The king of heavy metal proves to be too much for cognitive therapy.
By JP Sutherland
When I first became a psychiatrist, I did not expect to have Ozzy Osbourne as my patient so often. I saw most of Ozzy during the early 2000s, at a time when he not only continued to tour with his band, but was also starring with his family in the TV reality show The Osbournes. And it was likely this surfeit of public attention that brought him to me repeatedly. So repeatedly in fact that on one memorable occasion there were three separate Ozzy Osbournes on the inpatient psychiatry unit where I worked.
In case there is any doubt about that first paragraph (or in case lawyers of the great man’s estate are reading this) I should spell it out that I am not writing about John Michael Osbourne, founder of Black Sabbath, and for long considered the king of heavy metal, but about patients suffering from the delusion that they are him. Hence the multiple individuals with the same issue, and hence the increased likelihood of meeting them at a time when his name was so frequently in the public eye.
Although he had always looked somewhat like a metalhead, he had now adopted the characteristic dark round glasses and necklace of his hero, and did actually resemble Ozzy a little.
The first of our triad of Ozzies was really Steve. I knew him from a previous admission to our ward, and knew that he suffered from schizophrenia. Mental illness had derailed his life as a teenager, leading him to drop out of college, and he now lived in sheltered accommodation, and appeared to have adjusted to his disability. He was an active volunteer with the local schizophrenia society and as long as he continued his medication, he managed to avoid the delusions and hallucinations that had previously hospitalized him. He had always been a heavy metal fan, and liked Ozzy’s work in particular, but none of his previous delusions had been anything like this. Although he had always looked somewhat like a metalhead, he had now adopted the characteristic dark round glasses and necklace of his hero, and did actually resemble Ozzy a little. His relapse had come from inadvertently stopping his medication, and we were confident that he would recover once we reengaged him into treatment.
Delusions appear as extraordinary things to people who haven’t seen them before, yet after working as a psychiatrist for all these years I have seen so many that they merely represent yet another day at the office. However, I am reminded of their strangeness when I see the open-eyed wonder in the medical students who work with me, and who go home from their first days on a psychiatry ward to tell colleagues about the mind-blowing things that they’ve seen. Their wonder is easy to understand, but then we need to make sure that their reaction gets channeled into a compassionate wish to help the delusional, rather than the instinctive reaction of many people to laugh at them.
The more common delusions tend to be about persecution, such as believing that the FBI is following you, and that every car that slows slightly as it passes you is proof that it really is the FBI, no matter how much your friends and family may tell you that it isn’t. But however dramatic and frustrating these delusions are, they are nothing to the sheer impossibility in others’ eyes of delusions of personal identity. Believing that your identity has changed is unusual even for someone with schizophrenia, and yet it does happen, often enough that three Ozzies are possible on the same psychiatry ward at the same time.
It is one of the varied functions of a psychiatry ward to provide this safe asylum from the outside world, allowing some illnesses to resolve on their own, given time, support and withdrawal from whatever led to their problems.
Our second Ozzy was not previously known to us, but had arrived at his delusion in another way, that allows its own path to recovery. Thomas was a heavy user of cocaine and methamphetamine, two drugs that not only provide a high (and then take their terrible toll on the individual’s life, and function, and family) but can also in a minority of users lead to delusions. A particularly potent supply of cocaine from a new dealer had led Thomas to the delusional belief that he was Ozzy. He then started accosting strangers downtown and offering them autographs (in return for money), which brought him to the police’s attention, and so in turn to us. His delusion was likely to settle if we could just keep him safely away from the drugs, and it is one of the varied functions of a psychiatry ward to provide this safe asylum from the outside world, allowing some illnesses to resolve on their own, given time, support and withdrawal from whatever led to their problems.
In most cases we can offer release from the delusions that so distress people and impair them. In those with an ongoing mental illness our mainstay of treatment is using antipsychotic medication, which blocks the action of a single chemical in the brain, dopamine, and leads to recovery from the delusions in about two thirds of patients taking these medications. Yet psychiatry is a medical specialty that works not just through medications, but also via psychotherapies (or ‘talking therapies’) and by making what changes we can to a person’s environment that will help them. This is the tripartite mantra of ‘BioPsychoSocial’ that we instill in all our trainees, and try to live by professionally.
