Online IOP for College Students and Emerging Adults in MA
Estimated Read Time: 8–10 minutes
What You Will Learn From This Article
- The meaning and clinical relevance of an intersubjective orientation to reality
- Why openheartedness and vulnerability are essential when addressing therapeutic impasses
- How mistrust develops in people with psychosis
- Three practical strategies for beginning therapy with a mistrustful patient
- A clear definition of hope, and how it differs from optimism
- The key factors that help restore hope for people living with psychosis
In his presentation “Techniques in the Psychotherapy for Psychosis” – part two in a two-part series – Austen Riggs Center Director of Testing and Associate Director of Admissions Jeremy Ridenour, PsyD, ABPP, talks about how psychosis remains one of the most challenging experiences to address in psychotherapy, not only for patients but for clinicians navigating fragile therapeutic terrain. Rooted in paranoia, fear, and emotional disconnection, psychosis can sever the thread of human relatedness. However, a transformative approach rooted in intersubjectivity, openheartedness, and hope provides an essential roadmap for recovery.
Understanding Intersubjectivity: A Relational Reality
Intersubjectivity refers to a shared space of meaning-making between people. It recognizes that our understanding of reality is not a solitary experience, but a co-created phenomenon built through relationships. In the context of psychotherapy, particularly with psychotic individuals, this orientation emphasizes the mutual, relational construction of the therapeutic encounter.
Recovery, therefore, arises not from control or correction, but from compassionate presence and attunement to the other’s experience.
The Power of Openheartedness and Vulnerability
When working with individuals experiencing psychosis, openheartedness and vulnerability are not luxuries—they are necessities. These qualities help establish a secure relational environment where mistrust can begin to soften.
Patients with psychosis often arrive in therapy with deeply ingrained expectations of betrayal or abandonment. Their life stories may be shaped by trauma, neglect, or repeated invalidation. In response, they have learned to protect themselves by retreating into internal worlds or projecting distrust onto others.
To engage meaningfully with these patients, therapists must be willing to show up authentically. This includes acknowledging their own limitations, being affected by the patient’s pain, and relinquishing the need to “fix” them. Compassion is not passive—it is an active stance of non-defensive engagement. Vulnerability in the therapist makes emotional safety possible for the patient.
This compassionate stance also helps therapists manage therapeutic impasses. Rather than reacting with frustration or distancing, an openhearted therapist approaches these moments with curiosity, asking: What is being protected here? What fear lies beneath this anger or silence?
Understanding the Developmental Roots of Mistrust in Psychosis
Mistrust is typically the outcome of developmental trauma, relational inconsistencies, and a life history where others were sources of threat rather than safety.
Children raised in environments where caregivers are neglectful, intrusive, or frightening often develop maladaptive internal working models. These models teach them that the world is unsafe and that others cannot be relied upon. Over time, these beliefs can crystallize into paranoia or delusional systems—attempts to make sense of a world that feels inherently dangerous.
As a result, the very presence of the therapist—someone who offers interest or concern—can be experienced as deeply threatening. The therapist may be perceived as manipulative or part of a broader conspiracy. Recognizing this developmental trajectory helps therapists remain patient, grounded, and compassionate in the face of extreme reactions.
Strategies for Engaging a Mistrustful Patient
Starting therapy with a mistrustful patient requires a nuanced, slow, and respectful approach. Here are three key strategies:
1. Emphasize Safety
Early in the therapeutic relationship, emotional safety must take precedence over interpretation or confrontation. Trying to challenge delusional beliefs too quickly can reinforce the patient’s sense of danger and distrust. Instead, offer consistent presence, respect boundaries, and prioritize emotional containment.
2. Acknowledge and Normalize Suspicion
Rather than dismissing or denying the patient’s suspicions, it is helpful to acknowledge them with empathy. For example, saying “It makes sense that you might be wary of me” helps validate their experience without endorsing delusions. This can open the door to more honest dialogue.
3. Model Relational Repair
When inevitable ruptures occur in therapy—such as misunderstandings or missed sessions—the therapist can model repair. Apologizing, checking in, and demonstrating accountability show the patient that conflict does not always lead to abandonment. These micro-repairs can challenge long-standing expectations of relational danger.
Redefining Hope: Beyond Optimism
Hope is often confused with blind positivity or the expectation of a good outcome. However, in the context of psychotherapy—and particularly with psychosis—hope is something more profound and resilient.
Unlike optimism, which depends on circumstances turning out well, hope is an internal capacity to imagine possibilities even in the face of despair. It is a relational phenomenon, born not from logic, but from connection.
Hope does not require a promise that things will improve. It only requires the belief that one is not alone, that their suffering is seen and honored, and that their pain has meaning. For many patients, simply having someone sit with them in their darkest hour—without judgment or agenda—can rekindle this fragile spark.
What Restores Hope for People with Psychosis?
Drawing from the lived experiences of those with psychosis, several key factors emerge as essential for restoring hope:
1. Feeling Understood and Accepted
Many patients describe profound relief in being met with curiosity rather than scrutiny. When therapists make the effort to understand the patient’s inner world, without rushing to label or fix, the patient begins to feel human again.
2. Belonging and Connection
Isolation is both a cause and consequence of psychosis. Finding community—whether through group therapy, peer support, or meaningful relationships—offers a vital antidote. Belonging tells the patient, “You are not alone. You matter.”
3. Having a Voice and Choice
Empowerment is central to recovery. When patients are included in decisions about their care and given space to express their needs and preferences, they begin to reclaim agency. This contrasts sharply with the often disempowering experiences they may have had in mental health systems.
Conclusion: Recovery Through Relationship
The intersubjective approach offers a powerful lens through which therapists can co-create meaning, nurture emotional safety, and ignite hope.
By meeting mistrust with humility, openheartedness, and clinical skill, we offer patients more than insight—we offer them the chance to feel human again. And in that shared humanity, recovery begins.
To hear Ridenour’s presentation in full and receive CE/CME credits, please visit the Techniques in the Psychotherapy for Psychosis course page.
To learn about how the Austen Riggs Center treats psychotic disorders, please visit our treatment page.
Related Resources
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Techniques in the Psychotherapy for Psychosis
March 12, 2025
Free CE/CME course with Jeremy Ridenour, PsyD, ABPP
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