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.

Have you ever met people who reported that “asking too many questions” was what seemed to have led them into madness?

Or maybe you noticed yourself that the more you looked into the deeper aspects of existence, the more paradoxical, and maddening, reality seemed to become?

If these sorts of issues interest you, and if you think understanding them may help us provide better help to people who are struggling, then you may want to view this recording of the webinar “How Can the Uncontainable Be Contained? Paradoxes of Madness & Philosophy:”

In this talk, Wouter explains a bit about himself, and how he came to write the book, and gives an overview of its main arguments and perspectives. He presents three text fragments, pertaining to both philosophy and madness, that address the themes of nothingness, infinity, and fragmentation, then shows a 13 minutes video, “Unravelling Reality,” that lets these themes come to life in a modern, metropolitan setting (that is, Brussels in Belgium), and also engages in dialogue and discussion with an audience.

About the presenter: Wouter Kusters (1966) obtained a Ph.D. in linguistics and earned an MA on the philosophy of psychosis. In the Netherlands, he is known for his books on the experience of psychosis and its relation to philosophy. For his Pure Madness (2004), and A Philosophy of Madness (2014), he won the Dutch Socrates Award for the best philosophy book of the year in Dutch. The latter has recently been translated into English (2020, MIT Press). Wouter Kusters works as an independent writer, researcher and teacher in the Netherlands, see: https://kusterstekst.nl/. “…madness is less about living in another private bizarre reality and more about living in our ordinary reality but then stumbling on problems that are hidden in (or ‘under’ the pavement of) ‘realism,’ and being haunted by them, which grow the more attention you pay to them.” “Now, an important difference for many ‘madmen’ is that they just find themselves in these abysses, without preparation, with no language or tools to navigate there, with no others, and without any sense of freedom within the fall. The seduction to reduce it to a psychological crisis, or even a neurobiological crisis is then overwhelming — and from a practical point of view it is quite prudent to do so. Nevertheless, many of the questions and problems that continue to haunt those deemed mad or psychotic have nothing to do with a personal or neurological problem, but all with the greater questions. Being in a condition of madness means you are trying to resolve the most fundamental questions of existence, but in an uncontrolled, wildly associative way. You want to know what it’s all about, what good and evil are, what is at the very heart of existence: you want to know the meaning of life and the cosmos. “ Those two quotes are from https://www.madinamerica.com/2021/04/wouter-kusters/

In a talk linked to below, award winning medical journalist Robert Whitaker reviews the science that indicates the need for a radical change in psychiatric care, and describes pilot projects that tell of a new way.

Starting in the 1980s, our society organized its thinking and systems of care around a “disease model” narrative that was promoted by the American Psychiatric Association and the pharmaceutical industry. That narrative has collapsed. The biology of mental disorders remains unknown; the diagnoses in the DSM have not been validated as discrete illnesses; the burden of “mental illness” in our society has risen; and there is an increasing body of evidence that tells of how psychiatric drugs, over the long-term, increase the chronicity of psychiatric disorders.

The collapse of that paradigm provides an opportunity for radical change. In Norway, the health ministry has ordered that “medication—free” treatment be made available to psychiatric patients in hospital settings. A private hospital in Norway has opened that seeks to help chronic patients taper from their psychiatric drugs, or to be treated without the use of such drugs. In Israel, a number of “Soteria” houses have sprung up, which provide residential treatment to psychotic patients and minimize the use of antipsychotics in such settings. Research into Hearing Voice Networks is providing evidence of their “efficacy” for helping people recover. Open Dialogue treatment, which was developed in northern Finland and involved minimizing use of antipsychotics, is being adopted in many settings in the United States and abroad.

About the presenter: Robert Whitaker has written three books on the history of psychiatry: Mad in America, Anatomy of an Epidemic, and Psychiatry Under the Influence (the latter book he co-authored with Lisa Cosgrove.) He is the president of Mad in America Foundation, which—through its webzine, radio podcasts, continuing education webinars, and town halls—promotes an exploration of these issues. He is also on the adjunct faculty at Temple Medical School, in the psychiatry department.

When people talk about finding something of value in “mad” or “psychotic” or “extreme” experiences, they are usually accused by those in mainstream psychiatry of “romanticizing an illness,” and overlooking how disruptive and distressing these states can be. But when only the negatives about mad experiences are noticed, the focus goes to attempts at suppression, despite increasing evidence that attempts at suppression can contributes to long term dysfunction.

In an ISPS-US webinar – Exploring the Promise and the Pitfalls of “Mad Pride” – I explored a middle ground approach, which balances an awareness of the hazards of mad experiences with a willingness to notice what might be positive about them. Starting with a more open mind, it becomes possible to help people to eventually understand their experiences in life promoting ways, rather than being stuck in either avoiding and suppressing them or being overwhelmingly immersed in them. Methods of applying this approach to improving interactions with “mad” people, and with the “mad” portions of our own minds, were discussed.

