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PROLOGUE
During psychosis, the world is turned upside down. Voices that no one else can hear whisper confusing messages, other people look as if they might harbor dark intentions, and reality is behaving strangely. Difficult times, not only for those who experience an episode of psychosis but also for those around them. But what exactly is psychosis? Can you really understand what someone is going through at such moments? Or is their head simply full of madness? And how is it even possible that delusions, hallucinations, and other alienating experiences can take over someone’s thoughts and make them do and say strange things?
To get in touch with the world of a person experiencing psychosis, the first thing we need to do is to look beyond the simple conclusion that psychosis is strange. The strangeness of a psychotic experience is self-evident. Someone who has never heard secret messages transmitted in the radio news or has never suddenly discovered that words no longer have meaning will inevitably think it strange that someone else can experience these things. To bridge the gulf of incomprehension this observation entails, it is better to regard psychosis as a deep crisis experience. A psychotic episode is a crisis in which the very nature of reality becomes unreal. Words no longer guarantee certainty of thought, and familiar stories lose their supportive power, resulting in all different kinds of alienating experiences.
The fact that something like this is possible can cause astonishment. Using words and telling stories are things that we all do. Does this mean we can all be affected by psychosis? At the very least, it shows that language and stories are crucial for giving meaning to what we experience, because our reality is never as straightforward as it might seem. We give expression to this reality by verbalizing. That is, we combine words and events to create thoughts, which we use in turn as building blocks for stories. Stories that we first tell ourselves and then tell aloud to others, or sometimes the other way around.
Stories smooth over troublesome cracks. With words and thoughts we seek truth and meaning, freedom and connectedness. At best, these stories help us to make events comprehensible and reality acceptable. Not fully, of course, but enough so that we do not despair. Enough to share with others the things that touch and concern us, which in turn creates connectedness.
Sharing words and thoughts is powerful because language and patterns of social interaction are linked in ways that are not always visible. The stories we take for granted help us to make choices about who we are and how we should act. However, as we make these choices, our perception of reality becomes selective. Narratives shape our perspective, and they also create blind spots that inevitably determine how we approach the world. As a psychoanalyst, I refer to these blind spots in consciousness as “the unconscious”— an endless collection of messy and usually invisible stories that also pass through our minds and shape us in ways we may not be aware of.
However, organizing reality in such a narrative way is not always possible. Sometimes our stories are too insubstantial, or events are too devastating for words. That is when we say: “This is inconceivable.” Incapable of being expressed in terms of normal conceptions. Too overwhelming and too incomprehensible to be forged with mere words into ordered thoughts. When that happens, the storyteller cracks. And if the storyteller cracks, your experiences crack as well. This tips your consciousness into confusion, and a strongly associative way of thinking starts to take over. The consequences of this are not inconsiderable. Reality becomes sinister and unpredictable, and everything you knew and in which you trusted, including yourself, is disrupted and thrown off balance. Until you almost go mad. Or go mad completely.
Without a cohesive narrative, our minds lack a framework to rely on and have no messy subplots to distract us. This leads to a highly distressing experience where reality itself becomes messy, with fragments of unconscious horror, resulting in the severe mental crisis known as psychosis.
That kind of crisis experience is the subject of this book. A colleague once told me that “wei jie,” Chinese for “crisis,” also points to the ideas of opportunity and challenge. I found this thought so inspiring that I was unable to get it out of my head, because a psychotic experience is also an opportunity and a challenge to deal with stories, ideas, and others in a different way. An opportunity to provide the madness of life with its own space.
In this book I examine in detail how different kinds of discrete and manifest psychotic experiences can be understood. I also explain how hallucinations and delusions attempt to create order in a world of thoughts that no longer have a story to tell, and I discuss the challenges to which a psychotic crisis serves as a response. In the final chapter, I investigate the ways in which connective dialogue and creativity can offer a way out of the madness that psychosis brings.
The latter statement may surprise some readers. Nowadays, many people tend to believe that psychosis is primarily a genetically determined brain disorder that should be treated with medication. So, why is it meaningful to invest in engaging in conversations with individuals experiencing psychosis?
The reason is that understanding the causes of psychosis is not as straightforward as is often thought, especially in terms of biology. For example, when we compare patients with non-patients, genetics accounts for only about 7 percent of the risk for psychosis. This is surprising, and it suggests that the environment plays a much bigger role in the overall heritability of psychosis than previously thought. For example, among other social factors, early-life adversities such as sexual abuse, emotional abuse, emotional neglect, and bullying have a significant causal impact. Such events can have a detrimental effect on a person’s self-perception and understanding of the world. They erode trust and disrupt a person’s sense of narrative coherence, potentially exacerbating psychosis. After all, how can one meaningfully express oneself in a world that actively contributes to the horror that one is experiencing?
Discrimination based on minority group membership and social alienation and isolation in big cities are also causally related to psychosis. This may be because the more people are treated as outsiders, the more unfamiliar the world becomes for them, making it difficult to articulate coherent ideas that connect them to the world. Again, this highlights that psychosis is not only a biological issue but also a social and a subjective event. A person’s entire sense of self in the world is involved.
This has clear implications for therapy and counseling. Assuming that antipsychotic medication alone will solve the problem is overly simplistic. These drugs may help, but they do not cure underlying disease mechanisms. If the medication is effective, it can suppress psychotic thought processes to some extent. But to truly help people recover from psychosis, we have to provide them an appreciative and supportive environment that helps to address the unconscious challenges they are facing, such that they can reintegrate into their lives and develop hope for the future.
It suggests that we need to view psychotic symptoms such as hallucinations and delusions in a different light. They should not be seen as mere signs of an illness, but rather as meaningful expressions and attempts to survive in a chaotic world. We should strive to understand these experiences in relation to the challenges an individual is confronted with. This is something I have learned to do during the past twenty-five years.
I obtained my degree in clinical psychology in the late 1990s. At the time, there was a strong belief in the power of biological psychiatry. In the 1970s American psychiatry held the belief that restructuring an individual’s ego through intensive inpatient psychotherapy was the most effective treatment for psychosis. However, by the 1990s, this notion had been discredited and a promising biomedical approach seemed to emerge. At least, that was the perception or understanding that was conveyed to me as a student. Currently, it is acknowledged that this promise was not fulfilled, and that today, more individuals than ever before are suffering from severe mental illness.
However, thanks to my training in Europe, I was meanwhile also exposed to other perspectives on psychopathology, such as those of Jacques Lacan, Michel Foucault, and Gilles Deleuze. These helped me understand that psychosis is not just a mental disorder but rather, or also, the subjective manifestation of a struggle that touches upon the fundamental aspects of human existence. The suffering caused by this is not limited to just the biomedical aspect. Practically, it stimulated me to start talking with patients and fostered curiosity about the structure and meaning of psychotic experiences.
How such curiosity translates into practice is something I learned to understand through working with cases such as Mario, a young man with Down syndrome whom I met at the start of my career as a clinical psychologist. I will share more about that in the next chapter, arguing that creating genuine encounters and paying detailed attention to what individuals experience are key to overcoming episodes of psychotic crisis.