What Role Does Talk Therapy Have in Recovery from Psychosis?

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The current treatment model for the mental difficulties called “psychosis” is deeply flawed, and is quite likely to traumatize people, define them as permanently defective, and create dependence on drugs that lead to physical and mental problems, including increased psychosis in the long term.

Fortunately, a number of alternatives have been proposed, tested, and proven more effective. Unfortunately though, the more intensive models are very difficult to get started within a community, as they require substantial investments and institutional support. I’m speaking of options like Open Dialogue, or Soteria or Diabasis.  It makes sense to continue pushing for these kinds of programs, but in the meantime, it may be essential to find other ways to start truly helping people right now.

Other proposed alternatives are easier to organize, but have their own limitations. Hearing Voices groups for example can be liberating and empowering, but many people with psychotic experiences are simply unwilling to attend a group. Peer support specialists can reach some people, but many who might need help don’t know about, or trust, the idea of turning to a peer specialist for help.

Talk therapy also has important limitations. It requires that people believe in the process enough to meet and work with a counselor, and that they be organized enough to make it to regular appointments. It also requires that people have enough support to somehow handle things out in the community in between appointments. There can be problems with the real or perceived power imbalance between professional and client. So, it certainly is not an option for everyone diagnosed with a “psychotic disorder.” But many people struggling with “psychotic” experiences are able to engage in and benefit from this approach, so it makes sense to offer it more widely.

I work as a therapist (aka counselor), and I specialize in helping people who are experiencing, or have experienced, “psychosis.” I know that I fail to help many people, when for example I can’t quite convince them to really engage, or maybe I fail to tune into what they uniquely need, or their lives spin out of control before any work we might do together takes hold, and they are perhaps hospitalized or just lose touch. But I also watch others gradually learn skills in handling their mental states, and they redefine their “symptoms” to be just experiences and part of their functioning that they can manage; worries, imagination, past trauma, etc. They gradually realize they can do things like have friends, lovers, jobs, or at least interesting activities in the world. This usually happens while they at least reduce, or sometimes get off, the psychiatric drugs that formerly had been proposed as forever essential.

Therapy of course is only likely to be helpful when the therapist can relate as a fellow human being with the person they are trying to help. That means taking the time to understand “psychotic” experiences as possibly making sense in the context of the person’s life history, and relatable to more everyday experiences rather than categorically different.  It also means seeing hope for the person to have the potential for eventually overcoming any “psychosis” related disability, or any ongoing need for drug treatment.

One barrier to therapists providing this kind of approach is simply lack of appropriate training. In my graduate education, we were taught how to deal with a wide variety of human troubles — but one big exception was psychosis! For that, we were told to send our clients to the psychiatrist. For those most alienated from other people, it seemed, help from another human being was not to be provided.

I’ve made it a primary mission in my life to change that, and to make education about how to be an effective therapist for people experiencing psychosis widely available.

One thing I’ve done to accomplish that objective is to create online courses that anyone can take to learn enough to get started in providing effective therapy for psychosis. The two courses are CBT for Psychosis: An Individualized, Recovery Oriented Approach, and Working with Trauma, Dissociation, and Psychosis: CBT and Other Approaches to Understanding and Recovery. People with lived experience or their family members can take these courses for free, and professionals can take them for CE credit with a discount that is being offered until 3/29/17.

I want to stress again that I understand that even competent therapy is not going to reach everyone, and I also know that less professional approaches can often accomplish things that therapy cannot. That’s why I also volunteer to co-facilitate a Hearing Voices group, and I helped organize a peer support specialist program at the agency where I work. And I also understand that many people will benefit, or perhaps only benefit, from approaches that are much more systemic than outpatient therapy or counseling. That’s why I continue to support initiatives like Open Dialogue, so we can move toward having a mental health system that supports recovery in a fully integrated way.

One analogy: working within the system as a therapist is kind of like working on the underground railroad, helping at least some people escape oppression!  To be more specific, the oppression people with psychotic difficulties face is actually two sided — both the oppression of confused and disorganized mental states, and the oppression caused by conventional, heavily flawed mental health “help.” Therapists can help some people find an escape route, but like people assisting on the underground railroad, they will see many others still caught in oppression and be unable to help until more systemic changes are put into place.

In the long run, we need a society with less child abuse and bullying, so that much “psychosis” will be prevented. We need to change our whole culture’s understanding of madness, so that people with psychotic experiences will find more understanding and less medicalizing and shunning.  We need a mental health system where everyone involved works to empower people to believe in themselves — one that provides real help, instead of causing people to see themselves as broken and forever reliant on destructive drugs.  But until we get all those things, we do need more  “underground railroad” therapists who can make an important difference for at least some people, and I hope some of you reading this will be inspired to begin, or to persist, in this line of work.

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Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.

