Biological psychiatry would have us believe that the state of mind called psychosis always results from something gone wrong with the brain, and that a drug intervention is the only way to have a substantial impact on that defect. 

But the reality is much more complex.  Research in past decades has shown that psychosis is often a reaction to adverse life events, to trauma, experiences of oppression, and other stressors.  And if it is a reaction, then the possibility exists that people can learn to react differently, and that this difference in reaction can play a major role in overcoming the problem.

That’s why I was interested when earlier this year I heard that a colleague was co-authoring a workbook designed to help people understand their state of mind in a more psychological way and to take an active role in their recovery.  I was asked to write a foreword for it (which you can read below) and the book is now published:

Here’s my foreword for the book:

Compared to some of the (relatively few) other workbooks or general self-help books devoted to psychosis, this book is notable for drawing on a number of different therapy approaches, including cognitive behavioral therapy for psychosis (CBTp), Acceptance and Commitment Therapy (ACT), Dialectical Behavioral Therapy (DBT) and Compassion Focused Therapy (CFT). 

If you like the idea of self-help books though, here’s a few others you might also want to check out:

Think You’re Crazy? Think Again

Relating to Voices using Compassion Focused Therapy: A Self-help Companion

The Dialectical Behavior Therapy Skills Workbook for Psychosis: Manage Your Emotions, Reduce Symptoms, and Get Back to Your Life

Overcoming Paranoid and Suspicious Thoughts, 2nd Edition: A Self-Help Guide Using Cognitive Behavioural Techniques

Overcoming Distressing Voices

Our minds are tricky, and the world is confusing, and it can be difficult trying to figure everything out. Well, we never figure everything out, but with some help, we can often get to a place where it doesn’t seem quite so hard.

Please do comment if you have any thoughts about this post!

Psychosis can seem to involve the loss of access to any kind of spiritual reassurance, while at other times it may appear as a preoccupation with spiritual themes, or taking what seem to be extreme or bizarre spiritual perspectives.  In response professionals frequently ignore the spiritual dimension and frame everything as a struggle with an illness, but that approach can create barriers to forming a common understanding and to accessing and supporting opportunities for development along what might be seen as a spiritual dimension.

What might work better?  How can professionals bring an awareness of this spiritual dimension and a willingness to talk about and work with it into treatment, without making mistakes such as romanticizing psychotic experiences, promoting specific beliefs or dogmas, or causing other kinds of harm?  In the talk below, I explore possible answers to those tricky questions.

Spirituality is a route to recovery frequently cited by service users, yet usually marginalized within treatment.  When professionals are instead willing to engage with people’s deepest concerns in an open minded way, balance may become more possible and new opportunities for recovery may emerge.

If you want to get deeper into this topic, I offer a 6 hour online course on Spiritual Issues within Treatment for Psychosis and Bipolar. You also might want to check out a list of resources for exploring more about that topic, at this link.

Also, note that the talk above was given for the Early Psychosis Virtual Summit put on by the Tennessee Association of Mental Health Organizations (TAMHO). You can access the recordings for other talks given at that event at https://www.youtube.com/playlist?list=PLWThhKstuRWB8po1n74vIad7tXeMxcK2n

Are psychotic experiences something that should simply be suppressed?  These experiences cause so many problems, it may seem that the answer should always be yes!

But there’s a paradox when we try hard to get rid of psychotic experiences.  Our efforts to do so can quickly make the problem worse! 

At its simplest level, we see the basis for this when we try too hard to get rid of a thought.  For example if you focus too much on not thinking about elephants, they will be on your mind all day.  If you focus on not having the thought that you might have germs on your hand, you might spend all day washing your hands to make sure there is no basis for the thought. 

And if you are very sure you shouldn’t be having a thought, it might start to seem that the thought is coming from somewhere else, like a brain implant or a demon or telepathy from someone you don’t like.  Now the battle is really on!  But the prognosis for winning this battle is not good.  Efforts to get rid of what now seem like voices etc. just make them seem more important and more compelling.  Things can rapidly spin out of control, and go to some really dark places, which often just convinces everyone involved that doubling down on attempts at suppression is the way to go!

Fortunately, there is a better way.  Paradoxically, it involves accepting even the “crazy” thoughts or voices that seemed to be causing so much trouble, but in away that avoids making too much of them.

