The Promise of Predictive Processing

I managed to spend a decade researching schizophrenia without seriously encountering the predictive processing literature. It was not until I put forward, on X, the controversial idea that we may one day see autism and schizophrenia recombined diagnostically that I began to look into it.

I was understandably chastised by X’s autism community, which includes many fierce advocates of autism as an identity rather than a diagnosis, as well as several self-diagnosed individuals.

My theory is not strongly supported by the evidence, and I am aware that the decision to split autism and schizophrenia in DSM-III carries a great deal of cultural baggage among those operating in the area of neurodiversity—not to be confused with neurodivergence, as it often is.

My hunch does not come from a desire to be edgy or to achieve fame or notoriety on X. It is instead the natural landing point following a decade of schizophrenia research that has inevitably required engagement with the autism literature. It is also informed by my clinical and personal experiences.

Many individuals with schizophrenia whom I have supported as a healthcare assistant or interviewed as a researcher have been referred, at some stage following their schizophrenia diagnosis, for autism assessments. This also happened to me. I was assessed for autism in 2023 and felt not to meet the criteria: many years after my schizophrenia diagnosis in 2015.

These observations lead me to question the idea that autism and schizophrenia are always sufficiently distinct in clinical presentation that one can confidently diagnose one while excluding the other. Many of my research participants appeared to speak in ways I had heuristically associated more closely with autism than with the schizophrenia and formal thought disorder literature. Many were quite concrete, had restricted or repetitive interests, and perseverated on topics that I sensed we had exhausted.

While processing the backlash to my post on X, I began looking into some of the criticisms coming my way. One man called me an idiot because autism and schizophrenia are ‘literally the complete opposite’.

I took this to mean that he was gesturing towards the diametric opposition literature, with which I am familiar. In some theoretical accounts, autism and schizophrenia are not simply situated at different points along a continuum. They appear more closely to resemble mirror images of one another.

My own suspicion is that they may nevertheless represent different expressions of some shared underlying processes, with developmental and life-course factors helping to mediate the direction in which predictive processing differences manifest. Concrete, bottom-up processing, with greater weighting of sensory information, is often associated with autism. More abstract, top-down processing, involving greater weighting of prior beliefs, is often invoked in accounts of schizophrenia.

This is obviously a gross oversimplification of a complex and contested literature, but that is about as far as my expertise on this particular issue extends.

I do not expect my suspicion—that decoupling autism and schizophrenia in DSM-III may have been premature or mistaken—to be empirically supported any time soon, if at all. Nor do I expect contemporary autism communities to suddenly become comfortable with the idea.

Schizophrenia remains heavily stigmatised and sits firmly within the category of severe mental illness. Autism is increasingly situated within a framework of neurological difference, with less overt stigma in at least some communities and contexts. Bringing these conditions together, even if it were eventually judged academically sensible, would therefore be ideologically charged.

But in looking into the predictive processing literature, I began to develop a much deeper appreciation for its explanatory potential within what appears to be a significant current in psychiatric thinking.

From my own experience, particularly of ideas of reference, I have noticed that my symptoms are much more severe when I encounter the speech of strangers or people with whom I have a complex and largely negative interpersonal history.

In interactions with my daughter, for example, I do not generally experience ideas of reference. There is no historical data to suggest that she is exploiting pragmatic communication to convey some unspoken insult. She is a six-year-old who says six-year-old things because she sees the world in six-year-old ways.

My experiences with strangers are different. Other people have historically been more hostile, more unpredictable, and more difficult for me to interpret. In those contexts, ambiguity carries a different weight. A predictive processing account therefore offers some explanatory potential for why my ideas of reference fluctuate in severity depending on environmental and interactional context.

The prior is not the same.

That, to me, is where the framework becomes particularly interesting. My response to an ambiguous utterance may depend not only on the words themselves, but on what previous experience has taught me to expect from the person speaking, from people like them, or from the interactional context more broadly. Under conditions of uncertainty, those expectations may shape what I perceive an utterance to mean.

For this reason, I think predictive processing accounts of schizophrenia are well worth keeping an eye on. I am particularly interested to see the area develop beyond broad accounts of psychosis as a state and turn, with greater specificity, towards phenomena such as auditory verbal hallucinations, delusions, and ideas of reference.

For now, I remain uncertain about whether autism and schizophrenia will ever be brought closer together diagnostically. I may simply be wrong.

But I am increasingly persuaded that understanding how people weight sensory evidence, prior expectations, and uncertainty may tell us something important about why the same world can become so radically different from one mind to another.

Sticks and Stones: On Linguistic Trauma

‘Sticks and stones may break my bones, but words will never hurt me.’

This adage was common in my childhood. After many years of psychological and linguistic research, I feel it could not be more wrong. We have long understood that language influences thought, and the ways in which people speak to others carry enormous potential for both good and harm.

In this piece, I want to speak briefly about the linguistic environment in which I was raised, where language often functioned as an instrument of control rather than care. After offering some examples, I want to suggest that people with schizophrenia and other neurodevelopmental conditions may be particularly vulnerable to unhealthy linguistic environments. I believe that more attention, in both research and clinical practice, should be paid to the relationship between communication and clinical outcomes. I touch on this to some extent in my latest—and final—Schizophrenia Bulletin first-person account, Language Under Pressure: Communication, Agency, and Recovery in Schizophrenia.

Both of my parents are people with a high need for control. This is not a moral judgement. They grew up in dysfunctional environments themselves and most likely inherited many of these behaviours. I do not view their actions as calculated acts of manipulation undertaken with full metapragmatic awareness. Rather, I think they learned, through reinforcement, that certain linguistic constructions and associated interactional behaviours induce compliance.

Take, for example, my mother’s use of the phrase: ‘Don’t you want the bookcase on the right?’

This followed an exchange in which she indicated that it was important to place a bookcase in my bedroom. I obliged, despite having no interest in a bookcase myself, to keep the peace. When I placed it where I felt it would look good, the question arose.

As a linguist, it stands out for a few reasons.

‘Don’t you want the bookcase on the right?’ appears, on the surface, to be a question about preferences, akin to ‘Where do you want the bookcase?’ But it functions very differently. ‘Don’t you’ or ‘do you not’ carries a loading, an expectation, and indicates that not wanting the bookcase on the right would somehow be incorrect.

There is also something else worth considering: her implied preference—for the bookcase to be on the right—is grammatically organised as though it should also be mine. The effect on the listener, at the psycholinguistic level, is essentially to trigger the question: ‘Why do I not want the bookcase on the right?’ From there, agency takes a back seat. Instead, a series of deliberations and justifications must arise to argue the case for the bookcase being on the left, alongside questions about whether it is reasonable or unreasonable to resist the expectation that it should be on the right.

You may, at this point, feel that I am reading too much into the linguistic structure of this phrase and the many ways it can be parsed and interpreted. This is partly what linguists are good at, and perhaps partly excessive.

But the point I am trying to make is that this question, while loaded in a bookcase-on-the-right direction, is not really a question at all. It is a compliance test. An instruction disguised as a question.

We can tell this from the consequences of expressing a genuine preference that resists the loading. When I replied, ‘No, the left is fine,’ the response involved nonverbal expressions of frustration and a series of punishments: the silent treatment, huffing and puffing, storming off, and slamming things.

Answering the question ‘incorrectly’ carried relational consequences.

This type of communication was persistent throughout my childhood. I was required to remain vigilant not only to what was said on its face, but to what was implied and what the consequences might be for ‘getting it wrong’. I learnt to process implied meaning more quickly than literal meaning. I learnt to keep myself safe, and in doing so I abandoned many of my own preferences and much of my agency.

I suspect that this linguistic environment may have contributed to the paranoid form my schizophrenia took. I do not mean that the linguistic pressures I grew up under caused schizophrenia itself. Rather, I wonder whether my longstanding vigilance towards implied meaning interacted with my core schizophrenia symptomatology, shaping how the condition manifested.

I became a student of language and linguistics partly to reclaim my agency: by telling stories, by writing, and by understanding the mechanisms through which meaning influences thought.

My father had a different linguistic style, but it was nevertheless equally preoccupied with control and compliance. He would speak over opinions he disliked by raising his voice and invoking my name. He would issue instructions openly rather than modifying them grammatically, as my mother did. He favoured tag questions appended to statements in ways that disguised their directive intent: ‘You will do X, won’t you?’ or ‘You won’t forget Y, will you?’

In many ways, his approach was easier on my cognition, but more directly controlling. My mother, on the other hand, was more discreet and required more mental effort to navigate.

One of my personal favourites, from an analyst’s point of view, is: ‘Don’t tell people you’re on benefits. They’ll laugh at you.’

I think back to this often, because I did not hear anything about people laughing at me in that phrase. I instead heard: ‘Don’t tell people you are on benefits. They will laugh at me.’

But instead of owning the fear, it was relocated in me. Much as my mother’s preferences about the position of a bookcase were located in me.

When I look back at these and many similar interactions throughout my life, I find myself wondering how many of my preferences, habits, and beliefs are actually mine. Given that I spent so long under a form of linguistic pressure that forced me to suppress my own desires and preferences in order to keep the relational peace, who am I?

Perhaps I am only now beginning to realise and explore that.

The effect of trying to find a way through the world while exposed to these equally suffocating, but ultimately quite different, forms of coercion made me incredibly sensitive to language and its power. It is why I am so careful with my words around my daughter.

When I interviewed fifteen people diagnosed with schizophrenia for my doctoral research, I noticed that most, if not all, were incredibly hesitant and careful in their use of language. In some cases, I could make out the sounds of relatives outright abusing them during the interview.

One man had to end our discussion because, if he did not cook his mother’s breakfast, she would become ‘a bit very angry’. The same man was interrupted mid-sentence when he began, ‘I’m—’

The other party offered: ‘Stupid?’

It is not a popular idea in mainstream psychiatry to suggest that people with schizophrenia may be made worse by the linguistic environments in which they are situated. Perhaps this is partly because of a legitimate fear that attention will turn once again towards parents and siblings, and that concepts such as the ‘schizophrenogenic mother’ or Bateson’s double bind will be resurrected.

These theories have a difficult and damaging history. But in rejecting crude and blame-laden accounts of family causation, I wonder whether psychiatry has sometimes become too reluctant to interrogate the communicative environments in which psychosis develops, persists, and recurs.

I am here to suggest that we should look at those environments, unapologetically.

Approaches such as Open Dialogue have renewed attention to relational and communicative contexts, while work on pragmatic rehabilitation—including Professor Valentina Bambini’s PRAGMACOM initiative—raises important questions about whether aspects of pragmatic functioning can be supported and rehabilitated.

If pragmatic abilities can change through intervention, then we should at least be willing to ask how the pragmatic difficulties observed in schizophrenia emerge. Which aspects are related to the illness process itself? Which reflect neurodevelopmental vulnerability? Which are shaped by repeated interaction across the life course? And how might these processes interact?

We should not be frightened of interrogating the communicative environments of patients with serious mental illness.

I think we owe patients a duty of care to do so.

When Preston Begins to Feel Again

I read a fine piece on the literature surrounding rebound psychosis by Thomas Reilly of Rational Psychiatry today, and it prompted me to write a little about my own experience of discontinuing a 200 mg maintenance dose of amisulpride after three difficult years of fighting to remain compliant.

I have already written a first-person account for Schizophrenia Bulletin, which bears the same title as this post, explaining why I eventually decided to discontinue. The title is a reference to the film Equilibrium, set in a dystopian world where order is maintained through the suppression of emotion. In Libria, citizens take regular doses of Prozium. Failure to comply results in one being labelled a “sense offender”—a criminal offence punishable by death.

I chose this reference because I strongly identify with the scene in which Preston, played by Christian Bale, experiments with missing a dose of Prozium and wakes one night suddenly aware of the rain outside his window. His new capacity to feel emotion overwhelms him. This very much reminds me of my own experiences of the prodromal phase of psychosis, which, for me, can be signalled by overwhelming emotional responses to music, film, and writing.

I was drawing less of a parallel between the psychiatric establishment and the Tetragrammaton Council of Libria, although I must admit that alerting the Community Mental Health Team to my decision to discontinue, via letter, did feel to some extent like outing myself as a sense offender.

