Hieronymous Bosch, Cutting the Stone (or The Cure of Folly) (c. 1494).
This is an excerpt from Stijn Vanheule’s Why Psychosis Is Not So Crazy: A Road Map to Hope and Recovery for Families and Caregivers, published last September by Other Press.
Completely withdrawn, sitting alone in a stuffy attic room in his parents’ house: that was how Mario was living when I first met him. He came downstairs only for meals, and even then, it was difficult to get through to him. In fact, Mario was locked in an imaginary world of his own, which seriously disrupted all contact with his surroundings. On his shoulder sat an invisible companion, with whom he was constantly in conversation. Mario talked out loud with this companion, so that everyone could hear quite clearly what he was saying. However, it was possible to observe the silent answers he received based only on his facial expressions and gestures. I could sometimes see him soundlessly mouthing the words, but it was clear that Mario regarded his own mumblings as a voice that came from somewhere outside his own being. It was a kind of audio play, with both roles being performed by the same person, to the amazement of those around him who witnessed the spectacle.
From my training, I knew exactly what was happening with Mario: he was experiencing hallucinations. Textbooks had told me many times what a hallucination was—a vivid perception of noises, images, or other sensations, while in reality, no reasonable source for these perceptions can be found. In Mario’s case, as is common for most people suffering from psychosis, the hallucinations consisted of words—utterances coming from without.
But there was more to it than that. Such hallucinated words have surprising impact. They bring the unthinkable to the fore and disrupt the narrative of how one thinks reality is organized. Like all of us, Mario was a storyteller, with a unique story of his own. However, somewhere along his path through life, his narrative had been interrupted. He lost his way. For him, all that remained was loneliness and a series of confused dialogues in a world that had lost its coherence. To help him rediscover that world, I and a few other mental health care workers organized an intensive program of home-based counseling. It was within this context that Mario found for himself the threads of a new story, partially woven from the fabric of the past, but above all focused on the future. This helped him to leave his attic room, attempt new things in the outside world, and carve out a new route through life. Gradually, his imaginary companion disappeared from the scene.
For me, when I was still a junior clinical psychologist, Mario was a teacher. Not an ordinary teacher, but more a master of the Zen Buddhist kind, who says very little but still makes everything crystal clear. Above all, he taught me that a therapist does not need to be afraid of the strange and the bizarre, of the things that exist only inside someone else’s head. Being afraid makes it harder to connect with others. If you want to work together to find new anchor points, you need to move beyond your fear. At the same time, he also showed me that as you work your way through this process, you do not need to be afraid to trip and fall. If you fall—if you show that you can fail—this can sometimes help the other person to escape from their own role as a failure. In my dealings with Mario, my “fall” was at first pretty literal.
One rainy day, about three months after I started visiting him, I arrived at his house for a new session. Afterward, I was scheduled to attend an important meeting, and, with this in mind, I was wearing my best suit, hoping to make a good impression. With my thoughts already half on the meeting, I got out of my car and walked quickly up the garden path toward Mario’s front door, forgetting that this path was covered with moss that had now been made super slippery by the recent downpour. I felt my feet slowly sliding away from under me and, notwithstanding my best efforts to maintain my balance, soon found myself lying flat on my back in the grass, wet and spattered with mud! Mario had witnessed this whole unedifying episode from the loneliness of his attic room. As I struggled to get back to my feet, cursing my stupidity, he opened the front door and called out, “You okay?” Once I was finally inside, he disappeared for a few seconds and returned with a towel, which he pressed to my chest. “Here, clean yourself up.”
Suddenly, he was no longer the one with the problem: it was me! This turned out to be an important breakthrough. Many young professionals, which I was at that time, hold rigid views about their role as a professional. They strive to be seen as an expert and impose their own agenda onto their patients. Or, even worse, they want to be a savior or act as if they are the patient’s closest confidant. In my case, I probably tried to be the clever and heroic therapist who would achieve a breakthrough. However, to my surprise, significant changes were not achieved through my earnest efforts, but rather when I let go of my desire to be the hero and instead focused on being present and attentive for Mario.
Being present and attentive in the moment may sound easy but is very difficult. In daily life, we are often preoccupied with our own thoughts and miss what others are saying. However, if therapists remain deaf like this, they make a serious mistake. Regardless of their level of education or professional experience, all mental health care workers have blind spots they should be aware of. It is part of their job to examine their own attitudes and behaviors. Through discussing this event with my own psychoanalyst, I came to realize that the secret fantasy of being the smart savior was one of my blind spots. It was only by recognizing and acknowledging the caricature of the savior in myself that I was able to let it go.
More than twenty years have passed since my sessions with Mario. I have since been working in academia, currently serving as a professor of clinical psychology and psychoanalysis at Ghent University in Belgium, and as a clinician in private practice. In both my clinical and my academic work, psychosis has been a main focus. A key lesson I have learned is that to be effective as a therapist, one must set aside any personal agenda and strive to be fully receptive to what patients are expressing, both verbally and through their symptomatic behaviors. Understanding these expressions can be difficult, as speech may be chaotic, patients’ experiences may be far from reality, and silences can be overwhelming. While this can be frustrating, it becomes less so when you accept that it is inherently difficult to truly comprehend the subtle meanings another person is communicating. Even with detailed attention to an individual’s problems, a missing link will always be present in our understanding. It is by accepting this lack and taking it as our starting point that a true encounter is possible.
