Commonly, psychosis is explained to people as being a medical condition. But it is not diagnosed by any medical test: instead, people get identified as being “psychotic” when they speak and act in ways that appear extremely confused and/or out of touch with what the rest of us perceive as reality.

There are medical conditions that can cause psychosis, such as Huntington’s or Parkinson’s disease. But reasoning that all cases of psychosis are caused by a medical problem does not appear to be justified. Instead, it appears that psychosis commonly results from reactions to life events, especially adverse life events.

It is also common for people to be told that recovery from psychosis will require medical intervention, in particular, a class of drugs that have been called “antipsychotics.” People are even told that psychosis is the result of a “chemical imbalance” and that the drugs will correct it, like “insulin for diabetes.” But outcome studies find that many people recover without using such drugs, and long term studies suggest that recovery may even be more likely on average when people avoid long term use of the drugs. And they definitely do not function “like insulin for diabetes.” Insulin always brings blood sugar down, but “antipsychotics” often fail to reduce psychosis, and in some trials they do no better than placebo. And for some people, antipsychotics may even cause psychosis!

Many professionals recognize that the reality of psychosis and even of the longer episodes of psychotic problems that get labels like “schizophrenia” is much more complex than the medical stories and theories, and they talk about this amongst themselves, but then still give simplistic medical explanations to their patients. One purpose of this appears to be to convince their patients to stay on medications, but the end result is to sell people on medications under false pretenses, and to interfere with people making informed choice.

I was recently invited to give a talk at my local community college about the nature of psychosis. I’m posting it here as an example of how to talk about psychosis in a balanced and honest way, and in a way that sets the stage for understanding and recovery. If you like it, please do share it with others!

What does it mean to be called “crazy” in a crazy world?

If you are familiar with Madness Radio, that’s a question that you’ve heard before!  But it is also a question that seems increasingly important in a society where ever larger groups are organized by what seems to be paranoid or overtly delusional perspectives.  Incredibly, beliefs like the notion that powerful elites are arranging to replace white people and/or to promote pedophilia, are now held by perhaps a third of US citizens and are shaping our politics.

In psychiatry, believing in “conspiracy theories” is distinguished from “delusion” since belief in conspiracy theories makes one part of a group, and so in a perverse way can increase social connection, while delusional beliefs are unique to an individual and serve to separate the individual from others.

But this distinction is fuzzy, and may be more one of scale rather than a clear categorical difference.  Those who endorse a conspiracy theory for example may experience improved relations with their fellow believers, but these beliefs at the same time cause problems in their relations with non-believers.  And while those with unique “delusions” do not have the possible benefit of improved relations with other believers, they may be seeking a kind of internal consistency, an improved relationship with other parts of themselves which now all agree on one “truth” however strange it may seem to outsiders.

Mainstream mental health approaches have framed “delusion” as inevitably the result of something wrong with the brain, but the rise of what seem to be outlandishly untrue beliefs in society generally supports the alternative notion that such beliefs can result from certain social and psychological dynamics, as individual minds and groups attempt to organize themselves in the face of threats and uncertainties.

Unfortunately, while these kinds of belief may be a response to perceived threat and uncertainty, they tend to create and spread more threat and uncertainty!  And while only individual “delusions” can lead to people being forcibly “treated” in attempts to change beliefs that are judged to be dangerous, it seems that the group-endorsed conspiracy theories are the greater danger, as they can motivate large groups of people to move in ill-informed directions that may endanger us all.

In addition to the ethical problems with use of force in attempting to change beliefs, there is also the problem where such efforts often backfire when people “dig in” to protect their autonomy and hold onto their belief even tighter.  So what else is possible?

Cognitive behavioral therapy (CBT) has developed ways of working in a friendly and collaborative way with people experiencing apparently delusional beliefs and paranoia.  This approach can help people learn to feel safe enough to re-engage socially and to resume life goals, and often to eventually drop the paranoia and the beliefs that had been impairing progress.

One way to learn more about this approach is in a live online seminar, Paranoia and Troublesome Beliefs: A CBT Approach that I’m offering on 6/10/22.  The early bird discounted price is $89.99 until 5/20/22, then $109.99.  CE credit is available.

We are all facing very uncertain times.  And a key difficulty is that some of what we feel certain to be true may not be, and sometimes powerful groups do conspire to do dastardly things while keeping the rest of us in the dark!  One positive thing about CBT for psychosis is that professionals do not have to take a position of certainty: rather, the emphasis is on collaboratively facing uncertainty and sorting out what is likely to be a positive direction.  I do hope some of you join this seminar and/or forward the information about it to your colleagues.