Check it out for yourself!

What are the relationships between the experiences caused by psychedelic drugs, and those we call “psychosis?” And what are the relationships between both those types of experiences, and experiences that seem to be a “spiritual awakening?”

There may be a number of answers to those questions. Many different perspectives were shared and discussed at an conference, titled Psychedelics, Madness, & Awakening: Harm Reduction and Future Visions. This conference was held January – April 2021, and the recorded videos can be found on the website (click on the “schedule” tab, then select a panel, then scroll to the bottom of the page to find the videos.)

I was one of the panelists, I talked about ‘Revolution Within the Mind: A Common Factor in Psychedelic Experience, Madness, and Spiritual Awakening.’ Check out the video:

Voice hearer Dmitriy Gutkovich defines “a positive voice ecosystem” as a state of mind where voice-hearers talk to friendly voices, on enjoyable topics, and only when they are not busy. For those voice hearers who do not want to or can not get rid of their voices, creating such a state of mind is key to reducing distress and moving toward a desired lifestyle. After a decade of lived experience and community leadership roles, Dmitriy Gutkovich has completed a book to help voice hearers achieve harmony with hostile voices and to avoid confusing beliefs, all while maintaining physical community. The book’s title is Life with Voices: A Guide for Harmony.

He also offered a webinar on this topic, which you can find here:

Among the strategies presented in the webinar are understanding the motivations of distressing voices, defending against their attacks on attention and happiness, and navigating the relationships into harmony rather than hostility. Listeners also gain insights on how to explain the hearing voices experience, and how to recruit a physical community that helps voice hearers, rather than causing additional pain.

Whether you are a voice-hearer, a family member, a friend, an academic, or a provider, this webinar aims to deepen your understanding, and to teach you the core skills for navigating, a life with voices.

About the presenter:

Dmitriy’s journey to help the hearing voices community has earned him leadership roles in 4 nonprofits (Hearing Voices Network USA, ISPS-US, HVN-NYC, and NYC PWC), an advisory role for the Yale Cope Project, and to being a coach, facilitator, and advocate for the hearing voices community.

His main projects include celebrating the stories of those with lived experience, and creating a forum where those with lived experience can share their tools and strategies for improving quality-of-life.

While the experience of psychosis can be highly distressing, many who recover report that the treatment was often worse than the psychosis itself. What is it that goes so wrong with treatment, and what could we do to improve efforts aimed at helping?

In a webinar titled “What Hurts & What Helps in Treatment for Psychosis:  Insider Perspectives” (see below for the recording) two “experts by experience” reflected on their own experiences of treatment and on what eventually worked better. They also discuss attempts to get professionals to be more open to learning from the experience of those who have undergone treatment.

About the presenters:

Brenda Froyen is a motivated teacher/educator in language didactics and children’s literature. Besides her passion for education she is active in the field of mental health care, organizing conferences and giving lectures and workshops based on her own experience as a patient. Her writing skills have resulted in several books including Psychotic mum: an inside story, editorials in newspapers, and in the website www.psychosenet.be, one of the pioneer projects concerning E-health care in Belgium. For three years she was part of the Belgian Superior Health Council who formulated advice on the DSM5. Brenda is constantly looking for new ways and initiatives to improve the quality of mental health care and education: two fields that have a lot more in common than one might think.

Dmitriy Gutkovich is an activist for those with hearing voices lived experience. In addition to facilitating weekly groups for those with lived experience, Dmitriy sits on the boards of HVN NYC, HVN USA, and the NYC Peer Workforce Coalition, and is chair of the ISPS-US Experts-by-Experience Committee. His main projects include celebrating the stories of those with lived experience, and creating a forum where those with lived experience can share their tools and strategies for improving quality-of-life. He is also a loving husband and hard-working professional.

When people are told they have “psychosis,” it’s usually because they are experiencing one or both of the following:

• “hallucinations,” defined as sensations that don’t seem to have any physical cause, and
• “delusions,” defined as beliefs that don’t agree with others in one’s culture and/or with physical reality.

Thanks to the revolutionary impact of the Hearing Voices Movement, many people around the world are now able to think of the experience of  the first phenomena, “hallucinations,” as something much broader than just as part of a “psychosis.”  In fact, even the term “hallucination” has been questioned, with less medicalized terms like “hearing voices” and “seeing visions” proposed instead.  And it has been asserted that hearing voices itself should never be defined as an illness.  Instead, hearing voices is conceptualized as a human variation, like being left handed or gay.  It is understood that people may have problems with the voices and may need help figuring out how to relate to them, but once the relationship has been improved, the experience may change to something that is overall benign or even beneficial to the person.

