In 2006, the American Journal of Psychiatry published an editorial ‘Are we still talking to our patients with   schizophrenia?’¹ in response to a review article on cognitive therapy for schizophrenia. It supported engaging in direct discussions with people experiencing psychosis about what they said – why they believed the government or their neighbours were conspiring against them or what exactly the voices they heard were saying. Evidence now supports skilled intervention for psychosis using exploration, formulation and discussion ^2,3 and this has been reinforced in the recently revised NICE guidelines⁴.

However, do techniques developed in the UK with predominantly white patients work elsewhere - in the US, China, or Pakistan? How important is cultural influence on psychological intervention? In the UK, it has emerged that people from black & minority ethnic communities have not been doing as well with CBT as white patients⁵. In Pakistan, evidence has also emerged that simply applying unmodified CBT in depression can lead to high drop-out rates and poor response⁶. Successful modification is possible⁷ but requires due attention to cultural   factors. These factors can be advantageous, e.g. much greater involvement of families, as well as   complicating, e.g. in development of a fully collaborative therapeutic relationship. Similarly work with Black & Ethnic Minority (BME) groups in the UK has shown that routes to services and models of psychosis differ and influence intervention⁸. Style of interaction also seems important, for example, with very differing expectations of therapist Self-disclosure between the two groups studied – Black African/African-Caribbean & South East Asian Muslim. Self-disclosure was expected by the former but not the later.

But how we talk and succeed in communicating goes beyond cultural issues. Stigmatization and discrimination seriously affect people who are making recoveries from mental illnesses. We are trying to convince people that it is ‘Time-to-Change’ but are we communicating clearly what we want them to change to? Currently the way we talk about mental health issues may be increasing confusion and discrimination. We use terms like schizophrenia which are stigmatizing through its erroneous associations and intensely disliked by most of those to whom the term is given9. ‘Personality disorder’ is no better: over-generalising, arguably insulting and degrading to people who have often suffered appalling trauma and distress in their lives. It is not a useful term in clinical practice, rarely used directly with patients. Even anxiety and depression are used in ways which confuse – is depression a mental illness or a normal reaction?

One conclusion coming from a session on ‘Drop Schizophrenia?’ at the 2009 Annual Conference of the American Psychiatric Association and from a debate in the British Journal of Psychiatry¹⁰ is that we need to work with people who have used mental health services, and also the general public, to develop terms for the new revisions of ICD & DSM which are clear and acceptable to them.

We have been making the case for ‘the schizophrenias’ to be replaced by early-onset (‘stress-sensitivity’), late-onset (‘anxiety-precipitated’), drug-related and traumatic psychosis⁹. Kraepelin divided early onset schizophrenia from the late onset paranoid disorders but this distinction appears to have survived only in division of schizophrenia from delusional disorders. There is evidence to support ‘stress-sensitivity’ as being important in early schizophrenia possibly related to criticism or bullying in relatively shy or schizoid individuals. With later onset, personal relationships have developed but anxiety symptoms can be misinterpreted delusionally, e.g. stomach pains could be misperceived as poisoning or criticism at work as conspiracy, and systematised into broad self-perpetuating ‘explanations’. There is also a group of patients who develop persistent symptoms after use of stimulant or hallucinogenic drugs at the time of their first psychotic episode. This group differs to some extent from the ‘stress-sensitive’ group in being more sociable with more prominent positive and less negative symptoms. Lastly trauma in childhood in the form of physical, sexual or emotional abuse occurs in some patients with a diagnosis of schizophrenia and the term ‘traumatic’ psychosis can be helpful in defining the relevant problems that require psychological work.

