TEACHING AS THOUGH STUDENTS WITH PSYCHOSIS MATTERED
AUTHOR(S): Rose Parker, Pamela Reed Gibson (James Madison University)
DATE: May 2021
ABSTRACT: People with psychosis/schizophrenia are attending colleges in greater numbers and needing support and accommodation services. In fact, recent memoirs of persons with psychosis have illustrated that persons with psychosis can become highly educated and make substantial contributions. Yet students with these mental health problems encounter stigma and multiple barriers at colleges and when managing their health. We review these barriers and make suggestions for including and teaching these students in the psychology major.
ARE STUDENTS WITH PSYCHOSIS WELCOME IN THE PSYCHOLOGY MAJOR?
While it is generally accepted that some students in the psychology major will have experience with mild and moderate forms of mental illness, how likely are we to have students with psychoses enrolled in our courses and how can we teach to them in a sensitive manner? How can we teach compassionately about this topic while including students with psychosis?
Students with psychosis likely encounter negative attitudes from faculty and other students. Spaulding et al. (2017) state that many professionals still ascribe to Kraepelin’s model of lifelong deterioration. Yet this belief that there is no recovery is not congruent with the research, which shows that many persons are able to have substantial recovery. Bleuler’s model was much more generous and proposed that one third are disabled for life, one third have a mixed course, and one third have considerable recovery. Spaulding et al. view a failure to believe in any recovery as a prejudice that will lead to discrimination.
Students are not at equal risk of being affected by psychosis. Male persons have a 1.4:1 ratio of schizophrenia incidence, and immigrants also have a greater likelihood of developing the condition (McGrath et al, 2008). Female persons tend to have a later onset of illness, as well as a less severe illness course (Abel et al, 2010). This later onset may prove crucial, as Isohanni et al (2001) found in their 1966 cohort study that no one with early onset schizophrenia (onset under age 22) was able to complete tertiary education. Additionally, while schizophrenia’s neurodevelopmental nature is generally accepted now, early-onset male patients seem to have the most neurodevelopmentally degenerative form of schizophrenia, with the greatest level of cognitive and disorganized symptoms (Abel et al, 2010). Male schizophrenia patients are also significantly more likely than female patients to exhibit deficit syndrome, a prolonged period of negative symptomatology independent of other causes (Roy et al, 2001). This is important to note, because negative symptoms are often unresponsive to antipsychotic treatment and manifest in ways likely to interfere with academics (Spaulding et al, 2017).
Stuart (2012) discussed the process of how colleges’ attitudes became more hostile to mentally ill students following the Virginia Tech shooting. Mental health became treated as a disciplinary issue, and colleges began treating mentally ill/psychotic behavior as violent behavior despite there being no statistical or medical evidence for this. Disability rights legal cases have resulted. The author calls for a more humane approach to the treatment of mentally ill students and a more accurate view of modern human development: all students can benefit from greater supports on campus, not just mentally ill ones. Indeed, Parrish et al. (2019) found that persons with prior education and familiarity with psychosis projected less stigma onto persons labeled as having schizophrenia, clinical high risk, or attenuated psychosis.
Hardy et al. (2018) found that college students had shorter periods of active psychosis before diagnosis (median of 12 weeks; mean of 29 weeks) than their peers who were not enrolled in higher education (median of 29 weeks; mean of 44 weeks), but their DUPs (durations of undiagnosed psychosis) were still longer than the WHO recommended time limit. Christianson (2018) pointed out that the gradual development of symptoms over an imaginary line between “normality” and “psychosis” makes it likely that this delay in diagnosis will drag on. To prevent college drop-out, students developing symptoms of possible psychosis should be referred to university counseling centers quickly to help them to maintain their academic and social functioning. Hardy et al. recommend training instructors, peer advisors, resident advisors and others to recognize early symptoms of psychosis. Koch et al. (2018) described students with psychiatric disabilities and learning disorders/ADHD students as generally coming from higher socioeconomic statuses and having had parents who attended college, as well as being better socially integrated into their university communities. This, however, does not serve to protect them from the effects of their disability. This should be of special concern when talking about psychotic students, because people with schizophrenia are at an increased risk for both learning disabilities and ADHD (Spaulding et al., 2017).
McEwan and Downie (2019) found that students with psychosis took 7.56 semesters to graduate, compared with 5.41 for students with depression and 5.03 for students with no disabilities, and also had longer periods between their first and last enrollments (17.8 semesters for psychosis group versus 11.3 for depression group and 8.99 for students without disabilities). Student groups with all disabilities also made more program changes than did students with no disabilities (McEwan & Downie). And according to Koch et al (2018), having a psychiatric or learning disorders/ADHD was an independent indicator that a student would not complete an undergraduate degree, moreso than any other variable. This is in line with the research of Isohanni et al (2001), who found in a 31-year follow up study that Finnish students who developed Schizophrenia before age 23 were unable to finish their undergraduate degrees. This not the only study to find more severe psychosis in younger people; the same trend was found by Castle et al. (1993).