For many psychiatric disorders, such as depression, it is wonderful to have such a three-pronged approach available. Someone’s depressive illness may respond to cognitive therapy, or increased amounts of support, or to changing their brain chemistry with antidepressants. But there are some disorders that respond mostly to only one of the three modes of treatment, and for schizophrenia (and delusions more generally) it is biological treatment with medications that makes the most difference. However, at the time I was working with the three Ozzies, there was a move to make cognitive therapy more central to the treatment of delusions.
Normally we would say that a delusion is defined as a fixed, false belief, and so by definition it wouldn’t change if you try to debate or argue about the truth of it with someone. But we’ve always known that the definition isn’t quite watertight, and for some people it is possible to lessen their delusion by discussing how likely it is to be true. The downside of this tends to be that although you can sometimes reduce the intensity of the delusion while you sit with a patient and discuss it, when you go away their certainty of belief tends to recover, and then you start at the same point again the next day. But cognitive therapy takes the process a step further.
Merely telling someone that their delusion is not true is not only unlikely to work, but may also damage any therapeutic alliance that has been carefully developed. But if we can find any evidence against the delusion, and particularly if we can persuade our patient to look for evidence themselves, then the chances of cognitive therapy having an effect are increased. The presence of three separate Ozzies allowed an opportunity for this, since if one of them could see how bizarre the others appeared, then it might shake their belief in their own delusion.
Our third Ozzy was not so fortunate as the others, not that anyone with a delusion can ever be considered lucky. Jeremy also had a diagnosis of schizophrenia, but about a third of people suffering from the disorder don’t respond to our medications, and have to struggle with life despite ongoing hallucinations and delusions. The job of those of us working in mental health is then to try and help people adjust to this long-term disability and minimize what problems we can. We knew Jeremy from previous admissions to hospital and knew that his schizophrenia was sadly treatment-resistant. He had never previously shown much interest in Ozzy or his music, but a friend had recently introduced him to The Osbournes on TV. Jeremy had become a regular viewer of the show, and had gradually developed this new delusion, in addition to his ongoing beliefs about how his phone was bugged, and people were listening to him through the walls of his apartment.
Three patients sharing the same delusion, in the same mental health facility at one time, may sound like an extraordinary event, and it is. Yet it is not so uncommon that others haven’t noticed it and written about it. Will Ferguson based his novel ‘The Shoe on the Roof’ about three individuals all believing that they were Jesus, and Milton Rokeach wrote about a similar situation in ‘The Three Christs of Ypsilanti’. Rokeach was an academic psychologist describing a real situation, whereas Ferguson was a famous humorist writing fiction, and yet the academic treatise reads almost like a novel, and has a story that was transformed into a movie.
Both of these books describe how healthcare staff had extraordinary freedom to manipulate their patients’ lives. Ferguson has all three patients fraudulently discharged from hospital into the care of a medical student, who then made them confront each other about their identities while sharing his apartment. Rokeach was also making each of his patients address each other’s delusions, but he went further still, inventing for one individual a fictional wife who wrote him letters with the aim of trying to ground him in an existence other than being Christ. There is a terrible irony in using one falsehood to try and address another, and twenty years after he published his work Rokeach wrote a regretful note lamenting his manipulation, and realizing how he may have been unethical. This is a stark reminder about what power and control psychiatrists and psychologists had over people’s lives in the past. It also makes me think about how much more constrained and ethical we are in our practice now, even if we still have enormous authority to detain people in hospital and even sometimes treat them against their will.
“I’m only here because the police are idiots and brought me, and because you are too stupid to see the truth when it’s in front of you.”
Neither Rokeach’s nor Ferguson’s descriptions demonstrated much benefit to the patients’ delusions from meeting each other and discussing their beliefs, so maybe I ought to have been more wary of trying a cognitive therapy approach. But I was keen to see if the latest research on the subject would bear fruit, and so I went ahead, though with a much less heavy-handed approach than described by the others. I first approached Thomas, our cocaine-induced Ozzy, and asked politely if he had met the other patients on the ward. His answer was that he wasn’t talking to anyone else, and he was wholly absorbed in listening to all of his (meaning Ozzy’s) back catalogue on his iPod. And when I suggested that he might try to socialize and maybe even meet someone who shared his interests he put his headphones back on and ignored me.
