You Get Better at Being Psychotic

Long-troubled actress Amanda Bynes has apparently been checked into a psychiatric facility to address the mental illness that has plagued her for years. She’s reported to have been wandering naked outdoors when she flagged down a car and asked for help, telling the driver that she was having a psychotic episode. People are naturally grateful that she was able to request help in that way, but I’m also seeing a lot of confusion. Which is understandable; a psychotic person being cognizant enough to request help is out of step with how most people conceive of serious mental illness. But psychosis is more complex and multivariate than most people think, and I hope this incident prompts people to broaden their understanding of the condition. The mind is complicated, and so are the ways in which it breaks down.

I wrote a piece last year titled “Psychosis is Not the Absence of Consciousness,” and I encourage you to read it. As I say in that piece, casual conceptions of psychosis typically assume that the condition is animalistic or thoughtless, that the conscious mind turns off. But for many people, psychosis entails something like too much consciousness - self-fixation and overthinking to the point that the thoughts double back on themselves and create intense paranoia and delusional beliefs. Also, during a psychotic episode some wander between states of more and less impairment, having periods of lucidity even within deep dysfunction. There’s no doubt that there are some people whose psychotic moments render them essentially unthinking, unable to parse who or where they are or what’s happening to them. But it’s a mistake to think that a psychotic patient couldn’t possibly apprehend what’s happening or make rational decisions under the influence of their disorder.

This includes potentially understanding the fact that they’re in a bad way and need help. As I’ve mentioned before, the technical term is anosognosia - the inability of the sick to understand that they’re sick. Anosognosia is indeed very common among people with schizophrenia and schizoaffective disorder, but not universal, and while many bipolar patients experience the condition, most estimates I’ve seen suggest that a majority don’t. (There are some conditions that aren’t psychotic disorders which also preclude the understanding that one is sick, with Alzheimer’s probably representing the most obvious example.) In my experience, many people assume that anosognosia is an inherent element of psychosis, and I can understand why; it’s core to pop culture representation of severe mental illness. But you can hold delusional beliefs or be buffeted with paranoia that’s so intense that it causes you to believe things that are not rational in any sense and still have a core of understanding inside of you that something has gone badly wrong. This is not necessarily that much different than when you hold any other kind of irrational fear and try to tamp it down with your rational mind. It’s just that when psychotic that war with paranoia is both harder and higher stakes, and it tends to have the final say. In the face of primal fear there are no heroes.

This may sound weird, but what can happen over time is that you get better at being psychotic. Again, I think this likely violates most people’s intuitive sense of how mental illness works. But in my experience the process of getting sick and then negotiating the process of receiving care is like anything else in human life, in that you experience, you learn, and your behavior changes. I don’t want to oversell this; obviously, serious psychiatric crises degrade your ability to respond intelligently to your situation and your own behavior, which you can’t fully control. You can’t learn how not to be psychotic if you have a psychotic disorder. But there’s a definite sense in which repeated exposure to both your own illness and the way that the medical system reacts to it conditions you for future experiences. You develop better understanding of your own tendencies, including your capacity for self-deception. Meanwhile triage nurses, ER shrinks, friends and family - in acute crises, they’ll react in some predictable ways, and you can teach yourself to react in kind. I don’t know. I’m aware that this all sounds arch and underexplained, but it makes a great deal of sense to me.

This all may appear to be a good thing, and this situation with Bynes turned out as positively as it likely could. Certainly it’s good if people come to better understand when they need help, as Bynes appears to have. But it’s important to say that getting habituated to psychosis can be very dangerous. The trouble is that, if you’re treatment-resistant - and most of us are, at some point, for various reasons - the ability to better handle psychosis without actually curing it can make it harder for you to receive effective treatment. As you become experienced at navigating the ins and outs of mental health care, you better understand how to manipulate the system for what you want, and what you want very often will be to not receive the care you need. As frustrating as ER personnel can be, they can often mean the difference between life and death for a severely mentally ill person. But because they operate under legal and procedural restrictions, and because the institutions they work for are often starved of doctors and beds, there are some consistent techniques that can be used to avoid involuntary care. And as you know, I’m a big believer in involuntary care. You don’t want to find yourself in a position where you control your disorder sufficiently to slip through the cracks of treatment without being able to manage your self-destructive or violent impulses. In a strange way, the most severe crises you have can be the safest, in that you have the least ability to avoid care.

I hope Bynes gets the care she needs. She has, as I understand it, been in and out of treatment for more than a decade. Her continued struggles are a record of just how persistent and debilitating serious mental illness can be, and how money and celebrity are no defense.