When Doug Turkington, a UK psychiatrist, first announced to his colleagues that he wanted to help people with psychotic experiences by talking to them, he was told by some that this would just make them worse, and by others that this would be a risk to his own mental health, and would probably cause him to become psychotic! Fortunately, he didn’t believe either group, and in the following decades he went on to be a leading researcher and educator about talking to people within the method called CBT for psychosis.
I’m writing about Turkington because I just spent a week learning more about CBT from him at a training in California. This training was part of a bigger effort to bring this psychological approach into wider use in the western US. Attending this training and seeing the interest and passion in those who attended got me reflecting on what the role of CBT might be in changing our mental health system overall.
A key question related to that, it seems to me, is the question of how CBT can improve its relationship to another key change effort in the field of psychosis, that of the Hearing Voices Movement (HVN). I have a lot of interest in the possible improvement in that relationship between CBT and HVN, because for quite a while I have had my “feet in both worlds.” My first involvement with the mental health system was as an activist for change and increased choice, then I became a mental health professional so I could work to provide some of the alternatives I believed should exist.
The first alternative approach to voices I heard about was the CBT methods of Paul Chadwick, so I started with that, and went on to become a CBT practitioner and educator. Then, when I heard about the HVN, I adopted many of its ideas as well, arranged for Ron Coleman to come to my town of Eugene Oregon to do some trainings, and got an HVN group going here. While I have always interpreted CBT for psychosis in a flexible way, integrating it with HVN ideas, I have sometimes been unsure how well that would fit with the approach of the CBT for psychosis establishment. So it was really interesting to spend a week with Turkington, and to have a chance to explore his views in depth.
According to Turkington, the very most important part of cognitive therapy for psychosis is “normalizing” which means framing psychotic experiences as understandable and as just a fairly common variation of normal human experience and issues. This includes talking with people about how to get past fearing or “catastrophizing” such experiences, and even how to see them as possibly valuable; for example by seeing how such experiences can be part of a creative process or of a shamanic journey, etc. I have always been open to talking about this positive, somewhat shamanic side of psychotic experiences, and discussion of such views is common within HVN, but it was nice to see Turkington teaching this approach as part of standard CBT for psychosis!
Probably most of you recognize just how uncommon such views are within traditional psychiatry. Karl Jaspers, for example, stated that the psychotic symptoms of schizophrenia are “un-understandable: not reflecting a person’s personality or experiences.” Turkington mentioned that quote and others like it, and then confronted such views sharply, stating that “everything I know about psychosis tells me that such statements are delusional.” (In a previous MIA post, Olga Runciman faulted CBT for never confronting standard psychiatry. Turkington may not confront everything that needs to be confronted, but he definitely was willing to strongly critique many existing approaches, and I was amused and impressed by his story of how he measures progress in psychiatry in the US – that is, by the gradual reduction in booing he receives when he speaks about his ideas at the American Psychiatric Association!)
CBT has often been criticized for lacking an interest in people’s stories, but Turkington taught the opposite: that it is essential to hear people’s stories and to help people clarify them. He told a story himself about how he and his fellow professionals came to realize this was important. In some of the earlier research on CBT for psychosis, a control group was arranged of people who were supposed to receive only a “befriending” sort of therapy, where people could just chat about whatever they wanted.
It turned out that many of the people in this control group chose to tell their stories, and these stories were typically about traumas that had happened to them. At the time, Turkington did not conceptualize psychosis as being particularly related to trauma, but this view quickly changed as a result of what was heard. Turkington does still sees some psychosis, in particular those which start with a lot of “negative symptoms” and problems in thinking, and where “positive symptoms” develop only later, to be likely mostly genetic or biological rather than a result trauma or life stress.
I was skeptical of his conclusion about this, though he did present a fair amount of research indicating that there may be very different explanations for why some people become psychotic compared to others. The key thing I believe is that we continue to listen and learn, so we can really understand people’s stories even when they vary from our preconceptions, and such listening is very consistent with good CBT. It may be true that some people are more vulnerable or “sensitive” due to genetic or biological factors, but even in that case, they still may be able to learn to live well with that sensitivity, as when a person genetically vulnerable to sunburn learns how to protect themselves while continuing to be active outdoors, etc.
Developing a “formulation” or story of what has and is going on with a person’s experience and life situation is what Turkington described as the second most important part of CBT for psychosis. At times in the training, we focused on developing understandings of the story of what was going on “right now” with people – and this is what people more commonly think of as CBT – but at other times, the focus more clearly on understanding the bigger stories of how people’s experience and beliefs had emerged over time, in a meaningful way in response to life events.
The third most important component of CBT was described as being “reality testing.” This component is usually not emphasized as part of the HVN approach, and may even seem to clash with its “tolerance of all points of view” perspective. I find, though, that important elements of reality testing can be found in individual stories of HVN members. Eleanor Longden for example described starting to question the voices herself, then being told by the voices that she would either have to cut off a toe that evening, or they would come that night and kill her entire family. It was when she was able to stand up to this threat, and stand guard all night over her family instead (with a plastic fork, her only available “weapon”) that she was able to really demonstrate to herself that the voices were not actual beings outside of herself, but something more personal. This was a key event in her recovery.
Still, it’s easy to imagine “reality testing” being taken to mean the imposition of the therapist’s ideas about reality onto the client, and this is often believed to be the CBT approach. Turkington argued against this, and suggested it was impossible to do good work unless the therapist could keep an open mind about what might possibly be real. During the training, he shared stories of apparently supernatural and ghostly events that he had personally experienced, and emphasized that therapists should talk about such experiences with clients and with other therapists, in order to acknowledge our basic uncertainty about the nature of reality.
At the same time, he described CBT as often being often helpful in getting people to notice the ways their experiences might be personal rather than part of the reality being experienced by others, so that they could deal with them more effectively. In the film “Voices Matter“ and in anearlier MIA blog post, Rufus May suggested that we need to go beyond “just CBT” and appreciate the value of experiences like voices for their role as messengers about emotions and issues that need to be dealt with. I think Rufus is correct, but also, it seemed to me that Turkington was often saying the same thing in different words….