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The source of positive and negative distortions in psychosis

Where do all the distortions that are common to what we see as psychosis come from?  That’s the question I took on in a short series of PowerPoint slides that I created this morning.  In these slides, I suggest that these distortions come about out of attempts to resolve two kinds of stress.  One type is stress that can result when we are over-estimating the level of external threat, and the second is stress that can result when we under-estimate such threat and so are vulnerable to jarring encounters that we hadn’t anticipated. 

I will be using these slides in presentations I do, where I will be able to explain the concepts in more detail.  But I just thought I would post them here, to see how much sense they might make to  you standing on their own.  [Note:  there is an option to look at the slides in full screen, and you may have to pick that mode to see all of the slides.]

12 comments… add one
  • I must admit, I have a problem with the term “distortions”. It’s the same problem I have with terms like “hallucination”, “delusion”, etc. that indicate that there’s no reality value to these phenomena, and it is the same problem I have with psychoanalytic (and psychological) concepts like transference when they are used to devalue the client’s perception of reality.

    Your slides take a look at these “distortions” from the perspective that they are a coping mechanism allowing the individual to escape reality as it is (which presupposes that there is an objective, “true” reality, hm… ), and this view may very easily lead to the conclusion, that they are mere fantasy, have got nothing to do with reality, the supposedly objective, “true” kind. In my experience, this is not so. Someone may for instance react to something their therapist says in a way that seems to be an overreaction, or even plain “inappropriate” (yes, just as “inappropriate” emotions/reactions are said to be a “symptom” of “schizophrenia”). Personally, I’ve certainly reacted extremely sensitive, with extreme fear and anger to any attempt by my therapist to pathologize, and thus devalue, me and my perception of reality as distorted (sic!). That my reaction was extreme, because it wasn’t alone a reaction to what happened here and now, but also included all the fear and anger I should have reacted with to past abuse, but wasn’t allowed to, and subsequently didn’t allow myself to react with, doesn’t mean that the attempts weren’t real. They so were.

    I agree, that as long as someone reacts more or less unconsciously, this is very likely to get the person into trouble, although I think, much of this trouble also is caused by everybody else’s unconsciousness about the fact that their attempts to objectify the person — for instance by pathologizing her — is a threat to this person’s self/life. Nevertheless, I also think, the only way to have someone become conscious of their reactions, and get in control of them, is to fully validate these reactions, as in: “Yes, you’re right to be angry. To call you a patient, a schizophrenic, and your perception of reality distorted, is indeed an invalidation of you, and threatens your self/life.”

    When it comes to “delusions of grandeur”, I think, the same applies. They’re not completely unfounded in reality. Consciousness as such is unlimited in its possibilities. That’s a spiritual reality. But we’re limited in our possibilities by being human beings. So, although human beings can’t fly, consciousness can. Also, if someone believes they are some kind of savior, chosen to redeem humanity, this is nothing but a very appropriate picture of having been made the scapegoat by one’s family, or having been bullied at school or work, that is, having been made the one who has to pay for everybody else’s sins and vices. So, in taking on the role of the victim, you also at the same time take on the role of the savior (cf. slide 4: “inconsistency, flip/flops”).

  • Thanks Marian. I see a lot of value in what you write, though I do differ with some of it.

    I actually wasn’t saying that stuff like what gets called hallucinations and delusions are necessarily attempts to escape reality: I think what is going on is often more complex. For example, the person with paranoid perceptions is often actually trying to avoid the kind of mistakes in perception where someone is trusted who actually isn’t trustworthy, but the person often goes too far and may distrust people who could reasonably be trusted.

    My sense is that it helps for all of us to acknowledge that our perceptions of reality are probably distorted in various ways. Our maps of reality are all imperfect, or as the Taoists would say, “the Tao that can be spoken is not the eternal Tao.”

    I often speak with people who believe things such as that they are surrounded by people who will capture and physically torture them if they do not obey obscure commands. While these beliefs may express some kind of truth, they are not literally true as far as I can tell, and I don’t think it would help for me to “validate” them in believing that they are.

