By Ron Unger, LCSW
It’s now widely known that a good relationship between helper and person to be helped is one of the very most important factors determining the outcome from many different types of mental health treatment.
But when people are in an extreme state such as the kind we call “psychosis,” forming a good relationship is not an easy thing to do.
And unfortunately, the typical interaction between professionals and clients seen as psychotic in our current mental health system has characteristics which make a positive human relationship almost impossible. To start with, rather than starting from a place of equality, where two people negotiate to see each other and to define reality, the professional holds onto a position of assumed superiority and declares himself or herself as able to define both the other person and the overall nature of reality, without any need to reconcile that view with the viewpoint of the “psychotic” person. This makes sense within the standard paradigm, as once a person’s mental process is defined as “psychotic” it is understood to be determined by illness, and to be senseless, with nothing of any value to offer.
While taking this position allows to professional to feel comfortably secure and affirms the professional’s “grip on reality,” the person defined as psychotic now feels forced to choose between either digging in and insisting on the validity of his or her own experience (and so appearing to the professional as “lacking insight into their illness”) or joining with the professional in defining their own experience and mental process as invalid and sick, and in attempting to suppress it.
Unfortunately, it typically doesn’t work very well for people to define their own mental process as invalid or sick or psychotic: this is likely to set off what Eleanor Longden calls a “psychic civil war” where the person attempts to suppress aspects of their own mental process, which in turn fight back: this fighting can intensify distress and can last a lifetime if no resolution is found, if no peacemaking is attempted.
In other words, when we define people as definitely mentally ill, or “psychotic” in a way that has no possible redeeming value, we frame things such that the only way a person can form a good relationship with us is to turn against significant parts of themselves and of their own process.
Under such circumstances, true dialogue, in which the experience of the professional meets the full experience of the other, is impossible. It is only when we professionals accept and communicate the uncertainty of our own position, which includes uncertainty about what truly is “illness” or “psychosis,” that we can engage people in conversations which are sufficiently non-polarized as to allow exploring options for mutual improved understanding and perhaps mutual recovery from our difficulties and misunderstandings.
Professionals of course gain their identity by virtue of being defined as “knowing something” and so it can be quite difficult for them to imagine that their “knowledge” may be incorrect! Yet without being able to imagine this possibility, professionals become incompetent at really dialoging with people in extreme states about their experiences and understandings.
What we call “psychosis” often involves the radical rejection or dropping away of established ways of making sense, and then experimentation with often unconsciously produced alternative ways of making sense. If we look at the natural history of madness, we see this can lead to both disaster and to the emergence of new visions that can be helpful or even possibly “save the world” as Paris Williams recently proposed. Learning how to stay with the uncertainty can also lead to a mystical or transcendent state, as I’ve written about in an earlier article “Distinguishing Mysticism from Psychosis: Is That the Wrong Idea?” In that article, I touched on how it was my own discovery of how to be radically uncertain about both what I and what others claimed to know that allowed me to find balance in relationship to my own extreme process and perspectives that I experienced as a young man.
So is it possible for professionals and other helpers learn to take a position of radical uncertainty, while also continuing to be curious and to be continually learning and avoiding being so uncertain that they are simply ignorant?
I definitely believe the answer is yes! Within more progressive practices ranging from Open Dialogue to CBT for Psychosis, and certainly within any truly “peer” intervention, there is awareness of the need to be uncertain, and to explore with others what might possibly be going on rather than insisting on the helper’s own conclusions as correct. This doesn’t mean coming into the interaction with a sense of “knowing nothing” but rather of holding one’s own knowledge in a provisional way, being open to the possibility that much of it may only be half truths or that it will look very different once a wider context, a wider story, is understood.
Consider a case where the “patient” says that he has become convinced by his voices that his parent is an alien. Following standard procedures, the clinician will conclude simply that the patient is hallucinating, or hearing something that isn’t present, and delusional, or believing something that is totally untrue. There will be no conversation exploring for any possible truth in what is being expressed. And yet, what the patient is hearing is at least in some sense “present” within the person’s mental process, and so the person is hearing something that is “present” and that might have valuable messages to convey if listened to in the right way. And what exactly might it mean to say that the parent is an alien? An exploration of this assertion might uncover ways the patient has become alienated from the parent, or perhaps something else of real significance.
Just the other day,a client of mine expressed fear that the government could monitor where he was in his house, from outside his house or even by flying overhead. I was tempted to see this as a “delusional” fear because I thought this was impossible, but instead we talked about how my client had decided it was possible: it turned out that my client was being realistic and it was my belief that was “delusional” because technology does indeed exist to allow such monitoring. Of course, it is often the case that our client’s claims instead lack much independent backing, but even then it can be interesting to inquire into what makes them seem to our client to be true, and be open to the idea that in some cases minority viewpoints may be partly or entirely correct while “consensus” views are not.
If you are interested in further exploration of how to practice in this sort of way, I encourage you to join me for the next ISPS online meeting/webinar, which will happen on Friday, 7/24/15, at noon EDT (that’s 9 AM for those of us on the West Coast). I’ll be presenting on “Admitting Uncertainty about “Illness” and “Reality”: A Key Step Toward Dialogue” and following my presentation of about ½ hour there will be question/answer and discussion. I hope everyone who attends will go away with an understanding of how to better set the stage for healing by “knowing less!” These meetings are free to ISPS members, with a donation of $5-$20 requested from others, though you can also sign up if you can’t or don’t want to donate. Please do register if you want to attend, at https://admittinguncertainty.eventbrite.com
Here’s an excerpt from the description for that webinar:
“This presentation will draw on ideas from the Hearing Voices Movement, CBT for psychosis, Open Dialogue, and from various spiritual traditions as well as personal stories and experiences in order to highlight the value of dialogues that transcend certainty, and to identify practical ways to do this even when talking with someone whose experience is extremely different, disturbing and/or apparently dangerous. We will explore ways use such dialogue to find positive value at times in psychotic experiences as well as to cope with distressing aspects. In the process of letting go of our own certainty in this way, we can model for the person we are helping how they might let go a bit of their own certainty, allowing us to meet in a way that is squarely centered in our mutual fallible humanity, a great starting place!”
Ron Unger is a therapist and educator specializing in cognitive therapy for psychosis, Ron Unger explores emerging understandings of psychosis and of efforts to change mental health treatment to support human rights and full recovery. Visit his blog here: Recovery From Schizophrenia and Other Psychotic Disorders