Category: Psychosis

Psychosis isn’t always pathological

Unusual, psychotic-like symptoms, such as hearing voices, are not as rare among the general population as you might think. For example, it’s estimated that ten per cent of us hear voices that aren’t there, with only a small minority of hearers likely to ever receive a clinical diagnosis. According to a new study, this means that the factors that cause psychotic-like symptoms are likely different from those that lead to a diagnosis of pathological psychosis. Charles Heriot-Maitland and his colleagues argue that this distinction has been missed by the majority of past studies that hunted the causes of psychosis by focusing only on patients, neglecting those who live happily with their psychotic-like experiences.

To make a start rectifying this situation, Heriot-Maitland’s team interviewed six patients with psychosis (recruited via psychosis teams in SE England) and six “healthy” non-patients, who reported similar unusual experiences (recruited via UK networks involved with spiritual or psychic phenomena). Across both groups, these experiences included: receiving visions from God, hearing voices, and feeling that their body had been taken over. Based on their symptoms alone, you couldn’t tell which group a participant belonged to – clinical or non-clinical. The researchers asked all the participants open-ended questions about the circumstances that led to the onset of their unusual experiences, how they felt about them, and how their friends, relatives and other people had responded.

Using a qualitative method called Interpretative Phenomenological Analysis, the researchers looked for emerging themes in the participants’ answers. Both similarities and differences emerged. In both groups, their unusual psychotic experiences had started after a period of negative emotion, most often accompanied by feelings of isolation and deep contemplation about the meaning of life. However, the groups differed in how they responded to and perceived their odd experiences. Members of the non-clinical group had been more aware of non-medical interpretations of their symptoms; they viewed them as transient and desirable; and people close to them shared this non-pathologising perspective. By contrast, the patients encountered invalidating, medical interpretations of their experiences and were themselves less able to accept their experiences and to incorporate them into their personal and social worlds.

From a theoretical point of view, Heriot-Maitland and his colleagues said there was a need for a more precise approach to the study of psychosis, which distinguishes risk factors for psychotic experiences from risk factors for actual clinical vulnerability. “It would seem that the more out-of-the-ordinary experiences are associated with clinical psychosis, the less chance people have of recognising their desirability, transiency, and psychological benefits, and the more chance they have of detrimental clinical consequences.”

The researchers added that this has important clinical implications: “psychotic experiences should be normalised,” they said, “and people with psychosis should be helped to re-connect the meaning of their out-of-the-ordinary experiences with the genuine emotional and existential concerns that preceded them.” They also acknowledged that more studies, including quantitative investigations, are needed to build on this initial work.

ResearchBlogging.orgHeriot-Maitland, C., Knight, M., and Peters, E. (2011). A qualitative comparison of psychotic-like phenomena in clinical and non-clinical populations. British Journal of Clinical Psychology DOI: 10.1111/j.2044-8260.2011.02011.x

Further reading: The British Psychological Society’s response to the planned changes to the DSM – psychiatry’s diagnostic code. In its response the BPS airs its concerns about the over-medicalisation of people’s experiences.

Post written by Christian Jarrett for the BPS Research Digest.

Provoking paranoid interpretations in a ‘healthy’ sample

Traditionally, psychiatrists saw the paranoia exhibited by patients with schizophrenia as qualitatively different from the feelings of mistrust and suspicion expressed by ‘healthy’ people. Today that view is changing. New research, much of it by psychologists, is demonstrating that clinical paranoia is on a continuum with the experiences of the general public (see earlier). Much of this has involved use of questionnaires or interviews to gauge rates of paranoid feeling in non-clinical samples. Better than this, though, would be observing people’s actual paranoid interpretations unfolding in response to real events. Catherine Green and her team think they’ve found a way.

The researchers had 58 healthy participants sit in a room with a male experimenter and write about their journey to the lab that day (ostensibly as part of research into people’s ‘understanding of the causes of events’). Next, a male colleague knocked on the door and asked the experimenter if he could come outside for a moment. After the experimenter exited, the sound of male laughter was played for 35 seconds on speakers in the corridor.

What would you think if an experimenter left the room to talk to a colleague and then you heard laughter outside? Asked to explain these events, two of the participants thought the experimenter’s departure had something to do with them; five of them thought the laughter was about them; and two participants thought both events were somehow connected to themselves. ‘They laughed at something they read in my questionnaires,’ one participant said. In all, 15.5 per cent of the healthy sample showed evidence of mild paranoia – what’s known as ‘an idea of reference’ in which they misattributed self-relevance to the events. None of the participants showed more severe persecutory paranoia, and in fact 28 participants failed to notice the laughter.

