Psychosis can present a real challenge to therapists working with the condition. Here are nine theoretical perspectives to help. They are alternatives to the standard brain disease perspective. I don’t mention that theory here, because most of you know the dopamine brain disease theory for psychosis already. None of these perspectives is intended to be “anti psychiatry.” They are instead meant to be practical ways to overcome clear issues that are unique to working with people with psychosis.
From years of knowing them and working with them, these are some of the best alternative ways of thinking about people with psychosis I could offer.
Perspective one: Generously Validating
How do we validate a person with psychosis? What do you say to a client who tells you they can influence history by concentration upon certain television characters? For one we can do so on the basis that it sounds interesting. ‘Really?! Which characters? What historical events? I want to know more.’
Secondly we could analyze our own consciousness for a bit of non-ordinary thinking. Some very common thought patterns do not line up with conventional reality. For example, did you ever have Living La Vida Loca stuck in your head? I did. Or back in the 80s, True Blue, Thriller, or Back In Black? Ever believe someone was talking about you and they weren’t? Ever think someone cut you off on purpose, only to find out they didn’t? What’s that about?
Connecting with those experiences can help us relate to the psychotic experiencer a little more. It can take some of the potential alienation out of an interaction where we simply feel we cannot personally relate in any way whatsoever to what the person in front of us is saying.
Analyzing our dream life could be another way. In dreams we pass uninhibited into the ether. Is the psychotic experiencer not stuck in a dream, halfway in his own unconscious, and halfway in conventional reality? Maybe the psychotic mind overlays basic reality with more of its own production-house of effects. Can we use some of the psychoanalytic tools of dream interpretation to make a little more sense of the psychotic experience?
Perspective two: Symbolic Significance
In this section, I propose a possible symbolic interpretation of a client’s expressions as an example. Note that the particular interpretation I use is not meant to be determinative in any way. It is just one of many ideas that could be used in the situation. The use of symbols in the interaction is also where the therapist’s reflections about what a client says become more influential. It’s a creative process, based on associating in our own minds, what we ‘see’ in the images conjured by clients, through expressions such as dreams or drawings.
To implement this perspective, we could look at the many granular details of the psychotic client’s descriptions, leaving nothing out, and noting their potential symbolic value. This can help with case formulations, or notes for direction in future sessions.
One of Jung’s students once supposedly asked him, “’My patient told me she went to the moon in her sleep last night. What should I do?’ And Jung apparently answered, ‘She went to the moon. Proceed based on that.’”
A long time ago, I was presenting a short talk on yoga in front of a small crowd of schizophrenic clients, their families and a nurse, gathered for a class I was teaching. A young fellow stood up and abruptly and asked me for the flip chart marker I was using, which I resisted before handing it over. He proceeded to draw what he called his invention- an, “engineering breakthrough,” he said. The crowd watched him and I expectantly for about three minutes. He defined its edges with the black marker efficiently. No one spoke. (note: generous validation was helpful in surrendering the flipchart marker to him).
When he was done, he turned around and smiled proudly.
He called his drawing a wedge that could be used for various construction projects. From a symbolic perspective, it’s rich. I began to entertain the idea that he had indeed created an advanced construction tool. He believed on some level that he had. I wanted to hear his truth…
This wedge was an important idea to him, beyond just its monetary value. I looked up ‘the wedge’ afterwards, and was curious to learn that wedges are considered one of the six classical, simple machines, with a vast impact on human progress. This confirmed that discussing his invention on that level could well make for a productive session. How was it made? What applications did he have in mind for it? Where did he get the idea for it? Why was it so revolutionary? Amazing!
Furthermore, could the wedge be a primal, psychic image of some sort? If the image he had drawn showed up in a dream, what fundamental ideas could it be expressing? The wedge is an important tool for the real world, but wedges might also sometimes be helpful to our psychology. A wedge might help people with the extremely common but difficult psychotherapeutic goal of creating boundaries. Was an interpersonal boundary the kind of wedge the young man was trying to draw out?
Some of the things the client said next confirmed this inference. Certain details emerged. I then asked what other important ideas might be encapsulated in the client’s drawing? I noticed then that the drawing he made of his wedge could have easily been mistaken for a kind of diagram of a human vagina- the kind associated with an aspect of the universal feminine archetype. What he talked about next lent credence to the idea.
(Again, [please don’t take this as an assertion of what I know was going on. It’s just one possibility in a rich field of symbolic referents, employed in a psychoanalytic dynamic).