I made a somewhat grandiose case in writing. I explained that I had a complex physical health history and had previously been advised to discontinue medication on medical grounds; that I was aware of the dopamine supersensitivity hypothesis; that I was actively monitoring myself for signs of relapse; and that I had reviewed the literature on rebound psychosis and concluded that it was generally considered a clinically rare event. The team were very gracious in their reply. They simply said that they would discharge me from their caseload, but that the door was always open.

My rationale for discontinuing was that I was struggling to find and maintain employment while on maintenance therapy. I attributed this to sedation and to negative symptoms that I believed were secondary to the antipsychotic, as they had emerged at around the same time as my second episode and subsequent maintenance treatment. I no longer believe this account is entirely correct. I now think the negative symptoms may have arrived before maintenance therapy began.

In the Schizophrenia Bulletin piece, I explore this uncertainty and the difficult trade-off between wanting to comply with clinical guidance, managing side effects, and operating within society in a way that makes other people comfortable. At the end of three long years, I decided to explore discontinuation. Anyone who wants to read the Schizophrenia Bulletin piece can find a PDF on ResearchGate, as the journal article itself is paywalled.

What I did not write about in that piece is what happened after I discontinued—and why I very quickly restarted a maintenance regimen.

First, I did not taper, despite being advised to do so. After a brief conversation with my GP about the possibility of stopping, I actually stopped cold turkey. Six weeks later, I told him the truth: I had simply been unable to tolerate the side effects any longer. My GP was very forgiving and suggested monitoring.

Throughout those six weeks, I noticed a striking return in productivity. I recorded a forty-hour video series on the phenomenology of psychosis, life with schizophrenia, and a deconstruction of inpatient psychiatry. This became my YouTube channel. With the assistance of ChatGPT, I published three books by turning the video transcripts into prose. I built the website that now hosts the sum total of my academic and public writing, again with AI assistance, and formed strong thematic links between pieces of work I had produced over the preceding twelve years.

I also secured new housing.

On the flip side, I decided to re-enter the dating scene. I had intense, involved conversations with women I barely knew, one of whom I had dated as a teenager. After only a few days of conversation, I began looking for some sort of ring. Not an engagement ring, but a ring nonetheless.

My sex drive increased while my inhibitions plummeted. I began struggling to sleep, shifting from a stable pattern of being unable to remain awake beyond 9 p.m. to lying bolt awake at 4 a.m.

None of these signs concerned me.

None of them even registered as problematic.

As far as I was concerned, I was back to my old self.

Then, one night, while I lay in bed completely alert, a burst of music I had never heard before rang out inside my skull. I enjoyed it, but I also recognised it clearly as a hallucination. Historically, I had only ever experienced voices during the acute phase of illness, never while receiving treatment in the community.

This did register as unusual. It gave me reason to reconsider discontinuation.

I called my GP, explained what had happened, and restarted my antipsychotic.

I do not know whether what happened to me was withdrawal, rebound psychosis, relapse, or something else. I am not qualified to determine that from my own experience. I am cautious about describing it as rebound psychosis, particularly given the uncertainties and disputes in the literature. Perhaps the insomnia was associated with withdrawal. Perhaps the wider pattern reflected emerging relapse. I do not know.

But the onset of hallucinations after sudden discontinuation has always struck me as evidence, at least in my own case, that stopping was not without cost.

At the time, I made sense of what had happened as though I had been hubristic and my illness had progressed as a result. I wondered whether the increase in dopaminergic activity had somehow advanced the course of my illness and whether, in that limited sense, my experience amounted to a case study in favour of the dopamine hypothesis. But this is speculation, and a single first-person account cannot resolve questions of mechanism.

What I have learnt is simpler: regardless of the scholarly position on these issues, there is much to be said for caution when discontinuing antipsychotic medication, particularly when discontinuation is abrupt.

I am more stable now on maintenance therapy. Yet the voices that arrived around the time of discontinuation have not entirely gone away, and I am again faced with the very problems that led me to consider stopping in the first place.

Patients with schizophrenia can find themselves in a double bind. We can comply, with great effort, with our treatment regimens and experience sedation, weight gain, and what may feel like a compounding of negative symptoms. Or we can discontinue and risk relapse, destabilisation, and potentially serious consequences. The second path is obviously more dangerous. But that does not make the costs of the first path unreal.

I long for the day when schizophrenia treatment spares more of the chemistry that makes life worth living.

Who Gets to Represent Schizophrenia?

I have been following several social media influencers who document life with schizophrenia for some time now, and I have become increasingly frustrated by some of their decisions.

In a recent interview, Kody Green, who describes himself as a schizophrenia advocate, challenged person-first language and expressed his preference for describing himself as schizophrenic. He argues that calling himself schizophrenic does not reduce his identity to a diagnosis because he is much more than his schizophrenia. He nevertheless seems surprised when people suggest that he adopt person-first language.

As a linguist, my take on this at the level of language is quite straightforward. ‘Schizophrenic’ is an adjective. In the phrase ‘I am schizophrenic’, the adjective is predicated directly of the person. In isolation, the construction characterises the subject through the qualities associated with schizophrenia.

Now, predicative adjectives are common in English, and in most cases it is clear that speakers are not consciously reducing their entire personhood to a single characteristic. When someone says ‘I am male’ or ‘I am mixed heritage’, we do not immediately assume that they believe their identity begins and ends with that descriptor. Context is also important. Saying ‘I am white’ in response to a demographic survey is more neutral than saying ‘I am white’ in response to a question about one’s views on immigration.

But ‘schizophrenic’ is qualitatively different from many other predicative adjectives because its cultural baggage is so heavily loaded. Dr James Balfour conducted an entire PhD on media representations of schizophrenia and identified a tendency for the word ‘schizophrenic’ to appear in newspaper reports where a person with schizophrenia had engaged in violent or criminal behaviour, while person-first language was more likely to appear in articles celebrating the artistic talents of people with mental illness. Society carries a heavy stigma towards schizophrenia, and so the risk of totalising a person’s identity through the phrase ‘I’m schizophrenic’ is not purely a grammatical issue.

There is an argument for reclamation here, too. We could argue that Kody is resisting person-first language as a way of asserting control over how people with schizophrenia are perceived. Linguistic reclamation is a legitimate phenomenon, with notable examples such as Richard Pryor coming to mind. Reclamation has had demonstrable cultural and social effects: some positive, some negative.

We could extend this argument to SchizoKitzo, who produces YouTube videos about life with schizoaffective disorder. ‘Schizo’ is a slur and a pejorative, and decisions about social media branding are usually intentional and strategic. While I do not doubt that SchizoKitzo may be operating from a position of reclamation, people with large audiences have a significant responsibility to consider whether their messaging challenges stigma or inadvertently reproduces it.

My concern with using a slur in public-facing social media content intended to reduce stigma is that reclamation efforts can fail in ways creators do not anticipate. By building an online identity around a slur, and gaining popularity while doing so, the slur enters public discourse more often than it otherwise might. More people type ‘schizo’ into search bars, ironically while looking for content ostensibly intended to challenge stigma. There are also legitimate questions about whether the shock value and memorability of such a username form part of the branding strategy.

I think building a public brand around the word ‘schizo’ is misguided. More strongly, I think it is reckless. Reclaiming a slur for oneself is one thing; deliberately building a large public-facing identity around it is another. The latter has downstream consequences for other people with schizophrenia who did not consent to that reclamation and who may ultimately have to live with the language it helps normalise.

Kody Green also sells merchandise, including hoodies and T-shirts carrying slogans such as ‘my mental illness makes me funny’. I expect that Kody is well-intentioned, but I wonder whether he has anticipated that his brand of advocacy may not be particularly appealing to everyone living with schizophrenia.

I am personally quite sensitive to the idea of other people laughing at me. Merchandise that appears to connect serious mental illness with being an object of humour is not something I am interested in buying or wearing. There is, of course, another way to read the slogan: that people with mental illness may develop comedic talents as a direct result of their illness. This is a more charitable interpretation, but one I still find problematic. We should be cautious about glamorising serious mental illness or framing it as a route towards developing socially desirable traits. Whichever way I read the slogan, I see problems.

My broader concern with prominent mental health creators is that some appear to engage in forms of advocacy that make sense to them as individuals, without enough care or attention being given to the downstream effects of what personally feels right to them. SchizoKitzo may value her reclamation of a slur. Kody may genuinely believe that his foray into stand-up comedy is a direct by-product of his illness. But these personal interpretations travel far beyond the living rooms and bedrooms in which much social media content is filmed.

There are real consequences for people who are extremely unwell: people who are often too busy struggling with intense symptoms to consider picking up a camera and ensuring that their microphone and ring lights are arranged just so for content creation. Those too unwell to make content of their own can still feel the effects of content produced by those well enough to make it.

This gap between the unseen majority and the visible minority carries enormous responsibility, and I do not feel that responsibility is being taken seriously enough.

I see a related problem in the public trajectory of Lauren Kennedy West, a YouTuber who gained a large audience through her videos about life with schizophrenia. She later pivoted towards claims about the ketogenic diet and schizophrenia and now offers public speaking and consulting services connected to metabolic approaches to mental health.

Research interest in ketogenic and other metabolic interventions for serious mental illness is growing, but the evidence base remains developing. That distinction matters. Early research interest is not the same thing as established efficacy, and personal recovery narratives are not substitutes for robust clinical evidence.

When a creator has built a strong parasocial relationship with a large audience, claims about recovery and treatment can carry enormous weight. Some viewers may interpret a prominent creator’s experience as evidence that they, too, should alter or discontinue established treatment in favour of an intervention whose efficacy is not yet well established. That possibility should be taken seriously, particularly when the audience includes people living with severe mental illness.

Creators in this space have enormous influence and, with it, enormous responsibility. My concern is not that people with schizophrenia should be denied autonomy over how they describe themselves, build their identities, interpret their experiences or discuss their recovery. My concern is that personal choices cease to be purely personal when they are broadcast to large audiences and deliberately turned into public advocacy, brands, merchandise, services and treatment narratives.

The most visible people with schizophrenia are, almost by definition, those well enough to become visible. They are able to film, edit, publish, promote, speak publicly and build audiences. Meanwhile, many of the people most severely affected by schizophrenia remain largely absent from public discourse.

Yet they, too, live with the consequences of how schizophrenia is represented.

That is the responsibility I think too many creators are failing to take seriously.

I Saw Psychiatry from Underneath, Inside, and Above

I came away from my first episode of psychosis feeling angry. I had spent a month in a psychiatric intensive care unit, and many of my experiences were objectively indicative of poor practice. Much of what happened is detailed in my book, Fought Disorder. People who have read it and who also work in services have told me they were horrified by how I was treated and how my condition was managed.

It would have been easy for me to find solace in the harmed-patient community. I could have shared my experiences in forums, written blog posts for anti-psychiatry publications, and engaged in forms of activism at the more aggrieved end of the spectrum. Instead, I gravitated away from these people and their ideas—not because I thought they were wrong to be angry, but because I felt that the way they expressed that anger was unlikely to bring about the reform they seemed to want.

I ultimately concluded that the people managing my behaviour were, for the most part, well-intentioned. There were indications, though, that I was not the only person who felt aspects of my care occupied morally grey territory.

I recall becoming severely delirious before my arrival on the PICU and being profoundly disoriented on my first night there. I have fragmented memories of trying to escape; of being dragged down a corridor, howling in tears from confusion and the physical pain of the holds. I assaulted one of the men dragging me and was kicked in the head while wrestling with him on the floor. I woke the following day covered in yellow and purple bruises.

Two nurses took me into a side room and told me that, if I wished, I could complete a body map: a diagram of a human body on which I could mark my bruises and injuries. The nurse offering it to me was in tears. I sensed that I was not safe, and that I was in the presence of people who were at once complicit in what had happened and aware that something was wrong.

I then joined the service that had once contained me, believing that if I became one of the staff, I might come to see what happened to me differently. I hoped I would understand why force was sometimes necessary, and why patient injuries were sometimes unavoidable, if not justifiable.

