Hugh: A few weeks ago you told me that working with clients who’ve been diagnosed as psychotic is changing how you practice. What does that look like?
Ann: I’m kind of amazed about it myself, really. I’ve been seeing one client – I’ll call him Richard – for about four years. He was hospitalized during a “psychotic” episode – having severe panic attacks that included terrifying hallucinations that made it impossible for him to function at home or at work. After getting discharged from the hospital, he returned to therapy. At first he was suspicious and very guarded, and I reacted by being distant with him. Still, we managed to talk about what was going on between us. During these conversations, which were awkward and difficult for both of us, we discovered that we were both disappointed about his breakdown, especially since he had been doing well during the time we had worked together.
Hugh: Did you explore what you each meant by being “disappointed?” I would guess that it was different for each of you.
Ann: Yeah. I told him that I was disappointed in myself —-if I were a better therapist, he wouldn’t have had a breakdown – so in fact I was thinking more about me than about him. And he said he was disappointed in himself for not being a better patient and letting me down – and in that way relating to me as an authority figure who was sitting in judgment over him. Talking openly to each other, difficult as it was, brought us much closer. And that’s what we’ve continued to do.
Hugh: Sounds like it’s not just what you’re talking about, but how you’re talking,that’s changed.
Ann: Right. I came to see that doing well, experiencing yourself as growing – as Richard had been doing during the time he was in therapy with me – can be unsettling, even disorienting. But I had never asked him how he was doing with being better. So I decided that I needed to be more curious and less “therapeutic” – with him.
Hugh: How do you mean?
Ann: I’m asking him questions about how he sees and understands things, without assuming that I know. It allows him to be more open with me, and it gives both of us a way to explore and even play with his “philosophy of life,” his history, his ways of understanding and being in the world. Talking in this way has helped us to discover that his psychosis is part of his day-to-day life, ordinary, something that he usually manages but sometimes can’t. So in those moments, rather than be controlled or overwhelmed by them, he now recognizes that he can make emotional choices.
Hugh: I’m very touched by what you’re saying. Most of the time patients who’ve been diagnosed as psychotic are too ashamed or too scared to even talk about it – and with good reason. They’re afraid that they’ll be ostracized or get locked up in a hospital. And therapists often find it frightening to get close to psychosis, both because it’s so painful to be intimate with that level of suffering and because they might not know what to do, or how to help. These days “talk therapy” is rarely viewed as a serious option for people with psychotic experiences, despite there being a distinguished tradition of practitioners who’ve helped such people through therapeutic work.
Ann: What’s been your experience in working with people who’ve been identified as psychotic because they hear voices, or have delusions, or exhibit other recognized symptoms?
Hugh: I’ve worked in both inpatient hospital settings and in community outpatient clinics, as well as in my social therapy practice with people who were severely emotionally distressed. One of the things that’s been most striking to me is that people may be psychotic, but it’s not all of who they are.
Ann: Meaning?
Hugh: Well, like all of us, they’re not reducible to just one characteristic. They may have a sense of humor, they may like to watch cooking shows, they may love their dog, they may work in some high-powered corporate setting or be a beloved teacher…psychotic is not all of who they are, nor are they psychotic all the time or in all contexts. I think it’s important to demand that our clients create the therapy with us – the way you’re doing with Richard. People with psychotic experiences are typically related to as passive. Practitioners are taught that the client’s job is to report his or her symptoms and that our job, as the “experts,” is to do something to treat them.
Ann: It can be hard to undo some of the ways that a psychiatric diagnosis affects people, don’t you think? We human beings are so much more complex and multi-dimensional.
Hugh: Yes, and it’s really important, in my opinion, to remember that that’s as true of people who are said to be psychotic as anyone else.
Ann: I’m going to be talking about this work — and what we’re touching on with the therapeutic relationship — to colleagues at the annual meeting of the International Society for Psychological and Social Approaches to Psychosis. Thanks for your input!
Hugh: You’re welcome!