As he referenced the diagram he had drawn, the young man talked about his mother. According to him, the wedge was going to help resolve some problems he was having with her, including financial ones. He was dependent on his mom, and he said that she was controlling his fate by frivolously locking him up in psychiatric units. She did other disturbing things to him, related to his challenges with mental health. For instance she worked hard to make sure no one believed him and that she undermined the potential success of his wedge invention.
His views upon the wedge and my own associations with the image, potentially revealed a tectonic energy-system at work: from a symbolic perspective, the young man may have been grappling with and trying to grasp the universal feminine, the mysteries about the female organ itself, and perhaps be released from the overpowering figure of his mom.
How could this interpretation have helped? It can be very tricky- even for perfectly sane young men- by necessity to outgrow their mothers. Often, people meet a partner in their early adult years that enables the individual to leave the childhood home. For someone with psychosis, this is much less likely to have happened in the normal timeframe. Mom often won’t let go either, creating powerful biosocial feedback loops. Seeing mother and wedge as unique symbols added explanatory power to what could have been an ongoing case formulation. I think it is also fair to say that psychoanalytic concepts like archetypes and the unconscious mind are indispensable to this perspective.
These symbolic interpretations could help a therapist contextualize what might otherwise seem like nonsensical, haphazard ideas, expressed by a person with psychosis. Symbols add structure to the work with psychosis, a condition deeply affected by an apparent lack of order. The ideas came from working with the symbols he presented, what he said, my own reflections, and investigating unconscious elements within them.
Perspective three: The Sudden Loss of Conventional Cultural Perspective.
The young man and many others like him have convinced me that psychosis is not just an illness. Under the spell of psychosis, conventional use of language disintegrates in varying degrees. Seeing symbolic structure in psychosis appears to reveal a language all its own, associated with the sudden, extremely uncomfortable collapse of conventional norms inherent in everyday language.
From this perspective, the assumptions, body-language-conventions and symbols embedded in normal use of language are weakened in the mind of the psychotic experiencer, causing all kinds of issues for therapists trying to relate to them.
Perhaps it’s more accurate to state that psychosis is a dialect. This dialect may be precisely part of the construct of psychosis. Thus working with psychotic people on how they speak from only a place of behavioural appropriateness, may be ineffective at times.
I believe that if we can see past our own conventional-cultural-linguistic limitations as a practice, the psychotic can suddenly sound a little friendlier, a little more relatable, a little more interesting, a little easier to follow.
Perspective four: Anti-Oppressive
This is the social justice perspective. As I’ve said many times in the past, psychotic experiencers’ fate would change overnight if people in the West just started to treat them with radical respect and kindness, rather than fear. By radical, I mean all the way, with our full bodies and minds. Also with gratitude. As if what they said mattered. To truly undo the stigma around being psychotic, we have to start treating such people- and their experiences- with the dignity and respect we do anyone else. More so, as they’ve been oppressed so strongly for so long.
Perspective five: Annihilation, Phenomenology and the End of Mind Body Dualism.
In the essay, “Shattered Worlds/ Psychotic States: A Post Cartesian View of The Experience of Personal Annihilation,” George Atwood introduces the idea that psychosis is a destruction of the self. This destruction is the central experience, and the consequent symptoms seen in psychosis, such as believing oneself to be a famous person reincarnated, are the compensatory measures taken by a psyche that believes itself to no longer exist. (It’s supposed to sound mind-blowing!):
One of the most dramatic consequences of adopting a consistently phenomenological, post-Cartesian viewpoint, is the opening up of the most severe ranges of psychological disorder- the so-called psychoses- to psychoanalytic understanding and treatment. This opening occurs because the experiences that characterize these psychological disturbances tend to cluster around themes of personal annihilation and the destruction of the world. Such experiences occur outside the horizon of Cartesian systems of thought, which rest on a vision of the mind as an isolated existent, that stands in relation to a stable, external reality. The Cartesian image of mind, rigidly separating an internal mental subject from an externally real object, reifies and universalizes a very specific pattern of experience, centering around an enduringly stable sense of personal selfhood, that is felt as distinct and separate from a world outside. Experiences of extreme self-loss [psychosis] and the disintegration of the world cannot be conceptualized within such an ontology of mind, because they dissolve the very structures this ontology posits as universally constitutive of personal existence (Atwood, Orange, Stolorow, 2002. file:///Users/paulgalloro/Downloads/shattered_worlds_psychotic_states.pdf).
