“Present Through It All”: A Qualitative Exploration of Psychotherapy and Psychosis

Participants

I interviewed a total of four psychotherapists in private practice from two urban locations in the United States. I interviewed each for about 2 hours in their psychotherapy offices. In accord with homogeneous sampling procedures of interpretive phenomenological analysis (IPA; Smith, Flowers & Larkin, 2009), I recruited participants who shared a similar theoretical orientation (in this case, primarily psychodynamic approaches) to achieve a more in-depth understanding of a particular mode of psychotherapy, rather than a cross-section of various orientations that would make comparison of essential features of the process more challenging.

I also wanted to include a representative range of experience levels, and in the descriptions of each participant below, I note how long each has been in practice. After getting institutional review board approval, I sent e-mail invitations to participate to various therapists in my region that advertised that they specialized in working with people with psychosis. I also used a snowball method of recruiting as some of the participants passed along my contact information to colleagues.

The first therapist, Sean ¹ , had been in private practice for over 20 years and had numerous theoretical influences including psychoanalysis and interpersonal–psychodynamic (e.g., Harry Stack Sullivan) approaches. It was evident that he had a long-standing intellectual curiosity for psychology and the various theoretical approaches since he was in college.

The second therapist, James, was also a seasoned clinician who has been a psychologist, mainly in private practice, for about 30 years. Earlier in James’s career, he had the opportunity to work with R. D. Laing at one of his milieu homes in England, and this experience of being a coresident deeply influenced James’s views on the nature of psychosis. His theoretical orientation was largely shaped by psychoanalytic and existential–phenomenological theory.

The third therapist, Paul, had been in private practice for about 7 years, and also worked in a group practice organization after his graduate training that specialized in provided outpatient services for people with serious psychological struggles. In his current practice, Paul sees a wide range of clients, from children to adults experiencing psychosis and other serious life challenges. His work is influenced by psychoanalytic and existential–phenomenological theory.

The fourth therapist, Hudson, had worked for 2 years in a community mental health setting, and at the time of the interview had recently transitioned to a research position for a government institution. In his work at the community mental health agency, Hudson provided group and individual therapy for clients labeled with schizophrenia and schizoaffective disorder. His work was largely shaped by existential–phenomenology and psychodynamic influences.

Interpretive Phenomenological Analysis

I created a semistructured interview protocol that included open-ended questions such as “How do you conceptualize the process of psychotherapy for people with psychosis?” and “What have been some turning points in your work with this population?” After completing the interviews, I transcribed the audio recordings of our conversations, and analyzed the data using IPA. IPA is a qualitative method that focuses on participants’ lived experiences and the ways that they construct meaning. IPA provides a systematic method of identifying and organizing the central themes that emerge both within and across interview data.

First, each interview was analyzed individually, noting key phrases, consistent themes, initial interpretive impressions, and summaries of the overall content of the conversations. From these initial analyses, a multistep process of identifying essential themes was completed that yielded a collection of superordinate and subordinate themes for each individual interview. I also continuously cross-checked the emergent themes with the exact quotes from the participants so that they accurately reflected the lived experiences of the therapists and were not unduly influenced by my own biases with the research topic. Once each of the interviews had been analyzed individually, I did a cross-analysis of themes across all interviews, which ultimately yielded four superordinate and numerous subordinate themes for each.

I sent the participants the preliminary write-ups of the interviews and copies of their transcripts, and requested feedback and suggestions on the themes I had generated. I also consulted the existing psychotherapy literature on this topic to compare the themes I had generated as another step in the self-reflective process of analysis. Over the course of the project, I have consulted with various colleagues with expertise in qualitative research and the subject matter of psychosis to discuss my emerging understandings of the data in light of my own preconceptions and potential biases as another stage of the self-reflective process.

Superordinate Theme I: “Living in a Territory That Language Could not Adequately Communicate”

A prominent topic in each of the interviews was how each therapist conceptualized the often-perplexing meanings that psychosis held for their clients and reflected through their theoretical lenses. The therapists’ desire to understand was in service of being greater assistance to their clients, rather than trying to “figure out” or determine a static categorization of them. One of the ways the therapists’ understood psychosis was a way of coping with unbearable and traumatic circumstances. Paul explained,

And so I do see psychopathology as strategies that are invented to cope with a situation that’s become unbearable. And I see what’s called schizophrenia or psychosis as one possible way of coping with these situations.