    What I think does help is for both myself and the person I’m talking with to acknowledge that we are human and do make mistakes, and then to explore in more detail why the person sees things as they do, and what alternative perspectives exist, with attention given to emotions and emotional history as well as the facts of the situation. This allows a bigger story to emerge, that can identify truth within the person’s original perceptions as well as error.

    I added a new post where I tried to explain myself better, you can read it and see if it is helpful, or if I am just muddling things up worse!

  • Ron and Marian,

    As always, I enjoy reading the comments you both make on this blog…
    Sometimes, I read them, only to have to go back, and read them again…
    There’s always a lot there – a lot of insight, which leads to a lot more questions…

    Good stuff!

    Thank you both,


  • It is important to distinguish between content and process. The “obscure” content need not be judged in terms of right and wrong; valid or invalid. I would view the expression of the obscure belief by the individual as an opportunity to explore the process that is occurring. In many cases these expressed beliefs are symbolic or parabolic in nature.

    I suggest, given an opportunity, the inidivdual will come to his or her own understanding of the validity and appropriateness of the obscure belief. If the client says “I am surrounded by people who will capture and torture me if I do not obey obscure commands.” the response may be “Let’s talk about that. I am pleased that you trust me enough to share this with me and it must be a frightening situation to find yourself in. Please tell me more about this. When does it occur? When did you first experience it? Does it reoccur frequently? What commands do you need to follow to keep them at a distance?…etc.”

    If, and as the individual shares his or her experience a pattern may emerge. The process, likely a defensive one, will begin to take shape and the therapist can begin assessing the process and exploring the source(s) with the objective of helping the client reframe the formative experiences that have given rise to their interpretations and false beliefs in the first place. The client’s realization may occur during the session or at some later date.

    While I agree with the value of CBT as being significant in leading a productive life, defined by action, where there are recurrent false beliefs that are an ongoing interference, it is impossible to simply varnish over these and indicate to someone that they need to get on with their lives.

    I agree that we all have false beliefs and distorted perceptions of reality. Should I be expected to substitute my false beliefs and distorted reality for someone else’s? The fundamental objective is opening up awareness and the distinction of choice.

  • Hi Alan,

    I agree with you that therapy should not be about expecting the client to replace his or her views with the therapist’s views, and that instead it’s about opening up awareness around the possibility of thoughtful choices. I also agree that it can be very helpful to explore development and the process of how beliefs have been and are being formed. But in regards to the example you discussed, I would say some things differently.

    For example, instead of saying ” it must be a frightening situation to find yourself in” I might say “it sounds like according to your observations you are in a very frightening situation.” And instead of asking ” What commands do you need to follow to keep them at a distance?” I might ask “What commands have you decided you need to follow to keep them at a distance?” I would avoid saying things that made it sound like I was agreeing with their perceptions and conclusions, or seeing them as fact, because that might just add more perceived weight to them.

    I try to follow the CBT guideline of neither colluding with an apparently delusional or distorted belief, nor confronting it, but just opening up an exploration. This is easier said than done, and their are many nuances in what works that vary between individual, but the idea is to create a space of openness and curiosity, slow to reach conclusions about what is the “whole story.”

    And while sometimes the symbolism of a belief may be more important than whether it is literally right or wrong, at other times it is important to sort out whether the belief is or is not literally true, because this often determines people’s actions. I’ve seen people’s lives open up as they decide that certain beliefs about persecution are not literally true, and they decide they can re-engage in public life, for example.

  • I just want to say that when someone is in the gripps of something whether it be love, anger, fear, demons, or any other human abstraction, it is real to them. It may not be objectively real, but it is subjectively real.

    I would recommend to any person involved in human wellness to help the client to make a clear distiction between the man-made and the given. To help them develop their rational faculty better and to lead them to question their conclusions for validity and truth with reason. I would also caution against rationalizing.

    Also, there is a real world. An objective real world. Objective reality is like a blank canvas… subjective reality is like the scene depicted on it.

    THIS world is that distant star we must try to rreach.

