When most people think of challenging clients in therapy they immediately think of a few different labels: one of which is borderline personality clients- few think of those with schizophrenia.
Today I’m weighing on a challenging client group: those with psychosis/schizophrenia. I find these clients tricky to figure out if and how to do therapy.
Historically in the psychoanalytic schools of thought some people thought it was inadvisable to do therapy with those with psychosis, as classical psychoanalysis (going back to childhood) can be indeed in some cases cause more harm than benefit for someone with psychosis. (However- this is not to say that it is never helpful- please see Elyn Saks’ book- The Centre Cannot Hold a story of a woman with schizophrenia who found medications and psychoanalysis helpful). Jung however, formed his theories by observing those with psychotic illnesses and worked directly with them. Currently there are numerous articles on CBT for psychosis, some of which I’m trying to wade into.
Here are the challenges:
1) For psychotic illnesses the first line of treatment is medication management with antipsychotics. For many when this is accomplished they have nearly eliminated positive symptoms of hallucinations and voices- although some have residual symptoms. For those folks for whom medications are working therapy seems unnecessary however even those successfully on medication relapse sometimes due to stress and other times because they go off their medications. Do you do CBT for psychosis for those in remission? Or just educate about warning signs? Mostly we just check that people are sleeping well and not getting too stressed out.
2) Those with residual symptoms of paranoia, voices, and delusions can be hardest to engage personally due to fixation on ideas, or fear of their voices. Some with delusional ideas it seems that their connection to the ideas are so strong that it can be hard to find a window of uncertainty to introduce doubts are hypothesis testing around their beliefs.
I’m struggling to offer my clients some therapy but end up offering a conversation here and there and am uncertain how to and when engage these clients.
I’ve been reading a lot about psychosis these days to help and finding various models in addition to the purely biological vulnerability model that is espoused that help me think of windows to address psychotic illnesses. I think for clear-cut cases of schizophrenia with an average onset age and classical symptoms that there is likely a strong biological component. However, there have been numerous other studies that have linked mood disorders, anxiety, and experiences of trauma with psychosis.
If you are a therapist what have you found works in therapeutically working with those with symptoms of psychosis?
If you have experienced psychosis yourself and attended therapy or had psychiatric treatment, what helped and what didn’t help?