Cognitive dissonance is a state of tension that occurs when a person simultaneously holds two cognitions, thoughts or beliefs that are psychologically inconsistent with a person’s behavior. Cognitive dissonance occurs in terms of internal behavior wherein an individual’s thoughts or beliefs are rooted in inconsistency. In terms of dissonance, the psychotic individual may have conflicting views of their internal experience, their experience of auditory hallucinations, and the reality of their experience as stated by their treatment providers.

Psychotic individuals are told that their auditory hallucinations are not real, yet this is counterintuitive to their internal experience. This may be a significant dilemma for the person experiencing psychosis. The experience of hallucinations has a visceral quality that is somewhat similar to sexuality in its immediacy. Auditory hallucinations represent primitive experience, and corresponding delusions are formed almost instinctually. As sexual pathology is extremely difficult to change, so is the thought disorder related to psychosis.

The experience of stigma regarding the psychotic presentation – the outward appearance of being psychotic or mentally ill – can force some psychotic individuals into hiding their experience and delusional beliefs from the external world. Many schizophrenics, and paranoid schizophrenics in particular, fake a presentation of not being mentally ill. In terms of the biopsychosocial model of mental illness, the experience of auditory hallucinations is produced by biological causes and brain chemistry. The experience of stigma – a social phenomenon – drives the psychotic individual into a situation of hiding his mental illness. This results in alienation, or aloneness within the mind, coupled by an emergence of deepening experience of auditory hallucinations. The dissonance between the mental world of the psychotic individual and the external world represents a split view of the internal, mental experience and external reality. It is interesting that we speak of ‘behavioral health’. This connotes putting on a façade of mental health, and the donning of a façade enforced by stigma, creates poor mental health.

People are motivated to reduce dissonance by changing a belief or rationalizing. The mentally ill often try to prove that their auditory hallucinations are ‘real’, thus attempting to counteract the experience of stigma and seeking validation. They seek to prove to others that entities are speaking to them in their minds. The sense of rejection and alienation that they endure as a consequence, results in further rejection and alienation.

There is the possibility that the psychotic person may refrain from making a judgment about their psychotic experience. However, this will lead to a state of no knowledge about an experience that may be threatening in terms of its presentation. A nonepistemological assertion that one has no knowledge about knowledge can lead one to not making a judgment about auditory hallucinations, but the possibility of living in the world with this assertive stance may not be feasible. This may be the case simply because no knowledge about knowledge is frightening, perhaps more frightening than one’s delusions.

Psychotic experience and the condition of being mentally ill is ego-dystonic. It violates the psychotic individual’s self concept, and it is incompatible with their self-identity. This type of conflict is perpetual in that mental illness is chronic and episodic at best. The knowledge of stigma and attempts to combat it are somewhat encouraging. However, the problem of psychosis – as a biopsychsocial phenomenon – renders it a condition that is cyclic in terms of its course, and the prognosis is therefore poor.

It is clear that cognitive dissonance operates in the minds of the psychotic individuals. Some examples of the conditions in which the psychotic individual may deal effectively with their cognitive dissonance are as follows:

• When people have some expertise in the area
• When people understand the bias

While the delusions of psychotic people may seen to be intractable, psychoeducation may ameliorate some of the cognitive dissonance that contributes to their psychotic ideation. Nevertheless, telling someone that their very convincing experience of ‘others’ talking to them in their mind is hallucinatory is like telling them the color they are observing to be red is really the color blue. The visceral qualities of hallucinations may leave psychotic individuals in what seems to be a permanent state of cognitive dissonance between internal experience and internal reality.

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