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Estimated Read Time: 8–10 minutes
What You Will Learn from This Article
- Common fears experienced by individuals with psychosis, including fear of harm, recurrence of psychotic episodes, and social stigma
- How therapists may also experience fear when working with people experiencing psychosis
- The difference between loneliness and social isolation, and why it matters
- The relationship between psychosis and loneliness
- Four common types of losses people face following a psychotic episode
- Various recovery styles and how they influence the healing process
- Therapeutic strategies for building trust, addressing fear, and fostering meaningful recovery
In his presentation “Core Emotions in Psychosis” – part one in a two-part series – Austen Riggs Center Director of Testing and Associate Director of Admissions Jeremy Ridenour, PsyD, ABPP, talks about psychosis as a deeply complex and often terrifying experience that affects not just the individual, but also those around them—including mental health professionals. He suggests that understanding the emotional undercurrents of psychosis is essential for fostering meaningful recovery and explores key emotional elements—fear, loneliness, and grief—through the lens of psychotherapeutic insights, to help identify the nuanced challenges of psychosis and recovery.
If this topic is of interest to you, check out the Core Emotions in Psychosis course in its entirety and receive free CE/CME from our online catalogue.
Common Fears Among Individuals with Psychosis
Fear is a central feature of the psychotic experience, often overwhelming and distinct from anxiety. While anxiety may be diffuse, fear in psychosis is typically linked to perceived threats—either from within (such as voices) or from external agents (like surveillance or persecution).
Three primary fears frequently emerge:
1. Fear of Psychosis: Many individuals describe the onset of psychosis as terrifying, with fears of losing control, confusion about reality, and the dread of recurrence. After diagnosis, nearly half will experience another episode within five years, heightening anxiety about relapse.
2. Fear of Harm: Auditory hallucinations can include hostile or denigrating voices, which individuals may interpret as omnipotent and malicious. Paranoid beliefs further exacerbate this fear, leading to an overwhelming sense of vulnerability and a heightened perception of threat.
3. Fear of Stigma: Social stigma often portrays people with psychosis as dangerous or irrational. This societal judgment can lead individuals to hide their symptoms, resist treatment, and suffer in silence, further isolating them.
Therapist Fears When Witnessing Psychosis
Therapists are not immune to fear when working with psychotic patients. Their professional role requires them to manage their emotional responses, but this is easier said than done.
Therapists typically encounter three forms of fear:
1. Fear of Harm: Concerns about the potential for violence or exacerbating a patient’s symptoms can lead therapists to become overly cautious or avoidant.
2. Fear of Confusion: The disorienting nature of psychosis can induce feelings of destabilization in therapists, including fear of losing their own sense of reality.
3. Fear of Inadequacy: Engaging with psychosis can be challenging, often triggering the therapist’s feelings of helplessness or fear of failure.
These therapists' fears highlight the reciprocal nature of the therapeutic relationship, underscoring the emotional intensity both parties endure.
The Relationship Between Psychosis and Loneliness
Loneliness is not simply social isolation—it's the distress experienced when one's relationships are perceived as inadequate or emotionally unfulfilling. For individuals with psychosis, this is especially acute. While social isolation refers to the objective lack of social contact, loneliness is a subjective emotional state.
In the context of psychosis, loneliness is not only common but also profoundly impactful. It can exacerbate symptoms, hinder recovery, and heighten vulnerability to subsequent episodes. Key contributors to loneliness include:
- Interpersonal Rejection: Many people with psychosis report feeling discarded or misunderstood by friends and family.
- Internalized Stigma: The belief that one is "abnormal" or "broken" discourages social engagement and fuels isolation.
- Ambivalence about Connection: Some desire "normal" relationships outside clinical or peer-supported settings but simultaneously fear rejection or misunderstanding.
Psychotic symptoms themselves—such as hallucinations and delusions—often contribute to loneliness. These experiences can be so idiosyncratic and difficult to communicate that they isolate individuals, even when they wish to connect.
Four Common Types of Loss Following a Psychotic Episode
Recovery from psychosis often requires grieving multiple forms of loss. These include:
1. External Losses: Disruptions in work, education, or housing are common when people are acutely psychotic.
2. Interpersonal Losses: Psychosis can strain relationships. Erratic behavior, withdrawal, or paranoia may push loved ones away, leaving the individual socially adrift.
3. Loss of Symptoms: Surprisingly, some individuals mourn the loss of their delusions or voices. These symptoms may have offered comfort, identity, or meaning—even if they were distressing.
4. Loss of Self: Psychosis can shatter self-concept, leaving individuals uncertain of their identity or mistrustful of their own minds. This existential disorientation can be deeply traumatic.
Acknowledging these losses is crucial in helping individuals integrate their experiences into a coherent and resilient sense of self.
Reactions and Recovery Styles After Psychosis
Following a psychotic episode, people adopt different coping and recovery styles:
- Lack of Integration: Individuals may deny or downplay their psychotic episode. They avoid discussing it and reject its relevance to their identity. While this may preserve a positive self-image temporarily, it often hinders long-term healing.
- Negative Integration: Here, the individual accepts the psychosis but internalizes stigmatizing beliefs, developing an "illness identity." This can lead to hopelessness, depression, and a diminished sense of agency.
- Complex Integration: This style represents a more adaptive recovery. Individuals acknowledge their experiences, explore their meaning, grieve their losses, and begin to reshape their identity with greater nuance and self-awareness. This approach enables growth and renewed purpose.
Therapists play a pivotal role in facilitating complex integration by offering a safe, empathic, and reflective space.
Toward Healing: Building Trust, Vulnerability, and Hope
Therapy for psychosis is emotionally demanding but also profoundly transformative. Key practices that support healing include:
- Accepting Fear and Uncertainty: Both patient and therapist must tolerate ambiguity and fragmentation. Naming fear—rather than avoiding it—can be a catalyst for connection and understanding.
- Fostering Open-Heartedness: Therapists who speak vulnerably and authentically can model the courage required to face terrifying realities. This reduces the power imbalance and nurtures a stronger therapeutic alliance.
- Rebuilding Meaning and Identity: As individuals process their experiences, they can start to reconstruct their identities around resilience rather than pathology. They move from feeling damaged to feeling human.
- Reconnecting with Others: As trust is rebuilt and shame lessens, individuals can begin to pursue the “social goods” they long for—friendship, love, community—and decrease the chronic loneliness that so often accompanies psychosis.
Final Thoughts
Psychosis is not just a clinical condition—it’s a deeply human experience shaped by fear, loneliness, and loss. But with thoughtful, courageous therapy, it can also be a pathway to transformation. Recognizing the complexity of these emotional landscapes—both for patients and therapists—is essential to fostering recovery that is not just symptom reduction, but also the restoration of meaning, dignity, and connection.
To hear Ridenour’s presentation in full and receive CE/CME credits, please visit the Core Emotions in Psychosis course page.
To learn about how the Austen Riggs Center treats psychotic disorders, please visit our treatment page.
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