We have also suggested substituting personality disorder with terms such as complex PTSD for the ‘borderline’ group¹¹ as Personality Disorder is a much misused term and over-inclusive. Depression also is broad and confusing: CBT studies in this area are suggesting that sub-division may be helpful into following categories. ‘Social’ depression where overwhelming life events have occurred, requiring a problem-solving and short term supportive response:  Perfectionist’ depressed patients are those who strive to achieve but in failing in some way become self-blaming and depressed with persistent negative beliefs about themselves:

 Whereas the dependent group have lost supports which they need to cope and become anxious, depressed and ‘needy’. Work focuses on developing coping, relationship and life skills¹². Maybe these terms can be useful or maybe not – there may be alternative concepts and terminology which are more acceptable and valid but at least we need to start the discussion.

Explanations also need to be refined and clarified using widely-accepted normalising   vulnerability-stress models¹³ ‘We all get stressed, we  just react differently’: some get anxious, some depressed, and others drink too much, work too hard or get confused. Responses differ according to temperament, genetics, previous experiences, available supports and the type of stress: broadly whether the experience involves loss or threat.

Mental symptoms are rather like physical ones. We all get physical symptoms – a cold, the flu, or a cut, and we get mental symptoms – anxious, distressed, frightened even depressed. Usually it is transient and we get on with life: sometimes we make adjustments, take time off work or just ease back a bit. We may need help from friends and family if they can offer it – or treatment in which case being described as physically or mentally ‘ill’ is meaningful. We may have lasting effects from the physical or mental illness and be disabled by these effects – permanently or temporarily. But we should be able to expect care, consideration and support whether these problems, illnesses or disabilities are mental or physical.

We can talk. But we need to develop simple clear explanatory models of mental health issues, terms acceptable to those they affect and ways of communicating effectively.

REFERENCES

1. Keith SJ. Are We Still Talking to Our Patients With Schizophrenia? Am J Psychiatry 2006; 163:362-4.

2. Kingdon DG, Turkington D. Cognitive therapy of schizophrenia. Guilford: New York, 2005.

3. Wright J, Turkington D, Kingdon D, Basco M. Cognitive therapy for severe mental illness: an illustrative guide. APPI: Washington DC, 2008.

4. National Institute for Clinical Excellence. Clinical Guideline: Schizophrenia (CG1). Department of Health: London, 2009.

5. Rathod S, Kingdon D, Smith P. Turkington D. Insight into schizophrenia: the effects of cognitive behavioural Therapy on the components of insight and association with sociodemographics—data on a previously published randomised controlled trial. Schizophrenia Res 2005; 74: 211-9.

6. Naeem F, Waheed W, Gobbi M, Ayub M, Kingdon D. Development and preliminary evaluation of a culturally sensitive CBT for depression in Pakistan: Findings from Developing Culturally-Sensitive CBT Project (DCCP). Behav Cogn Psychother 2009. (Under  review).

7. Rahman A, Malik A, Sikander S, Roberts C, Creed F. Cognitive behaviour therapy-based intervention by community Health workers for mothers with depression and their infants in rural Pakistan: a cluster-randomized controlled trial. Lancet 2008; 372: 902-9.

8. Rathod S, Phiri P, Gobbi M, Kingdon D. Developing Culturally Sensitive CBT for Psychosis in BME communities. Poster Presentation at Royal College of Psychiatrists Annual Meeting: Liverpool, 2009.

9. Kingdon D, Gibson A, Kinoshita Y, Turkington D, Rathod S, Morrison A. Acceptable terminology and subgroups in schizophrenia: an exploratory study. Soc. Psychiatry Psychiatr Epidemiol 2008; 43: 239-43.

10. van Os J. Author’s reply. Br J Psychiatry 2009; 194: 570.

11. Kingdon D. DSPD or ‘Don’t Stigmatise People in Distress’: Invited commentary on Challenges in the treatment of dangerous and severe personality disorder.  Adv Psychiat Treat 2007; 13: 333-5.

12. Kingdon D, Finn M. Tackling mental health crises. Routledge: London, 2006.

13. Turkington D, Rathod S, Siddle R, Pelton J, Kingdon D. Back to life, back to normality. Cambridge University Press: Cambridge, 2009.