The more time I spent working with patients and colleagues, the more I came to believe the opposite. Restraints were often avoidable. Communication failures were often traceable to staff burnout, frustration, and unresolved distress. Challenging behaviour was dismissed as “behavioural”, while genuine patient frustrations were pathologised. When combined with a personality disorder diagnosis, ordinary and understandable irritation could be reframed as “splitting”.

At the same time, I was working to contain my own symptoms while navigating the culture of gallows humour on the ward. I recall one patient whose infant child had been rehomed through adoption because she was too unwell to parent him. She came to the office only to be met with staff singing, “Bye bye baby, baby goodbye.”

I asked my team lead whether she understood the significance of what she was doing, how it might be perceived by a woman with schizophrenia, and whether they were intentionally being cruel. They had not realised how it could land.

I found myself occupying a strange space: trying to uphold the model of care while feeling fundamentally connected to the inner lives of patients in ways that many of the staff around me could not see.

I met with the medical director to discuss these concerns and proposed new communication training that could be delivered as part of my role as a restraint trainer. I was told that, if my aim was to influence practice and policy, I should gain credentials.

And so, eventually, I left.

I spent a decade in isolation, working on a PhD from home. Much of that time was spent reading books in a garden shed, learning about schizophrenia and formal thought disorder. When I finished, I became active on the platform X, where it quickly became apparent to me that there were two camps of prominent voices: those challenging mainstream psychiatry from a critical position, and those defending it.

I learnt very quickly that my thoughts would travel if I echoed the sentiments of mainstream psychiatric thinkers. If I dismissed someone asking whether psychotherapy could benefit people with psychosis as “anti-psychiatry”, I would be boosted. If I drew on my knowledge of research design and methodology to challenge an intellectually dishonest take, I could rally support from medical and mental health professionals.

But once I began introducing my own criticisms of psychiatry, I was ousted and othered. I revealed myself to be an unknown quantity: someone embedded within mainstream psychiatric discourse, who spoke the language of psychiatry, but who also advocated for reform and patient benefit.

Critical psychiatrists were reluctant to engage with my work because I had historically challenged the ways in which they presented their ideas, rather than necessarily the ideas themselves. Mainstream psychiatrists were hesitant to explore my work because I was no longer a clear ally of psychiatry. I had essentially dug myself a private little hole, where I explored difficult topics from multiple positions using the vernacular of the establishment, and no one really knew how to respond.

I occupy a strange position.

I spent a decade trying to convince myself that psychiatry is good, and that aggrieved patients simply do not appreciate the work involved in caring for people in crisis. I cared for people in crisis. I used the positivist methods of clinical research. I take my medication. I am a good boy.

But those ten years taught me that there is much within psychiatry that could change, and that many of the points raised from critical positions are worth listening to—even when they are undermined by an affronting and politicised style of argumentation.

I have specialised myself to the point of being unplaceable. I am neither critical nor pro-psychiatry. I am an ex-patient who became staff and then a researcher; someone who saw the system from underneath, from inside, and from above.

Those insights are of little interest to people who thrive on the conflict of warring ideologies. What is sad is that these people—the ones engaged in an endless exchange of blog posts, provocations, and rebuttals—are often those with the positional influence to make changes for the benefit of patients.

They use their power to challenge each other, rather than the problems experienced by those at the bottom of the heap.

The Problem with “High-Functioning”

I am often described as "high functioning". The evidence given for this usually centres on my PhD. I have been told that people with schizophrenia do not normally complete doctorates, despite there being several examples on the r/schizophrenia community alone. There is a tension, however, between what I appear to be on paper and what living with schizophrenia is actually like.

People see the blog posts, the peer-reviewed publications, the books and YouTube videos. They do not see the afternoon naps, the excessive drooling in my sleep, leaving the hob on overnight by accident, or boiling the kettle four times in succession because I cannot remember what happened five seconds earlier.

My journey through mental health care has also been unusually complicated.

I was first detained under Section 2 of the Mental Health Act in 2014. An ECG revealed Wolff-Parkinson-White syndrome, a congenital heart condition that made clinicians understandably cautious about prescribing antipsychotic medication. As a result, I remained unmedicated throughout the acute phase of my psychosis for four weeks. During that time I requested two Mental Health Tribunals, both of which I attended while still experiencing obvious delusions.

When my Section 2 expired, I was transferred to Section 3. On discharge, I was informed that I was entitled to Section 117 aftercare. What nobody explained was that this entitlement could include practical support such as supported accommodation. Instead, I returned to live with my mother. I remember one of her first concerns being whether she could receive financial support for looking after me. My Employment and Support Allowance was subsequently paid directly into her account, and I never received the payments myself.

The Early Intervention in Psychosis team saw me once before discharging me on the basis that my mother was caring for me.

After experiencing neuroleptic malignant syndrome on both quetiapine and amisulpride, I was advised to try living without antipsychotic medication. Regaining some physical energy enabled me to return to work, and I secured a job as a healthcare assistant on an acute admissions ward. I have many positive memories of that role. It was there that I developed an interest in psychiatry and worked alongside dedicated staff within what I came to see as an imperfect but fundamentally well-intentioned system.

At the time, I believed I had recovered from what I thought had been a single episode of drug-induced psychosis. I did not know that I had already been diagnosed with schizophrenia in 2015.

Looking back, I was clearly still unwell. I believed colleagues were bullying me and accessing my NHS records. A recent PALS investigation has confirmed that there is no evidence that my records were accessed inappropriately. At the time, however, these beliefs felt entirely real, and I eventually resigned because I believed I was being forced out. In hindsight, I suspect many of my colleagues were actually trying to support me during periods of fluctuating health and insight.

Around this time I met my former partner. After beginning my PhD and briefly returning to my mother's house, she offered me somewhere to live. We remained together for ten years. Throughout much of that relationship I believed I was well, despite repeatedly describing what I now recognise as paranoid beliefs about local conspiracies involving friends and acquaintances. Eventually, those beliefs extended to the relationship itself.

Five years into my PhD, my daughter was born. Gradually my psychotic symptoms returned, becoming particularly noticeable when she was around three years old. Concerned that I was relapsing, I visited my GP and requested that I restart antipsychotic medication. The GP sought advice from the Community Mental Health Team and prescribed amisulpride.

Shortly afterwards, I spoke with a community psychiatrist who suggested that I was not experiencing psychosis. Because my first episode had occurred many years earlier and I had lived without medication for around eight years, he felt this argued against relapse. He also suggested that people experiencing psychosis do not normally request medication themselves, and interpreted my insight as evidence that I had become attached to the idea of having schizophrenia through my doctoral research. I was advised to stop taking the medication.

Not long afterwards, I confronted my neighbours because I believed they were making hostile comments about me from their garden. The incident led me to contact the First Response service. During that call, the operator told me that my record stated I had paranoid schizophrenia. When I asked whether that was really what the record said, I was told, "Sorry, I was looking at someone else's record."

Several months later, after relationship counselling and discharge from the Community Mental Health Team, I admitted myself to A&E because my beliefs had become so bizarre that I genuinely could not tell whether I was relapsing or whether I was in real danger.

I was detained under Section 2 once again.

During that admission I was informed that I had, in fact, carried a diagnosis of schizophrenia since 2015. I was also told that my Section 117 entitlement had "lapsed". Both pieces of information came as complete surprises.

Following discharge, I spent around a year recovering from what was now clearly a second episode of psychosis, accompanied by prominent negative symptoms. When my discharge referral was sent to the Community Mental Health Team, it was rejected twice. I was told the reason was that I was "too high functioning".

Eventually my relationship ended, largely because my illness had exhausted my former partner. I left both my home and my job and returned once again to my mother's house. I became severely depressed and made a serious attempt on my own life.

After being assessed as unfit for work through Universal Credit, I was eventually able to rent a flat near my daughter, where I now live independently.

On paper, my story appears impressive. I experienced psychosis, remained unmedicated for many years, worked in the NHS, completed a PhD, published research, and now live independently.

The reality is rather different.

I rarely leave my flat because residual symptoms remain significant. I no longer drive because I do not believe it is safe. I avoid many social situations because I continue to experience ideas of persecution. I have resigned from two jobs because I mistakenly believed colleagues were orchestrating campaigns to force me out.

Only today, while walking home from the shops, I passed a man who looked in my direction while speaking loudly to someone beside him. I could not hear what he said, but I immediately became convinced that he was talking about me. For a moment, I nearly confronted him before recognising that this was far more likely to be another manifestation of my illness.

Recently I contacted my local authority's Adult Social Care team to ask about my Section 117 aftercare entitlement. They informed me that they held no records and could not arrange an assessment without a GP referral. I have therefore asked my local NHS Trust's PALS team to investigate what happened. I know that I was told in 2014 that I qualified for Section 117 aftercare, and I know that I was told in 2023 that it had "lapsed". What I do not know is whether the legal process required to end that entitlement ever took place.

I am not pursuing clarification because I expect supported housing. I already have somewhere to live. Rather, I wonder whether there are forms of ongoing support that might have helped me, and may still help now: regular contact with a support worker, psychological therapy, or structured support with managing the long-term effects of schizophrenia. I have repeatedly been told that talking therapies could be beneficial, yet historical self-referrals to the local Improving Access to Psychological Therapies service were rejected because my history of psychosis made me "too complex".

When I reflect on my experiences, I recognise that my case is unusual, and that unusual cases are often harder for services to navigate. I do not believe that fully explains what happened, however. Nor do I think that professionals—or even people who know me well—fully appreciate what living with schizophrenia actually involves.

I am described as high functioning, but I do not feel high functioning.

I am fortunate to have retained insight into my illness and to have spent years researching it academically. Ironically, those strengths have sometimes seemed to close doors rather than open them. My own interpretations of my experiences have often been viewed with suspicion, while my research background has rarely been considered relevant within clinical consultations.

There are many people living with schizophrenia whose symptoms are far more severe than mine. If navigating the system has often been difficult despite my insight, education and ability to advocate for myself, I cannot help wondering how many others quietly fall through the same gaps.

Perhaps I am "high functioning" if the label simply means that I managed to complete a PhD while living with schizophrenia. But if that same label obscures the daily reality of memory problems, paranoia, cognitive impairment, exhaustion, and an ongoing need for support, then it explains very little. Labels can be useful shorthand, but they should never become a substitute for understanding the person behind them.

‘Are We There Yet?’: An Outsider’s View of Psychiatric Diagnosis

I recently read a fine piece by Awais Aftab on validity in psychiatric classification, and it prompted me to reflect on how I think about diagnostic systems and mental illness as someone outside psychiatry: a linguist who also happens to live with schizophrenia.

I had my work cut out for me when I began my PhD. I had no prior research experience. My BA and MA were in creative writing, so everything I did during my doctoral work had to be built from the ground up. I learnt research methods while designing experiments, practised critical appraisal while reviewing the literature, and gradually found my footing as a researcher. One of the earliest challenges was identifying my epistemology (how we know) and ontology (what can be known). In the end, I described myself as a positive pragmatist: someone who believes that reality can be observed and measured, while also taking the view that the best method is the one that solves the problem at hand.

Given that positionality, I tend to view arguments between the critical and mainstream branches of psychiatry—particularly debates about how "valid" DSM categories are—with a degree of indifference.

My own research required me to trace the history of formal thought disorder back to its earliest descriptions. Those early psychiatrists relied on descriptive psychopathology. They observed recurring patterns in patient populations and developed theories and rating scales that helped clinicians describe what they were seeing. Their overriding concern was practical: helping people.

In the case of thought disorder, however, this approach inevitably produced rigid descriptive frameworks. Language actively resists neat categorisation, something clinical linguists understand well, so it is unsurprising that these frameworks sometimes overfit the rich and varied linguistic behaviours they sought to describe. In the process, much of what patients continue to do well has been overlooked. Across more than a century of thought disorder research, only a handful of researchers have seriously documented preserved linguistic abilities—and I am fortunate to count myself among them.