‘The current study illustrates that paranoid explanations for events can be elicited and assessed in a real life situation,’ Green and her colleagues said. Questionnaires completed before and after the main part of the study showed that those participants who came up with more paranoid explanations also tended to score higher on ‘trait’ paranoia. However, they scored no higher on a measure of social avoidance and distress, which suggests their paranoid explanations were not merely a consequence of social anxiety. They did however score higher on interpersonal sensitivity and negative self-regard.

‘The current data suggest that some of the processes considered central to clinical paranoia … may also be operating at the milder end of the spectrum,’ the researchers concluded, ‘but the data raise questions as to what processes might be responsible for transition across the spectrum from ideas of reference to persecutory ideation.’

ResearchBlogging.orgGreen CE, Freeman D, Kuipers E, Bebbington P, Fowler D, Dunn G, and Garety PA (2011). Paranoid explanations of experience: a novel experimental study. Behavioural and cognitive psychotherapy, 39 (1), 21-34 PMID: 20846468

Post written by Christian Jarrett (@psych_writer) for the BPS Research Digest.

Further reading: Is paranoia increasing? Free Psychologist magazine article.

Floral arrangement as a cognitive training tool for schizophrenia

It’s the hallucinations and delusions associated with schizophrenia that typically attract discussion and research. However, patients with a diagnosis of schizophrenia also exhibit deficits in memory and perception and, importantly, the severity of these is predictive of quality of life, social functioning and autonomy. How can these cognitive deficits be helped? Researchers have found some success with computer-based training but patient motivation can be problem. Now a team of researchers led by Hiroko Mochizuki-Kawai at the delightfully named National Institute of Floricultural Science in Japan have tested out the benefits of floral arranging. ‘The use of natural materials may reduce tension and anxiety’ they predicted.

Ten patients (six men) with a diagnosis of schizophrenia or schizoaffective disorder agreed to undertake four one-hour sessions of flower arranging, supported by staff, over two weeks. The arranging involved following simple written instructions, holding them in memory one at a time, and placing flowers and leaves into the correct slots in an absorbent sponge. Two patients failed to attend; average attendance for the remainder was 3.1 sessions.

Before the intervention, the flower arranging patients’ performance on the ‘block-tapping’ measure of non-verbal working memory was the same as that displayed by ten controls. After two weeks’ flower arranging, however, the flower patients’ performance had improved and was now superior to the controls. The block tapping task involves observing blocks being touched one at a time and then reproducing that same order from memory. On another test, which involved copying a complex figure from memory, the flower arranging patients were again no better than controls at the study outset but were superior to controls after the two weeks of training (although this was because the controls had deteriorated at the task rather than because the flower arrangers had improved).

This was only a pilot study and it has obvious short-comings including the small sample sizes, the lack of any comparison intervention for the control group, and no way of measuring the impact of cognitive gains on quality of life. However, the researchers were upbeat in their conclusion: ‘We believe that the findings of the present study may contribute to the improvement of cognitive rehabilitation in schizophrenic patients’.

ResearchBlogging.orgMochizuki-Kawai, H., Yamakawa, Y., Mochizuki, S., Anzai, S., & Arai, M. (2010). Structured floral arrangement programme for improving visuospatial working memory in schizophrenia. Neuropsychological Rehabilitation, 20 (4), 624-636 DOI: 10.1080/09602011003715141

Disclosure of their diagnosis impairs the social functioning of people with schizophrenia

People don’t need to be treated as a stereotype for harm to occur; their mere belief that they could be viewed in a stereotyped fashion is enough – a phenomenon known as ‘stereotype threat’. For example, women reminded of the stereotype that men are better at maths tend to perform more poorly in a subsequent maths task, even if they are actually treated fairly. Now Julie Henry and colleagues have extended this line of research to the domain of mental health. They’ve found that patients with a schizophrenia diagnosis function less well socially, when they think that the person they’re chatting with knows their diagnosis.

Thirty people diagnosed with schizophrenia or schizoaffective disorder spent a few minutes chatting on their own to one research assistant and then they did the same with another assistant an hour later. There were a few points of deception: first, the participants were led to believe that the assistants were participants from another study. Also, most importantly, before one of the conversations began, they were told that the assistant knew about their diagnosis of schizophrenia; before the other, they were told the assistant did not know. They were also told, truthfully, that both the people they were to chat with did not themselves have a diagnosis of schizophrenia.