The literature identifies a number of institutional barriers for students with psychosis. McEwan and Downie (2019) state that psychiatric disabilities are not well integrated into Offices of Disabilities. And unlike some students with learning disorders, students with psychosis often enter college without a psycho-educational assessment. The authors also identify the often-needed breaks in education for students with psychosis. The learning profiles of these students have not been attended to by colleges, nor have bureaucracies created outreach to students with more severe psychiatric disabilities (McEwan & Downie, 2019).
Mental health resources that exist on campus are often for anxiety and depression, leaving students with psychosis to feel isolated from structures that were created to serve them. Mobray et al. (2006) state that “many campuses place the onus of evaluating the urgency of needs upon the students” (p. 231), and that long waiting lists and lack of training in serious mental illness for staff at college counseling centers limit support for these students if they do reach out for help. Students may be reluctant to request help (and be referred off campus for longer term care than most college counseling centers provide) due to the need to file insurance claims, as parents will find out (Mowbray et al., 2006).
WHAT CAN INSTITUTIONS DO?
A number of recommendations already exist in the literature. Disability Services and Counseling Centers need to interface (McEwan & Downie, 2019; Roy et al., 2016). Students need to be seen by counseling centers within 48 hours of referral (Mowbray et al., 2006). Rehabilitation practitioners and OTs could expand their academic/campus support. Roy et al. (2016) allege that more financial support is needed for students with psychiatric disabilities, and that improved support from staff and other students is necessary.
McEwan & Downie (2019) warn against targeting higher academic achievement, as research shows that it comes at the cost of students’ already sparse relationships. The same authors suggest assigning senior undergraduate mentors to ease the way in interfacing with institutional bureaucracy. Mowbray et al. (2006) add that follow-up and continuity of care for students referred to community resources will help prevent students from falling through the cracks.
Our own suggestion to institutions is to talk openly about psychosis and schizophrenia: use the words rather than just hinting at it. Schools advertise programs for anxiety readily, but not often for psychosis.
Similar to Spaulding et al. (2017), Christianson emphasizes that recovery is a process rather than an outcome. She emphasizes students’ need for opportunity (housing employment, social involvement), support (family, friends, peers, and staff), and enhancements (available treatments and services). The fact that students with psychosis are more likely to live local and rely on family support makes it likely that their social support is lacking.
WHAT CAN FACULTY DO?
1.) Picture students with psychosis in your classroom.
Author two admits that before meeting author one, she assumed readily that a number of students in her Abnormal Psychology class experienced depression and/or anxiety. But she never consciously pictured students with psychosis sitting in the classroom. So this may be the first step in creating a respectful classroom where students with psychosis are welcome – to picture their presence.
2.) Create a respectful environment
If you picture students present, it will be easier to screen teaching content to be sure that it is in accord with a respectful environment for students with serious mental illness. This will mean filtering language that excludes, avoiding words like “crazy,” “psycho”, “schizo,” “psychotic” (outside of a medical context), “insane,” “maniac,” “so ocd,” “wacko,” “mad,” “nuts,” “bipolar” (outside of a medical context), and “anorexic” (outside of a medical context.) Many of us use those words in casual conversation (e.g., “You are driving me crazy”) and will need to make some effort to remove them. By exposing students to language like this, you are exposing them to stereotype threat and stigma. Anti-psychosis stigma has been linked to decreased self-esteem in people with psychosis as well as great psychopathology (van Zelst, 2014). These micro-aggressions literally make your psychotic students sicker.
Other ways of respecting students with psychosis include being generous with accommodations. Students’ lives may be peppered with intermittent negative/flat symptoms that make it difficult to work, or with positive symptoms that are distracting and interfere with focus. In a related vein, being flexible with structures and willing to discuss incompletes and course drops past the withdraw date may be needed due to psychotic episodes.
It takes considerable effort and courage for a student to out themselves to a faculty. We must be willing to listen to the lived experience of the student with psychosis, even when we don’t understand this experience or have the tools to cure it. It will also help to have some awareness of possible risks for the student, which may include depression, suicide, drug or alcohol use, and physical health problems (Spaulding et al., 2017).
A special note about communication is important. We need to tailor our communication for our students. Students with psychosis may experience Alogia (sparse speech) and their spoken responses may be slow. If we allow time in between comments, students are better able to speak to us and to feel heard.
4.) Become cognizant of common triggers for persons with psychosis
Perceptual difficulties are commonly present with persons with psychosis. To accommodate this, it might be prudent to give a warning before doing activities with mindfulness, as they may possibly be triggering. And as faculty we should be aware that demonstrations using flashing lights or repetitive noises can trigger people and/or cause flashbacks.
Also know that playing music at the beginning of class can be triggering for some people. In addition, if you teach biopsychology or neuropsychology, the chemicals and dissections can be difficult and triggering for persons, as a number of people with psychosis seem to report having the chemical sensitivities. The intensity of doing and seeing a dissection may be something that a student needs either to steel themself for or to request an alternative assignment to fulfill that lab.
