Our Treatment of Psychosis is Thoroughly Wrong

August 15, 2016

After decades of practising as a psychotherapist, I am convinced that our treatment of psychosis is thoroughly wrong-headed.

What do you think of hallucinations? Do you wonder how they work? Recently I talked about this with a woman I know well, who was experiencing some as we spoke. Her hallucinations included ‘bugs’ – microphones that she saw scattered around the room that she assumed had been put there because she was coming in, by people who wanted to keep track of everything she said, and might hurt her at any point. She could see the bugs, but I could not.

Martha is in her mid 30s. Her bright blonde hair is natural. She sat on one side of a corner from me, her body tense and passive at once, the odd mixture one sees with people who are gripped with inner distress but whose musculature is flattened out by atypical antipsychotics. She carries the tight, extra weight that also accompanies those drugs. Her eyes are shy and furtive, checking the room, checking my face.

She is a very intelligent person and is vexed by people telling her that such things are not real. She cannot doubt her senses, and she sees them. (I say: ‘I agree. I don’t doubt my senses either.’) Same thing with the voices speaking to her on the turned-off radio. She understands that I do not see and hear these things, but she does.

She frames a question that carries deep implications of challenge and shame: ‘Do you think they are real?’

An answer came out of my mouth that I had never quite thought before, but as I heard the words, they seemed true: ‘It’s not as simple a question as we usually think. We usually think that whatever we perceive is what is there. Perception equals reality. But research shows that every perception we have is actually constructed by the unconscious mind, which then instantly hands it to consciousness.

What the unconscious mind uses to do this constructing is largely sensory stimulations. We grasp this information with our senses, we process it with our brains unconsciously, and the product enters our consciousness. Because we all share this sensory world, we do very similar unconscious constructing. We can both look at a lamp like this one and see the same lamp, as far as we can ever know. It’s easy to say, this lamp is real.’

Martha trusts me. She is hanging in with this.

‘However, sensory information isn’t all the unconscious mind uses to create experience. If a concern or issue is pressing enough, that becomes raw material, too. If a person, like you, is dealing with a huge amount of fear, if you are in the middle of a withdrawal syndrome from Geodon and Seroquel, your brain is hugely agitated. What if you also grew up with an amazing amount of secrecy and danger and abuse?’

I could see in Martha’s face that she was remembering some of the things she had told me.

‘Agitation feels like danger and danger brings up hurt and shame. These things get factored in too. All unconsciously. You perceive the same lamp and room as me, but some additional things, like the bugs. It’s not that the lamp is real and the bugs aren’t, it’s that your constructed reality has some things in it right now that my constructed reality does not. It’s not that my version is real and yours isn’t. They’re both real, but both constructed, only out of somewhat different materials.’

She answered thoughtfully: ‘That seems true.’

I said then: ‘I think that when we have done more work on your terrible memories and on danger and shame, and all that is more out and somewhat neutralised, you’ll have an easier time getting off of Seroquel.’ Seroquel is a cause of weight-gain, so a big priority for her.

‘Yes, probably,’ she said, then changed the subject to tell a very private story that revealed, in a new way, the dreadful danger of her parents. We talked about it in depth, then at the end of the session I thanked her for the story (which she had never told to anyone before). She thanked me for listening.

Talk of suicide, which had begun our meeting, was gone for now.

If you are unfamiliar with the standard treatment of psychosis – drug treatment, almost exclusively – you won’t understand what an odd approach I took with Martha in this interaction. Most of modern psychiatry dismisses the idea that psychotic experience is a meaningful response to the condition of one’s life in favour of the view that the voices, the visions, come from meaningless disease.

By contrast I’ve learned to distinguish between the ravages of chronic psychotic disorder in the long and persistently afflicted, and the kind of acute aberrations experienced by Martha, which can usually be better understood as a ‘spiritual emergency’ instead of an impersonal state of disease.

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