Our brains are weird, our minds are weird, and that’s OK.  We can learn to help people not make too much of the weirdness, and to identify what helps them move on and make a life they value, and to connect with the people and activities they love.

Finding the common humanity within the sometimes freaky experiences that get called psychosis is a key part of the CBT for psychosis approach called “normalizing.”  It can help a lot in getting people to change their relationship with tricky experiences, rather than seeing those experiences as pathology that requires suppression and elimination.

If you would like a better idea of what normalizing is, check out this video:

For those who want to learn more about how CBT and a few other therapy options can be helpful for psychosis, or what gets called that, there is a series of 5 seminars that I am offering over the next few months.  Attending one or more of these seminars could be a very affordable way to grow your competence in a psychological approach for psychosis – and you can save by accessing Early Bird pricing that only lasts through 4/5/24!

Each seminar will be 4 hours long, and will provide time for questions, discussion, and practice. Continuing education credits will be available for most US professionals. Each seminar will be recorded, and those who register will have access to the recording. CE credit however will only be available to those who attend the seminar live (on Zoom, or in person in Eugene OR) for the entire seminar.

The seminars are:

Date: 3/29/24 –  Essential Elements of CBT for Psychosis: Engagement Style, Normalizing, & Developing a Formulation

Date: 5/10/24 – Paranoia and Troublesome Beliefs: A CBT Approach

Date: 6/21/24 – Voices, Visions, and Other Altered Perceptions: Changing Outcomes with CBT

Date: 7/19/24 – Trauma, Dissociation, and Psychosis: CBT and Other Approaches to Understanding and Recovery

Date: 8/16/24 – Addressing Cultural and Spiritual Issues Within Treatment for Psychosis

The most affordable option is to register for all 5 seminars as a bundle (only 59.99 per seminar if you register by 4/5/24) but you can also register for seminars individually.

For more information and to access options for registration, go to this link.

When people report the extreme beliefs that are often labeled “delusions,” it can be difficult to know how to make sense of what is going on and what might be helpful. That’s why I took the time to review a new book on the subject, “Decoding Delusions: A Clinician’s Guide to Working with Delusions and Other Extreme Beliefs,” edited by Kate V. Hardy and Douglas Turkington.

What follows is a draft version of the review, but if you are one of the first 50 people to click on this link, you can see the final version that is now published online in the journal ‘Psychosis.”

One other resource of note on alternative ways of understanding and working with “delusions” is this video presentation by Rufus May – a psychologist who was once hospitalized due to his own extremely paranoid beliefs!

I often hear from family & friends of people with psychosis that they want to be helpful but don’t know how. So I put together a list of resources that might provide some guidance.

One simple overview of how family and friends can help was put together by Mind in the UK.

There are some free videos for family members teaching perspectives and skills drawn from CBT for psychosis – these go into a lot of detail, and the instructor is very knowledgeable.

There’s also a free online training course for family members based on CBT for psychosis offered by SPIRIT Labs in WA. They also offer a list of possibly helpful resources.

There’s a short guide for family members in communicating with someone with psychosis

There’s a weekly online meeting for family and friends of people who hear voices And Understanding Voices has a page of helpful ideas for friends and family.

Family support groups organized by NAMI may be helpful and are available in many locations across the US.

Or parents who are skeptical of conventional drug-based treatments for children struggling with mental health issues and who are looking for alternatives may be more interested in Mad in America’s online parent support groups. And they have this list of additional groups.

Survivors And Families Empowered (SAFE) is a coalition of psychiatric survivors, families, and mental health professionals who believe in the power of hope and the resilience of the human spirit. Their experiences have taught them that deconstructing the fears and myths about mental illness will reduce the over reliance on restrictive interventions which interfere with recovery.

There’s an online course called “Demystifying Psychosis for Family Members” that might be of interest.

EASA, the Early Assessment and Support Alliance, has a list of resources for families, allies, and young adults

Some of these resources, in particular NAMI, may be at times overly invested in describing psychosis as definitely an “illness” rather than as a possibly understandable reaction to difficult or confusing life experiences. But there’s a lot that can be helpful in these resources, despite their imperfections.