At the same time, my pragmatic side fully understands why these categories were developed and why they proved useful. We simply were not "there" yet. Corpus linguistics, the approach I applied to naturalistic speech data, did not exist in Kraepelin's day, nor even during much of Andreasen's work. We now possess methods capable of far greater precision, but descriptive psychopathology solved the immediate problem of its time: providing clinicians with a systematic way to describe what they were observing and to support patients accordingly.

I view the DSM in much the same way.

My research ultimately suggested that formal thought disorder is both transdiagnostic and linguistically fingerprinted. We observe thought disorder in autism, mania, schizophrenia, and even in people with no identifiable psychiatric condition. However, the linguistic profile differs across these groups. The formal thought disorder associated with autism is measurably different from that associated with schizophrenia.

I also found something that much of the existing literature—with the notable exception of Peter Liddle's work—had not led me to expect. Thought disorder is not characterised by speech errors that are absent from healthy populations. Rather, the linguistic behaviours associated with formal thought disorder occur in everyone as natural artefacts of speech production. They simply occur more frequently, and become more noticeable, in schizophrenia and other neurodevelopmental and psychiatric conditions.

For that reason, I recommended moving away from a categorical conception of formal thought disorder and towards a dimensional one.

What I did not conclude, however, was that the concept of thought disorder, or the rating scales built around it, are therefore meaningless. I criticise aspects of their methodology and argue that developments in computational psychiatry can move us towards a far more precise understanding. But I do not regard the previous century of work as a mistake.

This is where I find myself parting company with much of critical psychiatry. It often treats the imprecision of our current methods as evidence that the entire enterprise is fundamentally flawed. I disagree.

My own experience, and the literature I have read, suggest something rather different. Psychiatric diagnoses are useful approximations. They represent the best conceptual tools available at a given point in scientific history. As our methods improve, those categories will almost certainly become more refined, more dimensional, and perhaps eventually replaced altogether. But that does not mean they have failed.

Science advances through approximation. Each generation inherits imperfect models, improves them, and passes better ones to the next. There is little value in discarding useful frameworks simply because they are incomplete. Better tools do not invalidate the work that came before them; they build upon it.

We will arrive at more precise understandings when the evidence and methods allow us to do so. Until then, researchers and clinicians are doing what science has always done: using the best tools available while working to create better ones.

The Double Life of Schizophrenia

I have deliberately designed for myself a small, manageable life. I chose a flat close to my daughter's school and the high street. These are the only two places, beyond my home, that I regularly visit.

In doing so, I have become known to my immediate neighbours as a quiet man who enjoys his potted plants, spends time with his daughter, and has recently adopted a cat. They do not know about my diagnosis, and I have no plans to tell them. I have learnt that once people know you have schizophrenia, almost everything you do is viewed through the lens of its cultural baggage. Singing to yourself becomes a symptom of madness rather than a harmless indulgence.

A great deal of energy goes into concealing my illness from the people I encounter on the school run, at the local shop, or while walking through the park. Small talk is effortful, often painful. It feels like a series of social moves I do not truly understand.

Over the years I have realised that my face must move in just the right ways. My eyebrows must rise at certain moments, but not for too long. My head movements must appear fluid. Eye contact must last long enough to register eye colour, but no longer.

The truth is that my face no longer moves of its own accord. That changed in my mid-twenties. Since then, I have had to move it myself. I consciously puppeteer my expressions for the benefit of others, and I am tired. Even conversations lasting only a few minutes can require hours of recovery.

This also extends to my interactions with my daughter, but I do not begrudge that effort. It is genuinely a pleasure to appear animated for her because I can see how much she values the engagement. Beyond her, however, living with negative symptoms while simultaneously masking them feels like a salmon swimming upstream.

I do this because society still struggles to understand schizophrenia. Affective flattening is interpreted as rudeness or arrogance. Reduced motivation and diminished capacity for pleasure are mistaken for laziness or cynicism.

There is a perverse irony in living with schizophrenia. The experience is full of double binds.

Medication worsens my negative symptoms but relieves my positive symptoms. Breaks from medication bring the return of motivation at the cost of an almost certain relapse. Society rewards a neurotypical presentation, yet pretending to be normal is metabolically expensive. Social withdrawal is driven not only by negative symptoms but also by stigma. Attempts to be open about the condition can lead to being seen differently, othered, or quietly pushed away. Concealment keeps interactions smooth and civil, but it feels morally compromising.

Occasionally, a visibly mentally ill man will pass us: unkempt, drinking from a bottle, listening to music through the speaker of his phone. We look at him and talk about "those people" and their "problems."

I pretend that I am not one of them.

I pretend that I was not once naked in handcuffs on an industrial estate in Plymouth, explaining to police officers that they were actors in a television programme about my life.

I lie every day, hoping that I pass for well. Hoping I will not be discovered. Yet I also write publicly about this very tension, increasing the likelihood that I will be.

This double life is lonely.

And yet I cannot become too good at the lie. I must be honest with my GP about my symptoms and truthful with the Department for Work and Pensions about my limitations. If I become too convincing, I risk losing the support that helps keep me well enough to maintain the façade in the first place.

It is an exhausting balance. One that leaves me feeling morally compromised, profoundly lonely, and often unsure where authenticity ends and performance begins.

I recently took part in a research study examining loneliness in people with psychosis. It was one of the few occasions in recent years where I felt both permission to be myself and genuinely seen.

I raised many of these points with a compassionate master's student working within a psychiatry department. She seemed to recognise what I was describing.

For just over an hour, it felt like it was OK to be me.

The Task

Twelve years ago, I stood alone in my university dorm room staring at the ceiling. Cannabis smoke drifted upward from my right arm. I did not know that I was transitioning from the prodromal phase of psychosis into an acute episode. I did not know that I would be sectioned the following morning.

Yet I found myself engaged in a sincere, one-sided conversation with God.

I explained that I could not shake the feeling that there was something I needed to do. I asked to be shown what that was.

At the time, I was a creative writing student. Mental health was not part of my wider awareness.

That night marked the beginning of a long project concerned with language, psychosis, and meaning in schizophrenia.

My first psychotic episode and subsequent admission left such an impression on me that I felt compelled to document it. Clinicians told me it was unusual for patients to remember their psychosis in vivid detail, let alone to reflect on it metacognitively. I felt an epistemic obligation to catalogue what had happened: how delusions formed and were rationalised, how misinterpretation and clinical care became intertwined, and what it felt like to emerge from a complete break with reality carrying a grief that few people could understand.

After finishing the book, I found work on an acute psychiatric admissions ward. For two years I worked as a support worker, learning about psychosis, schizophrenia, personality disorder, self-harm, suicide, clinical risk, and recovery.

At that time, services still prioritised one-to-one engagement. Much of my working life consisted of sitting with patients in side rooms, discussing their experiences of the ward, their hopes for discharge, and their fears about the future.

I loved the work.

Yet I was never entirely comfortable within the culture that surrounded it. Clinical teams often rely upon a clear distinction between those who are unwell and those responsible for their care. My own history complicated that distinction. I occupied both sides of the divide, and not everyone found that comfortable.

I eventually realised that I had taken the role as far as I reasonably could. Although I later trained as a control and restraint tutor, I found myself far more interested in communication and de-escalation than physical intervention. We spent considerable time preparing staff for confrontation and comparatively little time teaching them how to avoid it.

So I left and pursued a PhD.

Looking back, the decision appears straightforward. It was anything but. The project nearly collapsed several times. Securing support required months of negotiation, and there were understandable concerns about whether I could complete the work. In the end, the project survived through a combination of persistence, opportunity, and good fortune.

By the time I finished, I had changed considerably. Ideas that seemed self-evident to a twenty-five-year-old recovering from his first episode of psychosis no longer seemed so clear to a tired thirty-five-year-old researcher living with schizophrenia.

I briefly returned to clinical work afterwards and quickly realised how much services had changed. There was less time for meaningful engagement and a greater focus on managing incidents. The distance between services and the people they served felt wider than I remembered.

At the end of all this, I found myself returning to that conversation in the dorm room.

I have never been religious in any conventional sense, but I have always prayed.

For the first time, I felt that I had completed the task I had been given.

Take the experience of that first psychotic episode and transform it into something that might outlive you.

A book.

A thesis.

Articles.

Conversations.

Whether any of it ultimately matters is not mine to decide.

For a long time, I worried that I had failed. Stigma remains. Mental health services continue to struggle. Academia moves at its own pace, often unaware of work occurring beyond its immediate concerns.

Yet I am satisfied that I produced the work.

People often become anxious when someone with schizophrenia speaks about faith. In many cases, that caution is warranted. I have worked with people whose religious beliefs became inseparable from severe psychosis, sometimes with devastating consequences.

My own relationship with faith has always been different.

For me, faith is less about certainty than meaning. It is the possibility that effort matters, that intentions count for something, and that our lives form part of a larger story than we can fully see.

I cannot know whether the feeling I had that night in my dorm room came from God, from psychosis, or from somewhere in between.

What I do know is that I paid attention.

I followed the path that emerged from that experience as honestly as I could.

And, looking back over twelve years, I believe I did my best with the opportunities that followed.

A Good Enough Father

One of my central preoccupations is my efficacy as a father in the context of having schizophrenia.

I have enjoyed many privileges that most fathers do not experience. I worked from home and balanced my PhD with being a stay-at-home dad. My ex-partner returned to work after her maternity leave, and I spent the four years that followed taking my daughter for long walks through the local forest. We developed a routine that worked for us and accommodated my condition. "Sleep when the baby sleeps" is actually quite good advice for someone in my situation. We traced the same route day after day for months: breakfast, a walk around the woods, and a nap under a tree.

This sounds idyllic, and in many ways it was. Older men would pass us and confide in me that they wished they had spent as much time with their children as I was spending with mine.

On one occasion, I spilt a coffee and burned my daughter's legs. We attended the Accident and Emergency department, where it became clear to me that my diagnosis was influencing my interactions with healthcare staff. I was not simply a father presenting after a tragic mistake. I was a case of "dad has schizophrenia, and his child is injured."

For several years, this rhythm sustained us. For the most part, I functioned under circumstances that would have been difficult for many people. Caring for a young child while working remotely and completing a PhD is demanding under the best of conditions.

While these were the best days of my life, bar none, they were not without challenges. We lived in a small one-bedroom bungalow. Our daughter slept in our bed. She cried in the night, as all infants do, and kicked and wriggled as a toddler. Sleep has always been one of the foundations of my stability. Spending long days caring for a young child while managing academic and professional responsibilities added a layer of stress that increased my vulnerability to psychosis.

As my daughter grew older and I approached the end of my PhD, the pressures that I had largely managed began to accumulate. My behaviour became increasingly disorganised, and the signs of a prodromal phase emerged.

This eventually led to a psychotic relapse. In the run-up, I would cry uncontrollably over dinner, uncertain whether the food was poisoned. I photographed bruises on my daughter's legs—bruises she had acquired simply by being three years old—believing I was documenting potential abuse that I could not prove. I began to suspect that my hair was being cut in my sleep, and that my belongings were being deliberately rearranged and hidden to destabilise me. Conversations with neighbours took on a familiar darkness, and beliefs that I was being gossiped about and surveilled took hold.

Eventually, I searched the house for cameras and listening devices, all the while maintaining the routines of the school run and attending my supervisory meetings.

The uncertainty eventually became too much to bear. I recognised that my relapse signs were present, the most obvious of which, in my case, is uncontrollable crying. I hugged my daughter and took myself to hospital, where I was assessed and sectioned.

My first psychotic episode was chaotic, confused, and agonising. My second was calmer—still difficult, but more controlled. I understood the psychiatric system, and I had visits from my daughter to look forward to. When granted leave, I would visit the hospital newsagent and buy magazines for her visits. We would sit together in the visitors' room and colour while I struggled with overvalued ideas that became increasingly difficult to distinguish from reality as evening approached.

Once I was discharged and placed on maintenance therapy, I noticed a significant difference in what I could manage. The school run became exhausting. Sleeping through much of the day became common. It became necessary to wear a mask of enthusiasm and positivity in the face of emotional blunting. People noticed the weight gain. People commented when I fell asleep during birthday parties. No one really knew or understood why.