For instance, people who believe that their food is being poisoned may be communicating the ways they feel metaphorically “poisoned” by hurtful people in their lives, and their efforts to remain safe by avoiding certain foods could be seen as a way of coping with their fears. However, the therapists were quick to point out that such rigid belief systems often become problematic for the person and are the types of issues that they seek help with in therapy.

The phenomena of vulnerability and loneliness were also associated with the experience of psychosis for several of the therapists. Following the example aforementioned, one might expect that a person who fears that others are trying to poison them would often feel vulnerable and symbolically express these feelings through persecutory belief systems. Furthermore, some manifestations of psychosis have been described as ontologically insecurity in which the normally taken-for-granted boundaries between self and other are blurred and the person questions her very existence as a real being across space and time. This would be another example of vulnerability and the consequent loneliness that ensues from such profound detachment from self and others.

Finally, psychosis is a phenomenon that is often difficult to understand and the therapists’ noted that many of their clients utilize therapy to help make sense of confusing, distressing, and sometimes frightening experiences. Likewise, the therapists regarded psychosis as a mysterious and complex phenomenon that can make it difficult to find common ground for communication in therapy. Hudson explained,

And I don’t think there is language—I guess this might be the easiest way to say it: I got the sense that these people were living in a territory that language could not adequately communicate.

Connecting Hudson’s thoughts to the last point, the qualities of psychosis that make it difficult to comprehend for both the person experiencing it and to others also contributes to the isolation and loneliness that many people experience. In the next superordinate theme, the therapists describe the ways that some of these issues can start to be addressed in the context of a caring and supportive therapy relationship.

Superordinate Theme II: “I Have to Be Here, Present Through It All”

Perhaps the clearest point on convergence across the interviews was the importance the therapists placed on the role of the therapeutic relationship. They emphasized the time and thoughtful care building a strong relationship with a client takes, particularly noting the need to be genuinely present in each interaction:

. . . and I can’t fake it. I have to be here, present through it all. (Paul)

And so everything about you as a person is ultimately going to be what you’re using. And use it. (James)

Therapist presence involved careful attunement to subtle changes in relationship dynamics, admitting missteps and processing them with the client, acknowledging the therapist’s feelings when appropriate (including feeling confused, joyful, or frustrated), and conveying a sense of being with the client in the shared therapeutic endeavor. First though, the therapist has to work to create a safe and trusting space for the process to unfold. One of the ways Sean fosters a comfortable and safe space for his clients is striving for transparency and openness in their conversations:

I like to acknowledge things. I like to keep things open. You know, sometimes I’ll state the obvious just to show I hear what they’re saying or this is happened, just to get it out there. I don’t want to hit any hidden agendas. Well, it’s unavoidable, but I want as little subtext as possible running through the session. I want it out there. This is what we’ll look at you know. We’ll put it out there and the two of us will look at it together.

Related to the quality of openness Sean described, another important aspect of the therapy relationship is being grounded, yet flexible in responding to clients’ needs. Being grounded was described as having a coherent theoretical orientation, adequate training and supervisory support, and self-awareness. In the moment-to-moment interaction though, the elements of one’s grounding drop into the background, and one’s focus remains on being flexible and open to understanding the needs of each unique client:

And you have to find a different way of relating to each and every single person that you’re going to work with, and they will guide you. They will help you. They will show you ultimately what they need for you to do or what not to do. (James)

There are also inevitable challenges to maintaining a positive connection, including being frustrated or frightened by a client, feeling stymied by the slow nature of the work, or experiencing emotional burnout. For instance, Paul notes the perils of overly zealous therapeutic ambition:

[There’s this] essay [by Harold Searles], it’s so good. And it’s basically about therapeutic ambition. And it’s like the physician that’s really going to sort of come in and rescue and save and rehabilitate the psychotic disorder. And sure, you can do that and spend a lot of fuel to try and do that. But that’s ultimately that’s not—you’re going to burn out really quick. And will be sorely disappointed in your efforts.

