What Role Does Talk Therapy Have in Recovery from Psychosis?

Ron Unger, LCSW
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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.

16 COMMENTS

  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”

    • “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

  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.

  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

  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

  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.