From this perspective, psychosis disintegrates the very system of thought therapists often use to understand the condition. This system is often a set of clinical assumptions informed by the idea that individuals are self-contained subjects interacting with an objective world of reality. This worldview, Atood states, has been annihilated in psychosis, along with the self as we think of it. Thus, conventional Western, individualist assumptions are of much less value to the therapeutic process with a psychotic experiencer.
Annihilation provides explanatory power to some of the commonest psychotic beliefs, such as that individuals or groups of powerful people are deliberately maligning them- the young man with his mother, for example. It is also very common for psychotic clients to believe large police efforts are directed at them. Within the personal annihilation model, such behaviour is viewed as an attempt at a solution to reverse annihilation by bolstering a fantastic identity.
The phenomenology of Atwood’s perspective, “takes as its central focus, the world of experience of the individual, understood in its own terms and without reference to an external, objective reality (Atwood, 2002).” I use this challenging perspective often when speaking to psychotics. It helps me feel confident, helps me work with their families, and often leads to more grounded, productive sessions.
There are fundamental basic questions the psychotic mind is often dealing with, however unconsciously, that it can help to ask ourselves as well: “Am I here? Do I exist? How do I know I am here or that I exist? How does anybody know we are here, and that we exist?”
Perspective six: Abram Hoffer’s Perspective.
I have been surrounded by psychotic experiencers my whole life. I thus inevitably came across the work of Abram Hoffer. Hoffer’s approach is biomedical. He was a scientist, and published prolifically. Though he discusses brain theory, he departs from what has become the status quo version significantly. The status quo brain theory is related to the idea that psychosis results from excess dopamine. We derived this idea largely by applying hindsight into how antipsychotics work in the brain to reduce symptoms.
Hoffer took a different tact. He found that schizophrenia was based on a chemical imbalance in the brain, however his work focused on adrenochrome imbalance rather than dopamine. He postulated that a chronic overabundance of adrenaline-like compounds were behind some of schizophrenia’s most troubling symptoms.
This idea is important, because it links psychosis back to trauma, and the cascade of chemical changes that occur when we have stressors that we cannot escape. Disturbances in the ’hypothalamus-pituitary-adrenal axis,” a powerful brain-body system, alters how we manage stress. I have noticed that psychotic experiencers have often been exposed to extensive trauma, often during developmental years, and that they have extremely low tolerance for stress. To me, Hoffer’s biology seems to dovetail well with what we know about trauma.
Hoffer observed a structural similarity in chemistry between compounds like mescaline (that cause intense hallucinations) and adrenochrome. He then chose Niacin (vitamin B3) as his main intervention, based on Hoffer’s astute observation that severe niacin deficiency- a condition called pellagra- was nearly identical to the symptoms of schizophrenia.
Hoffer conducted at least six, randomized controlled trials that showed results, and tons more have been done since with niacin for psychosis. This is especially hopeful for sufferers, who often turn to such remedies, when conventional medicine takes them only so far. A great place to start in this direction is the following article: (Hoffer, 2008. http://www.altmedrev.com/archive/publications/13/4/287.pdf).
Why is this perspective important to psychotherapists?
Hoffer’s work bears discussion on the basis of it’s published, scientific findings alone. Orthomolecular medicine, basically invented by Hoffer, remains a rich field of academic study, with particular hope shed upon chronic mental health conditions like psychosis, studied over lengthy periods of time, using compounds that are nontoxic. There are very serious side effects from long term use of drugs like quetiapine, such as parkinsonism. Niacin seems to help prevent some of these.
Hoffer created tons of clues and leads within the mystery of psychosis. In doing so, he created hope, and I believe this hope can be spread to therapists who work with psychotic experiencers. Also, since the orthomolecular perspective on psychosis is consistent with other neurochemical frameworks about chronic stress and trauma, psychotherapists can with some degree of confidence, explore clients’ pasts for trauma. From this perspective, psychosis possesses similarities to dissociation- as an adaptive mechanism resulting from severe mistreatment, invalidation and abuse.
Perspective seven: Psychoanalyst Jacques Lacan
Lacan’s discussions of psychosis were reflective of an attempt to listen to the whole history of the individual sufferer. His doctoral thesis on a woman he had treated, Aimee, included her own rich history of the events in her life. She had lived with extreme pain and isolation. Lacan listened.
