When a person has a break from reality, others often feel a sense of urgency. Most people think that if this does not get treated with antipsychotic medication immediately, grave and progressive brain damage will ensue. Friends and loved ones may fear that this is the beginning of degenerative process that will leave the person shuffling between institutions and poverty for the rest of their life.
This article is written for the loving supporter or social worker. It invites you to learn about the world of your loved one. My hope is that it will help you gain strategies for how to handle the relationship with someone experiencing psychosis.
The State’s Social Control Model
When you think about the public mental health system, images of crowded psychiatric emergency rooms, violent police restraints, rapid tranquilization needle sticks, jail time, or substandard warehousing barracks may come to mind.
These are all realities of the system. They are mechanisms of the state. These realities either neglect the person in the break or set them up to be forced back into consensus reality. It can become a punitive and damaging process.
Ultimately, I view the goal of the state as enforcing social control, not healing and recovery. It can become about saving money or making the afflicted impotent. It can become about endless submission, silence, and the perpetuation of lies.
There are times when the social control model does help a person improve their behavior. Improving one’s behavior can help a person minimize their risk of escalations of trauma via social punishment. It can be better than nothing. Sometimes, people can learn lessons from abuse, improve their circumstances, and even heal.
Efficacy of the State’s Social Control Model
Still, in America, state social control that guides behavioral change has a low efficacy in terms of promoting recovery. It’s more a part of the problem than the solution. Even of the people who receive early intervention treatment for psychosis, only 42% have a response classified as “good.” And studies in developing countries show higher recovery rates than developed countries! Could it be that state social control is still part of the picture?
Social myths and stereotypes leave many people thinking that degenerative decline is to be expected if schizophrenia is left untreated—when actually it can be the result of treatment. When such social myths are maintained, it can seem like social control is the only option to prevent a horrible outcome.
Still, as I suggested above, stints of incarceration can result in an increase in compliance with consensus reality. However, they also reinforce the idea that it is unsafe to talk about what is happening. In many cases, the follow-up homelessness or warehousing can be so hard that incarceration starts to look better. Throughout all such “treatment,” exhibitions of psychosis are systematically shut down rather than explored. Many go through this process and give up hope of ever working through their experiences with other people.
In this culture, when incarceration and trauma happen, all is not lost. As someone who went through a three-month incarceration that left me outraged, I believe we can learn healing alternatives instead of nurse-ratcheting up social control. Ultimately the fear of returning to dilapidated and neglectful situations did help me conform. I eventually found that with medication I could get better jobs and more quickly restore my social standing. However, it was a two-year process, and I feel like I barely got through. And the night terrors were bad!
And so, I believe that “healing” is not the most likely result of forcible social control.
Few Approach Psychosis in a Curious Manner
To promote healing instead of social control, I believe it is important to understand, normalize, and navigate the break. This doesn’t happen often enough in the system because most people are too afraid to be curious about psychosis.
Society doesn’t understand, and so neither do our psychologists and social workers! Mental health professionals are forced to do the work with little guidance. I was once one of them. Many are untrained interns/workers, and their managers may not be curious about psychosis.
Who is trained to be curious? None of my supervisors ever were. Many I work with question my tactics. There are few organized trainings for being curious about psychosis. Even if professionals are trained to work with psychosis, they may not be able to listen in a validating matter. Invalidating body language can trigger their loved one and they can conclude it is not worth it.
It is very hard to offer treatment when a person is incarcerated against their will and feels betrayed by the people who put them there. Curiosity about psychosis is imperative to initiating voluntary treatment. People who learn alternative ways and grow like flowers through the concrete cracks are so often marginalized.
Meanwhile, the basic myths are maintained. Most are trained not to reinforce the delusions. Others fear they will catch the disease if they listen. Still others fear retraumatizing the respondent and making them angry. Then they do because their fear is apparent.
There are ways around that—by validating the experience of psychosis, so keep reading.
Why Do We Choose Social Control over Healing?
There are several reasons that “treatment” via social control is so vastly promoted in the United States.
