When working with people with psychosis, a compassionate approach is critical, given the high rates of trauma history and the trauma that can be experienced as a result of psychosis symptoms. In some cases, the treatment of psychosis itself can even be traumatizing (for example, being brought into treatment involuntarily by the police).
Given the often extremely isolating nature of the experience of psychosis, an approach that has at its core the appreciation of the ubiquity of suffering and our common humanity encourages connection between the client and therapist. A normalizing approach, including the metaphor of therapist and client as co-travelers, is implicitly humanistic, destigmatizing, and depathologizing. This understanding of the therapeutic relationship enables the client (and clinician) to experience a greater sense of connectedness. In their model, the therapeutic relationship is oriented toward wellness versus illness and strengths versus symptoms or pathology, and it emphasizes recovery, values, and pursuit of valued life goals.
One such example of this type of approach, based on CBT for psychosis, was developed by Nicola Wright, Douglas Turkington, and the other authors of Treating Psychosis: A Clinician’s Guide to Integrating Acceptance and Commitment Therapy, Compassion-Focused Therapy, and Mindfulness Approaches within the Cognitive Behavioral Therapy Tradition. Their approach emphasizes a deep and sophisticated understanding of the experience of psychosis rather than a superficial attempt at “challenging and eradicating” the client’s symptoms. It focuses on the process and function of thoughts and behaviors. For example, they emphasize investigation into what purposes worry, rumination, and attention to threat serve for the client, and what are the client’s beliefs regarding the pros and cons of each?
The therapeutic alliance—which was recently shown to be a powerful determinant in treatment outcomes with psychosis clients—and goals are based on the client’s values and valued goals in therapy that are synergistic with the overarching model (and the clinician’s values). This yields an increased focus on the integration of values and one’s experience of self and relationships in the therapeutic work. The therapeutic approaches are used by both the client and the clinician—for example, the clinician engages in mindfulness practice and incorporates a mindful approach to self and the client in the therapeutic relationship (Siegel, 2010). Thus, a beautiful synergy emerges as the therapeutic relationship is implicitly, in and of itself, an empowering and emotion-regulating relationship within which the client is able to strive for optimal well-being.
A number of issues can come up in therapeutic work with those who experience psychosis, issues that call for a therapeutic relationship that is built on compassion, trust and validation. For example, clients can be hesitant to discuss thoughts, beliefs, and voices due to therapeutic safety concerns; perceived judgment by others and self-stigma related to the diagnosis of “schizophrenia” or the fact that one hears voices can present a barrier that may limit client disclosure. Understanding that clients may perceive potential for increases in medication or length of stay if they report unusual thoughts or experiences to health care providers can also impact their willingness to work on certain issues or topics in therapy. To ensure that the client feels comfortable disclosing the truth about their experiences, what you’ll disclose should be discussed with the client at the beginning of treatment. This and all other client concerns should be addressed proactively and transparently.
To further enhance safety and trust, therapy should be adjusted to address any increase in symptoms. Individualizing treatment is critical. Instead of working directly with symptoms like voices by exploring their identity or content, the client’s relationship to them, and so on, therapeutic work should aim to identify the client’s individual values and goals, and the core beliefs (such as those underlying low self-worth) that drive the theme and content of the symptoms. By focusing on core beliefs and schemas, it’s then possible to undermine the core beliefs supporting the content and believability of distressing symptoms. The “symptoms” can also serve other purposes, such as a compensatory purpose (for example, making the person feel special or important) or that of staving off loneliness. Therefore, it is essential to take a compassionate and curious approach to understanding what purpose symptoms may serve for the client.
Another area where a compassionate therapeutic approach specifically may be called for is when isolation or loneliness is an issue. Activity scheduling, including social activities, can be done with the client. If a sense of worthiness and value is an issue, coping strategies, self-esteem-enhancing strategies, and value-driven goals can be an initial and ongoing focus. A focus on valued goals can redirect energies from the client’s preoccupation with symptoms to more strengths-focused and meaningful pursuits. Exploring the advantages and disadvantages of the amount of time and energy spent on symptoms using motivational interviewing strategies can help the client to engage in more meaningful, goal-directed activity or committed action.
A compassionate therapeutic approach to the lived experience of clients is fundamental. The therapeutic stance should be one of respect, compassion, understanding, and normalization. Through this therapeutic stance, the client experiences validation and safety in the therapeutic relationship and is able to work toward meaningful life goals.
For more about the approach developed by Nicola Wright, Douglas Turkington and their colleagues, check out their book, Treating Psychosis: A Clinician’s Guide to Integrating Acceptance and Commitment Therapy, Compassion-Focused Therapy, and Mindfulness Approaches within the Cognitive Behavioral Therapy Tradition.
Siegel, R. D. (2010). The mindfulness solution: Everyday practices for everyday problems. New York, NY: Guilford Press.