Conversations about my illness became necessary, and it was important to frame them in an age-appropriate way. My daughter would ask what my tablets were for, and I would explain that I have schizophrenia, which means that "sometimes Daddy gets poorly."

As she grows older, those conversations will inevitably become more involved. We will have to talk about my condition, my decision to speak publicly about it, the realities of stigma, and the fact that she will ultimately decide for herself what she wishes to share with others.

I am fortunate that my daughter has a strong support network around her. She has a supportive mother and grandparents who provide her with opportunities, activities, and experiences that I cannot always offer. They take her on outings that provide social and intellectual enrichment. My own limitations are often accommodated by her surprisingly strong interest in simply resting and spending quiet time together, and so things largely work out.

I sometimes think back to an article written by the adult daughter of a man with schizophrenia and how she made sense of his illness. I project forward to a time when my own daughter may face similar questions and feelings, and I wonder how my condition will shape her journey through life.

It is my hope that, despite my illness, I will remain a good enough father.

At the same time, my inability to give her some of the things many fathers take for granted—day trips, holidays, endless energy—still troubles me.

I have found surprisingly few accounts online written by men with schizophrenia about their experiences of fatherhood. If anyone with schizophrenia who has young children happens to read this, my suggestion would be simple: build a life around what you can offer, rather than measuring yourself against what other fathers can.

Children do not need perfect fathers. They need fathers who keep showing up.

Psychiatry’s Guild Wars: A Linguist’s Take

I was treated for psychosis in 2015 and again in 2023. The difference was night and day.

My first admission was not perfect. Psychiatry rarely is. But my care felt coherent. I dealt almost exclusively with psychiatrists. They identified psychosis, managed the complications arising from my physical health problems, explained my Section 117 entitlement, and ensured that appropriate support was in place when I left hospital.

My second experience was very different.

By 2022, a community mental health team had rejected my referral and advised that I be managed by my GP. During my subsequent admission, I found myself repeatedly exposed to what appeared to be competing professional frameworks. At one point I completed a patient-reported outcome measure with a nurse consultant. The instrument consisted of vague descriptions of subjective experiences, inviting me to report my symptoms. Yet many of my answers were second-guessed. What should have been a straightforward self-report exercise became a discussion about research methodology and the distinction between patient-reported and clinician-reported outcome measures. I was being asked what I experienced and then, at times, being told that I was wrong.

I also found myself subjected to an autism assessment at the urging of a clinical psychologist despite being admitted for psychosis.

None of these experiences were catastrophic in isolation. What struck me was the sense that I had become caught between competing professional perspectives. As a patient, I could see disagreements that were usually hidden from view. It felt as though different parts of the mental health system were operating from different assumptions about what my problems were and how they should be understood.

To patients on wards, the Guild Wars are observable within the consulting room.

Clinical psychologists undermine psychiatrists. Psychiatrists jab at clinical psychologists. Different professional groups advance different theories, priorities, and treatment philosophies. The patient sits in the middle, increasingly aware that mummy and daddy are fighting and not particularly interested in the outcome. They simply want help.

This is one reason I have become increasingly frustrated by the endless debates that take place on Twitter/X between psychiatry and critical psychiatry.

For years, I have watched familiar names exchange essays, rebuttals, and counter-rebuttals. Yet we seem no closer to resolving the underlying disagreements than we were when I joined the platform around 2018.

What interests me most is not the arguments themselves but the way those arguments are conducted.

Recently, in response to an article by Awais Aftab, James Barnes quoted the following statement:

"I take it for granted that the project of defining the authority of medicine and clinical disciplines in terms of disorder concepts on the basis of objective, value-free facts has failed."

Barnes interpreted this as a significant concession:

"This is no minor concession. It amounts to an admission that one of psychiatry's central legitimating narratives has failed."

I read this as a linguist.

Linguists spend a great deal of time thinking about the difference between what is said, what is intended, and what is received. We know that these things are often very different. The problem with many online debates is that participants frequently treat their interpretation of a statement as though it were the statement itself.

Barnes' interpretation is one possible reading of Aftab's words. It is not the only reading.

My own interpretation is rather different. To say that a particular scientific project has failed thus far is not to say that it must always fail. Mental illness presents uniquely difficult conceptual problems. Kidneys are not self-aware. Livers do not interpret themselves. Human beings do. Psychiatry is attempting to study and treat some of the most complicated phenomena in nature using scientific tools that are still relatively immature. Imperfect though it is, the enterprise remains grounded in recognisably medical goals: alleviating suffering, reducing harm, and improving lives.

Where I struggle with some forms of critical psychiatry is their lack of pragmatism.

Suppose, for example, that treatment-resistant depression is found to be driven primarily by poverty, housing insecurity, social isolation, or unemployment. What intervention can a clinician offer tomorrow morning? How long will it take to solve structural inequality? What should happen to the patient while society works on those problems? What happens if they take their own life before those solutions arrive?

These are not arguments against social determinants of health. They are practical questions about what to do in the meantime.

Yet I suspect both sides of the debate miss something important.

The endless exchange of essays, position papers, and social media arguments often becomes detached from the people supposedly being served. Increasingly, the arguments seem less concerned with solving problems than with establishing epistemic authority. Who gets to define disorder? Who gets to define suffering? Who gets to lead mental health care?

These are legitimate questions.

They are also secondary questions.

The primary question is whether people experiencing severe mental distress receive effective help.

As both a researcher and a patient, I find myself increasingly uninterested in disciplinary turf wars. The philosophy matters. The theory matters. The science matters. But all of these things are ultimately valuable only insofar as they improve the lives of the people sitting in consulting rooms and psychiatric wards.

The tragedy is that the debates themselves sometimes become visible to patients. What begins as an academic disagreement eventually filters down into clinical practice. Patients encounter competing theories, conflicting advice, and professionals who appear more invested in defending their own frameworks than understanding each other's.

Everyone involved in these debates wants to help people.

I genuinely believe that.

But after years of watching psychiatry and critical psychiatry exchange increasingly elaborate arguments, I am left wondering whether the energy devoted to winning those arguments might be better spent addressing the realities that patients continue to face.

The Guild Wars have been running for years.

The patients are still waiting.

When the Voices Finally Arrived

For most of my life with schizophrenia, I did not hear voices.

Diagnosed with paranoid schizophrenia in 2014, I often found myself questioning the diagnosis because one of its most iconic symptoms was absent. The accounts I encountered online described voices commenting on people's actions, narrating their daily lives, or arguing amongst themselves about the person hearing them. I experienced none of this.

As a child and later as a teenager, I can recall only two occasions where I was clearly hallucinating.

The first occurred when I was around ten or eleven years old. I was lying in bed preparing to sleep when I very clearly heard the words, "I'm here," spoken into my right ear. The voice resembled that of my Uncle David. He was a gentle man with a warm voice. I was not frightened by the experience and did not interpret it as a sign of mental illness. Instead, I viewed it as evidence of the supernatural.

Years later, I was alone in an empty house. I had just made a coffee and was leaving the kitchen when the voice of an older man with a thick Cockney accent whispered a single word into my right ear:

"Boo."

The experience startled me so much that I froze and spilled the coffee. Once again, I concluded that the house was haunted.

Both experiences predated my exposure to cannabis. While my first psychotic episode followed a period of heavy cannabis use, these earlier experiences suggest that I was likely already genetically or neurodevelopmentally vulnerable to psychosis.

During my first psychotic episode, I experienced one or two auditory hallucinations but failed to recognise them as such. On one occasion, I heard a high-pitched ringing that gradually became louder and louder until it was physically painful. At the time, I interpreted the experience through the lens of my delusions. Rather than considering it a hallucination, I concluded that someone was directing sound into my skull or attempting to implant messages.

During my second psychotic episode, I experienced externally located auditory verbal hallucinations for the first time.

A member of NHS staff would walk past me and, while looking at the back of their head, I would hear dialogue or commentary in their voice. These experiences were impossible to reality test in the moment because they sounded entirely real. To my mind, a nurse had just walked past and called me a "ponce."

When I complained to the ward manager, who had been present at the time, he explained that nobody had said anything.

The experience reminded me of my own time working as a healthcare assistant. Years earlier, I had accompanied a woman with schizophrenia to a local shop. The shop assistant briefly turned away from the counter in silence to retrieve an item. The woman immediately became distressed.

"What did you call me?"

The assistant looked confused.

"Did you hear what she just called me?"

At the time, I was struck by how unusual this style of voice hearing seemed. Years later, I found myself experiencing something remarkably similar.

For the next decade, however, I largely escaped auditory verbal hallucinations.

That changed last year.

I was once again lying in bed preparing to sleep when I heard several bars of a song I had never heard before. The music resembled progressive rock and was surprisingly enjoyable. What struck me most was its location. Unlike my earlier experiences, the sound was clearly situated inside my head. Phenomenologically, it felt as though a speaker had been installed inside my skull. The music possessed all the qualities of a genuine acoustic signal, yet it was obviously not arriving through my ears.

Since then, I have begun experiencing a variety of auditory verbal hallucinations.

Most commonly, I hear the voices of people close to me expressing concern for my wellbeing. Sometimes the voices appear just behind my right ear, as they did when I was younger. At other times they seem to originate entirely within my head. Occasionally, the experience occupies both locations simultaneously, feeling somehow internal and external at the same time.

What strikes me most is the variety.

There does not appear to be a single phenomenological profile for these experiences. The voice may seem internal, external, or both. It may be immediately recognisable as a hallucination or almost impossible to distinguish from reality.

When I hear my former partner ask whether I am okay, my first thought is not, "I am hallucinating."

It is:

"How did you get into the flat?"

Only a few seconds later do I realise that nobody is there.

This delay fascinates me because it illustrates how convincing these experiences can be. Even with years of psychoeducation and a diagnosis of schizophrenia, my first interpretation is often the mundane one.

I am also intrigued by what these experiences might tell us about theories of inner speech and sub-vocalisation. The fact that some voices seem clearly external while others feel entirely internal suggests a degree of variation that simple explanations may struggle to capture.

Fortunately, the voices I experience are largely benign. They are often pleasant and rarely distressing. They occur infrequently enough that my daily life is not constantly interrupted.

I consider myself fortunate in this respect.

At the same time, I remain fascinated by the experience itself. For many years I wondered whether I really fit the stereotype of schizophrenia because I did not hear voices. Now that I do, I am struck less by their presence than by their diversity. They seem capable of occupying different locations, carrying different emotional tones, and presenting different challenges to reality testing.

The more I experience them, the less convinced I become that there is any such thing as a typical voice.

The Realities of Being ‘on Disability’

For ten years after my schizophrenia diagnosis, I remained in the workforce. Part of the reason was that several health complications prevented me from staying on maintenance therapy. Following my first psychotic episode, I spent a year taking quetiapine before developing neuroleptic malignant syndrome. The same thing happened when I was switched to aripiprazole. After two dangerous reactions, my community psychiatrist suggested coming off medication entirely. It was not ideal, but it seemed safer than continuing to search for an antipsychotic that I could tolerate.

I spent the next eight years unmedicated, convinced that I had recovered and that I was "well." Looking back, I clearly was not. I was paranoid, preoccupied with ideas of persecution, and often flirting with overvalued ideas and delusions. Yet I maintained that I was functioning perfectly normally.

In many respects, I was.

I worked as a healthcare assistant on an acute psychiatric admissions ward for two years. I spent a year teaching control and restraint techniques to NHS staff. When I realised that career progression would eventually require a move into nursing, I left to pursue a PhD. Alongside my doctoral studies, I consulted for charities in the alternative education sector, worked as a private tutor, proofread academic work for other students, and eventually secured a full-time position with a localisation firm that carried out extensive work for the pharmaceutical industry.

On the surface, I looked productive and successful: employed full-time, studying for a PhD, and raising a young daughter. Behind closed doors, I was suspicious, paranoid, and only faintly tethered to reality.

Living with someone under constant stress and quietly battling psychotic symptoms takes its toll. My former partner eventually fell out of love with me, and I do not blame her. I am honestly amazed that she stayed as long as she did.

