Core Emotions in Psychosis

Fear can be a central factor in the subjective experience of psychosis, and an important issue of focus in psychotherapy. The fears of the patient as well as those of their therapist can impact the quality of the therapeutic alliance and serve as a barrier to meaningful recovery. We have detailed several different types of fears patients and therapists may experience and have suggested that it is important for therapists to be sensitive and responsive to these in therapy. As therapists create space for the cultivation of trust, carefully notice the presence of fear, they can begin to help people experiencing psychosis to make sense of their fears and the impact these have on their lives. For many, this process may involve cultivating the abilities to recognize their own fears and to integrate this information into a larger account of themselves and others, allowing them to make self-directed choices about how they might respond to their fears.

People with psychosis experience loneliness at higher rates than the general population and identify loneliness as one of the most significant barriers to personal recovery. While many researchers have called for psychosocial treatments to specifically target loneliness for people experiencing psychosis, there are limited treatment models that provide direct recommendations for therapists working with people with psychosis. In this paper, the concept of loneliness is explored through a review of psychological and philosophical literature and through first-person accounts of psychosis. Additionally, the correlation between specific psychotic symptoms and loneliness is also reviewed. Following this, four key practice elements are outlined, including addressing barriers to accessing the patient’s longing for connection, the loneliness of psychotic experiences, internalized stigma, and loneliness within the therapeutic relationship, that can serve to reduce loneliness through psychotherapy. These elements are transtheoretical and can be integrated into various theoretical orientations. Finally, future directions are considered and factors that can attenuate loneliness for people with psychosis.

One relevant factor to recovery from psychosis that has often been overlooked in the psychotherapy literature is the importance of facing loss and processing grief in relation to psychosis. Persons who have experienced psychosis often experience the loss of role functioning, interpersonal relationships, cognition, and self-concept. However, when these losses are not fully integrated into the person’s identity, it can result in either more losses due to denial and metacognitive impairments or increased hopelessness and depression due to internalized stigma. Five elements in psychotherapy of psychosis were identified that can facilitate the integration of loss and processing of grief: understand the personal experience of the psychotic episode, attend to feelings of grief and the primary loss, explore the meaning of psychotic symptoms and identity implications, integrate psychotic vulnerabilities into the sense of self, and foster realistic hope in the face of an uncertain future. Psychotherapy can enable persons with psychosis to make meaning of their losses, process their grief, integrate their psychotic vulnerability into their sense of self, and develop realistic hope.