In reality, the research assistants didn’t know whether each participant had a diagnosis of schizophrenia or not. This was achieved by having them chat to the participants diagnosed with schizophrenia plus a number of control participants. Crucially, they weren’t told in advance who was who.

After each conversation, the research assistants rated the social behaviour of the person they’d just chatted with. The participants in turn rated the behaviour of the assistant they’d just chatted with and they said how they felt the conversation had gone.

The key finding is that the social functioning of the participants with schizophrenia seemed to deteriorate when they thought their conversational partner knew their diagnosis (even though they didn’t). Specifically, when they thought their diagnosis had been disclosed, the participants were rated by the research assistants as being more impaired at initiating conversations and at switching topics appropriately, and the assistants also found these conversations less comfortable.

Henry’s team can’t be sure, but they think these apparent deficits emerged because the participants’ concern about how they would be judged, in light of their diagnosis having been disclosed, interfered with their ability to converse in a more effective manner.

A further twist was that the participants with schizophrenia seemed unaware of these effects – they reported finding the conversations, in which they thought their diagnosis was known, just as comfortable and successful as when they thought their diagnosis had been kept hidden. This contrasts with non-clinical research on stereotype threat, in which people seem to be aware of the effects on their performance.

The results provide food for thought regarding when and how mental health diagnoses should be disclosed. The researchers said their findings suggest ‘that one of the defining qualities of [schizophrenia] – social skill impairment – is not caused solely by the disorder per se, but rather, also derives from feelings of being stereotyped.’

ResearchBlogging.orgHenry, J., Hippel, C., & Shapiro, L. (2010). Stereotype threat contributes to social difficulties in people with schizophrenia. British Journal of Clinical Psychology, 49 (1), 31-41 DOI: 10.1348/014466509X421963

Post written by Christian Jarrett (@psych_writer) for the BPS Research Digest.

Treating schizophrenia without drugs

There’s no doubt the discovery of anti-psychotic drugs was a breakthrough. Previously people with schizophrenia could expect hospital confinement and little in the way of actual treatment. Today’s anti-psychotics are safer than the early versions, but they still have serious side-effects and because their prescription for psychosis is so routine, there’s a danger that some people, who might otherwise recover with psychological help only, are taking them unnecessarily.

This is a difficult area to study because any research that denies patients the drugs they need will rightly raise alarm bells. John Bola and colleagues scoured the literature looking for studies where drug treatments for schizophrenia were delayed for a set period of time, in conditions where patients received plentiful psychological and social support. They found five such studies involving 261 participants with schizophrenia, many of whom were not given anti-psychotic medication immediately. Their outcomes were compared between one and three years’ later with patients who were treated with drugs straight away.

These studies included the Rappaport Agnews State Hospital Project (pdf), the Soteria project and Soteria Bern Project (pdf), the Finnish API Project and the Cullberg Parachute Project. Across all these studies, the psychosocial treatments varied, but in general patients were provided with a community-based therapeutic milieu with ample social support, a relaxing environment, and with family therapy often also included.

Among the patients for whom drug treatment was delayed, about one-third actually ended up recovering without needing to take medication at all, and longer-term, their outcomes tended to be superior to those patients who were treated with drugs immediately.

Bola’s team said these findings show that in a residential care context (where medication can be prescribed swiftly if needed) it is possible to research drug-free approaches to schizophrenia in a safe and ethical way. And they added that that the findings point to a sub-type of schizophrenia that is associated with spontaneous recovery, in contrast to the trend for deterioration shown by the majority of patients.

“The above cited studies at least highlight the fact that no disadvantages and several advantages have been noted with no or a low-dose anti-psychotic medication in combination with psychosocial interventions for first episode schizophrenia spectrum patients,” the researchers said.

Previously on the Research Digest: “Caring for psychotic patients with maximum kindness and minimum medication“.

ResearchBlogging.orgJR Bola, K. Lehtinen, J Cullberg, L Ciompi (2009). Psychosocial treatment, antipsychotic postponement, and low-dose medication strategies in first-episode psychosis: A review of the literaturePsychosis, 1 (1), 4-18

Post written by Christian Jarrett (@psych_writer) for the BPS Research Digest.