Following my second psychotic episode, I was finally placed on maintenance therapy and developed the negative syndrome that had largely spared me during the first decade after my diagnosis. Once it arrived, things that most people take for granted became incredibly difficult.

An hour at the park with my family could leave me exhausted for days. I slept fourteen hours a night. Even now, not much has changed.

As my functioning declined, I fell into a deep depression. I became convinced that my presence in my partner's home was making everyone around me miserable and anxious. Eventually, I moved in with my mother.

Things became harder still.

I was now living an hour away from my daughter. Despite having never missed a school pick-up, I found myself struggling to maintain even basic routines. At the same time, I was trying to continue working in a psychiatric intensive care unit. Constant exposure to aggression, antisocial behaviour, and what I felt were repeated examples of poor clinical practice became increasingly difficult to tolerate.

Eventually, I left healthcare altogether.

My depression deepened. I made an attempt on my life before ultimately seeking help myself. After three days in hospital, I realised that something had to change.

I found myself in an uncomfortable grey area. I was not as severely disabled as many people with schizophrenia, but neither was I well enough to sustain full-time employment. I had already been denied Personal Independence Payment twice and had no clear idea how I was supposed to rebuild my life when even searching for work felt overwhelming.

I began claiming Universal Credit while signed off sick from work. Because I was submitting fit notes, I was placed on what the Department for Work and Pensions calls the health journey. At the time, I had no idea what that meant. I completed a health questionnaire with little thought and eventually underwent a work capability assessment.

Some weeks later, I was informed that I had been assessed as having Limited Capability for Work and Work-Related Activity (LCWRA).

I had never even heard of LCWRA.

Not long afterwards, my mother asked me to leave. Faced with finding accommodation, I contacted Universal Credit and was told that housing support would be available once I secured a tenancy. I eventually found a small flat near my daughter's school and submitted the tenancy agreement.

That is where I live today.

I am enormously relieved that this support exists. Before entering the system, I had no idea that LCWRA was available. Without it, I would almost certainly have become homeless.

The reality, however, looks very different from the picture often presented in the media.

Since my second psychotic episode, my condition has worsened significantly. I have begun hearing voices, something that was entirely absent during the first decade after my diagnosis. Fortunately, they are benign. Sometimes I hear my former partner asking whether I am okay. Sometimes I hear snippets of music that I do not recognise. Occasionally, I hear what sounds like someone speaking just behind my right ear.

My memory has deteriorated dramatically. I routinely boil the kettle two or three times because I cannot remember whether I have already done it. I have left hobs and ovens running overnight without realising. Everyday tasks that once required no effort now demand constant attention.

At the same time, I have watched public discussion of the benefits system with growing disbelief.

Many people seem to imagine that disability benefits provide a comfortable alternative to employment. That has not been my experience.

Before I became too unwell to work, I earned around £40,000 a year, taking home roughly £2,600 a month after tax.

Today, my monthly income is approximately £1,377.

My rent exceeds the local housing allowance, meaning I must make up the difference from my living costs. After rent, utilities, and council tax, I am left with roughly £200 a month for food.

In practice, this means making choices most people never have to think about.

Bread and milk, or eggs and butter.

One, but not both.

Every grocery shop is planned with military precision because mistakes have consequences.

I live in a state of constant financial precarity. If my landlord increased my rent by £100 a month, I would face a genuine risk of homelessness. I have no savings. When I buy furniture, birthday presents, or Christmas presents for my daughter, it is usually because I have managed to secure occasional lived-experience advisory work. Even then, payment often arrives six to twelve months later, if it arrives at all.

Most recently, I was paid eighteen months after completing a project.

The payment arrived as a foreign cheque.

I cannot cash it.

When I think about my own circumstances, I often find myself thinking back to the interviews I conducted during my PhD. Many participants spoke about financial hardship. Some described carefully restricting their activities to ensure that they could afford food and housing. Others reported not watching television because they could not afford a licence. One participant described corned beef and rice as a luxury meal.

At the time, I understood these accounts academically.

Now I understand them personally.

The idea that people receiving disability benefits are living lavishly while laughing at the taxpayer needs to be laid to rest. Most seriously unwell people are not living comfortably. They are trying to remain housed, fed, and as well as possible while navigating illness under significant financial constraint.

That reality deserves far more attention than it receives.

In Defence of AI

During my PhD (2017–2024), I almost never considered using artificial intelligence. Looking back, there were plenty of opportunities where it might have helped.

I was building a corpus, and the idea of automating transcription certainly appealed to me. In practice, though, this never took hold because the corpus was a clinical dataset focusing on disorganised speech. Systems trained on healthy speech do not perform particularly well when transcribing thought disorder. There was another reason, too. Manual transcription gave me a level of control over my data that automated transcription simply would not allow. I was able to develop my own transcription convention, designed to capture details that I and other researchers could later analyse. This meant spending eight hours a day, for almost a year, holding a fairly complex transcription convention in mind while agonisingly working through more than twenty hours of fuzzy audio.

I also developed a linguistic experiment. The initial plan was to run it in a laboratory setting, with participants travelling to the university. The COVID pandemic required me to redesign the study so that it could be delivered remotely. I had already spent years designing the task and several months implementing it in SuperLab. Were it not for the release of SuperLab Remote at exactly the right time, I may have had to learn Python and rebuild the experiment from scratch. That could easily have added a year to the timeline and may even have threatened the completion of my PhD.

Most of my doctoral work involved wrestling with ill-defined concepts and a literature filled with gaps. There are only a handful of researchers working directly on thought disorder, and relatively little attention has been given to possible links between thought disorder and creativity, although there has been some renewed interest in recent years. An AI would not have been much help at that stage. Large language models generate responses based on existing patterns of knowledge, and what we knew about creativity and thought disorder prior to my thesis was very little.

So I spent a great deal of time with books. Books on thought disorder, creativity, linguistics, psychology, research design, and corpus building. I found myself tracing what had been written about thought disorder over the last century, identifying where interest had faded, and considering what broader schizophrenia research might contribute to the puzzle. Much of the work consisted of following loose threads and seeing whether they connected.

I am glad I took that route because completing a PhD without involving LLMs forced me to develop skills I would not otherwise have acquired. If I had asked an AI to design an experimental task, it would almost certainly have produced something competent. It would also have been heavily shaped by the conventions that dominate psycholinguistics, experimental linguistics, and experimental psychology. The more interesting outcome of doing things the hard way was that I continually encountered methodological gaps. Nothing that had been done before quite met the needs of my project. Nothing directly addressed the specific problems I was trying to solve.

I would not have developed a novel method for norming linguistic stimuli in a clinical population by consulting with AI. Nor would I have thought to take a reviewer's criticism that “this reads like a tutorial for students” and rewrite the paper as an actual tutorial in order to get it published. That remains one of my favourite publication experiences. Rather than defending the paper against the criticism, I accepted the premise and leaned into it. AI does not generally suggest that sort of lateral move. It weighs, averages, predicts, and often reassures. Useful qualities, but not quite the same thing.

After my PhD, I began experimenting with AI. The result of doing so is this website, my YouTube channel and podcasts, the Python implementation of my experimental task, and three of my four books.

AI did not script my videos or generate the ideas behind my books, but it allowed me to take material I had already created and repurpose it into new formats. This is the workflow that has worked best for me since integrating AI into my projects. Rather than asking AI to generate ideas, I ask it to transform my existing work.

Androids DO Dream is one example. The book began as a collection of ideas spread across my thesis, a memoir of psychosis, years of video essays, and podcast discussions. I gave the model those materials and asked it to produce a short mass-market book in my voice that adhered closely to the themes of my existing work. The result sounded surprisingly like me, not because AI can read minds, but because it had access to a substantial amount of personalised source material and a very clear prompt.

The Python implementation of my experiment is another example. AI did not design the study. It did not spend two years standing at a whiteboard, chain-smoking with a migraine, trying to make linguistic stimuli, theoretical concepts, research design best practices, and statistical rules fit together. It was given my methodology paper and PhD thesis and instructed to build a software replica of what participants experienced during the study. It succeeded because it was working from detailed, high-fidelity source material. The difficult intellectual work had already been done.

How Language Holds provides another example. This book was produced by an LLM using my own work as source material. It was given my thesis, memoir, and corpus and asked to identify patterns in the interview transcripts that reflected preserved ability, expression, and adaptation rather than simply signs of disorder. The instructions were explicit: be transparent about the method, acknowledge the limitations, and avoid presenting the analysis as rigorous academic research. The result is not a scholarly monograph. It is a way of showing readers another side of the data, one that they can engage with and reflect upon. Had I not transcribed those interviews manually, many of the patterns highlighted in the book would likely never have been captured in the first place.

This is the use of AI that I find most compelling. Giving AI real human ingenuity, creativity, and effort and asking it to automate tasks for which the original creator no longer has the time, energy, or inclination. That feels fundamentally different from asking a model to generate a novel, a painting, or an entire creative project from scratch. While newer models are increasingly capable of such things, I still believe there is more satisfaction in creating something yourself and then asking AI to do something interesting with it.

What strikes me about my own use of AI is that every successful project has followed the same pattern. The model performed well whenever it was given a large body of high-quality human work to transform. It was far less relevant during the earlier stages where the actual conceptual breakthroughs were being made. The corpus had to be built. The experiment had to be designed. The ideas had to be developed. The books had to begin somewhere.

Every successful use of AI in my own work has followed the same principle: start with something that required human effort, expertise, or creativity, and then use the model to transform, extend, or repurpose it. My thesis became software. My videos became books. My corpus became a different way of thinking about language and psychosis. None of these projects began with AI, but all of them were made easier by it. To me, that feels less like cheating than a natural extension of creativity itself.

Lived Experience Is Work. We Should Start Treating It That Way

Over the last decade, I have participated in numerous research studies, advisory panels, consultation exercises, and lived experience initiatives. In almost every case, compensation has arrived in one of two forms: an Amazon voucher or a bank transfer.

Neither method is inherently problematic.

What is striking is how long these payments often take to arrive.

Several months is common. In some cases, considerably longer. At the time of writing, I am still awaiting payment for one project more than eighteen months after my contribution. A separate focus group initiative, to which I contributed over a period of months, has yet to compensate participants.

The issue is not primarily the amount of money involved.

Rather, it is what these arrangements communicate.

Researchers, charities, and public bodies increasingly emphasise the importance of lived experience involvement. Co-production has become a familiar term in grant applications, ethics submissions, and project documentation. Yet the practical treatment of lived experience contributors often tells a different story.

In my experience, lived experience involvement is frequently treated as something that sits outside the normal structures of work and employment.

I was reminded of this recently while reviewing a research proposal. The application contained detailed staffing costs running into the hundreds of thousands of pounds, alongside assurances that lived experience involvement would remain a relatively modest component of the budget.

Nothing about this was unusual.

What struck me was the implicit distinction between "staff" and "lived experience contributors."

The latter group attends meetings, reviews documents, provides feedback, influences study design, and contributes specialist knowledge that researchers themselves do not possess. Their activities have many of the characteristics we would normally associate with professional work.

Yet they are rarely discussed as colleagues.

Instead, they often occupy a curious position somewhere between volunteer, consultant, and symbolic stakeholder.

This distinction matters because language shapes expectations.

If lived experience contributors are viewed as peripheral to a project, delays in payment become easier to tolerate. Administrative difficulties become easier to excuse. Following up on compensation becomes something contributors must chase rather than something organisations actively manage.

Over time, this has diminished my enthusiasm for both research participation and lived experience involvement.

I have repeatedly encountered situations in which researchers enthusiastically discuss co-production during project development but become difficult to reach once contributions have been obtained. Requests for updates, publications, or information about study outcomes often go unanswered.

I do not assume bad intentions.

Most researchers are overworked, under pressure, and balancing multiple responsibilities. Yet the cumulative effect is difficult to ignore.

Lived experience contributors are often highly visible during the funding and design stages of a project and far less visible afterwards.

This raises a broader question.

What would it look like to treat lived experience contributors as genuine colleagues?

In a recent review, I encouraged a research team to think of lived experience advisors not as a group assembled for a specific task, but as long-term collaborators. The funding body responded positively to that suggestion. Whether it ultimately influenced the project, I do not know.