Steve, who had been my patient before, was at least ready to talk, and appeared keen to meet me each day. The problem here was that he not only had the delusions that come with schizophrenia, but he also suffered from the difficulty with thought process that can be part of the disorder. These issues are unusual, and many people find them hard to understand. ‘Thought process’ describes the way that someone’s thoughts run on from one subject to the next. Most people have likely never given it much attention, because normally it just proceeds logically from one subject to the next, and they focus on the detail of what is being discussed rather than how the speaker got from one subject to another. However, in mental illness this process can go wrong, and it goes wrong differently in different disorders. This means that psychiatrists spend some of our time analyzing the thought process to help us make diagnoses. In the thought process of schizophrenia people wander off subject, and sometimes jump subjects altogether, but without any understandable pattern being detectable. And so it was when I asked Steve about the other Ozzies on the unit, and before his risperidone medication had kicked in.
“Have you noticed other people here who are also fans of Ozzie Osbourne?” I asked.
“The guy with the big headphones likes ‘Blizzard of Ozz‘ best but has bass interest in having supper soon, and I’m thinking baldly about Sunday…”
When talking with someone who suffers from a serious thought process problem it is natural to feel confused by the chaos. Pink Floyd sang that “… if the band you’re in starts playing different tunes, I’ll see you on the dark side of the moon.” That has long stood as a metaphor for mental illness in general, but I think it applies even more so as a description of how it feels to listen to someone such as Steve, because there do seem to be different tunes in the same sentence. His thought disorder was fairly major, and disruptive to any meaningful conversation. But although cognitive therapy wasn’t looking that promising under the circumstances, I pressed on regardless.
“Have you noticed if he is just a fan or actually might think the same way as you about Ozzy?”
“Ozzmosis is best because the title under guitar reading blows away three get outside for a smoke.”
I would repeatedly try and bring him back to the subject, but inevitably he would wander off again in his thought process. Once someone has thought disorder this badly, it’s impossible to get a coherent answer to almost any question, and there isn’t too much to do in an interview other than maintain what rapport one can, and watch for any signs of improvement or deterioration. Giving up on cognitive therapy, I checked Steve’s medication regime, and sat back to allow risperidone to help him recover as it usually would over a week or two.
Jeremy, our third Ozzy, was someone I was particularly hoping to help with cognitive therapy, since medication-based treatment had been unsuccessful in the past, and was therefore unlikely to be helpful now. I had seen him talking to the others, so I knew he was aware of them, and I also knew that his thought process was not affected by what was otherwise a severe and untreatable schizophrenia. So I asked him about the others, only to be to be told that they were obviously mentally ill in his opinion, and any belief they had about Ozzy Osbourne was delusional.
“Yes,” I said, hoping to use this line of thinking further, “but if they appear delusional because of their beliefs, do you think that you might appear delusional to others when you talk about being Ozzy?”
He looked at me as if addressing a particularly slow student (and he’s not the first patient of mine to do this) and said with a sigh “But the difference is that I really am Ozzy Osbourne.”
Unable to take no for an answer I continued, “You see, they might have been admitted to a psychiatry ward because of their beliefs, and yet here you are as well…”
But he finally silenced me with an answer that proved I was not going to get anywhere.
“I’m only here because the police are idiots and brought me, and because you are too stupid to see the truth when it’s in front of you.”
So, the promise of cognitive therapy for schizophrenia faded for me. Others have continued to use it, and I keep trying, but with only very occasional moments of success. Our medications helped Steve as expected, and the withdrawal from cocaine let Thomas recover, allowing both to be discharged from hospital. And even Jeremy settled down and was dischargeable back to his group home, but without ever losing his new delusion.
After all three patients had left, one of my wittier students (who was also a keen soccer fan) summed up the whole process with his typically pithy comment.
“Final score – Cognitive Therapy 0, Ozzy Osbourne 3.”
All names and other identifying details have been changed to protect patient confidentiality.
JP Sutherland 