Support for the aberrant salience account of schizophrenia

According to the aberrant salience account of schizophrenia, the positive symptoms of the condition – the hallucinations and delusions – come about because patients see meaning where there is none. The neurotransmitter dopamine, associated with learning and reward, is found in excess in patients with schizophrenia, and it is this chemical anomaly that is thought to underlie their tendency to misinterpret the meaning of things.

The aberrant salience account was proposed by psychiatrist Shitij Kapur and while it has provoked a lot of interest, few studies have attempted to directly test its predictions. Now Jonathan Roiser and colleagues have shown that patients experiencing delusions show more aberrant salience in a learning task than do patients whose symptoms are in remission – a finding entirely consistent with Kapur’s account.

On each trial, 20 patients on medication for schizophrenia and 17 healthy controls had to press a button as fast as possible in response to a black square appearing on a computer monitor. Sometimes participants were rewarded for responding quickly to this square and sometimes they weren’t. Crucially, the reward schedule wasn’t completely random, and the likelihood of a trial being rewarded could sometimes be predicted by an image (e.g. a household item) flashed on-screen before the black square. However not all images were predictive in this way. Some were irrelevant, and a key feature of the task was whether or not participants would learn which images were predictive and which weren’t.

If participants responded more quickly after predictive images than irrelevant ones, then this would indicate they had learned correctly – a sign of so-called “adaptive salience”. By contrast, speedier responding after irrelevant images would indicate that they’d read predictive meaning where there was none – a sign of “aberrant salience”. After the testing, the participants were also asked to report which images they thought were predictive and which weren’t, thus providing another, more explicit, measure of adaptive and aberrant salience.

Overall, the medicated patients with schizophrenia showed no more aberrant salience than the controls. That is, they were no more likely to believe an irrelevant image signalled a forthcoming reward. Crucially, however, among the patients, those who were still experiencing delusions showed more evidence of aberrant salience than those whose symptoms were in remission.

Moreover, the patients showed reduced adaptive salience relative to the controls. This is also consistent with Kapur’s account, which predicts that patients treated with anti-psychotic medication will show impaired learning as a side-effect of their medication. A final supportive finding was that control participants who scored higher on a test of schizophrenia-like experiences also demonstrated increased aberrant salience.

A finding not predicted by Kapur’s account was that patients with more negative symptoms of schizophrenia – lethargy and lack of emotion – also tended to display more aberrant salience.

“…these data are consistent with the hypothesis that schizophrenia patients with delusions exhibit aberrant salience,” Roiser’s group concluded. “The aberrant salience hypothesis warrants further investigation in unmedicated patients with schizophrenia.”

ResearchBlogging.orgJ. P. Roiser, K. E. Stephan, H. E. M. den Ouden, T. R. E. Barnes, K. J. Friston, E. M. Joyce (2008). Do patients with schizophrenia exhibit aberrant salience? Psychological Medicine, 39 (02) DOI: 10.1017/S0033291708003863

Post written by Christian Jarrett (@psych_writer) for the BPS Research Digest.

Link to related feature article in The Psychologist magazine (open access).
Link to related post on Mind Hacks blog.

The same voices, heard differently?

It isn’t just people with a diagnosis of schizophrenia who claim to hear voices inside their heads. Many other people do too. However, a key difference between psychiatric and non-psychiatric voice hearers is that the latter usually claim not to be bothered by their unusual experiences. One explanation for this difference in the hearers’ interpretation is that voice hearers who develop schizophrenia have been traumatised in their past, thus predisposing them to find the voices in their heads distressing.

A new study by Liz Andrew and colleagues explores this idea further. Andrew’s team compared the traumatic history of 22 voice hearers who were in contact with psychiatric services, with the history of 21 psychics and mediums, who also claimed to hear voices, but who had never been in contact with psychiatric services.

Both groups actually reported having experienced similar rates of trauma in the past. However, the psychiatric group reported having experienced more childhood sexual abuse. And crucially, there were also differences in the lasting psychological impact of the traumatic experiences the two groups had lived through. The psychiatric group still experienced anguish related to their trauma, and the persistence of these difficulties was related to how they interpreted the voices they heard. Specifically, the more that trauma-related anguish persisted, the more likely a participant was to say that they found their heard voices malevolent. In turn, interpreting voices as malevolent was associated with mental distress, in terms of depression levels.

