Understanding and Working With Psychosis (Part II of II)

by Joel Schwartz, PsyD

Note: Presented cases are composites of various individuals, with significant details changed to maintain confidentiality.

In Part I of this series, we looked at contributions to the understanding of psychosis from a humanistic and psychoanalytic perspective. In summary, psychosis was conceptualized as an extreme version of two normal processes that lead to human bonding and psychological growth:

1. Reification of complex and often horrific and chaotic feelings into comprehensible delusions and hallucinations, and

2. An Anti-Learning drive within the psyche responsible for making room for new learning; the breakdown of associative links can be seen in thought disorder of psychotic individuals, but also represents a severing of empathetic and relational links.

Within this conceptualization, we also brought up Carl Jung’s idea of Metanoia – that psychosis is a breakdown of the mind in order to re-emerge in a more functional manner, much like a Phoenix being reborn from flames.

The outcome of viewing psychosis from this perspective is that conditions like schizophrenia are not a process of disease, but a process of severing and re-growth. Indeed, cultures around the world that do not rely on modern conceptualizations and over-use of medications show much better quality of life and recovery – yes recovery! – of people with psychotic conditions.

So how does one treat psychosis from a humanistic perspective? What does the above theory suggest as a manner of concrete interventions?

First and foremost, if psychosis is indeed a process of growth and reorganization following an initial breakdown, then the primary task of the therapist is not to cure or prevent the psychosis in the person, but accompany them through their transition into something else. Accompanying means creating an environment of warmth and acceptance regardless of the anger, rage, and hatred often being expressed by the psychotic person. It can be important to temper one’s warmth somewhat, as too many emotions from the therapist can be experienced as overwhelming by the psychotic person. With more severe clients, this may take the form of parallel play. Drawing, singing, writing, praying along side them. This initial process can take months.

When psychotic individuals are met with skepticism or fear, or when well-meaning therapists insist on psychotic individuals returning to rational reality, or when family members express hostility at the psychotic individual’s strange perceptions and thoughts, it almost guarantees that the person will retreat farther into their psychosis, or worse, try to harm self or others.(most of the time to self – it is a stigmatizing myth the psychotic people are dangerous) Almost any therapist who has directly challenged a delusion has been met with rage, suicidality, withdrawal, or the client lying that they are no longer delusional.

So the first step in working with the psychotic individual is to get to know the person’s psychosis – begin to understand the person’s reifications. There is ALWAYS method to the madness. Often, reifications are emotionally similar to personally experienced traumas, the legacy of cultural or generational traumas, and/or intense emotionality felt on the non-verbal level. An example of the latter: A client who grew up with a father who intensely hated him. The father would try to do fatherly things and be there for the family, but was constantly pouring unacknowledged and unexpressed hatred into the family system. This emotional turmoil was felt by the sensitive child growing up. And as a young Jewish man, he began to hallucinate Nazis from which he had to protect other family members. Interestingly, he never had to protect his father from the Nazi hallucinations; they were a reification of the father’s hatred.

Instead of trying to convince this client that the Nazis were his imagination, we got to know the soldiers. I validated the horror of living Nazis. We put faces and names to the soldiers, did research into World War II, and expressed rage at racial hatred that exists in the world in myriad ways. Eventually, through this and family therapy, the hallucinations stopped and now the client dreams of being a civil rights attorney.

A key aspect in working with reifications is to pay attention to the emotional content of the hallucinations and delusions, instead of the actual content. It is very much like doing dream work. Sometimes clues can be found by developing an understanding of what stressors trigger a flight into psychosis. Is it abandonment? Assault? Racism? Next, it is important to validate the reality of the emotional experience, even in the psychotic person pushes back (remember, Anti-Learning often takes the form of breaking relational links too).

Another key to this is to not be frightened of the client’s subjective world. It is always easier to journey into the underworld and lead someone out than try to pull someone out from above. It takes the ability to hold two realities at once.

Once trust has been established, one can begin to build bridges between the psychotic reality and reality generally understood by non-psychotic individuals. This takes a lot of care and finesse, as the moment the therapist betrays skepticism is the moment the client withdraws. I had another client who was a victim of incest and would begin to see demons and conspiracies whenever a male would grandstand to her. I would say something to the effect of “There really are monsters everywhere in the world. It is so frightening. You’ve been fighting monsters since you were a child in that house.” In this way, I am linking the client’s trauma and intense emotions directly to the psychosis, hopefully creating a little wiggle room in the rigid reification.

Another example: A severely neglected client who developed the delusion that a famous actor was in love with them – “It must feel so good to be adored like that. Given what your parents put you through, you could use all the love you can get!”

More often than not, these bridges will be burned right away. Even the most empathetic statement will be met with denials of the empathy and flat out ignoring the link to non-psychotic reality. But a seed will have been planted, and scaffolding will have been built. Every time I’ve done this, the idea has re-emerged, sometimes months later as if it is an original thought of the client’s.

Another way to help with re-learning is through gentle interpretations that make complex emotions more manageable. An example frequently cited by a friend and mentor, Brent Potter, is “sometimes love and hate go together.” This gentle interpretation links a chaotic emotional experience into something shared and comprehensible.

Above all trust your clients. Recognize that they are going through something meaningful, shedding old selves that no longer work in order to make room for the new. Accompanying clients through psychosis is harrowing, but highly rewarding work.

More related: Healing psychosis: stories, information and resources

Joel Schwartz, PsyD treats people, not disorders. He aims to re-humanize the mental health profession. He says, “I treat people, not isolated symptom patterns or disorders. All symptoms occur in the unique context of a person’s history, temperament, experiences, and capabilities. I am a warm and compassionate therapist that goes the extra distance to sit with and humanize what others may be afraid of or view as not in the “norm.” I help people who desire to really know themselves, to understand their thoughts, feelings, and behaviors in order to make the life that is best for them. My orientation is primarily relational psychoanalytic psychotherapy, but I have a firm grounding in cognitive behavioral techniques and borrow from humanistic and existential traditions. I am a sex-positive, pro LGBT therapist in the South Bay of Southern CA.” see profile here