What I do know is that many current arrangements feel transactional.

Contributors are invited into projects for a meeting, a panel, or a consultation exercise. Afterwards, compensation is routed through administrative systems that often appear unprepared for the realities of paying people promptly and consistently.

The result is a paradox.

Organisations increasingly acknowledge that lived experience expertise is valuable. Yet the structures surrounding compensation often imply the opposite.

For that reason, I have gradually stepped away from much of this work.

The issue is not simply money. It is recognition.

If lived experience genuinely improves research, then the people providing that expertise should be treated accordingly. They should be compensated promptly, included meaningfully, and regarded as contributors rather than accessories to the research process.

Lived experience involvement is often described as a moral good.

I would argue that it is something much more practical than that.

It is work.

And we should start treating it like work.

Why I No Longer Believe in Seclusion

One of my most viewed and controversial TikTok videos concerns the use of seclusion in inpatient psychiatry. In that video, I argue that I see little place for seclusion in modern mental health care.

I do not hold this view lightly.

Over the last decade, I have encountered seclusion from multiple perspectives: as a psychiatric patient, as a healthcare assistant implementing restrictive interventions, as a control and restraint tutor teaching the legal framework surrounding seclusion and segregation, and later as a researcher and returning member of ward staff.

Taken together, those experiences have left me increasingly unconvinced that seclusion consistently achieves the purposes for which it is intended.

In theory, seclusion is a last-resort intervention used to manage severe behavioural disturbance and reduce immediate risk to others. In practice, I frequently observed something more complicated.

What struck me most was not the existence of seclusion itself, but the gap between policy and practice.

When I returned to inpatient psychiatry in 2024, I was disappointed by some of what I observed. Patients who had damaged property or behaved aggressively towards staff were sometimes directed towards seclusion as though it were an expected consequence of their behaviour. Conversations among staff occasionally suggested that prolonged periods in seclusion were anticipated long before any formal review had taken place.

I also observed patients remaining in seclusion while engaging in behaviours that appeared to indicate significant distress, including self-injurious behaviour. My expectation had been that such situations would trigger immediate therapeutic intervention. What I often saw instead was a system struggling to respond effectively once a patient was behind a locked door.

Another change surprised me.

When I first worked in inpatient services in 2015 and 2016, planned interventions typically involved relatively small teams. Communication and de-escalation remained central to the approach, even when restraint became necessary.

By 2024, the scale of some interventions appeared to have increased significantly. Wards routinely requested additional staff from neighbouring units before entering seclusion areas. In some cases, so many staff were present that movement within the area became difficult. Whether intended or not, the visual impact of these large groups struck me as potentially intimidating for already distressed patients.

Watching twenty people physically contain a single individual, I found myself wondering how this had become normal practice.

The core problem, as I see it, is that seclusion often appears poorly suited to de-escalation.

Once a patient is inside a seclusion room, meaningful communication becomes difficult. Doors cannot be opened casually. Staff require support to enter safely. Conversations are often reduced to brief exchanges through reinforced barriers. The intervention creates physical separation at precisely the moment when communication may be most needed.

In practice, this can create a troubling cycle. Distress leads to seclusion. Seclusion limits communication. Reduced communication makes it harder to resolve distress. The result can be prolonged confinement without obvious progress towards recovery.

I repeatedly observed patients remaining in seclusion long after the immediate crisis appeared to have passed. Meals were delivered. The room was cleaned. Patients were engaged by staff. Yet seclusion sometimes continued for days.

This raised a question for me.

If seclusion is intended primarily as a short-term response to immediate risk, what exactly justifies its continuation once that risk has subsided?

My interpretation was often that seclusion had drifted away from its stated purpose. Rather than functioning solely as a measure to manage severe and immediate risk to others, it sometimes appeared to operate as a means of securing compliance or managing behaviour that staff felt unable to address in other ways.

I also encountered situations earlier in my career where patients were secluded primarily because of self-harm risks, despite posing little obvious danger to other people. Whether these decisions were clinically justified in the circumstances, I cannot say. What concerned me was how frequently seclusion seemed to be employed in ways that sat uneasily alongside the legal and policy frameworks I had been taught.

This led me to a broader conclusion.

The problem is not necessarily individual staff members. Most inpatient staff work under extraordinary pressure. They are exposed to violence, distress, trauma, and chronic understaffing. Many receive limited supervision and inadequate organisational support.

Under those conditions, restrictive interventions can begin to feel inevitable.

Much of the criticism I have received for expressing these views has come from inpatient staff. Patients, by contrast, often seem to understand immediately what I am describing. Staff frequently respond by pointing to the most extreme examples of violence and behavioural disturbance. Such cases certainly exist, and they are challenging.

The question, however, is whether those exceptional cases justify the routine use of a practice that may be ineffective, traumatising, and difficult to reconcile with therapeutic aims.

As a healthcare assistant, I believed there was a better way.

As a restraint tutor, I became frustrated by how difficult it was to persuade people that seclusion should genuinely be a last resort.

After ten years spent working, researching, and reflecting on mental health services, I have become increasingly convinced that many behavioural crises are fundamentally crises of communication and relationship.

Patients are often frightened, confused, detached from reality, or struggling with histories of trauma. Staff, meanwhile, are stretched across multiple competing demands and frequently lack the time needed to build meaningful therapeutic relationships.

In such environments, behaviour is managed and contained rather than understood.

My own experiences as a patient reinforced this view.

During my first admission, I was restrained and rapidly tranquillised following verbal aggression and repeated attempts to abscond. During a later admission, I was struck not by the intensity of the intervention but by the relative absence of therapeutic engagement. Many patients received very little meaningful clinical contact. Some were left alone with frightening beliefs and experiences until they eventually reached a crisis point.

When those crises occurred, restrictive interventions often followed.

It seemed to me that attention was directed towards managing the consequences rather than addressing the conditions that had produced them.

This is why I no longer believe seclusion should occupy the central place it currently holds within many inpatient services.

My objection is not primarily moral, although there are moral questions worth asking. Nor is it ideological.

Rather, I have become unconvinced that seclusion consistently achieves what it is supposed to achieve.

There are alternatives. Models such as Safewards have demonstrated that better communication, stronger therapeutic relationships, improved staff training, and carefully designed ward environments can reduce conflict and restrictive interventions significantly.

The challenge is not a lack of evidence.

The challenge is culture.

Restrictive practices become embedded within organisations. Staff inherit them, learn them, and eventually stop questioning them. Under pressure, these practices begin to feel normal and necessary.

My hope is that inpatient psychiatry continues moving towards approaches that place communication, trauma awareness, therapeutic relationships, and human understanding at the centre of care.

If we are serious about helping people through periods of extreme distress, we should be asking not how to confine them more effectively, but how to understand them better.

I discuss my experience of inpatient psychiatry, both as a patient and staff, on my YouTube channel and in my book Androids DO Dream.

When Lived Experience Joined the Ward

Mental health trusts in the United Kingdom increasingly encourage applications from people with lived experience of mental illness. This was already the case in 2014, when I was recovering from my first psychotic episode.

In 2015, I secured a healthcare assistant position on an acute psychiatric admissions ward. The recruitment materials explicitly welcomed applications from people with lived experience, and I entered the role believing that my experiences as a former patient would be viewed positively.

My experience was more complicated than I anticipated.

At interview, I met both the ward manager and a senior manager. As I left, I shook the senior manager's hand. She immediately performed a breakaway technique before I had finished thanking her. I suspect this was simply habit, given her role and training, but the moment stayed with me.

During my induction, I attended the trust's restraint training programme. When asked to introduce ourselves, I explained that I had recently been a patient on a psychiatric intensive care unit and had experienced restraint myself. The lead instructor was supportive and encouraging. Some future colleagues appeared less comfortable with the idea. I was told openly that there was suspicion about my reasons for wanting to work in mental health services.

Whether justified or not, I sensed that my background made some people uneasy.

On my first day, the ward manager offered a piece of advice that I would think about often in the years that followed. He suggested that I should be careful about who I told regarding my previous experiences as a patient because some people might use that information against me.

At the time, I dismissed the warning.

Over the following months, I increasingly felt that I occupied an unusual position. I had been allowed into the psychiatric system as a member of staff, but I never entirely felt accepted within it.

As I became more familiar with ward procedures, I occasionally raised concerns about practices that I believed might warrant review. One instance involved the way a patient's placement was being categorised within the service. Based on my understanding of the relevant policies at the time, I believed there may have been a discrepancy between what was occurring in practice and how it was being documented. I raised the issue through management channels and later with an individual involved in writing the policy itself.

The concern was never discussed with me directly, although the policy was subsequently revised. Whether the two events were related, I cannot say.

I later became involved in delivering restraint training to staff. While I valued the opportunity, my interests increasingly shifted towards communication, de-escalation, and the prevention of restrictive interventions. I often found it difficult to generate enthusiasm for these topics. Staff frequently emphasised the practical realities of ward work and the constraints under which they operated. I came away with the impression that organisational change occurred very slowly, even when there was broad agreement that improvements were desirable.

This became a recurring theme of my time in the service.

I often felt that my suggestions were modest: greater emphasis on communication, careful adherence to policy, and a stronger focus on prevention. Yet I frequently encountered resistance. Whether this was because of my ideas, my background, or the realities of large organisations, I never fully understood.

Eventually, I left the role following a period of deteriorating mental health. Looking back, I believe workplace stress contributed to this, although I recognise that it is difficult to disentangle occupational pressures from my pre-existing vulnerability to mental illness.

A decade later, after completing a PhD and establishing myself as a researcher, I returned to inpatient mental health work.

What struck me most was not how much had changed, but how familiar many of the same tensions felt.

The experience reinforced a conclusion I have reached repeatedly over the years. Mental health services often express a strong commitment to lived experience, and many individuals within those services genuinely value it. At the same time, translating lived experience into meaningful influence appears far more difficult than simply inviting people into the room.

My own experience has been that lived experience is welcomed most readily when it aligns with existing priorities. It becomes more complicated when it challenges assumptions, raises uncomfortable questions, or proposes alternative ways of working.

For that reason, I have become increasingly interested in the gap between the rhetoric of co-production and its implementation in practice.

The question is no longer whether lived experience should be valued. Most organisations now agree that it should.

The more difficult question is what happens when people with lived experience disagree with the system that invited them in.

I discuss these events and issues more on my YouTube channel and in my book, Androids DO Dream.

Speaking Under Suspicion: What People With Schizophrenia Do Well

One observation that struck me throughout my PhD was that much of schizophrenia research is concerned with deficits.

Even in 2026, researchers continue to publish studies showing that people with schizophrenia perform worse than healthy comparison participants on almost every measure imaginable: cognitive flexibility, semantic fluency, spatial reasoning, executive functioning, and many others.

My Google Scholar feed provides a regular reminder of this.

What receives far less attention is how these studies are designed. Most involve extensive battery testing: perhaps a full-scale IQ assessment followed by three to five experimental tasks, each lasting between ten and thirty minutes. Compensation is often modest. Participants may spend several hours completing cognitively demanding assessments in exchange for a £10 voucher that arrives months later after navigating university finance systems.

This raises an obvious question.

People with schizophrenia often experience symptoms such as anhedonia (reduced ability to experience pleasure), alogia (reduced speech output), and avolition (reduced motivation). Experimental testing is tiring even for healthy participants. Is it surprising that people experiencing these symptoms frequently perform worse on lengthy, repetitive tasks?

The problem is not simply that performance differs. It is that poorer performance may reflect multiple factors simultaneously: executive functioning difficulties, fatigue, disengagement, boredom, frustration, or a combination of all four. Separating these influences is rarely straightforward.

Psycholinguistic research faces a similar challenge.

One common method involves asking participants to describe a picture. While convenient for researchers, picture-description tasks bear little resemblance to ordinary conversation. Humans do not generally gather together to describe static images. Yet findings from such tasks are often used to make claims about natural speech and communication.

This longstanding focus on impairment was one of the motivations behind my PhD.