OK, this is changing the subject a little, but since I’m posting, I wanted to mention that I recently organized a webinar with two remarkable women, Gogo Ekhaya Esima and Emma Goude, who shared how they found their own approaches to working through strange experiences and uncertainties, ultimately finding a lot of value in the journey. The recording of this webinar is below!

You may have noticed that people diagnosed with psychosis are often encouraged to think of themselves as passive victims of their disorder. Psychosis is commonly framed as an illness that just comes into people’s lives, through no fault of their own. Framing it this way is often understood as the benevolent thing to do: “we don’t want anyone blaming themselves for what has gone wrong!”

But there’s a downside to this. When people see no role for themselves in what has been going wrong, they are also likely to see no possible role for themselves in getting things back on track. Instead, they naturally feel helpless, and despair can set in.

But what’s the alternative? Encouraging people to blame themselves for their mental confusion and psychosis seems unlikely to produce great outcomes!

Fortunately, some psychological approaches to psychosis, including cognitive behavioral therapy (CBT), have been developing a “middle of the road” alternative to either of the above. In this approach, emphasis is put on the way that both the world, and our brains (which we did not design) are quite tricky, and it is very easy to go down an unhelpful path. So there is no need to “blame” anyone for having gotten lost and confused; however, it is still possible, especially with help, to develop an understanding of what may have gone wrong and to take steps to correct mistakes.

This puts the person diagnosed with psychosis back into an active role, framing them as capable of making changes in thinking and behavior that can reduce or perhaps even eliminate any “psychotic disorder.”

This way of framing things, and of working with people, will be at the heart of each seminar in my upcoming series on CBT for psychosis.

This series starts on May 13th: information on the entire series, including details about how to register for the all of the seminars together at a discounted bundled rate, is available at this link.

Note that each seminar will be recorded and the recordings of the seminar will be made available to those who registered for 4 weeks following the seminar. But attending the seminars live will be required in order to receive CE credit.

When efforts to help backfire…..

One additional reason people with psychosis can feel helpless to do anything about their problems is because their efforts to make things better often inadvertently make the problem worse! This can also discourage professionals who don’t yet understand what is going on.

For example, efforts to “fight back” against voices often result in the voices being louder and more aggressive, and to the voice hearer feeling less in control. But giving up, and just becoming a helpless victim of the voices, or even a servant of the voices, doesn’t work very well either!

The CBT approach is to study what is going on with problems, map it out collaboratively, and then experiment with finding ways to truly make things better. It is often possible to identify how natural reactions to events have lead people into destructive “vicious circles,” but then also to identify alternative responses that can turn things around, leading to “virtuous circles” and possible recovery.

This approach does not require a professional who presents as fully comprehending “reality”: instead, it requires some humility, and a recognition that the world and our minds are too tricky and complex for anyone to claim certainty about what is happening. The CBT approach involves collaborative exploration of an uncertain world, aimed at discovering together some constructive path that can work for a particular individual.

So it is tricky, but there is reason for hope! I look forward to a time when everyone struggling with psychosis will have the chance to work with professionals who appreciate both the trickiness of the issues and the potential for people to make sense and to recover.

Anyway, please do contact me if you have any questions about these upcoming seminars, which I’m hoping will help make this approach become more available.

When mental health professionals encounter someone who seems to have “persecutory delusions,” they routinely assume there must be something wrong with the person’s brain, something that can only be treated by administering drugs. And to the extent that the drugs don’t work, it is often assumed that they must just live with a “chronic illness.”

Some have tried talk therapy approaches, but up till recently, the success rate seemed small, with most people not experiencing a lot of benefit.

That is why, over the past decade, Daniel Freeman and colleagues set out to develop a new cognitive treatment – translated from an empirically established theoretical model – that would produce large effect size reductions in persistent persecutory delusions. The primary outcome randomized controlled trial, published in the Lancet Psychiatry, reported success in reaching the aim of having 50% of patients experiencing recovery in their persistent persecutory delusion, and reported a treatment effect size several times higher than conventional CBT.

This approach reached its goals not by addressing delusions head on, but by addressing things that made people feel unsafe: things like sleep and worry problems, lack of self confidence, and patterns of avoidance that had become crippling.

In a webinar on 3/11/22, Daniel Freeman provided an overview of the principles underlying the development of the Feeling Safe programme; the theoretical model; a number of key empirical studies; the content and style of therapy, and the main randomised controlled trial outcome results. He argued that the Feeling Safe programme provides new optimism in the treatment of delusions. See below for a recording of that webinar.