Unfortunately, less attention has been brought to that other key component of psychosis, the “delusions.”  And yet, the need for a revolution in how they are approached may be just as intense.

Sometimes, revolutions start with changes in understanding.  One area to begin with might be the notion of a firm distinction between hallucinations and delusions.  Hallucinations are understood as disorders of perception, while delusions are understood as disorders of conception: but in practice conception plays a big role in perception, and vice versa.  For example, consider the difference between thinking that an external force is controlling one’s thoughts (classified as a delusion) and “hearing” thoughts that seem to be coming from outside one’s mind (classified as a hallucination.)  Are these two really that different?  Or are they better thought of as on a continuum, with some experiences in the middle and not easily classified as one or the other?

The history of the distinction between hallucinations and delusions is explored in the article Voices, Visions and ‘Persons Under the Floor’: ‘Delusions’ and ‘Hallucinations’ in Nineteenth-Century Psychiatry.  It notes that the belief in a clear distinction between the two was not always present, and that our imagining that there is a clear distinction can make us insensitive to the lived reality of people’s experience.

In hearing voices groups, the lack of a clear distinction between perceiving a different reality, and conceptualizing or believing in a different reality, is often understood, and so alternative ways of relating to “unshared beliefs” have been developed alongside alternative ways of relating to voices.    But these alternative approaches to working with troublesome beliefs have not received as much publicity as have approaches to hearing voices.

One example of a person working to change that is Rufus May.  At age 18, Rufus became convinced that he was a spy and that a device had been planted in his chest.  His beliefs were treated in the conventional way by the mental health system:  he was diagnosed with “schizophrenia,” hospitalized, and drugged.  But Rufus decided not to believe in the diagnosis and the drugs, and he eventually found his own way to regain control of his life.  Then, using undercover skills which he had previously just fantasized, he infiltrated the mental health system, keeping his psychiatric history secret as he completed his training as a psychologist.

With his training complete, Rufus shifted to being open about his history, and became an effective advocate and educator for alternative approaches.  And while some of his efforts have been around alternative approaches to hearing voices, he has also written very coherently about alternative approaches to working with difficult beliefs. for example in his article Accepting Alternative Realities.  He also explored that topic in a recent webinar, Believe It or Not! Ways of Working with “Delusions” or “Unusual Beliefs”  (See the link at the end of this post.)

One reason I believe Rufus is a great teacher on this topic is due to the degree of flexibility, creativity, and respect for people that he brings to the work.

A key issue with “delusions” is that people are often holding beliefs in a rigid manner:  this tends to prompt those around the person to become unhelpfully rigid in return.  In conventional mental health treatment, this rigidity involves insisting that the person “get insight” into the “fact” that their belief is a delusion and is a sign of the presence of a “mental illness” like “schizophrenia.”  This rigidity is maintained despite evidence that many ideas about “schizophrenia” may be as untrue as any “delusion,” and despite extensive evidence that confronting any strongly held belief in a rigid way tends to make the person holding the belief dig in and defend it more.

I’ve been practicing CBT for psychosis for many years, and CBT does have some ways to approach “unshared beliefs” in a less rigid way.  But there is still a tendency in much CBT literature to emphasize attempting to change the belief seen as troublesome.  That is sometimes possible, and work around reconsidering beliefs can be important, but it is also sometimes not possible or not the most helpful approach.

In many cases, it can be more helpful to work on things like understanding the life experience that led to the belief, exploring the possibility of living successfully even while continuing to have the belief, and/or looking at the belief as a possibly metaphorical message about something that needs attention, and then shifting the focus to that area.

A couple years ago I had a chance to hear Aaron Beck, a key founder of CBT, speak about his understanding of how to approach apparent “delusions.”  It may be common for older people to be rigid in their views, but I was pleased to find that Beck, then age 97, was advocating for a more creative direction.  He was asked for example how he might respond to a man who was claiming to have been roasted in an oven.  Beck said first he would acknowledge the man’s story, and be curious about what that experience was like, how it felt etc.  Then he would ask about other times in the man’s life when he may have felt that way, and then inquire about whether anything currently was making him feel something similar.  In other words, he was saying it might make more sense to follow the vein of emotional content to where it might connect with the man’s past or current issues and distress, which then could be addressed directly.  That could be way more effective than simply trying to change beliefs.

Too often in conventional mental health treatment, once people express a belief that seems “insane,” there is just an effort to suppress the belief, rather than to really understand where the person might be coming from, and what their most important concerns might be.