  • Ron, I wanted to get back to you before, but just didn’t reach it. Maybe we were talking past each other here. What I mean is not that you’d have to validate what is expressed literally when someone tells you the CIA is spying on them, or aliens are out to abduct them. But beliefs like that don’t emerge from out of the blue. Someone is/was “spying” on the person, respectively is/was trying to “abduct” them. In a metaphorical way.

    Somebody once told me in a chat situation he’d just been at the gas station around the corner to buy cigs. He had to leave in a hurry, because the voices in his head told him “Someone has to pay for it!” and he got afraid, he’d harm someone. I asked him what “it” was, and he told me his whole story, including an alcoholic, abusive father, institutionalizations, and, and, and… (well, it took a little more than that one question from my side, but you get the idea) Clearly, that was the “it” someone would have to pay for for having done to him. And it was as real as could be. Sadly. I don’t think, it would have helped much, if I’d just said something like “Oh, come on, no one at the gas station has harmed you, have they?” This is what people usually are told, by the system, that no one, neither at the gas station nor elsewhere, has harmed them, and that it’s all in their (diseased) head. Of course, the people at the gas station were “innocent”, but realizing that there was a real enough reason for the voices to ask for revenge, that he indeed had been harmed, traumatized, and how, and by whom, also had this guy understand that it was not the random person in the street, or at the gas station, who was responsible for his suffering. That’s, IMO, the understanding people need to get to in order to get in control of voices and stuff. And they don’t get to this understanding, if you tell them it’s all in their head, and not the least based on anything real.

    Now, I said that the people at the gas station were “innocent”. Quotation marks. Because they weren’t entirely. Something in their attitude, their behavior, something they’d said that he’d overheard, without doubt had reminded him of his father, the staff at the institutions he’s been at, and/or other traumatic experiences from his past. I myself am amazed, time and again, “studying” the average person in the street, at the supermarket, the gas station, wherever, and witnessing this incredibly huge amount of, mostly unconscious, violence and dysfunctionality s/he displays through his/her attitude, behavior, and/or words. I wouldn’t be able to see it this clearly, nor to see it as what it, mostly, is: unconsciousness, not a conscious wish to do harm, if I a) hadn’t had a reaction to it myself, and b) hadn’t had my experience and my reaction validated. I think, the only difference between what is called “paranoia”, and what is healthy skepticism, is that the first is the unconscious version of the latter. I don’t just react, in an unconscious, “paranoid” way anymore (at least, most of the time I don’t 😉 ), it doesn’t instantly put me in a fight-flight-freeze mode anymore, because becoming conscious of it also made it possible for me to react in a more conscious, “reasonable” way, even to choose whether to react at all, or not, but I do recognize it when it is there.

  • Thanks Marian, for your comment and interesting example. I think we essentially agree that there is some importance in both being open to seeing some truth in “paranoid” beliefs and perceptions, and also noticing the ways they may be false. In earlier communications we may have each been emphasizing one side or the other of this, but I think we really agree that both are important.

    When there are two sides to something, it can be difficult to talk about it in a balanced way. And sometimes one side or the other seems more prominent in a practical way. Sometimes I think it really is critical that a person notice a belief is not literally true, and any metaphorical meaning is pretty obscure (unlike in your example.) Other times the metaphorical meaning is pretty directly accessible to both the believer and the person talking to the believer, so it makes sense to talk directly about that meaning, and not very important at all to talk about ways the belief may not literally be true.

    Interestingly enough, the question of what is literally true, versus what is metaphorical, comes up in spiritual and religious discussions as well. We see lots of trouble caused by people who think things are literally true that aren’t, and lots of trouble as well caused by those who think that if something is not literally true, then it has no meaning or importance.

  • yes to the metaphorical line of thought.

    i once read about a man incorrectly diagnosed as paranoid schizophrenic because he said that “people were trying to control his thoughts”. in fact his family were trying to steer his thinking. but he lacked the calm and articulation to explain himself. or rather the psychiatrist lacked the ability to assume that the mans words might be true somehow.

    i think it would be helpful to treat some patients dicussions of thier thoughts/delusions as liguistic anomolies more than as persistant thought disorders. maybe if psychiatrists tried to learn the language of thier patients they could better teach the patient how to use the more common language of society.