Keeping a humble attitude about oneself and one’s therapeutic abilities are arguably universally beneficial qualities for a psychotherapist to hold, and can also help avoid the perils of hubris that Paul describes. In the next section, some of the ideal qualities of a therapist are discussed that will have evident connections to the aspects of a supportive therapy relationship.

Superordinate Theme III: Demonstrating Genuine Care and Respect for Clients

This superordinate theme described the ideal qualities that the therapists strove to embody in their work. These qualities reflected a combination of personal and professional attributes that were largely characterized by care, respect, genuine acceptance, and capacity for self-reflection. Sean made a distinction between people drawn to the work by curiosity or strictly intellectual interest rather than a genuine interest in understanding the experience of psychosis and helping others:

I think it’s ok for that interest to have a strong underlying intellectual component to it. But I think as long as its not manifested in your appearance. Because you see some therapists who may be gleeful: “Oh boy, this is a very bizarre case. This is going to be fascinating!” And this would be very disrespectful to anybody, of course, that they would not want to be looked at as a specimen or unlikely that they would be enjoyed being looked at in that way.

In other words, intellectual curiosity without genuine caring and a strong personal investment in the work may lead to “othering” of a person’s experience. In this example, Sean uses the analogy of being looked at as a specimen rather than a fellow human being that we can empathize with and find common ground in our shared humanity. Connected to this point, the therapists also noted that having a respect for unique subjectivity as a vital quality. From Sean’s perspective, respecting his clients’ unique subjectivity means trying to understand their lives in context and not only through the lens of a diagnostic label:

Well, I guess I just quickly learned how different people are and how different their needs may be too. And just how I really had to make a point of learning who this particular person was. It was just a small part of it to know that this is a diagnosis they’ve been given. Even to know the particular symptoms that they were reported to have. I had to also know who this person was . . . the personal context. (Sean)

Along with taking into account personal context, it is important that the therapist nonjudgmentally accepts their client as a fellow human being who is struggling, and not making stigmatizing assumptions due to their psychiatric diagnosis. Paul notes how taking a stance of caring acceptance toward his client helped him glimpse an extraordinary person, where others may only see someone with mental illness working a low-wage job:

All my attempts to make sense of his experience. Of accepting him. Of not judging him. He’s a very brilliant man underneath this all. You would never know it cause he’s living on assistance and works this menial job. But he listens to Wagner operas in his spare time. And he is incredibly intelligent, and he’s into silent film, and he’s a gentleman. . . . I can see him and I can validate that.

Finally, the therapists talked about the quality of self-reflectiveness as being an important one to embrace in this type of work. They were clear about their motivations for doing the work, how various life experiences influence their outlook, and can effectively utilize their experience of their clients therapeutically. On the latter point, James noted that working with people experiencing psychosis can sometimes be emotionally charged and the therapist is often the target of feelings such as anger or distrust. How the therapist responds to such intense emotions is influenced by their capacity for self-reflection, humility, and nondefensiveness:

[Clients] tend to be pretty angry or they blame you for lots of things, project things onto you. You can’t take this stuff personally. And some people might have trouble with that. I have a lot of colleagues who can’t work with that population for this reason. They get too upset. (James)

In many ways, the ideal qualities of a therapist go hand-in-hand with the elements that help facilitate a positive therapeutic relationship and center on a genuine care and respect for others. In the last superordinate theme, the therapists discuss the general goals that they and their clients have for therapy.

Superordinate Theme IV: Movement Toward Life

The last superordinate theme describes the therapists’ thoughts about what they and their clients are striving toward together in their work. I took the title of the theme from a quote by Paul who said that when clients struggling with psychosis are successful in therapy with him, he witnesses them “come more toward life.” This movement toward life stands in stark contrast to the themes of loneliness, isolation, and vulnerability that were previously discussed. James articulated a sentiment shared by each of the therapists, which was a belief in clients’ potential for change:

So I think that anybody in principle whether it’s schizophrenic, bipolar, all these different labels we use to try and close in on what’s going on with them, that they can all get better; that they can all live a better life, and be more independent and healthier. They’re still going to wrestle with problems just like any human being does. But some people that maybe have more issues than more deficits and people that get called schizophrenic are at the very extreme end of that process. But yeah, there’s no reason why somebody can’t, you know, if they’re lucky and have therapy, live as normal a life than anyone else.

