Psychosis results from a
complex combination of biological and psychological causes which may respond to different treatments. Medication can
help with biological factors. Psychotherapy addresses the thinking and emotional side of a person, which includes psychological
vulnerabilities a person might have had prior to their first psychotic episode, and psychotic symptoms which endure afterwards.
Psychotherapy is my focus. In my view and the view of many other clinicians, whatever their biological underpinnings,
psychotic symptoms have a psychological meaning.
Psychotic experiences occur along a continuum with
ordinary mental life, but unlike mental states such as dreams, which are familiar to all, most people see few similarities
between psychotic symptoms and their own experiences. Take for example the experience of hearing voices, which is common
in psychosis. This symptom can be considered a special case of the capacity most people have to engage in an internal
dialogue, where one part of the mind ‘speaks’ while another part ‘listens.’ For example, the
runner approaching the finish line may say to himself/herself, “Just fifty yards more!” In like fashion,
a psychotic person might hear a voice offering direction or criticism. We all engage in internal dialogues.
In the case of voices, the psychotherapist might interest the patient in the idea that hearing voices is a particular form
of internal dialogue, similar to, but different from, the internal conversations we all engage in.
In the case psychotic symptoms such as hallucinations and delusions, telling the
patient “It isn’t true” is rarely, if ever, a useful approach, because these experiences are part of
the person's subjective reality. My work is person centered rather than diagnosis centered. I attempt to establish
a good faith conversation with the psychotic person about experiences that person finds distressing. Then, with the
aim of reducing that distress, I attempt to explore with the patient alternative explanations for psychotic symptoms.
For example, in the case of a person who hears a critical voice that he believes is a frightening, powerful entity outside
himself, psychotherapy might lead to the alternate explanation that the voice is a meaningful expression of the patient’s
own self doubts, where talking about those doubts can now become a focus for emotional growth. In the early
stages of psychotherapy for psychosis I use CBT techniques to explore the literal falsity of maladaptive, delusional
beliefs; then, I use a psychodynamic approach to examine the figurative truth of psychotic symptoms that express
personal meaning for the individual. A more detailed outline of my approach is contained in my book, Psychotherapy
for Psychosis: Integrating Cognitive-Behavioral and Psychodynamic Treatment (2019) Guilford Press