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About Psychotic Spectrum Disorders and Working with Psychosis


Psychotic Spectrum Disorders: A Conversation with Jane G. Tillman, PhD, ABPP

Let’s take a step back for a moment. What does psychotic mean in the first place?
For a lay-person, it means an altered sense of reality, a lack of shared reality with other people. Of course, we all have our own slant on reality, but hopefully we have enough touch points or shared points where we can have what we call a consensual reality.
What’s a test you use to identify consensual reality?
When someone is in treatment you are looking to see if there is some acknowledgment of the trouble they have in their lives. A patient who has been arrested by the police, taken to jail, may say, “None of this ever happened.” They just hit someone yesterday, and you can point to documentation. They’ll say, “It’s a lie.” This disagreement about fundamental shared experience is difficult for the patient, their family, and for those providing treatment.
Is violence often a component?
It can be, but not often. You hear about violence in the news a lot and this contributes to the stigma that comes with psychotic disorders and schizophrenia. But only a minority of psychotic individuals is violent. That’s one of the great misconceptions that may keep people from admitting their trouble. The label “psychotic” segregates these individuals from the rest of humanity. People don’t want to be segregated and written off. And this is a population that is vulnerable to segregation, because they commonly misread social cues and think other people are trying to harm them. It can happen--though it’s rare--that patients become aggressive out of the fear of being harmed by others.
In the minority of cases where there is violence, that’s usually where it starts?
There may be an idea that someone is trying to hurt them, out of fear, or suspicion, paranoia — a delusion that someone is trying to attack. Also, in some psychotic episodes associated with bipolar disorder, people get revved up to the point that their judgment is clouded.
What do you find most compelling about working with people suffering from psychosis?
It’s a great question because I love working with these patients even though it’s heartbreaking sometimes. These are human beings at risk of becoming society’s throwaways. They’re often shuffled from one drug trial or one symptom management situation to another. And mental health professionals struggle to treat these people, because they can make you intensely uncomfortable. Patients with symptoms of psychosis can be oppositional and very negativistic. Imagine how painful it might feel to be isolated in a world of private belief without understanding others or feeling understood by them. In therapy, there may be long silences as patients struggle to put difficult thoughts and feelings into words. For most people there’s a longing for dignity and a wish to be respected. Patients want to find a place where they don’t feel exposed, ashamed, and humiliated. And often, patients are just grief stricken, asking, “Why me?” Often, on the surface, there may be delusions of grandeur, feelings of being omnipotent, of knowing better than everyone. But when that is stripped away, there’s a profound grief. We have many patients who are insightful and say ‘I would rather be crazy than face the sadness I have to face in my life,’ with so many relationships lost, so many opportunities lost, and people who think their future is lost. This is why it’s vital to get people into treatment as early as possible.
In this five-part series exploring psychotic spectrum disorders, we will present excerpts from a longer interview with Jane G. Tillman, PhD, ABPP, Evelyn Stefansson Nef Director of the Erikson Institute for Education, Research, and Advocacy of the Austen Riggs Center, a member of the Riggs clinical staff and an authority on psychotic spectrum disorders.