Sometimes the emphasis on “blaming the illness” comes out of a reluctance to say anything that might lead family or friends to blame themselves in any way for how their loved one became lost and confused. This has led leading organizations to promote statements like “Psychosis is nobody’s fault. People do not cause it.” Unfortunately, as I have written about before, this leads to a denial of how trauma and in particular interpersonal trauma is often a big cause of psychosis, and also to ignoring how other kinds of stressful and confusing life events can play a role.

My perspective is that rather than teach family members to “blame the illness” as a way of avoiding getting caught up in self blame, we can instead guide them in finding a middle way. That is, we can acknowledge that life is tricky and confusing, our brains are tricky and confusing, and because of this we family members may not always have been helpful to those we love and care about, and sometimes we may have been clearly unhelpful or hurtful in ways that may have contributed to the psychosis. But this does not have to mean getting caught up in blaming ourselves; we can instead shift our focus to learning what we can do now to be part of the solution. In other words, we can model accepting ourselves as imperfect and sometimes confused and confusing people who nevertheless can love and value both ourselves and others in the present- the same sorts of skills that will be so useful to our loved ones in their own journey toward recovery.

Back in 2015 Paris Williams wrote a 3 part series on Madness and the Family, see Part 1, Part 2, and Part 3 that explores some of the complexities around psychosis and families.  Or you might also appreciate hearing a 45 minute talk he gave on the same subject

While it’s still common for people to be told that psychosis is a brain disorder that was not caused by anything anyone did to them, there is now an extensive body of research that indicates that traumatic experience can be a cause of psychosis, and the link between having multiple types of trauma and later psychosis is close to the strength of the link between smoking and lung cancer.

But what is the nature of the connection between trauma and psychosis? One factor that seems to play a role is that of dissociation, which is something we all do at times but which is often very strongly triggered by trauma.

To help professionals understand and work with this issue, I offered a free one hour webinar “Trauma, Dissociative Splits, and Psychosis: Approaches to Healing” on Friday April 21st – the recording is now available, see below. (This event was hosted by APA Division 18 Community and State Hospitals Section.)

Here’s the description for it:

“Dissociation is a factor that can mediate the relationship between adverse life experiences and psychosis. This webinar explores how methods drawn from diverse sources like evidence-based practice (CBT) and peer support/lived experience (Hearing Voices Movement) can help people regain perspective and personal power. Discussion regarding the utilization of effective psychosocial interventions and supports to promote healing and quality of life will be conducted.”

Learning Objectives:

• Explain how dissociation as a trauma response can create risk for psychosis.
• Identify and describe at least 2 therapeutic interventions for dissociation that also reduce distress related to psychotic symptoms.
• Describe at least 2 individual factors to consider when selecting and adapting treatment for trauma and psychosis.

There are also recordings of a couple of earlier webinars that you can view:

Trauma and Psychosis: Exploring the Intersection

Moving from Trauma and Psychosis to a Recovery Story

Traditionally, psychiatry has taken the position that “getting out of your mind” is a bad thing: they have made “normality” in thinking the standard for health, with experiences going outside of that being viewed as pathology.

But more recently, there has been an interest in using psychedelic drugs within psychiatric practice.  That’s because traditional approaches to psychiatric practice haven’t helped very much, and some studies show that shaking things up with psychedelics can at least sometimes break people out of unhelpful patterns and set them on a better path.

This however raises a lot of questions.  For example,

• If going somewhat out of one’s mind on psychedelics can be a good thing, then maybe other experiences of going out of one’s mind also have possible value which psychiatry has been ignoring?
• On the other hand, if going out of one’s mind is often related to problems, is it possible that attempts to use psychedelics in treatment will lead to many people getting into increased difficulties?  And then when/if this does happen, will psychiatry blame this on an “underlying illness” much as it often does when. say, antidepressants trigger a manic episode?
• Is it possible that our entire culture needs a better understanding of ecstatic mental states that take one outside one’s usual state of mind, before we have any chance of handling such issues?

Jules Evans is a philosopher whose perspective has been shaped by experiences that included early use of psychedelics, including both apparently helpful experiences as well as a bad trip that caused problems that lasted for years, and an ecstatic near death experience.  He argues that our society needs to become more literate about ecstatic experiences of all kinds, in a way that appreciates both their gifts and their dangers.

