandestine device to normalise the experiences.

Now, again, I do understand the need for normalisation of psychotic experiences, be it because in such a way you can work towards reducing the stigma attached to them. But are all psychotic experiences to be normalised? Nothing to worry about, all great stuff, carry on as normal? Well, you yourselves say that such experiences can be frightening and upsetting (which is an understatement of the century!!). Are those to be normalised too?

But if you do, if you really do want to say that psychosis is just a normal reaction to life, nothing strange or particular, then, please, do that openly! Come out and say this is what we believe. Don’t patronise me with these linguistic tricks because I find them offensive. Do tell me straight that one of your aims is to reduce stigma, or to persuade people to demedicalise psychosis. But don’t slide this under the table.

As you might imagine by now, I really don’t like the guide to psychosis. And it’s not because I don’t agree with it. I actually do agree more than disagree. Unfortunately, I feel disrespected by it. I feel that a text written by an elite of clinicians and academics is trying to pull a fast one on me.  And I deserve more. Others too, I think.

Having said this, I have no doubt that this blogpost, or any other critiques, will do nothing to persuade the authors to revise the text. I together with what I have written here will be dismissed like an irritating fly on a sunny evening. Not even a passing thought will be given. This is because I think (I stress this hesitation), the ultimate function of the guide is to be another body blow for institutionalised, medicalised mental health. It is another loud manifesto against the psychiatric truth. And I wish it had been said openly too.

Yet, ironically, the manifesto doesn’t only pose questions. Not at all. It also aims to replace the rejected truth with a new one. One which is equally grand and unshakeable.