At least, by allowing such lack, Mario and I were able to interact with each other in a lighter and more relaxed manner, even if it was only because a smiling Mario occasionally referred to the day when I had gone head over heels in his front yard. In my contact with Mario, my “fall” was a way for him to take a step up. Whenever the dialogue between us became difficult, he liked to recall this anecdote, and soon we were able to move forward again. This was real progress, because previously it had often been during these awkward silences in our conversations that his hallucinations came to the fore.
Contact between people builds on the stories they tell each other—stories about their past, or about who they are and what they want. For Mario, it was difficult to find his way through the narrative of his life in a calm manner. At some point during his adolescence, he started to be confused. He lost the right words to describe large parts of his experiences. This was not mainly because of Mario’s Down syndrome limiting his verbal fluency; there were many topics about which he could easily engage in conversation. Instead, it was primarily because certain topics, particularly those related to love and sexuality, were so unmentionable that his personal struggles overwhelmed him by way of shocking messages coming from the outside. Words that would have allowed him to link what was happening in his inner world to events that were happening in the world around him, words that would have transformed the thoughts whirring inside his head into subjects for discussion, making it possible for a sense of commonality to be created, suddenly were gone. They had deserted him.
Abandoned in this way, Mario was left to cope as best he could. Reality moved on, but the sentences whispering in his ear marched to the beat of a different drum, one that the people around him were unable to follow. As a result, Mario increasingly found himself becoming estranged from his environment and the people around him. His mother and father saw their son sinking deeper and deeper into a whirlpool of unrealities, wrestling with fragmented words, and disappearing into a strange new world that for them was both frightening and incomprehensible. As it was, of course, for Mario.
By listening to Mario I realized that his problem was not so much that he was living a fantasy life that had gotten out of control. This is something that most of us experience at some point. Whenever we find reality unsatisfactory, we adjust it inside our head, to make it more bearable or more exciting. We usually do this by denying or misrecognizing aspects that don’t fit within the framework of our hopes and expectations, and by focusing on what we want to see. The net effect is that we continuously live in a somewhat dream-like state, even when we are awake, as we subtly distort reality to make it resemble our opinions of how life should look.
This is not what Mario was doing. For him, it was reality that was out of control. It was not Mario who was behaving strangely; it was reality itself. This is borne out by the existence of the imaginary person on his shoulder, who for Mario was anything but imaginary. She was as real as real can be. He saw her and he heard her. Try explaining this to others. Or to yourself. Sooner or later, everyone who is confronted with psychosis faces up to the same challenge: how to give a place to confusing and alienating experiences that turn your inner world upside down.
***
Looking back, I can now see that it was fortunate that after my humiliating fall, I did not make the mistake of trying to resume the role of “expert” too quickly. That is probably what everyone else was expecting of me: the outside specialist who knew it all and would soon put things right. But that is not what Mario wanted or expected. What he needed above all was not someone who was perfect, but someone who was sufficiently marked by their own shortcomings, by lack, and simply willing to engage in a dialogue with him; someone who would listen and talk.
To truly engage in the power of therapeutic encounters or, more broadly, any encounter with someone suffering from psychosis, it is crucial not only to begin from one’s own lack, but also to change one’s own discourse and mindset. As the French philosopher Michel Foucault argued, the discursive choices we make, expressed in the concepts we use, shape our understanding of the world and determine how we define and categorize individuals in society. Our words, opinions, and explanations form our attitudes and influence how we treat, or mistreat, others.
Nowadays, biomedical discourse dominates our collective understanding of psychosis. However, this does not mean that it is based on significant breakthroughs. Much of the information presented in handbooks, press articles, or websites, as well as opinions expressed by laypeople, focuses on brain, genetics, and medication. This might sound scientific, but mass media often draws selective and exaggerated conclusions from papers in biological psychiatry. Despite years of expensive biological research, no measurable physical indicators of psychosis have been found. Indeed, we have not found even a single small brain aberration that would systematically be present in, let’s say, 90 percent of all patients and only in 9 percent of normal controls. There are simply no biomarkers that might be used in diagnosis or treatment.
Likewise, and contrary to what is sometimes thought, antipsychotic medication is unable to cure psychosis. The word “antipsychotics” perhaps makes one think of a parallel with “antibiotics.” Yet these drugs do not eliminate presumed disease mechanisms, but rather reduce our perception of the significance of internal and external stimuli. Review studies have shown that pills have good results for only about a quarter of patients with psychosis. In roughly half of psychotic cases, medication has some effect, but in those cases antipsychotics also have undesirable and discomforting side effects (loss of motivation, numbing, restlessness, increased risk of diabetes …). For the remaining quarter there are no positive effects whatsoever. In other words, the results are sometimes good, but antipsychotic drugs are far from being a miracle treatment. Follow-up research over a period of twenty years has demonstrated that long-term use of this medication can be detrimental, and even increase vulnerability to subsequent psychotic episodes.
What we meanwhile also know is that biological accounts of psychosis reinforce stigma. The more people presume that it is a genetic brain disease, the more they believe that it is a fatal, deteriorating condition that makes people unpredictable and dangerous. This prejudice has increased over the past decades, resulting in social distance and violence toward people with severe mental illness. Importantly, these presumptions are not only incorrect but also unfair and even traumatizing for mental health patients.
Consequently, we need to shift our thinking and language when it comes to psychosis, placing more emphasis on subjective experience—that is, on the mind—than on the brain. It is important that we examine the nature of psychotic experiences more closely, and attempt to get hold of how they are organized, what they may express, and how they are embedded in the life histories and social contexts of those who experience them. By studying these aspects in detail, we change our discourse and mindset, enabling us to interact more openly and humanely with individuals suffering from psychosis.