Revised version 2017
This publication is licensed under a Creative Commons CC BY-ND 4.0 International Licence.
This report provides an overview of the current state of knowledge about why some people hear voices, experience paranoia or have other experiences seen as 'psychosis'. It also describes what can help. A parallel report is available entitled Understanding Bipolar Disorder - Why People Experience Extreme Mood States, and What Can Help.
In recent years we have made huge progress in understanding the psychology of what had previously often been thought of as a largely biological problem, an illness. Much has been written about the biological aspects: this report aims to redress the balance by concentrating on the psychological and social aspects, both in terms of how we understand these experiences and also what can help when they become distressing.
We hope that this report will contribute to a fundamental change that is already underway in how we as a society think about and offer help for 'psychosis' and 'schizophrenia'.
Note on Terminology
Part 1: What is 'psychosis'?
Section 1: What this report is about: Experiences sometimes called psychosis
1.1 What does it mean to experience psychosis?
1.2 Everyone's experiences are different
1.3 Our different cultures
Section 2: How common are these experiences?
2.1 How many people have 'psychotic' experiences? How many are given a diagnosis of schizophrenia?
2.2 People who do not use mental health services
Section 3: Are these experiences best understood as mental illness?
3.1 Can psychotic experiences be separated from normal ones?
3.2 Many 'normal' people have unusual experiences
3.3 Are mental health diagnoses reliable - can clinicians agree?
3.4 Are mental health diagnoses meaningful? Do they refer to real 'things'?
3.4.1 Naming something doesn't make it real
3.4.2 What a diagnostic label does not tell you
3.4.3 Experiences are on a continuum and don't fall into neat categories
3.4.4 The ever-expanding reach of mental health diagnoses
3.4.5 Has the idea of schizophrenia arisen as a result of the 'clinician's illusion'?
3.5 The advantages and disadvantages of seeing things as mental illness 3.6 Recent recommendations to move away from using diagnoses
3.6 Recent recommendations to move away from using diagnoses
Section 4: How do these experiences affect people's lives?
4.1 Variability in outcomes
4.2 Which outcomes matter?
4.3 Influences on outcome
4.4 The myth that psychosis leads to violence
Part 2: Causes: why do so many people have these experiences and when do they become distressing?
Section 5: Biology - our brains
5.2 Neurochemical theories
5.3 Brain structure and function
Section 6: Life experiences and how they affect us
6.1 Life events and trauma
6.3 Inequality, poverty and social disadvantage
Section 7: The way we make sense of the world: the psychology of 'psychosis'
7.1 The psychological link between life events and psychosis
7.2 Hearing voices, inner speech and memories
7.3 How we develop beliefs and reach conclusions
7.4 The relationship between emotions and psychosis
7.5 How psychotic experiences can lead to distress and disability
7.5.1 How we make sense of our experiences
7.5.2 Positive aspects of psychosis
Part 3: What can help
Section 8: Arriving at a shared understanding of the problem
8.2 Deciding what is likely to help
Section 9: Self-help, and help from family, friends and communities
9.1 Support from friends and family
9.1.1 How services can help friends and family to support people
188.8.131.52 Family meetings (sometimes called 'Family Interventions')
9.2 Self-help and mutual support
9.2.1 The Hearing Voices Network
9.2.2 Complementary approaches
9.2.3 Peer support
9.2.4 Recovery colleges: An educational approach to offering help
9.2.5 The service user/survivor movement
Section 10: Practical and emotional help from professionals
10.1 Making sure basic needs are met
10.2 Emotional support
10.3 Work and employment
10.4 Help with organisation and motivation
10.5 Getting help early
10.6 Help at times of crisis
10.7 Keeping safe
10.7.1 Self neglect, self harm and suicide
10.7.2 Risk to other people
10.7.3 Risk of harm from services
10.7.4 Compulsion: using mental health legislation
Section 11: Talking - psychological help
11.1 Cognitive behaviour therapy (CBT)
11.1.1 Effectiveness of cognitive behaviour therapy
11.1.2 Less formal support drawing on CBT related ideas
11.2 Cognitive remediation
11.3 Trauma focused therapy and psychodynamic approaches
11.4 Acceptance and commitment therapy and Mindfulness
11.5 Narrative therapy
11.6 Voice dialoguing
11.7 Helping families
11.8 Increasing Access to Psychological Therapy
11.9 Finding an approach that suits you
Section 12: Medication
12.1 How can medication help?
12.2 Problems with 'antipsychotic' medication
12.2.2 Unwanted effects
12.3 Collaborative decisions about medication
12.3.1 Weighing up benefits and risks
12.3.2 Finding the type of medication that suits you best
12.3.3 Working out when to take medication
12.3.4 Finding the right dose
Part 4: What we need to do differently
Section 13: What mental health services need to do differently
13.1 We need to move beyond the 'medical model'
13.2 We need to replace paternalism with collaboration
13.2.2 Accepting views other than the illness model
13.2.3 Collaboration rather than just 'involvement'
13.3 We need to stop 'prescribing' and start supporting people to choose
13.3.1 Trying things out
13.3.2 Talking therapy
13.3.3 Medication or no medication
13.3.4 Professional help or self-help
13.4 We need to make rights and expectations explicit
13.5 We need to reduce the use of compulsion and mental health legislation
13.5.1 Changing the culture of psychiatric hospitals
13.5.2 Is mental health legislation inherently discriminatory?
13.5.3 Is forced medication ever justified? We need to change the way we do research We need to change how mental health professionals are trained and supported
13.6 We need to change the way we do research
13.7 We need to change how mental health professionals are trained and supported
Section 14: What we all need to do differently
14.1 We need take on board that we're all in this together - there is no 'us' and 'them'
14.2 We need to focus on prevention
14.2.1 Prevention: towards a safer society
14.2.2 Prevention: towards a more equal society
14.2.3 Prevention: reducing discrimination and oppression
14.2.4 Prevention: reducing harmful drug use and addressing its causes
14.2.5 Prevention: what we can each do to protect our mental health
14.3 We need to campaign against prejudice and discrimination
Appendix: Useful books and websites
Details of Contributors