Supporting those who have unusual experiences including psychosis

In the Americas and Europe, medical doctors trained in psychiatry make reference to a list of symptoms to guide their opinion on how to diagnose a person with a medically recognized label in DSM V or ICD-11. Some people find it helpful to frame their experiences as a recognisable illness in the hope that this clarifies their experiences, that they are not alone with their symptoms and that there is hope for understanding and for life to improve in quality.

Others may understandably not like being labelled in this way, especially with negative wording such as ‘illness’, ‘disorder’ or ‘psychiatric diagnosis’. With many diagnoses, including psychoses and schizophrenia, these presentations are being re-diagnosed through a trauma-informed lens, for example, schizophrenia is being reconsidered now, in PTSD terms. Psychosis is defined in DSM V as when a person has unusual thoughts and perceptions, in relation to delusions, hallucinations and paranoia.

What are the needs of people who experience psychosis in therapy?

There are sensitivities for all people in therapy and meeting and starting to talk to someone about our thoughts and feelings, especially when feeling stressed and unsettled, is really very daunting. Individuals with psychosis get turned away from therapist after therapist, who don’t feel equipped to manage the person’s situation as it is perceived.

Where does this perception arise from? Perhaps media presentations but also perhaps due to a lack of knowledge and experience of being with people who experience psychosis. It breaks my heart that individuals who suffer exponentially with delusions, hallucinations and paranoia gain the courage to reach out for therapeutic help, and are rejected repeatedly. 

A need for someone experiencing psychosis would presumably be to be welcomed into a therapeutic safe and confidential space where their situation can be explored collaboratively, non-judgementally and securely. These words are not superficial but values that need to be instilled consistently and reliably to gradually help the person feel a sense of alliance and trust with the therapist. Trust can be established and maintained by the therapist by being genuine, consistently supportive, and predictable.

The person suffering from psychosis is dealing not only with the therapeutic dialogue but often hearing persecutory voices, commanding them to do harm to themselves and/or others. The therapist needs to be understanding of psychotic phenomena and to be able to manage changing conversations about different disturbing mind states. Additionally, there is often a second or third difficulty to consider such as OCD and/or depression. 

What are helpful interventions for people experiencing psychosis in therapy?

As mentioned previously, establishing an immediate positive rapport with individuals is paramount but one where it is clear what the therapeutic framework is, with clear boundaries discussed and maintained. People experiencing psychosis, share their thoughts and feelings very readily which is helpful to hear about and to think to understand how to best help as a therapist with the individual’s best interests at the heart of the work. 

However, this lack of a boundary between the internal and eternal world can render the person very vulnerable with confusing thoughts and feelings and can point to issues about self and identity to work through. A consistent and reliable therapy time and setting offers the start of stability and familiarity. Everybody has a normal aspect to their personality and connecting with this part of the person and building on the relationship henceforth, is often fruitful in therapy.

When a person presents chaotically, listening closely to the gist of what is being communicated both verbally and non-verbally can be very useful for gauging what is going on and gently reflecting a thought back can help the person to feel seen and heard and can help with a growing sense of containment. 

Individuals who experience psychosis often talk with me about finding it difficult to manage their changing emotions and I work, often using cognitive behaviour therapy interventions to help bring to awareness or highlight the link between their thoughts, feelings, actions (behaviours) and bodily sensations. It can be helpful to think about the person’s core beliefs about themselves over time and to clarify alternative beliefs.

Being an integrative therapist trained in a number of modalities, it can further be helpful to work with interpersonal therapy interventions such as thinking about the relationships in the person’s life and drawing these out on paper as a focus of the therapeutic work together. Often, the person is surprised by how many people are in fact in their lives and it can be useful to discuss each relationship to clarify whether each is helpful or not to maintain in their life and how.       

There are so many ways that people who experience unusual experiences and/or psychosis are very similar to everyone else and normalising such thoughts, feelings actions and bodily sensations is frequently very concerning for the individual who may feel very marginalised, isolated and downhearted.

It is very important that people who have unusual experiences and/or psychosis start to engage with other people, whether through a day centre, faith setting, support group or interest group. Often, ideas in the minds of individuals who experience psychosis, can reverberate or escalate if not checked with other’s perspectives, for a sense of groundedness.

Of course, self-harming and suicidal thoughts and plans need to be discussed in a professional, frank and matter-of-fact manner to assess for risk and appropriate guidance and actions taken, and always as much as possible in a collaborative way, to safeguard the working alliance and therapeutic relationship. Self-harm and suicidality need to be explored in detail but in a well-paced and consistent manner and thought about reflectively rather than reactively.

In sum, the therapist working with individuals who experience psychosis needs to be informed and think about delusions, hallucinations and paranoia, to be able to offer an understanding of the nuanced sensitivities of this population. Being appropriately curious about the person’s thoughts and feelings expresses interest and value but the paranoid structure needs to be observed and reflected on to intervene about fears with caution and care.

Working on psychiatric wards for men and women is the best way to get to know acute states of mind and for me, it has been fascinating listening to people’s experiences on wards. I hope that this article may have offered some initial signposts to ways of working with people with psychosis. There is so much more to say but perhaps this would need to wait for another time.