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16 COMMENTS

    • Well, most grand visions are pretty hard to put into practice, and do require a lot of luck. but every now and again, progress does happen! Getting even some people to change their understanding then opens doors that some people slip through, even though the masses may still be stuck. Civil rights work did change social attitudes around racism some, even though it’s still a huge problem. So, maybe work for change, but don’t hold your breath?

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      • Thank you so much for your article and your work.
        I trained in psychiatry, psychoanalysists and crisis intervention. We discovered that it was possible to run psychiatric units in a mental hospital in Denver, a general hospital in Edmonton and teach at a Canadian university.
        But it never lasted! People thought that drugs and ECT were faster and cheaper, and we could see the revolving door beginning with huge profits for psychiatry and the drug companies.
        Remember Ogden Nash: Candys dandy
        But liquors quicker.
        Psychotherapy is slower but it can prevent lifetimes of expense and suffering.
        I don’t know CBT, but I found that shutting up and listening to people, especially psychotics, usually allowed us to get in touch with each other and for healing to occur
        Also our health insurance program in Ontario allowed us to finish the therapy beautifully.
        It’s hard to understand why people aren’t interested in this.
        I can send you some papers I have written on this.
        [email protected]

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        • Hi Ed, thanks for your comments. I agree with you that it’s very unfortunate that more people aren’t interested in really relating to people with “psychotic” experiences. I think our culture, and especially those in charge, want everything to be easily understandable and digestible, with appropriate boxes for everything – so a model that puts a label on people and then matches them with the appropriate pill is much more comprehensible than one that says there might be meaning and something worth listening to in even “crazy” talk!

          Fortunately there are at least some who are interested in this kind of psychological work. If you haven’t already, I suggest you check out ISPS, the international society for psychological and social approaches for psychosis. the US chapter’s website is http://isps-us.org/ and they will be having a conference in Portland OR this November.

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  1. RE “One barrier to therapists providing this kind of approach is simply lack of appropriate training.”

    The only appropriate training is to have lived it yourself (psychosis) but good luck if you lived it yourself getting certified by the deeply entrenched education mafia as being qualified. Education mafias hoops and loops and rules and games good luck with that.

    What do you mean we need change ? “That’s the way we always done it”

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    • “The only appropriate training is to have lived it yourself (psychosis) but good luck if you lived it yourself getting certified by the deeply entrenched education mafia as being qualified.”

      I think there are records and personal experiences of people being helped by those who have not been through the kind of distress that gets labelled as psychosis. However I recently went to a conference on Peer Supported Open Dialogue where it was said that the peer supporters, who were trained and integral parts of the teams, often said the most helpful things to the clients as they had indeed been through it themselves. I suspect there position of training people who have been through psychosis and of employing them as equals is unusual. It does give me hope though.

      As a gay men I find the company of other supportive gay men means a lot more to me than anyone else, no matter how much they try to understand, but I wouldn’t completely right off non gay people when they offer support to me. I think it is likely to be the same for madness

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      • I agree with your points John. I’m in favor of noticing all the ways people can possibly be helped, and even when one way seems “better” I want to stay curious about how it may only be better in some circumstances and not others.

        It would be great to see mental health systems start seeing lived experience of psychosis as a plus rather than a minus for all mental health positions! At the same time, I hope we keep paying attention to all the factors that are involved in truly being helpful, and notice how it is indeed possible for people with lived experience to be unhelpful, and vice versa (and also having lived experience of some kind of “madness” is not the same as having lived experience of exactly what someone else is going through – we can notice similarities, but it is never the same.)

        And I think it helps to understand that we are all a bit mad, and for professionals who haven’t been overtly “psychotic” to still talk about their crazier experiences, perceptions, doubts, etc. As humans we are all peers in not being quite sure what true sanity is, and being on a turbulent quest to figure out what that might be. If we can meet on that dimension, their is hope for us.

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  2. “For that, we were told to send our clients to the psychiatrist. For those most alienated from other people, it seemed, help from another human being was not to be provided.”

    Psychiatrists are human beings! However, the help they deliver will typically be in pill form. That must be what Mr. Unger meant. Bertram Karon, a psychologist (professor emeritus) at Michigan State U, wrote

    “There has never been a lack of treatments that do more harm than good. They have in common that they do not require understanding the human condition.”

    http://www.examiningmedicine.com/the-tragedy-of-schizophrenia-without-psychotherapy-bertram-karon-ph-d-html-version/

    He doesn’t believe there is a “genetic component.”

    “I have never treated a schizophrenic patient whose life as experienced by the patient would not have driven me, or anyone I could conceive of, crazy.”

    http://healingwithdrcraig.com/video-films-radio/schizophrenia-is-a-chronic-terror-syndrome-not-genetic-dr-bertram-karons-acceptance-speech-for-empathic-therapist-award/

    Mainly, he listens.

