‘We must help people to embrace their stubbornness’
An extract from ‘Why Psychosis is Not So Crazy’, by Stijn Vanheule.
29 October 2024
Psychotic experiences have a disturbing effect on a person. They force their way in, take over, threaten, efface, and show the unthinkable. They seriously challenge a person's sense of self, so seriously that the person in question can have the feeling that they have gone completely mad. Thoughts, emotions, and perceptions rush out of control through their mind, and manipulations that appear to come from outside create even further disruption. At the nadir of such an experience, it can often seem as though there is no way out.
Even so, psychotic episodes are not an end point. Yes, they temporarily deprive someone of the director's role in the film of their own experience world. Yes, they redefine both language and perception. Yes, they force one to accept a different mode of associative thinking, which can create confusion and plant a time bomb under one's faith in reality. But this does not mean that the bomb will always explode. By regarding psychotic experiences not as an end point but as a starting point, it is possible to defuse this bomb. How? By somehow finding a way to give expression to the unthinkable and the unsayable.
In one sense, psychotic symptoms are already doing this. They express in a cryptic manner at which point someone's mental world has lost its coherence. This is something that we need to take quite literally. Psychoses project a frightening version of reality on top of the ordinary film that plays in our mind. But at the same time, they also highlight the issues with which we are struggling. The nature and content of this struggle vary from individual to individual. For one person, the issue might be abuse that has been concealed for years; for another, it might be problems at work, the breakup of a marriage, or the seeming pointlessness of their life. Psychotic experiences shine light on these concerns, not in the form of logical thoughts, but as a horror scenario or vision. Moderating the effects of this experience takes time, a willingness to search, and plenty of realignment.
In these circumstances, it takes courage to continue seeking new connections, notwithstanding the looming presence of threatening experiences. In their own way, all the people whose stories I have discussed in this book are courageous. In one, this courage finds expression through philosophizing; in another, through creative design, by saying "no" to the expectations of others, by creating a medieval world in which to live, and so on. True, none of them have found the ultimate solution, because the ultimate does not exist. However, they have all demonstrated that it is always beneficial to describe psychotic experiences, to listen to them, to investigate them, and to transform them into a lifestyle that can express a person's unique individuality.
Epilogue
If you ask (former) patients who have been affected by serious forms of psychosis what most helped them to recover, the answers will be surprisingly familiar for most people, even for those who do not work in mental health care. The things that really make the difference include everything that can give purpose and meaning to life: connectedness with others, hope for a better future, a suitable role in society, control mechanisms to keep further confusing experiences within limits, escape from the poverty trap, and a release from the stigma and prejudice as sociated with psychotic conditions.
In other words, things that are not so very different from what everyone else wishes for. Ninety-nine percent of the population have never experienced a serious psychotic episode and have never been affected by mental disintegration and the resulting anxiety, fear, and loneliness, but they have the same desire for connectedness, hope, and self-control over their lives.
The problem with psychotic experiences is that they wipe out so many of the things that are familiar and recognizable. They are logically unpredictable and incomprehensible, have an alienating impact, and can generate inexplicable fear. As a result, these experiences do not fit into the "normal" story of how we think about ourselves and others. People with psychotic experiences therefore might seem to be very different from the rest of us. But that is not the case. It is simply that their story is temporarily in crisis. They are flirting with the borders of what is humanly bearable, but it is precisely in their struggle to deal with these supremely difficult circumstances that you can see in exaggerated form all the struggles that make human beings human.
What can we learn from this in terms of our approach to helping people with psychosis?
The first important lesson is that a person's surrounding environment must respond calmly and receptively. The fear and despair generated by psychosis cannot be resolved by a display of power or some other anxiety-induced reaction. Using words, it is important to seek connection and attempt through conversation to find answers that can offer solutions for all that person's concerns, whether great or small. Without connectedness and relationships of trust, it is very difficult for a person with psychosis to reconnect with surrounding narratives and reestablish their grip on reality. Jaakko Seikkula, a Finnish psychologist with a background in both family therapy and psychoanalysis, regards dialogue as the most important medicine for psychosis. He argues that in this respect mental health professionals must be most accessible. Providing continuity in the care process and creating a safe climate in which the psychotic crisis can be discussed openly and honestly are their key tasks. Often, it is also useful to involve close friends and family members in this dialogue, since the problems that a psychotic episode reveals and perpetuates are often rooted in people's social networks, as are the potentially stabilizing factors. The stories that are told in these networks are many- voiced. Listening to these voices and processing what they have to say is crucial.
In addition, caregivers must, of course, provide a safe refuge, where the people are given time to be and to search for answers. This kind of safe base is of huge importance for reconnecting with kindred spirits and the outside world. For this reason, mental health care initiatives would be wise to create warm and welcoming environments, with an unforced atmosphere and flexible operational procedures that allow those they help the opportunity to pursue the things that interest them.
What about medication? In view of the fact that roughly a quarter of those who take appropriate medicines report a beneficial effect, in the sense of helping to reduce the impact of psychotic experiences or even eliminate them altogether, it seems sensible to consider their use. At the same time, it needs to be realized that antipsychotics are not a miracle cure. It is only via a process of experimentation and learning, following close consultation between the doctor and the patient, that it will eventually become possible to discover what works for that patient and what does not. In particular, it is vital to bear in mind the possible impact of side effects, such as drowsiness, dizziness, or the urge to move. These side effects must be kept in proportion and must not outweigh the other, beneficial effects of the drug.
Is talking therapy a viable alternative? As I make clear in my book, psychotic experiences are deep crisis experiences incurred by people who can no longer find the words to express overwhelming events. In this respect, therapies that can help us to identify and anticipate the threatening situations to which they offer an answer are especially useful. This is particularly the case if they create the necessary room to search for elements that can generate renewed powers of expression and connectedness. This requires therapists who are skilled in dealing with anxiety and powerlessness, both their own and that of others. They must also be capable of creatively exploring the meaning and the paradoxes of psychotic experiences.
There are no miracle remedies for treating psychosis. It is with good reason that Annie Rogers says that the real art of overcoming psychotic experiences resides in giving a place to knots in your mind that you cannot unravel and to twists and turns in your thoughts that remain devoid of meaning. Passion and creativity can facilitate this, as can contacts with kindred spirits and other like-minded people.
Let us embrace this freedom together.
Photo: Patrick Cohen