In other words, these findings suggest that a traumatic past can predispose people to hear voices, and that it is the long-term effects of that trauma, and whether or not it is resolved psychologically, that then determines whether or not those heard voices are experienced as distressing.

The findings have clinical implications, as the researchers explained: “The high prevalence of childhood sexual abuse in the psychiatric voice hearers suggests that this may be an important factor to consider in the assessment, formulation and intervention of individuals who hear voices.”

A final note of caution. It’s possible that the non-psychiatric group in this study don’t really experience voices in their heads in the same way that the psychiatric group do. Other researchers have excluded mediums and the like from their studies on the basis that they may experience “pseudo-hallucinations” not directly comparable to the voices heard by people with psychosis.

ResearchBlogging.orgE. M. Andrew, N. S. Gray, R. J. Snowden (2008). The relationship between trauma and beliefs about hearing voices: a study of psychiatric and non-psychiatric voice hearers Psychological Medicine, 38 (10) DOI: 10.1017/S003329170700253X

Post written by Christian Jarrett (@psych_writer) for the BPS Research Digest.

Link to related earlier Digest item.
Link to another related item.
Link to one last, related Digest item.
Link to related item at Mind Hacks.

Neighbourhoods with too much or too little social cohesion may increase risk of schizophrenia

The idea that social breakdown in a neighbourhood can increase the risk that some residents will develop schizophrenia may not come as too much of a surprise, but the notion that too much social cohesion might also be a risk factor, probably will.

James Kirkbride and colleagues sent questionnaires to over 16,000 people in South London to obtain their views on the social cohesion of their neighbourhoods. For example, participants answered questions about how much graffiti was in their area, how many thefts there were and whether someone was likely to help their neighbours. Just over 4000 people replied.

The data on neighbourhood social cohesion was then compared with new diagnoses of schizophrenia made in those areas over a period of twenty-four months, as recorded several years earlier by a separate study.

The researchers found that neighbourhoods with either below or above average social cohesion, tended to have had more new incidences of schizophrenia, even after taking into account differences between neighbourhoods in the age, gender and ethnicity of the local populations.

The harmful effect of low social cohesion is easier to explain: in socially fragmented neighbourhoods, people at risk of schizophrenia are less likely to receive the support they need to prevent them from developing psychosis. But what about the harmful effect of too much social cohesion? The researchers speculated that it’s likely “some residents in neighbourhoods measured as having ‘high’ social capital were excluded from access to that social capital, conversely increasing their risk of schizophrenia.” Another possibility is that schizophrenia is more likely to be detected in more socially cohesive neighbourhoods.

Incidentally, although this study design can’t prove that neighbourhood social cohesion directly causes changes in rates of schizophrenia, the researchers said it’s unlikely that the causal relationship runs in the opposite direction, simply because absolute rates of schizophrenia are so low.

Kirkbride, J., Boydell, J., Ploubidis, G., Morgan, C., Dazzan, P., McKenzie, K., Murray, R., Jones, P. (2008). Testing the association between the incidence of schizophrenia and social capital in an urban area. Psychological Medicine, 38(08) DOI: 10.1017/S0033291707002085

Post written by Christian Jarrett (@psych_writer) for the BPS Research Digest.

Hiring private detectives to investigate paranoid delusions

Vaughan Bell: “In 1684, the famous writer, Nathaniel Lee, was becoming increasingly disturbed and was promptly admitted to Bethlem Hospital. While protesting his sanity, he described the situation as one where ‘they called me mad, and I called them mad, and damn them, they outvoted me.’ Over three hundred years later, the difficulty of agreeing on whether someone’s belief is a paranoid delusion, a sign of psychotic mental illness, is still troubling psychologists.

Delusions are broadly defined as false, fixed beliefs that are held despite obvious evidence to the contrary. Sometimes, it’s a clear-cut case. If someone believes they are dead, a condition known as Cotard’s Syndrome, you can be confident that the belief is a delusion. On other occasions (and these occasions are by far the most common) the question relies on a judgement of how well the evidence supports the person’s belief. This is where it gets tricky, because what counts as evidence, and what counts as ‘well supported’ are often a matter of opinion.

Someone goes to a mental health professional and says ‘I feel awful. I’m being targeted by my neighbours, and they’ve implanted microphones in my house to listen to my breathing.’ It certainly sounds strange, and maybe they’ve already been diagnosed with a mental illness in the past, so we might just think it sounds unlikely enough to count as a delusion. But we know, for example, that people diagnosed with schizophrenia are much more likely to suffer violence and discrimination. Perhaps, some of the paranoia is driven by genuine persecution.