Of course, there is no guarantee that psychotherapy will be effective for everyone and he offers no false assurances that the process will “cure” anyone of a particular disorder. Yet James still maintains a cautious optimism that, many people can lead a meaningful life, certainly not free of difficult periods, but a life worth living nonetheless, sometimes with the help of psychotherapy. When discussing particular clinical examples, they focused on how their clients’ made choices that improved the quality of their lives such as engaging in meaningful work and relationships.

Last, each of the therapists saw a potential role for psychiatric medications as part of their clients’ treatment as another potential path of movement toward life. However, several also had strong critiques about an overreliance on psychopharmacology as the main mode of treatment for psychosis. Keeping with the theme of respect for clients’ unique subjectivities, the therapists tried to understand people’s particular needs and motivations for wanting to take medications, while also emphasizing the importance of informed choice for their clients in the process. Furthermore, several noted that if taking a psychiatric medication helped clients mediate their anxiety or helped manage the experience of hearing voices, this may in turn facilitate their meaningful participation the psychotherapy.

Meaningfulness of Psychosis

After analyzing the participants’ interviews, it was clear that there was no simplistic or singular way for the therapists to describe the meanings of psychosis, as this phenomenon took various forms in their clients’ lives. However, each regarded psychosis as somehow meaningful whether it was related to a person’s past traumas, current ways of dealing with life, or a more obscure purpose that the therapist was often left perplexed in trying to decipher. One of the particular challenging aspects of understanding psychosis is the lack of shared experience, or the difficulty of communicating sometimes-inexplicable sensory and perceptual phenomena to another person. Such difficulties can contribute to a person’s feelings of isolation, “otherness,” and frustrated attempts to have other people understand them. The psychotherapist can play a critical role of bridging the gap of dialogue by trying to facilitate shared understanding once again.

Thus, one of the ways in which psychotherapy might be useful is helping clients develop more coherent and complex self-narratives in a coconstructed dialogue with the therapist (Lysaker & Daroyanni, 2006; Lysaker, Lancaster, & Lysaker, 2003). Lysaker, Buck, and Hammoud (2007) noted in their case study that through the process of therapy, the client was able to develop greater cognitive flexibility, and a more complex understanding of his difficulties within the context of his life history. Participants in the current study also noted that it is important for the therapist to maintain flexibility and openness in their dialogues with clients, as the meanings of psychosis not only take time and patience to better understand but also shift over time and require a sensitivity to the process of the therapy relationship as well.

Essential Role of Therapeutic Relationship

A critical factor of underlying most approaches to psychotherapy is a strong therapeutic alliance, and meta-analyses have demonstrated that the therapy relationship is one of the most consistent, positive factors in outcome research (e.g., Flückiger, Del Re, Wampold, Symonds, & Horvath, 2012; Horvath, Del Re, Flückiger, & Symonds, 2011; Wampold & Budge 2012). For instance, in a study examining the experience of CBTp, Messari and Hallam (2003) note that a supportive and trusting therapy relationship played a key role and was not simply a means to an end of using CBT techniques on a client. Kilbride et al. (2013) found that service users regarded CBTp as a person-centered engagement that was built on a trusting therapy relationship, flexibility, a sense of partnership, and the therapist’s respect for the client’s worth as a person.

The service users in this study said that the therapy relationship created a safe, comfortable, and predictable environment in which a shared exploration might unfold. Of course, creating the conditions for such a trusting relationship to develop takes time, care and genuine presence, and openness to the client’s way of experiencing the world. Rosenbaum and Harder (2007) point out, “structure counts overwhelmingly in creating a therapeutic alliance, but of almost equal importance is the therapist’s personal qualities—not all therapists can treat patients with psychosis” (p. 17). The researchers’ caution is a reminder of the extent to which the therapist brings her or his whole self to bear in the therapy relationship, and the emotional challenges this intensity may bring.

Rosenbaum and Harder (2007) also note that the therapist needs to be finely attuned to the subtleties of the therapeutic relationship, and capable of holding the client’s emotional states of “horror, despair, uncontrollable aggression, the feeling of being dead, empty or not present, or no feeling of contact with one’s emotional inner life” (p. 20). In the current study, such capabilities were facilitated by the therapists’ capacity for self-reflection, a firm grounding in their training with a simultaneous flexibility to respond and be genuinely present to the unique needs of their clients.