About the presenter:

Daniel Freeman is a Professor of Clinical Psychology and NIHR Senior Investigator at the University of Oxford and a consultant clinical psychologist in Oxford Health NHS Foundation Trust. Professor Freeman’s research has focussed on using psychological theory to develop more powerful psychological treatments. He has also been pioneering the development of automated virtual reality treatments for mental health conditions. He is the recipient of the 2020 British Psychological Society Presidents’ Award for Distinguished Contributions to Psychological Knowledge. He presented the BBC Radio 4 series ‘A History of Delusions’.

Metacognitive Reflection and Insight Therapy (MERIT) is a form of integrative individual psychotherapy that seeks to assist adults diagnosed with psychosis to make sense and meaning of the challenges and possibilities in their lives and to find ways to manage these and direct their own recovery.

Building from advances in both cognitive and interpersonal research, MERIT seeks to expand the boundaries of cognitive-behavioral, personal centered and psychodynamic approaches to treatment by focusing on how persons make sense of their experiences of their own purposes and place in the world allowing the development of a sense of belonging to our larger communities.

In contrast to other approaches, MERIT focuses on core processes that should be present in a given session, rather than a predetermined curriculum. This allows for a therapy can be truly tailored to meet the needs of unique individuals in real world clinics while also unlocking therapists unique potential for creativity as they seek to jointly make meaning with the person diagnosed with psychosis.

I was happy to be involved in organizing a webinar during which Paul Lysaker presented the scientific basis for MERIT as well as detailed and inspiring descriptions of its practice allowing practitioners to begin to think about how to integrate this approach into their practice.

Paul H Lysaker has over 35 years of experience providing and supervising recovery oriented forms of psychosocial interventions to adults diagnosed with psychosis. He is also an active researcher and teacher with over 20 years of federal funding for projects related to recovery and the practice of psychosocial rehabilitation. This work has resulted in over 500 peer reviewed publications to date and several books. He is the primary architect of an emerging recovery oriented form of integrative psychotherapy: Metacognitive Reflection and Insight Therapy.

Paul also has a good sense of humor and a good appreciation of the difficulties people face, including the difficulties faced by those struggling with psychosis and those struggling to help them! So I hope you check out the video and let me know what you think of it.

When we feel sane, we believe we possess accurate ways of knowing reality. Hidden within this understanding however lies a curious circularity. When asked how we know our method of discerning reality is correct, we inevitably circle around to asserting that our method can be relied upon because it arrives at the correct result, and confirms what we know to be true!

But what if the whole circle is in error?

At times, we may become deeply skeptical, or even paranoid, and lose trust in that circle. Then, it may seem that solid ground disappears, and so we tumble in an abyss, or madness In this “cloud of unknowing,” it may seem that nothing is real, or that everything is real (since anything now has as much seeming claim to reality as anything else.) Or, overwhelmed by the infinity of possibilities, we may grasp onto some alternative “mad” reality, or swing from wildly positive to terrifying perspectives.

Since it was radical skepticism that led into the abyss, it may seem that climbing out would require a rejection of skepticism. But without deep skepticism, how can we question our mad perceptions or beliefs?

An alternative is to continue to value skepticism, but now in a flexible way that also allows for skepticism about skepticism itself. Then we can balance having definite perceptions and ideas about reality with an awareness that they may also be completely wrong.

Currently, the mainstream approach to helping the mad involves maintaining an absence of skepticism about dominant forms of “sanity,” paired with complete skepticism toward finding value in madness. But recovery might better be promoted by helpers who can accept the lack of a solid foundation for knowledge, and who instead promote a lively evolving dialogue in which all, including the mad, have something to contribute.

Below is a link to a talk on this subject I gave on 11/7/21, for the ISPS-US Annual Conference.

I hope you do check out the video, and let me know what you think!

“I would like to dedicate this award to all the other mad kids, to all the outsiders, the weirdos, the bullied, the ones so strange they had no choice but to be misunderstood by the world and those around them,” said Jason Mott, in his recent acceptance speech for the National Book Award.

I don’t think it is just a coincidence that it was a Black writer who made this point. Unfortunately, simply having skin color other than white is enough to make one an “outsider” of sorts in the US – and those pushed to the outside in this way may more easily develop insight into all those who are marginalized.

Those seen as mad or psychotic of course may be seriously lost and highly distressed, and this should not be forgotten. But what is seen as madness can also at times be something worth affirming, in the sense of affirming difference, and affirming resistance to oppression, a resistance to the forces that say we have to fit one mold or be dismissed as defective.

Another powerful Black voice writing about madness and oppression is that of La Marr Jurelle Bruce, whose recent book is titled “How to Go Mad Without Losing Your Mind: Madness and Black Radical Creativity.”