So here’s the experiment. Everyone who walks into a mental health clinic is interviewed and their seemingly paranoid beliefs are noted. The mental health professional is asked to make a judgement on how delusional the belief might be. Then, each client is assigned a world-class private investigator, who is given the job of checking out all aspects of the belief, no matter how unusual. Is anyone in the neighbourhood persecuting the person? Are there really microphones in the house? Is there anyone who might have an interest in listening to their breathing patterns?

At the end, the professionals’ judgements are compared to the evidence from the investigation, and we get to see how good we are at distinguishing paranoia from realistic concerns. Just as importantly, the study would indicate where the borderlands of paranoia lie, giving us a better understanding of how the mind exaggerates our fears. Further research could look precisely at how genuine threats spark, ignite and become inflamed by the cognitive distortions of psychosis.

The experiment, of course, will never be run. Even ignoring the practical difficulties, it’s simply too intrusive and risks breaking client confidentiality. To do their job, the private investigators would have to ask questions which would give away personal details. Thankfully though, good mental health care focuses on psychological distress, no matter what causes it, but the issue raises the important question of how much we rely on guesswork to judge other people’s reality.”

Dr Vaughan Bell is a researcher and clinical psychologist in training at the Institute of Psychiatry. He writes daily at the Mind Hacks blog.

Caring for psychotic patients with maximum kindness and minimum medication

Richard Bentall: “It is difficult to decide on the most important psychology experiment that has never been conducted, but the most important one in psychiatry is not hard to identify. Since Haenri Laborit discovered the psychological effects of chlorpromazine in the late 1940s, anti-psychotic medication has been the first-line (and often only) treatment offered to psychotic patients throughout the world. The evidence from clinical trials in favour of this approach appears impressive at first sight, but the drugs have terrible side effects, and their continued use at high doses is associated with a demonstrable reduction in life expectancy (Waddington et al. 1998). Because they are so unpleasant to take, often causing dysphoria and loss of motivation, many patients discontinue them, and this is true of the new atypical anti-psychotics despite their alleged kinder side effect profiles (Lieberman et al. 2005). Although patients who stop their medication in this way have a high probability of relapse, some of the exacerbations of symptoms that are observed are probably a rebound effect caused by the treatment rather than a return of a pre-existing illness – there is evidence that long-term anti-psychotic use leads to a proliferation of dopamine D2 receptors, thereby increasing the sensitivity of the dopamine system and exacerbating the very physiological dysfunction that the drugs are designed to treat. Hence patients who withdraw gradually are less likely to relapse than those who stop their medication suddenly (Moncrieff, 2006).

Bola (2006) recently reported a meta-analysis of clinical trials in which the majority of patients were experiencing their first episode of illness, in which some patients were unmedicated, and in which the follow-up period was at least one year. Amazingly he could identify only six studies that met these criteria and the evidence suggested that unmedicated patients did at least as well and possibly better than medicated patients in the long-term. One of the studies was the controversial Setoria project devised by Leon Mosher (1999), who devised a system of caring for acutely distressed psychotic patients with maximum kindness and minimum medication. No formal psychotherapy was provided, and the patients were looked after by untrained graduates who dealt with their difficulties with acceptance and emotional support. Despite evidence that Setoria patients did as well as first-episode patients treated in conventional psychiatric services, and the fact that Mosher was director of schizophrenia research for the US National Institute of Mental Health, NIMH closed down the project, probably because of pressure from the pharmaceutical industry (Whitaker, 2002).

In Britain, over the last decade, clinical psychologists have pioneered the development of cognitive-behavioural interventions for patients with psychosis, with promising results (Tarrier & Wykes, 2004). However, CBT has always been offered in combination with conventional antipsychotic drugs. Even though Soteria and CBT come from different philosophical roots, close examination of the two approaches reveals many common features, including acceptance and the normalization of symptoms. Psychiatric patients need to know the results of a clinical trial in which a CBT version of Soteria is compared to treatment as usual. Unfortunately, given the corrupting influence of the pharmaceutical industry (Angell, 2004) they are likely to have to wait for a very long time.”

Professor Richard Bentall is at the University of Wales, Bangor, and is the author of several books on the topic of mental illness, including ‘Madness explained; psychosis and human nature‘.