PRE.SINOPSIS

The following accounts of trauma and spirituality address issues that some who have experienced psychosis deem important while traditionally mental health services have deemed less important, which articulates alternative explanations of causality.

Trauma

Childhood trauma refers to negative life experiences including physical, sexual and emotional abuse as well as neglect which result in difficulties in early and later life. One of these difficulties is adult mental health problems including: anxiety disorders, substance abuse, eating disorders, post-traumatic stress disorder, dissociation and personality disorders (Anda et al. 2006; Chapman et al. 2004). Yet, according to Read (1998) the issue of childhood trauma as factor in the development of psychosis has traditionally been overlooked, where the focus remained on the biogenetic approach. Schäfer and Fisher (2011) postulated that this occurred due a belief that apart from medication, other interventions were not considered useful for psychosis, coupled with some uncertainty as to whether service user accounts can be trusted. However, recent large scale studies found that that someone who experienced childhood abuse was statically more likely to experience psychosis than those who reported no abuse (Janssen et al. 2004); while Whitfield et al. (2005) found that adverse childhood experiences significantly increased the risk of hallucinations occurring in later life. In addition, Romme et al (2012) interviewed over three hundred voice hearers within the last twenty years and found that between 70-80% relate their voices to ongoing, long term serious difficulties that they experience as traumatic. These voice hearers defined their abuse in the following groups: sexual abuse combined with physical; emotional neglect; adolescent problems; high current stress levels; being bullied; and physical abuse (Romme et al. 2009), where all but the high stress levels were experienced in childhood. With regards to causality, Romme and his colleagues found interviewees not only attributed the influence of early traumatic events (which creates a vulnerability), but also high prolonged stress and personally significant events occur before an onset or relapse of psychosis (event(s)). Hence, childhood trauma that continues to impact on the person as an adult can be an important issue in the development of a psychosis.

An expert by experience, Peter Bullimore (2012) believes that his experiences of paranoia were caused by childhood sexual abuse which occurred over an extended period of time. This resulted in him becoming isolated, fearful of the outside world, suffering high anxiety, and paranoid, thinking that others knew what happened to him. In his late teenage years he began to experience what he called ‘reassuring voices’, however over time they became multiple and abusive when feeling upset or recollecting his own abuse, which further contributed to his paranoia. The trauma and associated psychosis became more severe as an adult, in particular at times of severe stress, which had a serious impact on his mental health, personal relationships, and employment. Unfortunately, his experience of psychiatric care was not positive where he received a diagnosis of chronic schizophrenia and at one point was taking twenty-five tablets a day. Therefore, from his subjective experience he recommends that mental health professionals explore the relationship between psychosis and the person’s life story or actual circumstances in life, as people build constructs to keep themselves safe. In addition, they need to explore trigger factors both past (trauma(s)) and present (situations and emotions) with the service user, as it would contribute to understanding the underlying meaning of his/her psychotic experiences and aid recovery.

Hence, as the link between childhood trauma and the development of psychosis has been established, clinicians need to pay attention to the service user’s life story, their specific experience and understanding of psychosis as this will help them both in how help is given and received.

Spirituality

Spiritual experiences and psychosis have been linked together throughout recorded history. The hallucinatory and visionary experiences of religious prophets and saints have been an essential aspect of religion for thousands of years (Lukoff 2012). Indeed, it is reported that Socrates, one of the most famous Western philosophers, had experienced an ‘inner voice’ since childhood that at times advised him, which he believed was Divine in origin. Socrates also walked barefoot, wore old cloths, was unkempt, and was difficult to understand at times (Skodlar and Jørgensen 2013). Skodlar and Jørgensen argue that while Socrates’ wisdoms and insights are generally lauded (despite it being likely he could be diagnosed with a schizophrenia spectrum disorder), those who currently have Socrates-like experiences should be given time and space to explore them and learn from them, not only to aid recovery, but because it is possible that their perspective can contain wisdom and understandings of ourselves that others often are unable to reach. However, mental health clinicians usually

