The dictionary defines psychosis as mental disorder characterized by symptoms that indicate impaired contact with reality. The DSM 5 defines schizophrenia spectrum disorders through a cluster of behaviors, including disorganized speech, abnormal motor behavior, delusions, and hallucinations that have an impact of the individual’s level of functioning. We define schizophrenia and other psychotic disorders by impaired mental status, but we are able to recognize it by the behaviors displayed by the patients. Only when some atypical behavior such as talking to self, responding to non-contextual stimuli, referring to objects and people who are not present as if they were present is observed, one can infer the presence of psychosis. Behavior, or rather, bizarre behavior, is the key to diagnosis.
Behavior analysis is a science specialized in the interaction of human behavior and the environment in which it exists. Behavior is behavior. Whether it is hyper active behavior, depressive behavior, autistic behavior, or psychotic behavior, in the end we are talking about the same thing. All behavior is subject to the same laws, that is, all behavior is a function of its interaction with the environment. Why do you drink water? Why do students raise their hands when they have something to say? Why do you answer the phone? Why do you engage in delusional speech? Ultimately, because of what you get out of it. You drink water because it quenches your thirst. You raise your hand because it gets the teachers attention. You answer the phone because there is someone on the other side of the line to talk to you. You engage in delusional speech because you get something out of it: perhaps someone comes talk to you to convince you that your hallucination is not real; perhaps your delusional speech is taken as a sign that you’re not ready to talk about certain topics, so it gets you out of a tough discussion.
There are many possibilities for the functions of delusional behavior. All of these possibilities, however, follow the same laws that affect any other type of human behavior, and that behavior analysis explains. If the diagnosis is based in large part on the behavior (or rather bizarre behavior) that a patient exhibits, can modifying that behavior lead to an improvement of the overall condition? If you can’t see someone talking to the “voices” does it mean that they’re gone? We can’t say that for sure. What we can say, is that “he or she has not been seen responding to hallucinatory stimuli”. Behavior analysis can help develop skills that can serve similar function to the “psychotic” behavior, by developing an alternative adaptive response.
I once had a case of a patient who believed she was pregnant, when in fact she was not. She was for the most part a sweet woman, but at times she would start talking about her “unborn child”, and would perseverate for minutes on that topic. If anyone tried to redirect the conversation at the point, or tried to show her evidence that she was not pregnant, she would escalate and could progress to the point of being aggressive (making verbal threats, and yelling). After observing her interactions with the environment and the people around her, it was clear that she would only talk about her “pregnancy” what a difficult topic (discharge planning, getting collateral information from her family) was brought up. The intervention designed for her involved one simple step: before discussing any difficult topic with her, give her a way out – let her know that you would like to discuss that particular topic with her, but that if she is not interested in discussing it, she can let you know. By doing that, we observed a substantial decrease in the frequency of delusional speech. Of course there is more to her story than talking about her “baby”. This example is only to illustrate one approach that could be taken with that particular patient.
For the behavior analyst, mental illness is not the cause of the behavior. It is simply a motivating factor that will make certain behavior consequences more valuable than others. In my day to day at work, I often hear other mental health professionals say “he is too psychotic for a behavioral plan”. I can’t help but think “what’s psychosis got to do with it?”