Techniques in the Psychotherapy for Psychosis

Mistrust is a significant problem for people with psychosis and can interfere with their capacity to engage in psychosocial treatment. In this article, the developmental trajectory of mistrust is outlined, including the impact that attachment disruption, childhood trauma, attributional biases, internalized stigma, and discrimination can have on the person's capacity to form trusting bonds with others. After this review, three elements are described that may allow for the restoration of trust: the therapist's openness to understanding the patient's experience and agenda for therapy, the therapist's effort to honestly disclose their thoughts to encourage dialogue and mutual reflection, and therapist's attempt to promote metacognition through helping the patient develop more complex representations of the minds of others. These elements are framed in the context of metacognitive reflection and insight therapy, an integrative therapy that is well suited to address mistrust through its explicit focus on metacognition and intersubjectivity.

Openheartedness, despite pessimism in the field, persons experiencing psychosis can benefit from psychotherapy and recover. However, there are multiple factors that can interfere with the formation of a positive therapeutic alliance and lead to the premature termination of therapy, which is associated with poorer long-term outcomes. In this article, common therapist, patient, and intersubjective factors are identified that can inhibit personal growth and lead to stalled treatments. After reviewing these various roadblocks, four principles (e.g., an intersubjective orientation to realty, therapeutic openheartedness/vulnerability, “speaking the unspeakable”, and recognizing the pain beyond the psychosis) are outlined that can embolden the therapist to take judicious risks while avoiding common pitfalls when working with persons experiencing psychosis. These principles also enable the therapist to maintain an empathic connection to the patient and appreciate the pain beyond the psychotic symptom. The clinical implications and challenges of embodying these principles and implementing these interventions are discussed.

Hope is known to be a crucial factor that can facilitate recovery from psychosis. In contrast, hopelessness has been associated with a variety of poor outcomes for people with psychosis, such as low self-esteem, depression, and suicide. While hope is central to recovery, the concept of hope can be challenging to identify and define. Furthermore, little is known about how psychotherapists can help people with psychosis reawaken a sense of hope that enables them to recover and lead meaningful lives with a severe mental illness. In this paper, the concept of hope is explored based on a selective review of the psychological and philosophical literature and through engagement with first-person accounts of psychosis. Following the review, key principles and interventions are described, including the importance of reckoning with therapist’s hope, processing hopelessness, facilitating a sense of belonging, fostering agency, and making meaning of the psychosis and promoting spirituality, that can rekindle a sense of hope. These principles and interventions are transtheoretical and can be applied to a variety of psychotherapeutic orientations. Finally, future directions are considered and possible factors that might enable the formation of hope for people living with psychosis are explored.