Jules is the author and/or editor of some interesting books, including

and

Perhaps because his own experiences have been so varied – ranging from extremely helpful to extremely not – I think Jules does better than most in addressing this topic in a balanced way.

Psychiatrists commonly pathologize extreme and ecstatic experiences, while some who oppose psychiatry may seem to romanticize them – but what we really need is a deep understanding of the multiple sides of such experiences.  Kind of like with fire – fire is both great and very helpful, and quite terrible, and we do best with it when we are aware of this duality.

If you would like to learn more about this point of view, I encourage you to check out this recording of the ISPS-US webinar “The Mysticism / Psychosis Continuum, with Jules Evans,” of a talk given on 3/17/23. Note that the talk itself is about an hour, followed by an hour of question and answer. 

I recently wrote a book review for “Relating to voices using compassion focused therapy: a self help companion” by Charlie Heriot-Maitland and Eleanor Longden. Here’s what I said:

“A friend of mine who eventually recovered after spending many years in hospitals being treated for “schizophrenia” complained to me that all the professionals who treated him never mentioned “love” or anything like it – yet that was the essential ingredient he required to heal.

“Professionals have often been taught that to be scientific, they should avoid the “warm and fuzzy” while focusing instead on suppressing or eliminating “psychopathology”. But compassion focused therapy, on which this book is based, takes the opposite stance. It argues that while our brains have evolved to be tricky, and prone to getting stuck in destructive “loops” and inner conflicts, we also have an evolved capacity for compassion, and that the key to healing is learning to use compassion to reconcile with, rather than suppress, the parts of our minds that disturb us.

“This book makes this compassion focused approach accessible to voice hearers. The kindness and humanity of its coauthors (one of whom is herself a voice hearer) are a consistent presence as the reader is thoughtfully guided through possible steps toward changing relationships with voices.

“To begin, voice hearing is normalized as a normal human experience, and reasons to take a compassion focused approach are introduced. Issues of being safe and feeling safe (not always the same thing!) are discussed, and ways to access and/or develop a “compassionate self” are introduced. The next step is learning how to explore one’s conflicting emotions or “emotional selves” from the perspective of the compassionate self. This is good preparation for relating to voices, since emotional conflicts are usually less tricky than are conflicts with voices. Then comes work on developing a compassionate understanding of the voices and of their activity. By considering early experiences and key fears, voice hearers learn to discern how even voices that appear wildly destructive may have a protective intent. Finally, equipped with that perspective, ways of compassionately and wisely relating with the voices and with the emotion behind them are introduced.

“To support this journey, a variety of methods are employed. There are “check-in” boxes that encourage readers to notice how they are responding to what is being introduced, and “practical boxes” that lead the reader in exercises to practice new approaches. There is also a companion website to the book, relatingtovoices.com, which contains audio and print versions of the exercises, along with links to videos and other resources.

“While written as a self-help book, it will also be useful to professionals and to family members who want to increase their ability to support someone in using this approach, even those who may not themselves be inclined to read books.

“One of the persisting myths about mental functioning, which is especially destructive to voice hearers, is the notion that experiences of something hostile or disruptive within our mind is likely the sign of something wrong with our brains. This creates excess dependence on drugs and on a continued battle with whatever is disruptive, in a way that too often inflames into what one of the authors, Eleanor Longden, has referred to as a “psychic civil war”. By instead framing contrary emotions and emotional systems, as well as voices, as all deriving from evolved systems that are trying to help us (even as they may go overboard with that), compassion focused therapy and this book in particular point in a much more hopeful direction, creating possibilities for peace, healing, and the kind of true mental health that has its origin in our hearts.”

Unger, R. (2023). Relating to voices using compassion focused therapy: a self help companion. Psychosis, 1-2. https://doi.org/10.1080/17522439.2023.2172602

[Note that if you are interested in purchasing the book, you can also find it at relatingtovoices.com]

If you’ve ever been tempted to think of hearing voices and of “psychosis” as just something medically going wrong with one’s brain, I can think of nothing better than a recently released video to convince you otherwise!

In an awesome performance linked to below, Ren dramatizes a battle between himself and an apparently evil voice that seems bent on tearing him down. It progresses into an amazing intensity, then a resolution or transcendence of the battle that may stun you with its humanity.

Anyway, check it out. Note that the first comment listed on YouTube contains the full lyrics.