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    • Yes, I guess I could have said that better – I meant that people are sent to psychiatrists not to receive understanding, human connection, and exploring together, but rather just to receive pills, as you guessed.

      Bertram Karon is certainly one of the more important people in the history of therapy for psychosis! He wrote the book “Psychotherapy of Schizophrenia: The Treatment of Choice” and did research showing that experienced and motivated therapists could get better results with therapy and no drugs than conventional treatment could get with drugs. A recorded webinar with Bertram is available at http://isps-us.org/webinars.php (bottom of the page)

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  3. Wonderful! I was a psychotherapist for 50 years and accidentally, with help from a gifted supervisor, discovered that it was possible to learn to listen to and understand a psychotic patient. This was in London in the 1960s where it wasn’t uncommon for therapists to attempt this work.
    My patient became well with 4 years of daily insight oriented therapy. My supervisor, Dr Donald Winnicott , postulated that he’d developed a false self in group settings when his parents were away during the war.
    Dr Winnicott taught me to look for the true self in myself and others, and I’m sure that this helped us to run psychiatric units in the mental hospital in Denver without the use of drugs. Unfortunately, though, politics and administrations changed and drugs were thought to be quicker and cheaper and our units were disbanded.
    And so the lucrative revolving door began.
    After being a professor at a Canadian university for a few years I gave up on psychiatry and did private practice in Ottawa where health insurance covered open ended psychotherapy, and this began the most interesting last 20 years of my career.
    I had several patients who had gone for help but had had psychotic symptoms and so were deemed to have biological, genetic disorders that required physical treatments and repeated hospitalizations. This trapped them for life…..but having the luxury of being paid to listen to them allowed us the opportunity to discover the childhood trauma that had led to the psychosis, and then eventually to recovery, good health and ability to help others.
    I thought that this would be good news to the psychiatric and psychoanalytic groups to which I belonged, but they didn’t want to hear it. I even, wrongly, thought the media might be interested since health care is so expensive for Canada that other vital services are being squeezed. Our prisons and streets and cemeteries are being filled with the mentally unwell.
    I have been indirectly in touch with Canada’s health minister about this and she and the government are offering the provinces extra money for mental health issues, but if it’s used to stifle the voices of the suffering….
    I will try to write a short, simple article for the Canadian medical association journal about this, although my writings have been ignored.
    Science classifies things, but we have made a huge mistake to think we can classify distressed people into slots and drug them into silence, instead of helping the to sort out who they are and what has happened to them.
    Edward Childe BSc MD

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  4. Hi Ron
    I expect you’re also well aware of “Acceptance and Commitment Therapy (aka modern CBT) and Mindfulness for Psychosis” – text here http://au.wiley.com/WileyCDA/WileyTitle/productCd-1119950791.html and another recent text “Incorporating Acceptance and Mindfulness into the Treatment of Psychosis – Current Trends and Future Directions” https://global.oup.com/academic/product/incorporating-acceptance-and-mindfulness-into-the-treatment-of-psychosis-9780199997213?cc=au&lang=en&
    Warm wishes, Rob Purssey, psychiatrist and ACT therapist, Brisbane Australia

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    • Yes, I’ve followed the thinking and strategies used in Acceptance and Commitment Therapy, and I use some of it. I wouldn’t though frame it as “modern CBT” but just a new “wave” of thinking and practice, sometimes bringing in genuinely new and helpful stuff, and sometimes only managing to sound new because of the way it distorts discussion of what came before, and sometimes even a bit shallow and not so helpful!

      Anyone interested in more about my thoughts on this might want to check out an earlier post of mine, “Acceptance and Commitment Therapy for Psychosis: A Valuable Contribution Despite Major Flaws” at https://www.madinamerica.com/2013/09/acceptance-commitment-therapy-psychosis-highly-valuable-contribution-despite-major-flaws/

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      • Dear Ron

        My apologies – I should have been more respectful, and written a “modern form of CBT”. I just read your prior post, and commented – which of course won’t actually be read but there it is! The idea that we should not seek to understand and use the content of our thoughts and feelings is not actually integral within ACT, sometimes doing so can be extraordinarily helpful, and sometimes doing so can have us spinning in wheels which are not so terribly helpful – it is the workability in helping us live a life more fully and richly which matters of course. It is quite true that ACT takes good deal from “traditional CBT”, and also true that it differs in significant and fundamental ways from “traditional CBT”, particularly the strategy/philosophy of science underpinnings clearly articulated – functional contextualism – and the reticulated strategy from basic to applied and across fields. In any case thank you so much for your valuable work.
        Warm wishes, robpurssey

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  5. Talking about recovery, as in ‘recovering from psychosis’, still implies that the person has some kind of an affliction, as opposed to the fact that they live in an abusive and unjust world.

    So the most important thing to do if one is experiencing anything like psychosis, is to tell any therapists where they should stick it.

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