In just one small example, the client’s mother had lost a son tragically while pregnant with Aimee- the boy fell into a furnace and burned to death. Furthermore, Aimee’s onset of psychosis really began when one of her own pregnancies ended in a stillbirth. She was later hospitalized by her parents, and spent years in institutions, isolated and withdrawn. Listening to the whole story is key to this perspective.
In the Lacanian conception of consciousness, paranoia plays a central role. It is not considered abnormal. Lacan did not believe that we can achieve a state of permanent lasting wholeness,, since our ego is in part defined by the others around us. Since we can never fully know what others are thinking about or feeling towards us, paranoia is natural, even a fundamental building block of normal consciousness.
Relating to the inherent inability for any of us to know exactly what others are thinking about us, and the ways in which that causes natural paranoia, can enable greater depths of empathy for the psychotic client.
Perspective eight: Psychosis As Non-Ordinary Experience:
Non-ordinary experiences is a term coined by Stan Grof. Grof used it to describe psychedelic as well as psychotic experiences. Grof later used the term for the state of mind created when we engage in specific breathing techniques. In that sense, non-ordinary includes things like dreams, normal experiences of intoxication, and what yogis refer to as ‘prana.’
Psychedelic experiencers report deep psychic disintegration during trips, which resolve in creative ways upon “coming down.” Sometimes, a new platform of experience ensues by which the individual inhabits previously unavailable parts of themselves- for example when deep feelings of well-being and trust redevelop spontaneously during psychedelic-assisted psychotherapy. Does psychosis embody some of these elements of the non-ordinary experience?
Early scientific research into psychedelics was in fact based on various researcher’s attempts to understand psychosis. Applying the term ‘non-ordinary’ to psychosis enables therapists to view the psychotic experiencer with even more respect, based as the term is on a rich field of academic, psychotherapeutic study. To me, the term non-ordinary entails an acknowledgment of the variations in consciousness that nature seems to create.
Perspective nine: Shamanistic Perspectives
I saw someone at a mental health event once, standing in front of a booth for the Schizophrenia Society. Figuring it might be openly acknowledged by now, I noted how it seemed helpful to read that some indigenous people see schizophrenia as a gift.
The lady asked, “Really? How so?”
I said, “The experiencer is treated with high regard, as the voices they hear, the things they see that others don’t, were sometimes considered important messages.”
“Ahhh, um. The spiritual dimension, I believe,” I answered.
She looked at me like I had four heads, and that each one had dissociative identity disorder.
“Schizophrenia is a brain disease…” she said, we both smiled, and I walked away.
The shamanistic perspective, which has been unified as a theory by Joseph Polimeni, is the single most evolutionary perspective:
In its simplest form, the shamanistic theory of schizophrenia says that people with schizophrenia are the modern manifestation of prehistoric tribal shamans. In other words, the inborn cognitive factors or personality style that would have predisposed certain people to become shamans is the same psychological mindset that underlies schizophrenia. Although the idea is straightforward, a proper evaluation of the hypothesis is complicated and must take into account the latest discoveries from psychiatry, medical history, evolutionary science, anthropology, psychology, religious studies and genetics. The primary purpose of this book is to put forward a contemporary version of the shamanistic theory of schizophrenia (Shamans Among Us, 2012, http://josephpolimeni.com/excerpts.html).
If it helps, Polemni is a psychiatrist who takes pains to explain how the shamanistic theory of schizophrenia is not anti-psychiatry. Instead, it attempts to explain a confluence of symptoms that, although very troubling, do not correspond to a notable illness, such as how depression can be explained from a disease perspective:
Other common psychiatric illnesses have some sort of rational explanation within reach. Depression appears to have something to do with mammalian expressions of submission, while anxiety is connected to fear and fleeing. Obsessive-compulsiveness may be linked to overly persistent habits… In contrast, schizophrenia is not an obvious extension of any other behaviour and has no tangible analogue in nature. The motor and sensory systems have gone awry but not in a haphazard or unsystematic way. Clear patterns exist but are inexplicable in the context of twenty-first century life…The resemblance of schizophrenia to the ancient institution of shamanism surpasses coincidence.
The shamanistic theory involves incorporation of evolutionary psychology, fascinating unto itself. Polemni states that schizophrenia used to provide an evolutionary advantage to a group reliant on hunting or farming. They were ‘the seers,’of a community, which at about the dawn of the industrial revolution, became unnecessary to the social order.
I hope you have enjoyed these perspectives.