Find a therapist to treat psychosis

People with psychosis are trying to communicate with us as providers.

We aren't always able to listen.

Our own anxiety prevents us from staying curious.

“If you don’t take the injection, your parents aren’t going to let you come home after what happened this week. You’ll be on the street,” I say to the young disheveled man in front of me.

“If you don’t accept me as Jesus, your one true savior, you will burn in hell for all time.” Ben is looking at me with what seems to be the same concern I am feeling for him.

“But Ben, what’s the harm in just taking it? I mean, what if I’m right, and you’re wrong? The stakes are so high for you.” I shudder, thinking of what will happen to this confused, gentle, psychotic kid if he truly becomes homeless on the streets of Philadelphia.

“But if I’m right, and you’re wrong, you burn forever. The stakes are higher for you than they are for me.”

Alone in the room with my patient, our realities clash. My version of Ben as a mentally ill young man on the precipice of homelessness is no more defendable to him than his version of himself as the Messiah is to me.

I’m trying to help Ben, right? I’m worried about him. I’m offering him a treatment that will make him see that he is not Jesus so that he is less erratic at home, so he can stay there, maybe get a job, maybe start dating, having friends. I want the best for him, don’t I?

I’m not listening to him.

He is trying to tell me something. And I am dismissing it to push my agenda.

He wants to help me too. It’s important to him that he has something to offer me as well. I won’t accept it.

He doesn’t want to stop believing he is Jesus. He is communicating that to me as clearly as he can. I’m insinuating his wants don’t matter.

I am telling him, with all the authority of my M.D., my degrees hanging on the wall above us, the office we sit in, the years I have on him, that his reality is invalid and mine is the only one of value here.

And so he is choosing to execute the only power I am willing to grant him, the power to refuse the medicine.

I can also take that power away from him. I can have him locked up on an inpatient unit. I can take him to court to allow forced medications. I can force him to accept my reality, even if only through a chemical haze.

Why can’t I listen to him? Listen without arguing, without judging, without acting?

Why can’t I try to understand what he is trying to tell me?

Let me be clear. If it were just a matter of breaking the spell—giving Ben a medication that would change his perception of himself and the world back to how it used to be before his psychosis started—I would do it. If all he needed was a few months of an antipsychotic to bring him back to consensual reality, even if he fought me tooth and nail to avoid it, I would do it. In my fantasy, perhaps he would then be grateful, thankful that a pill could keep away those confusing and seductive thoughts, and allow him to move on with his life. If that was all it took, I would make him take the medication. I would convince myself that it was the lesser of the two evils.

Find a therapist to treat psychosis

But Ben has been on and off medication for years now. When he’s on antipsychotics, he’s not Jesus, but perhaps an archangel. And sedated, and gaining weight. And never grateful. And again and again, he goes off the medication. Even when the symptoms have essentially abated. Even when I can no longer pretend to myself that he is too psychotic to make the choice about medication, he chooses psychosis over meds. Why? Why is that his choice? And why can’t I hear it? Why can’t I just listen?

As a field, we have a curious inability to contend with the question of why some people keep choosing psychosis. Harold Searles, a psychoanalyst who worked for decades with very psychotically ill patients, suggests that we as providers must ask “a basic philosophical question of whether sanity or psychosis is the more desirable mode of existence. This question seems at first glance idiotic, and on more prolonged thought very disturbing. To the degree that the subjectively healthy therapist goes on obviously trying to rescue the perceivedly damaged and afflicted patient, the therapist is shielding himself from asking himself, seriously, that question” (Searles, 1976).

The implications of the above quote are unsettling. One partial answer, I believe, is that our difficulty tolerating both our patients’ psychotic communications and the issue of why they sometimes choose psychosis over “sanity” is linked to our own anxiety invoked by our patients’ insistence on their own version of reality. Analysts understand that beneath the defenses of a psychotic reaction is a terror of disintegration called annihilation anxiety. All humans feel this anxiety on some level. People refer to it obliquely as a fear of “going crazy,” or “falling apart,” or “having a mental breakdown.” It is visceral and disorienting, and we defend against it at all costs. Sometimes it is too terrifying to just listen; “reality” creaks and cracks under any real scrutiny. We can’t stomach the uncertainty of it. I assume that it was partly this anxiety, years ago, that made it so difficult for me to listen to Ben in that moment, and makes it so difficult for providers everywhere to listen to their patients with openness and curiosity instead of agitation. It is an anxiety that leads us to fail our patients who are in need of our bravery in the face of their own annihilation fears. Well, we need to get braver. Our patients are trying to tell us something.

Searles, H. F. (1976). Psychoanalytic Therapy with Schizophrenic Patients in a Private-Practice Context. Contemporary Psychoanalysis 12:387-406.

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