Personal and Professional Qualities of the Therapist

Closely related to the findings concerning the qualities of a positive therapeutic relationship are the characteristics that the participants identified as the ideal qualities of a therapist doing this type of work. One of those qualities was taking a genuine interest and care for one’s clients, which has been echoed in several other studies as well. In Messari and Hallam’s (2003) study, clients felt respected when their therapists took a genuine interest in them and treated them as equal partners working together toward common goals. Acceptance and nonjudgment was another important quality the participants notes, and similarly, McGowan et al. (2005) found that as having difficult experiences listened to and being taken seriously were very important for both clients and therapists engaged in CBTp.

Another ideal quality was respecting a client’s unique subjectivity and striving to understand their experiences in terms of their overall life history and context. Such themes are found in other accounts as well including Catherine Penney (1999) who has written about her 9-year psychoanalytic therapy for schizophrenia. Regarding her relationship with Dr. Dorman, her psychiatrist, she notes, “the most important thing that I feel about the therapeutic process is that Dr. Dorman always conveyed to me that I was a whole person, that I was not a label or diagnosis.” This sentiment is congruent with the participants’ sense that one must respect and care for their clients as fellow human beings, not reducing their lives to a static diagnosis.

Movement Toward Life

This group of therapists each articulated a steadfast faith in the potential for change in people’s lives. However, this was not a blind optimism, as each of the therapists acknowledged, both the limits of psychotherapy and also the fact that some people continue to struggle in profound ways despite the help they receive. Nevertheless, the participants held to the belief that their work with people struggling with psychosis has value, and more people ought to be given the opportunity to try psychotherapy as well.

The notion of progress or a good outcome of therapy can be defined in a variety of ways from both the therapists’ and clients’ perspectives. For instance, in a study where both therapists and clients were interviewed about their experiences of CBTp, McGowan et al. (2005) found that progress was often associated with having greater clarity, logic, and continuity over time in the process of working toward shared therapy goals. Kilbride et al. (2013) interviewed service users who sought psychotherapy for issues related to psychosis and found that positive outcomes were associated with increased levels of social functioning and greater engagement with life (see also Mancini, Hardiman, & Lawson, 2005). Participants in their study also discussed the importance of regaining hope and having positive self-acceptance.

Based on the findings of the current study, it was clear the participants regarded their clients as people with potential for growth and change rather than accepting the pessimistic limitations too often applied to people who experience psychosis. Such changes might take many forms from finding meaningful work, to spending more times with friends, taking a class, or leaving one’s home more regularly. As Sean noted in our interview, sometimes a seemingly small change in someone’s routine can lead to more significant ones over time, often in ways that are hard to anticipate.

Limitations and Future Directions

The current study’s findings have some limitations for generalizability, as the sample size was both small and focused on psychodynamic approaches to psychotherapy. There is a growing body of literature examining therapists’ and clients’ experiences of CBTp, and future research may look into other theoretical orientations, as the current study attempted to do, to gain a better understanding of the similarities and differences in the modes of working with people who experience psychosis.

Future research may also more closely examine the role of mental health professionals’ beliefs about the usefulness of psychotherapy for psychosis and how those beliefs influence their modes of practice, understandings of psychosis, and thoughts about the possibility of change for someone struggling with such issues. For instance, it would be interesting to see how psychiatrists, psychologists, and social workers may view psychotherapy of psychosis in different ways depending on their training and thoughts about recovery-oriented practice. Perhaps the most critical perspective to better understand is of the people we serve in our clinical practice and research. Future research should also be conducted from the client or service user’s perspective, ideally designed, and carried out by fellow service users (e.g., Pitt, Kilbride, Nothard, Welford, & Morrison, 2007), in order to understand what it is like to experience psychosis and psychotherapy via first-person accounts.

The therapists interviewed for this study consistently highlighted the resiliency and humanity of people who experience psychosis, and clearly learned a great deal from their clients. They had great faith in their clients’ capacity for insight, ability to form relational connections, the inherent meaningfulness of their lives, and potential for change. This group of therapists resisted the tendency to see the people they work with as nothing more than cases of “severe mental illness” and instead strove to engage with them as they would with any other client—with respect, openness, and genuine respect for the meaning of their experiences.