“Hold tight. The way to go mad without losing your mind is sometimes unruly.” So begins La Marr Jurelle Bruce’s urgent provocation and poignant meditation on madness in black radical art, How to Go Mad without Losing Your Mind: Madness and Black Radical Creativity, published in April 2021. Bruce theorizes four overlapping meanings of madness: the lived experience of an unruly mind, the psychiatric category of serious mental illness, the emotional state also known as “rage,” and any drastic deviation from psychosocial norms. With care and verve, he explores the mad in the literature of Amiri Baraka, Gayl Jones, and Ntozake Shange; in the jazz repertoires of Buddy Bolden, Sun Ra, and Charles Mingus; in the comedic performances of Richard Pryor and Dave Chappelle; in the protest music of Nina Simone, Lauryn Hill, and Kendrick Lamar, and beyond. These artists activate madness as content, form, aesthetic, strategy, philosophy, and energy in an enduring black radical tradition. Joining this tradition, Bruce mobilizes a set of interpretive practices, affective dispositions, political principles, and existential orientations that he calls “mad methodology.” Ultimately, How to Go Mad without Losing Your Mind is both a study and an act of critical, ethical, radical madness.”

You can buy “How to Go Mad without Losing Your Mind” from Word Up Community Bookshop/Librería Comunitaria here: https://www.wordupbooks.com/book/9781478010876

Or, for an eloquent introduction to the topic, watch this:

We now know that therapy can be helpful for psychosis. But there is still a lot of confusion around what type of therapy approach is helpful, and especially about how professionals can find training by experts in how to work with these experiences.

One thing I’ve done to remedy this is to put together a list of mostly online places that offer training in various approaches to psychosis. You can access that list here. I hope you get some use out of it, and pass this information on to others who may be interested!

Also, I recently offered a webinar on “Cognitive Behavioral & Related Therapies for Psychosis: Diverse Approaches to Supporting Recovery“

Here’s the description of what it covers:

People experiencing psychosis are often feeling stuck in bewildering mental states, and it’s easy for professionals to get lost when they attempt to help. This may explain why for many decades, the consensus among professionals was that therapy could not be effective for those with psychosis! Fortunately, research has emerged showing that cognitive behavioral therapy (CBT) as well as many related therapies can be modified to work reasonably well for people with various kinds of psychotic experiences.

This webinar will provide an overview of the research behind CBT for psychosis, and of the style and strategies used. There will then be discussion of approaches that can easily be integrated with CBT such as compassion focused therapy, acceptance and commitment therapy, psychodynamic therapy, mindfulness, family systems and dialogical approaches, and approaches developed within the hearing voices network. Resources for getting training in CBT for psychosis and related approaches will also be described.

This webinar was co-sponsored by Mad in America Continuing Education and by ISPS-US. You can find the recording of the webinar at this link (note you have to scroll to the bottom of the page to find it.)

When we go into severe mental health crisis, it can feel like a civil war inside, with various voices, demons, or other entities engaged in battle with each other. When the chaos is great, the idea that we might ever come back together might seem unbelievable.

One thing that can help though is recognizing that even when things are going smoothly, we still have different parts inside. And even when things are at their worst, we still have the ability to access something inside us that can guide us toward healing.

This is a subject that was explored in a webinar titled “Internal Family Systems (IFS) and the Inner World in Non-Ordinary States” that took place on Friday, Aug 6, 2021.

This webinar explored how IFS understands and works with people experiencing voices, visions, paranoia, and other non-ordinary states.

IFS posits that there is no such thing as a ‘Unitary mind’, indeed the mind is made up of multiple ‘parts’ who interact internally in the same way that we interact in external relationships. These parts can become wounded by life’s adversities, and take on extreme roles in order to protect the person from further wounding. Each of these inner parts holds its own unique feelings, thoughts, experiences and core beliefs.

A core tenet of IFS is that every part has a positive intent no matter how extreme their actions to protect the person.

IFS believes that under all these parts is a person’s ‘core Self’ and this Self cannot be damaged by life’s adversities and contains qualities of compassion and wisdom. Self is the natural leader of the system once parts are unburdened and trust Self’s leadership.

The IFS method promotes internal harmony by befriending parts and bringing healing to the parts who have been wounded.

About the presenter:

Stephanie Mitchell is a Level 3 trained IFS practitioner, psychotherapist, trainer and supervisor in private practice in Adelaide Australia. She specialises in working with complex trauma and experiences which often get labelled as ‘mental illness’. She is interested in how healing and change occur in the human to human relationship, within spaces of safety and acceptance and outside the constructs of diagnostic labels. Stephanie has almost a decade working in Mental Health settings including 3 years co-facilitating a Hearing Voices group.