consider that the above experiences fall within the realm of psychosis, which needs to be medically treated. Yet, spiritual/religious beliefs can have significant meaning for people, in particular when distressed and suffering. This is often pertinent (but not exclusive) to minority ethnic communities. Thus, given the importance placed on spirituality and religious beliefs, Murphy and Leavey (2014) recommend that mental health clinicians need to establish a dialogue with religious groups where cultural beliefs are shared. In fact, the service user movement in the United Kingdom identifies spirituality as a vital element in enabling people with serious mental health difficulties to rebuild a meaningful life (Ralph 2000). In addition, Koenig et al. (2001) found that religion is associated with positive mental health, where those with mental health difficulties use their spiritual beliefs to improve functioning, reduce isolation and facilitate healing. This implies that automatically placing spiritual experiences and beliefs into the realm of psychosis not only risks alienating the service user’s subjective experience, it also negates the possibility of a shared development of understandings about possible pathways to recovery.

Patte Randal (2012) recounted her experiences of spiritual emergencies, psychosis and the process of how she came to make sense of how a Christ-centred spirituality helped her to stop her psychiatric medication and maintain her mental health and emotional equilibrium, despite ongoing stressful life events. In her formative years she grew up in a non-religious family within a background of a Jewish and English Protestant culture, emotionally distant parents, and being sexually abused by a relative. Throughout her late teenage and early twenties Patte began to experience feeling elated, needing little sleep, and believing that she had a significant purpose in life. These experiences alternated with her considering life was meaningless, chaotic and feeling she was living in hell. As a result, was prescribed antipsychotic medication. This occurred in the contexts of witnessing her father’s sudden death; having a baby at a young age; being abandoned by her husband; smoking; and attending college. Over a period of time, she began to understand that life has some mystical meaning and purpose, a “a sense of pathway” (p.62) or meaningful coincidences which she had a part to play in. There was also recognition through her medical training that what she had experienced what could be named as a bi-polar disorder, but from her perspective deeming it as ‘spiritual emergency’ fitted better. As a consequence, the model of recovery she promotes is one that includes bio-socio-psycho-spiritual and cultural aspects. Her wish is that adopting this approach would provide a more hope-inspiring context for understanding mental health crises and avoid stigma and hopelessness.

In summary, paying attention to the service users’ subjective spiritual understanding of causality and experiences is important not only for clinicians to develop a connection with service users: these experiences and understandings can significantly contribute to service users and clinicians’ development of pathways to understand the meaning of what is occurring for them and how it can aid recovery. It is interesting to note that Eeles, Lowe and Wellman (2003) found that nurses demonstrate a tolerance of ambiguity, an awareness of their own subjective experience, and attempt to have a rounded and holistic view of the service users’ beliefs more than other professionals.

Critique of Biomedical Psychiatry

The anti-psychiatry movement provides a platform for the critique of psychiatry and

associated disciplines by deconstructing the dominant discourse based on

biological/biomedical psychiatry and supporting alternative explanations (Bracken and Thomas 2010; Thomas and Bracken 2004). Within these critical arguments it is maintained that psychosis is a meaningless construct that very few clinicians can agree on (Bentall 2013; Szasz 1970). Foucauldian analysis of mental illness argues that as Western culture became more technological discipline became important. This occurred through increased 'supervision and surveillance' in order to produce a compliant population. The aim was to increase production and profitability in the factories, to decrease social unrest, and increase social control (Foucault 1977). The effect of this surveillance is to make the person more self- regulatory through the internalisation of the rules of those in power; as a result it brings validation from others as well as reassurance that one falls within what is considered the norm. This emphasis on discipline with a dominant understanding of what is considered acceptable can be seen in the doctor's office and at nursing stations where internalised political and scientific theories turn people (subjects) into things (objects). Therefore, privileging and normalising certain cultural practices over others can disqualify whole groups of people. An aspect of objectification of people is scientific classification (Foucault 1982), such as the DSM-5 (2013). Hence, people with the power of diagnosis are seen as presenting their ideas as a 'truth', that is, what is normal and abnormal, and accepting the dominant 'truth' disqualifies other alternative stories/local knowledge.