    • Hi anonymous, I agree completely about the importance of mental health workers being open to exploring in what sense what the person is saying may be true and accurate, and not just labeling it as delusional because it contrasts with the worker’s way of thinking and the worker’s language.

      Looking for the truth within apparently delusional thinking is a key part of cognitive therapy for psychosis. Once people see that the person they are communicating with sees some value in what they are trying to say, they are often much more open to seeing that there may also be something confusing or misleading or inaccurate about what they are saying, and they are willing to experiment with saying it differently.

  • Wow what a beautiful conversation.
    If I may add something that is probably already said. During psychosis, I think it is not so much about what the person is saying and what it means, but to sit with the person and truly to listen to the person as a whole not just as oral object. I would also recommend that perhaps it is better to ask questions and clarifications of the meaning of the contents rather than being right with I do not see what you are saying as a truth.
    I recently shared with my therapist that I do not trust her. This is after a year of being in therapy where I struggle with the feeling of trust but arrived at knowing I do not trust her – and that can be from my past or could be something she does in the therapy that triggers me or combination of the two. What I did not consider was the feeling is wrong.
    So when I got the courage to say to her that I feel I do not trust you even though I feel by telling you this I do not trust you. She completely and 100% changed the topic to Covid19. I was flabbergasted. What just happened? I tried to reiterate so I could get some closure to this feeling, explore see where it takes me. No avail. Let us talk about Covid.
    Next session, I said I would like to talk about what I said cause I think there is something in there for me not trusting you. She said that is transference. It is your mother. Your mother is in the room. Now who is crazy? But that did not faze me so I said I can see it may relate to my past but I feel there is a trigger in the room that takes me from the present to the past, I am curious and trying to learn what that point is.
    She said I really hate you see your mother in me and this is not here and now.

    Maybe this is not as good example as the delusions but when a therapist stands at “I am not like you” crashes any human twinship, and refuses to sit with the client and tries truly to see what the client is talking about….maybe the client is imagining Dali like creativity…who knows? The act of the therapist to privilege his or her feeling, ideas and reference point is an act of aggression.

    I mean just ask yourself, what is the damage to you if you just allow yourself to play and go along for the ride? Are you afraid you may go into psychosis? What is the harm? You go along and then you can invite the client to go along your reality the next day…let us play and use our imagination together. I am not afraid to along with you in your journey even if it sounds crazy in today’s world.
    My therapist refused to acknowledge my not trusting her is not (or not 100%) a past thing since I am talking about it here with her. Unfortunately I had to let her go. It pains me but what is the point? Either my feeling of not trusting her is from the past (crazy, transference whatever you call it) or it is real and she was gas lighting and did not want to see the little things she does to drive me to the past.

    I think when delusion is out there, let us play. Let us use our imagination. Let us paint and see what you see. And if I get tired flying with you, I would invite you to come along with me…

    When a therapist is afraid for his or her own sanity or afraid of disintegration, then, they are instilling that fear into their clients.

    We never tell children their imagination is wrong why do we do that to adult who have delusions WHILE IN THERAPY? If they cannot have someone believe them and sit with them in the room of therapy, where else in the world can they talk about this and be that open to explore and go through it.

    You cannot teach sanity with I think you are insane mentality.

    • Hi JP, I think you express very clearly what it is like when a therapist refuses, perhaps due to fear, to look at the world from the perspective of their client. One of the most basic things we do for each other as human beings is try to understand each other’s perspective! For example, if someone doesn’t trust me, I want to understand why, how they arrived at that impression. It might be that I made some kind of error, or it might be because they interpreted something I said in a way I did not mean, or whatever, but if we can identify what that is then we can talk about it.

      I would definitely not trust a therapist who was not willing to talk in an open minded way about why I was having difficulty trusting them!


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