There is a very poor, medicalized understanding of what psychosis is. Unproven theories about the biomedical basis of psychosis—like the chemical imbalance myth, studies that find a tiny, clinically insignificant connection with genetics, and dubious, poorly conducted twin studies from 50 years ago—are all represented in the media as if they somehow explain psychosis as a medical condition.
If someone starts talking openly about hearing voices or referencing beliefs about being targeted or enlightened, the average person will flee or mock them. This translates into ridicule, social rejection, and pain—and couple that with the state’s aggressive treatments.
Too many people in the state and the public invalidate the trauma that ensues when social control measures occur. So many people feel it is justified. The state’s goal is simple: spend as little money on the victim as possible, tranquilize or imprison them, get them to fill unskilled labor markets, and don’t let them speak out against our cultural delusions. At least, that’s what I must conclude after a three-month hospitalization in a state hospital.
It can feel like there is not much left for loved ones and good social workers to do besides support the effort to socially control the person they love and wait and see if they will recover.
Some Basic Alternatives to Social Control
In order to promote healing from psychosis, it becomes very important to become uniquely adept at listening, validating, and contributing without getting confused, combative, or dissociated. Asking the right kinds of questions—being curious about any conspiracies the person expresses, rather than trying to argue against them—helps the person realize they are not alone. Trust building is very important.
It’s also important to assist your loved one in adhering to the requirements of work or making it possible for them to continue to socially network and have a social life. As L.A. psychiatrist Mark Ragins suggested in a CASRA keynote speech, work, or building relationships (to which I’d include studying spiritual traditions) are ways to teach us social skills, not incarceration.
Indeed, research in the United States behind Dartmouth’s IPS (Individualized Placement Services) model of vocational rehab suggests that a self-directed effort to conform to work with support is a real way to achieve behavioral benchmarks.
In the IPS model, a job is provided until the subject fails, and then another job is found and maintained until it is lost. Keeping the person moving through the job situation and adhering to social dictates until they can master the needed behaviors to keep a job has been shown by research to be the way to go. It’s in the research! Everyone loves research.
Perhaps we can add this mentality to social and spiritual connectivity and enhance outcomes even further.
The majority of persons with psychosis want to work, have friends, and believe in god. They want to avoid a life of poverty, imprisonment, and isolation. Work is a good motivator, and a good way for many to learn to comply with rules. But it requires emotional support which can be hard for people with psychosis to find.
Sure, some social workers and perhaps some families may form secret societies that monitor their loved ones. These secret societies (like treatment teams in the hospital or family discussions/gossip) can easily be abused and defame the person with psychosis. I think family members and social workers must realize that when they do this, they mirror the oppression of other organizations that may be real and may have something to do with their loved one’s awareness and ire—the police, the FBI, prison gangs, corporations, fraternities, the military, religious cults, and others.
Thus, when family or social workers recognize that they can function as agents of the state, they can be open, communicative, and transparent about the secret societies in which they participate. This can greatly enhance trust.
This might include taking responsibility to learn about things the person has experienced that pertain to you that you don’t feel are accurate. Consider asking about the things your voice has expressed to your loved one (as auditory hallucinations). Then try to see the reality of what they are saying so you can confirm ways the communication is and isn’t valid. Always lead with the way it is valid. Instead of denying everything the person experiences, consider how the hallucinations may express their feelings of persecution or danger. How might their hallucinations help you understand your loved one?
Focus on What Healing Interactions Look Like
Consider the opportunity that you have when the person enduring a break from reality gets mad and confronts you, their loved one, with something of which you are sure you’re not guilty.
I’d strongly recommend that before you confront that person with the reality check of your innocence, that you consider whether you want to avoid falling into the role of social control.
If you find yourself determined to prove your innocence, and confront your loved ones with your facts, I want to suggest they may see this as just another social control effort. It is a lot of the same kind of stuff they get in the state amidst the jails, hospitals, and shelters. It might not be appreciated
In other words, I am saying that defending yourself is a power play. It may gain you some compliance with consensus reality, but it also puts you at risk of diminishing trust between you and your loved one.
