Análisis de la entrevista semiestructurada y discusión de los resultados

This first section of the literature review chapter contextualised pertinent issues relating to the concept of psychosis, such as the biological/biomedical, biopsychosocial, dialogical, cognitive-behavioural, alternative explanations of the causality of psychosis, critique of biomedical psychiatry, subjective experiences of psychosis – both service user and family, voluntary and self-help support organisations and lay understandings. This included how the concept of psychosis has changed, and been redefined and challenged over time.

Within mental health services in Ireland the concept of psychosis is mainly defined by the dominant biological/biomedical approach which considers it as a central feature of the most serious forms of mental health disorders, for example schizophrenia, schizoaffective disorder, and bipolar disorder. Most who experience an acute psychotic episode attend mental health services either in a voluntary or involuntary capacity. It is in this context that they meet and communicate with nurses. One of the processes of attending a mental health service involves being given an interim ‘diagnosis’, such as acute psychosis. This ‘diagnosis’ is made when a person reports and is seen to experience what are considered by psychiatrists as signs and symptoms of psychosis. Another process is being prescribed anti-psychotic medication. Service user subjective experience of psychosis often includes hearing critical and derogatory voices; being hyper-vigilant and feeling under constant threat; feeling tormented; loss of control of their senses of self, and at times believing they have a divine or cosmic purpose and act accordingly. At the same time, their family members and significant others often

experience worry and uncertainty about how to be of help, and feel frightened, stressed and burdened. Nurses can also experience stress and burnout when dealing with tense and difficult situations, for example caring for those experiencing psychosis (McGowan 2001). In addition, the psychoses have a high economic cost on a society. Hence, the impact of psychosis on service users, their families, mental health services and communities is significant.

Help offered to those who experience psychosis is based on particular and sometimes mutually exclusive understandings of the nature of psychosis and associated treatments or approaches. The biological/biomedical approach considers it a disorder of the brain that is triggered by genetic, neurobiological and environmental factors and offers treatment based in this perspective, such as pharmacological interventions, hospitalisation or home support, and psycho-education. A potential advantage of this approach is that mental health clinicians are familiar with it and provides clear clinical pathways for treatment. In addition, some service users agree with this approach. However, other service users, their advocates, commentators and some clinicians have expressed dissatisfaction when the biological/biomedical model, in particular when it is presented as the sole treatment option. Furthermore, many service users choose to disengage with this treatment, mainly due to the unwanted effects of medication, not believing the assertion that they are unwell, or because of worries about stigmatisation. However, others question the validity of the concept of psychosis, as they claim neither consistent brain abnormalities nor specific genes have yet been identified, and there is no convincing evidence that antipsychotic medication significantly impacts on the brain biochemistry. While there is growing evidence that childhood trauma and adverse life events can cause unusual experiences that are difficult to understand, where service users need help is with problems of living and addressing past traumas rather than medication.

Another understanding of psychosis is the biopsychological approach, which promotes understanding and treating psychosis from three perspectives; biomedical, psychological and

social. Hence, offered treatment includes pharmacological, individual

therapy/support/interventions and family meetings, and support to reintegrate into the community. However, even within this approach it appears that the biological/biomedical approach remains dominant, in particular in the initial phase of services user interactions with mental health services. On the other hand, the dialogical and cognitive-behavioural appear to offer alternative non-pharmacological treatments that significantly include the service user

and families (dialogue and trialogue). However, there is also a growing importance on hearing and understanding the service user’s subjective experience of psychosis, its impact and its causality such as trauma, and recovery pathways, as well as the development of various voluntary organisations and self-help groups where they feel more accepted and empowered.

With regards to this researcher’s understanding of the concept of psychosis, from his experience as a nurse and family therapist both in the past and currently, he contends that mental health clinicians who only adhere to a strict biomedical treatment approach risk it having a negative impact on service users experiencing acute psychosis, such as being disempowered and stigmatised at a time when they feel very vulnerable. However, it appears that all approaches have something to offer the service user to manage and overcome their difficulties as long as they are practised in way that is helpful, empowering and useful. This is similar to Rorty's (1982) pragmatism viewpoint. He would probably say something like; 'It appears to be true that these treatments can be helpful for some people in psychosis', as we have a cherished story about their helpfulness. So, when people engage in these treatments it seems that they have less psychotic experiences and it is seen as useful thing to do in our culture.