Addition issues regarding triggers should be considered. While instructors might be familiar with triggers for trauma such as sexual assault, most do not realize that course content can trigger psychosis. Unreality content, content that has a surreal or otherworldly nature to it, can induce paranoia or hallucinations. Care should be taken when introducing human organs, as delusions and hallucinations can center around organ systems. Give warnings before introducing mindfulness exercises to the class, as many people with psychosis can be brought into derealization or panic episodes by these sorts of exercises.
5.) Revise your conception of psychosis
It is important to understand that persons with psychosis can be highly accomplished and make important contributions, as illustrated in three memoirs written by authors who have faced psychosis and survived in the professional world (Parker, 2019; Saks, 2007; Wang, 2019). And of course, Kay Redfield Jamison has contributed a number of titles, particularly “An Unquiet Mind” where she describes the psychotic episodes of her bipolar illness. Celia McGough heads up the Non-Governmental Organization “Students with Psychosis” and has talked openly in her TED talk “I Am Not a Monster.” Trask et al.’s (2017) study can be seen as a sign of hope, given that college students did not have strong stigmatic reactions to persons in vignettes with attenuated signs of psychosis. And Strassle’s (2018) study found that any effort to teach about stigma in Abnormal Psychology seemed useful, as all groups showed an effect of time.
The violence issue also needs a special comment. U.S. Society at large thinks of persons with schizophrenia as being more at risk for violent behavior. Spaulding et al. (2017) clarify that although having a psychotic disorder does raise the risk for violent behavior a small amount, the risk level is mostly related to specific factors including being male, not having a job, use of illegal drugs, and having a high level of psychopathy. Consequently, we probably don’t have to fear our students.
Parker (author one) believes that, “Psychosis lends a person the cruel irony of being invisible in your suffering and need but open to public scorn. Many people do not feel they have to educate themselves about us because we are simply nonexistent to them, even to many health professionals.” Consequently, it makes sense to be cognizant that your student with psychosis has probably endured their share of bullying, even at college. A supportive presence from a teacher or even mentor may be very therapeutic for a student who is blazing a trail that is not yet well traveled.
6.) Familiarize yourself with grassroots support sources for those with psychosis
Author one maintains an Instagram blog that persons with psychosis go to for support (“psychosispsositivity”). When she asked visitors what they would like people to know about psychosis, these were some of the responses. (Many address communication and speech).
“I forget what I’m saying mid-sentence I have to take a lot of breaks in constructing my sentences so what I’m saying makes sense to the outsider.”
“That is does not mean I am not intelligent, . . does not mean that the things I have to say are not important, and I still have the right to be heard and listened to.”
“I cannot focus on what’s going on inside my head. It moves too fast and too erratically. I can’t focus on what it’s doing or saying. It is very satisfying.”
“It’s so frustrating to mean one thing, and only to be able to say half of it, or another thing entirely.”
“I experience a lot of blocked thoughts that I know are there but I can’t articulate them. Sometimes it takes me while. I think this cognitive malfunction should be given patience especially if you know the person has psychosis. Let them articulate the thought before interrupting.”
“I’m still worthy of our respect when we talk. Just because my words get jumbled, doesn’t mean I’m stupid. Give me time and understanding.”
“People think I’m not paying attention because I’m constantly ‘off topic’. I am paying attention. My brain connects topics in a unique way and most of the time I truly believed what I was saying was on topic.”
“I am almost losing my job because of that. When I started working there my new colleagues thought I was on drugs constantly. Now they know that I am psychotic, but it seems that some of them just can’t bear my disorganized behavior anymore. I think they just don’t understand. I feel deeply sad about that and am giving 200% every day.”
“I know I look weird. I can’t help it. I am trying my best to seem coherent and it gets frustrating when no one understand what you’re saying! Please be patient and try to be sympathetic!”
Psychosis is not a popular subject, even within the Psychology major, but it must be discussed. With the university years being ripe for the development of psychotic disorders, psychotic students cannot be left to feel as though they are alone and unsupported by their universities. Unfortunately, this is often the case. Just as universities have changed their thinking to support other aspects of student mental health in recent years, so must they educate themselves about and include students with psychosis. Mental health cannot be split into “palatable” and “unpalatable” forms of pathology. To do so is hypocritical.
Students with psychosis want to go to college, they want to achieve these qualifications. Psychotic students are often ambitious and want to give to the world, but because of the institutional barriers they face are unable to do so. As long as universities continue to alienate students with psychosis and treat them as an unwanted “other”, we will continue to see high suicidality in psychotic patients and poor socioeconomic outlook (Alaräisänen et al, 2006; Parrot & Lewine, 2005).
Society treats psychotic people as though they are burdens on society. Because psychosis is difficult to treat, it gets pushed aside and the people who live with it get shoved out of view. Higher education is often at the forefront of new social movements, and now is its chance to do so again. Students with psychosis want to study, and they want to succeed—but there are many barriers. Often for students with psychosis, it is not the disease that permanently disables, but the unwelcoming society and lack of resources. As higher educators we need to work on our own comfort and knowledge regarding psychosis.
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