Another example Beck gave involved a man who told hospital staff that his psychiatrist was a threat, and revealed that he wanted to shoot the psychiatrist.  In a conventional setting, this would be seen as a sign of the worsening of a dangerous psychosis, and an increase in antipsychotic drugs, by force if necessary, would have been seen as the solution.  But in this case, the psychiatrist had been trained to proceed with more sensitivity and flexibility, so instead of treating it as a symptom, he asked the patient, “why do you want to shoot me?”  The patient responded, “because you are planning to shoot me!”  “But,” the doctor explained, “I don’t even own a gun!”  “Well,” said the patient, “you use your drugs like a gun.”  The doctor thought about it and said, “I wonder if you are feeling you have very little control?  That must be frustrating.  But I know you must have lots you want to do outside of here and I want to help you get out so you can do that!”  This made sense to the person and they started to work together.

In the hearing voices movement, it is often pointed out that the voices may be “poor communicators” and that working things out with them may require considering alternative interpretations of what they are saying, until a more constructive meaning emerges.  For example, a voice that tells someone “you need to die” may be better understood as a part of the person saying that “something is wrong, you need to change something” or “you need to let something about you die.”  Once the message is properly understood, it becomes something helpful rather than destructive.  The voice hearer can learn to be like the parent who hears the child say “I hate you” but is able to infer that the child needs some love and a nap, rather than taking the statement literally.

One interesting thing about “delusions” is that people can be disturbed by their own beliefs:  that is, they can find themselves falling into a belief, but sense there is something wrong with the it at the same time.  At that point, they are like the voice hearer who hears a message that seems disturbing, but which they are also starting to believe.

A key skill people need to learn is discernment:  sorting out what might be a valid message in the belief or in what the voice is saying, while dismissing what might be exaggeration or a too literal interpretation.  This allows them to resolve the situation by believing the helpful part of the message, while disregarding the rest.

At other times people are not at all disturbed by their belief, but their having the belief does become disturbing to others.  At that point, the person with the belief is, in relation to us, like the voice is in relation to the voice hearer.  The person is saying something, and we must decide how to respond to it.  Do we see them as the enemy, and someone whose views simply need to be suppressed?  Or do we consider the possibility that while the person may be a poor communicator, there may be some valid message in what they are trying to communicate, even if we can’t agree with all of it?

To develop an adequate approach to difficult beliefs, it is also important to think more broadly about the nature and function of beliefs in general, and to understand how all humans tend to “behave irrationally” around their beliefs when those beliefs become important to their world view and their identity.

Beliefs are often a tribal kind of thing:  people may believe something to fit in with others, not because of logic.  Having a tendency to do so may benefit individuals in an evolutionary sense, because it makes the individual more likely to get along with others in their social group.  (This works, of course, only when the belief is not so destructive as to lead to the extinction of the entire group:  it remains to be seen for example how the “tribal belief” in the non-existence of the climate crisis, popular in many quarters, will affect the evolutionary viability of humanity.)

Curiously, psychiatry identifies only untrue beliefs held by one or at most a few people who are at odds with their culture as having mental health problems, and doesn’t consider the possibility that beliefs held by larger groups or even entire cultures may be even more of a problem – even though the dangerousness of a belief tends to increase the more people endorse it!

(If psychiatry were more able to recognize the “pathology” of widely held beliefs, it might for example be more able to reflect on the damage done by beliefs it has itself promoted, such as the one about how “mental disorders” are caused by “biochemical imbalances.”)

But, one might ask, if people often hold beliefs just to fit in with their group or tribe, why do some individuals seem to go their own way and choose beliefs that put them at odds with their community?

One answer may be that when a person’s life does not seem to them to be working out, they may be motivated to try on different beliefs, sometimes desperately grabbing on to whatever seems to offer some chance at inner coherence amid chaos and disruption.  Once a belief that seem to help restore internal order is found, the person may be reluctant to let go of it, even when that puts them at odds with their culture and gets them labeled “psychotic.”

It is also true that evolution would never work if there were not genetic variations, and cultural beliefs can never evolve unless we have people trying on different perspectives.  Much variation in belief may be just a part of human diversity, and not a problem that needs to be solved.  A skilled approach to working with beliefs involves both toleration of differences in perspective, with an awareness of a variety of possible things that can be tried when a belief is causing problems that do not seem to be tolerable, either to the person or to others with whom they must interact.

There’s a lot more that could be said about this topic:  this post just scratches the surface.  To go a little deeper into it, consider viewing the “Believe It or Not” webinar:

Topics covered include

• understanding the protective function of beliefs,
• understanding how they may be linked to past life events,
• ways to be with someone with different beliefs, and
• if someone is motivated to hold their beliefs more lightly how we might help them with this.