Rather than asking only what people with schizophrenia struggle with, I wanted to understand whether there were areas of preserved or enhanced functioning. In particular, I was interested in linguistic creativity and whether it was related to formal thought disorder (FTD), sometimes called disorganised speech.

The answer turned out to be more nuanced than I expected.

In affective psychoses, particularly mania and bipolar disorder, there does appear to be a relationship between thought disorder and creativity. Mood seems to play an important role. In schizophrenia, however, the relationship is much weaker. The negative symptoms commonly associated with schizophrenia often work against the motivational and affective processes that support creative expression.

This also reinforced another conclusion from my research: the thought disorder seen in schizophrenia is not identical to the thought disorder seen in mania, bipolar disorder, or autism. Similar labels are often applied across conditions, but the linguistic patterns differ considerably.

Much of my thesis therefore focused on what goes wrong with language in schizophrenia because that is where the literature has traditionally directed its attention.

After completing the PhD, however, I became interested in a different question.

What were participants doing well?

To explore this, I revisited my interview corpus using a large language model. Rather than searching for errors, I instructed the model to identify moments where participants were doing linguistically interesting or meaningful things. The model was explicitly instructed not to alter the transcripts, infer information that was not present, or move beyond the data itself.

The results were encouraging.

Throughout the interviews, participants demonstrated humour, recognised irony, played creatively with questions, and occasionally challenged the assumptions built into the interview itself. They displayed many of the same communicative strengths that are rarely discussed within the schizophrenia literature.

One theme appeared repeatedly.

Participants often seemed cautious.

Many appeared reluctant to commit fully to what they were saying. They qualified statements, hesitated, or carefully managed how they presented themselves. My interpretation was not that this reflected pathology alone. Rather, it reflected an awareness of context.

People with schizophrenia often exist in environments where their words are interpreted through assumptions of illness, incompetence, impaired judgement, or diminished capacity. In such circumstances, speaking carries risks. What is said may be analysed, scrutinised, or attributed to symptoms in ways that other people rarely experience.

Viewed from that perspective, caution becomes understandable.

The most important finding from this post-PhD analysis was therefore not that people with schizophrenia possess hidden creative abilities. It was that they retain many ordinary communicative abilities that deficit-focused research rarely acknowledges.

Humour, irony, creativity, self-awareness, and strategic communication were present throughout the corpus. They were simply not the phenomena most researchers were looking for.

The full results of this analysis are available on my ResearchGate profile and in my book How Language Holds: Schizophrenia Beyond Structure.

I Was Told Lived Experience Wasn't Enough

I have a long history with lived experience involvement, which began in 2014.

I was recovering from my first psychotic episode and wanted to use the experience to do some good. My first attempt was to contact TEDx Exeter and offer to give a talk. The reply informed me that TED talks were generally for people who had "achieved something". Today, lived experience talks are commonplace at TEDx events. At the time, however, there was little interest.

Undeterred, I contacted a nearby university's mental health nursing department to ask whether they had opportunities for lived experience speakers. This led to a meeting with a senior lecturer, who introduced me to a community interest company that supplied speakers for nursing education. Through them, I delivered talks to second-year mental health nursing students.

I later found work as a healthcare assistant on an acute psychiatric ward, where I remained for two years. During that time, I also trained as a control and restraint tutor, teaching physical intervention techniques to staff. My growing interest in de-escalation and ward culture eventually led to a conversation with the medical director.

Her advice was simple: lived experience alone would have limited influence within the NHS. If I wanted my ideas to carry weight, I needed credentials.

So I left and began a PhD.

Before doing so, I attended a staff training event that featured recently discharged patients as lived experience speakers. The experience left a lasting impression. The speakers were physically positioned at the centre of a large conference hall and heavily outnumbered by clinical staff. Their suggestions were repeatedly dismissed as unrealistic or impractical. Frustration became increasingly visible, and one participant appeared visibly distressed by the experience.

It was my first encounter with what I would later come to recognise as a recurring problem: people with lived experience were invited into the room, but not necessarily listened to.

A decade later, I had completed my thesis and established myself as a researcher. I had published work, delivered training to psychiatrists and mental health professionals, and begun contributing to academic discussions about schizophrenia and thought disorder.

For the first time, I felt I had escaped the category of "person with lived experience". I was now participating as a researcher.

Or so I thought.

Shortly after completing my PhD, I was invited to an academic conference in Italy focused on thought disorder, the subject of my thesis. I assumed the invitation reflected interest in my research. When I arrived, I was asked whether I could give a brief talk about my experience of psychosis.

Moments before taking the stage, I realised that I had been invited not primarily because of the work I had spent seven years producing, but because I had experienced psychosis many years earlier.

I gave the research presentation I had prepared.

A similar pattern emerged elsewhere.

I joined a multi-year study on thought disorder, assuming I had been recruited as a researcher. Instead, my role centred on providing lived experience input. I remain involved with the project today. While I value the opportunity, I often find myself occupying a curious position: invited into discussions because of my personal experience, while my methodological and theoretical expertise remains largely peripheral.

The same dynamic appeared in another project examining social cognition. I was asked to provide lived experience feedback on a design that used AI-generated images of social situations. My concerns were less about lived experience and more about methodology. Social cognition does not occur in a vacuum; it emerges through interaction. Yet the role I had been assigned was not to critique the research design as a researcher, but to comment on it as someone with lived experience.

Over time, I began to notice a pattern.

The more lived experience became valued within mental health research, the more it seemed to function as a category separate from expertise. Researchers were researchers. People with lived experience were people with lived experience. Individuals who happened to be both were often treated primarily as the latter.

This is not true everywhere.

I currently sit on Bipolar UK's Lived Experience Advisory Panel, which consists largely of individuals with both lived experience and research training. Discussions there are thoughtful and substantive. One outcome of the group's work was a toolkit designed to assess the impact of lived experience involvement itself.

I have also participated in advisory work for Rethink Mental Illness. Some of those experiences, however, reinforced my concerns. In one project, panel members were asked to advise on a public awareness campaign whose core concepts had already been developed. Consultation appeared to occur largely after the important decisions had been made.

This is not uncommon.

Increasingly, I have the impression that organisations are more interested in demonstrating that people with lived experience were consulted than in genuinely sharing power with them. Consultation can become a box-ticking exercise rather than a meaningful collaboration.

That is unfortunate, because meaningful involvement is possible.

In my own PhD, people with lived experience contributed over a period of months. Their feedback directly influenced participant information sheets, consent procedures, research questions, and aspects of study design. Our correspondence was submitted to the ethics committee as part of the approval process, years before such involvement became an expectation.

At the time, I assumed this was normal.

I now suspect it was the exception.

Looking back over the last decade, I am struck by a peculiar irony. When I first wanted to contribute as someone with lived experience, few people were interested. I was encouraged to obtain credentials. By the time I had done so, lived experience had become highly valued, but often in ways that left little room for the expertise I had spent years developing.

The lesson I have taken from this is not that lived experience involvement is unimportant. Quite the opposite.

The challenge is ensuring that involvement means more than presence. Inviting people into the room is easy. Listening to them, sharing authority with them, and recognising the full range of expertise they bring is considerably harder.

Grammar, and Little Else, is at the Core of Formal Thought Disorder

Most of my PhD was spent reading what other people had written about formal thought disorder (FTD). Only near the end, when I analysed my own data, did I discover what it actually showed. Many of the assumptions I had developed over seven years of reading the literature turned out to be wrong.

FTD, sometimes called thought disorder or disorganised speech, is a core symptom of schizophrenia, although it can also be observed in conditions such as mania and autism. Importantly, many of the features associated with FTD can also be found in people with no psychiatric diagnosis.

In the early twentieth century, Emil Kraepelin and Eugen Bleuler were deeply interested in the language and communication difficulties associated with schizophrenia. Both believed schizophrenia reflected an underlying biological disease process and regarded FTD as one of its defining characteristics.

Interest in the phenomenon continued throughout the twentieth century, eventually culminating in the 1970s and 1980s with Nancy Andreasen's Thought, Language and Communication (TLC) Scale. The TLC is a 16-item checklist of speech and communication behaviours that Andreasen considered indicative of thought disorder. Even today, it remains the dominant assessment tool and forms the basis of several later instruments, including the TLI, TALD, KIDDIE and CLANG.

A substantial part of my thesis examined how Andreasen developed the TLC. What surprised me was how much earlier work she discarded. Concepts described by Kraepelin, Bleuler, Cameron, Wing, Kleist and others were removed, while entirely new categories were introduced. In effect, the modern understanding of FTD appears to rest heavily on one psychiatrist's decision to substantially revise the concept. Andreasen's justification was that the discarded phenomena were not commonly observed in her clinical practice. From a methodological perspective, I found that rationale unconvincing.

At the same time, linguists had been relatively quiet on the subject despite FTD being, at least on the surface, a problem of language and communication. One of my first tasks was therefore to compare pre-TLC descriptions with those contained in the TLC and classify them according to linguistic levels.

What exactly did Kraepelin mean by "derailment"? How did that differ from Andreasen's use of the same term? The more I compared historical and modern accounts, the more I realised they were all describing variations of the same four phenomena: grammar, word selection, thought completion, and discourse tracking.

I then set out to test this framework empirically.

I interviewed fifteen people diagnosed with schizophrenia and fourteen people with no self-reported psychiatric history. After transcribing their speech and compiling the material into an open-access corpus, I examined how often these four categories of communication difficulty occurred.

The results were not what I expected.

After years of reading about neologisms, semantic paraphasias, and other supposedly distinctive features of thought disorder, I anticipated finding clear qualitative differences between the groups. Instead, I found remarkably similar patterns. People without schizophrenia also produced grammatical errors, used unusual word choices, abandoned thoughts midway through speaking, and occasionally lost track of the conversational topic.

The difference was not the type of error. It was the frequency.

Participants with schizophrenia displayed these difficulties much more often, and participants diagnosed with FTD displayed them most frequently of all. Rather than revealing a unique language disorder, the data suggested that FTD may represent an amplification of communication difficulties that occur in ordinary speech.

This finding challenged much of what I had learned from the literature. Traditional descriptions often imply that people with FTD produce speech that is fundamentally bizarre or qualitatively different from that of healthy speakers. My data did not support that view.

Instead, I saw people grappling with the same communicative challenges everyone faces, only under much greater difficulty.

This interpretation led me towards the dysexecutive hypothesis of FTD: the idea that thought disorder is primarily rooted in difficulties with executive functioning associated with the prefrontal cortex. I found only limited evidence for the dyssemantic hypothesis, which proposes that semantic processing abnormalities are the primary cause. While some semantic disturbances were present, they were neither common nor severe enough to explain the broader pattern of results.

To explore this further, I conducted a second analysis using semantic classification techniques. This allowed me to measure how far participants moved away from the conversational topic during discussion.

Here I found a different pattern. Participants with schizophrenia referred to emotionally significant and autobiographical topics between sixteen and thirty-two times more often than control participants. Neutral topics were far more likely to trigger personally relevant or emotionally charged associations.

Taken together, these findings suggested that FTD is best understood as both a dysexecutive and dyssemantic phenomenon. The communication difficulties themselves appeared to be driven primarily by executive-function problems, while the tendency to drift towards emotionally salient topics pointed to broader semantic activation.

One finding stood out above all others.

Across the entire dataset, grammatical disturbances were by far the most common form of communication difficulty. This is striking because the literature often emphasises bizarre, flamboyant, or nonsensical speech. That was not what I observed. Most participants were trying hard to communicate clearly. Their difficulties were usually much more mundane: tense agreement errors, disrupted sentence construction, and other problems associated with the mechanics of speech production.

Even years after completing the thesis, I still think about these results.

For more than a century, researchers have often described the language of schizophrenia using highly abstract and sometimes opaque terminology. Yet when we examine what people actually say, the picture appears far less dramatic than terms such as Cameron's "interpenetration of themes" might suggest.

What I found was not evidence of incomprehensible speech, but evidence of ordinary communicative difficulties occurring with extraordinary frequency.

If these findings are correct, clinicians may benefit from paying closer attention to subtle changes in everyday language use, particularly grammatical deterioration, rather than focusing exclusively on the most extreme and obvious manifestations of thought disorder.