In contrast, I suggest you take this intensely emotional situation, a potentially false accusation, and keep the goal of healing in mind. Instead of asserting the power play, let the loved one explore all the experiences that the person who is in a break has had that indicate your guilt. Then, communicate and clarify without invalidating.
When This Does Not Go as Planned
I know this is an exceedingly simple suggestion! Let us not forget that asking the above question is a real test of the amount of trust that exists between the two of you.
For example, when I don’t trust the person who asks me to prove what I am saying with examples, I find I am often rendered speechless. It can be hard to put words to those experiences when you know they will be shot down.
In other words, unless I trust you and feel safe to speak about a misperception or two, words that define my experiences elude me.
Thus, if you are a social worker or a loved one and you don’t get any information, it is likely that you have rejected your loved one’s reality so much over the years that they are afraid to communicate with you. It is likely that they have no hope you would ever understand.
I believe working towards a healing relationship involves cultural curiosity into your loved one’s experience. If you can get yourself to be trusted to the point where you can explore all of your loved one’s associated experiences, then I think you are on the road towards healing them.
If you don’t have that kind of relationship with your loved one, focus on trying to get there and forget about the false accusation. Explore with curiosity other kinds of experience they have had.
Understanding the culture of your loved one’s psychosis to the point where you can admit the ways they are right about you is far more likely to reality check them in a more healing manner and really move your relationship forward.
Adapting Your Strategies
Also, it’s worth noting that people who experience psychosis often come from distinctive cultures, have different needs, and approach a break with different moods and core beliefs. In my experience, I believed I was being persecuted by secret, illegal societies overseen by the government. Other people can have vastly different experiences with secret societies.
For example, some may believe they are being spiritually aided by secret cabals like elite police and/or politicians on their mission. Perhaps not all people experience social control in their family of origin the way I did. Still, you can inquire about euphoric experiences that your loved one may have had. Just remember, you don’t want to come down forcefully on the side of your loved one’s punitive state administrators.
Consider the ways that some positive spiritual experiences really don’t need to be healed. Explore enough to identify those positive experiences that have consequences that might be curbed. Consider what happens, for example, if you make the person descend from heaven back into a living hell on earth. Staying on earth can be a challenge.
This may involve envisioning a world in which they do not have to endure social control to force them to come back down. Helping them takes communication and rational, healthy choices. It becomes more about reviewing the consequences that the state will impose if they go down that road. It becomes about mitigating those realities while maintaining your collaborative standing.
Either way, delineating yourself from the mechanisms of control that may have led to trauma or got in the way of healing is an important thing to do! As a parent or as a social worker, this may involve changing the historical role you’ve taken with your loved one.
This means, instead of telling them what to do, you should consider exploring their experiences.
Do not forget that psychosis, special messages, or a break from reality is a collection of experiences. When you force your loved ones to defy their experiences and accept your reality via reality check, it is really about you imposing consensus reality on them and it puts you on the side of social control. They may know better.
I feel this becomes about your power. Ultimately it puts them down. When you do this, they will recognize this and it may trigger trauma from their run-ins with the state. Thus, differentiating yourself from the state becomes an important strategy.
Helping your loved one heal is about using your relationship to help them to navigate consensus reality so that they can achieve their hopes and dreams. If you care about them and their relationship with you, adopt a collaborative approach to their experiences. This is far more important than them respecting consensus reality, which might be full of ignorance and propaganda.
Supporting their autonomy and freedom is needed. Learning about the mistakes you made can also be important. Give them transparent information about what you have said and done on their behalf. Ask them how they would like you to assist, then communicate.
It’s true, doing what they say and working on their behalf does require boundaries. Even if you are a lawyer, you can’t help them beat the state, only evade it.
But most importantly, differentiate yourself from the organizations that impose social control and discriminatory laws on your loved one. You really don’t want to be on the side of marginalizing them!
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.