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When I’m teaching psychiatry residents, medical students, or psychotherapy trainees about psychodynamic therapy for psychosis, I frequently hear the same refrain. They very much see the need for the work and want to do it, but are intimidated by the idea that therapy with psychotic people is very different than it is with other patient populations, and that they would have no idea how to begin.
What makes a therapy psychodynamic? Three core principles that define a psychodynamic therapy are:
- Attention to unconscious conflicts and fantasies
- Fantasies in analytic terms, meaning stories about themselves and others; they can be pleasant or unpleasant fantasies
- Genetic interpretations
- Fantasies in analytic terms, meaning stories about themselves and others; they can be pleasant or unpleasant fantasies
- “Genetic” in analytic terms, meaning regarding early childhood and family relationships
- Attention to transference
- Transference being the experience of projecting feelings about important childhood figures onto the therapist
- Transference being the experience of projecting feelings about important childhood figures onto the therapist
In my opinion, dynamic therapy helps people tell themselves a story about their lives that starts with their earliest relationships and evolves through time to describe the person that they have become and the world they inhabit. By making personal narratives more open and flexible, people are able to change their experience of their past, themselves, and the world that they live in.
But dynamic therapy, while incorporating these elements, isn’t only about those things. Often in the beginning I am using techniques more consistent with supportive therapy or CBT. But I am thinking dynamically about the person, even before I start talking dynamically with the person.
I think that some basic principles are useful in the early stages of therapy for most patients, and perhaps particularly for people with psychosis. It might be especially helpful to notice that many people with psychosis are seemingly poor at thinking about their own thoughts (mentalization) or feelings (alexithymia). Both of these issues may be central to the psychological mechanisms that continue to strengthen psychotic thought patterns even once the most generative period of psychotic thought production is over.
In my experience, the very act of staying curious with a person with psychosis about their mind, and both encouraging and modeling mentalization, makes significant inroads into reducing and softening delusional material.
Here are some strategies with some examples for the early stages of dynamic therapy for psychosis.
- Encourage and model mentalization: “I’m thinking about what this may feel like for you,” or “I notice that it is hard for you to put words to your thoughts and feelings about this topic. I wonder what that might be about?”
- Build curiosity: “I’m curious about X,” “Are you curious about this?” “What are your thoughts/what do you think?” “I wonder…”
- Help with depersonalization, limited emotional recall, and alexithymia: “What are you feeling in your mind or body?” “Where do you feel this in your body?” “As you experience this feeling you are having (in mind or body), does it feel familiar? What does it make you think of or remember?”
- Listen carefully to their narrative, psychotic or not, and believe them: This does not mean believing psychotic material, but it does mean believing the distress, fear, and anxiety beneath the manifest content. The message is not “I believe everything you tell me in a literal way,” but rather the message is “I trust you.” There is meaning all the way through, like a dream. But the material may not be literally true; instead, it is symbolically or metaphorically true.
- Listen to the narratives about the family. My last suggestion is perhaps the most controversial, but in my mind the most important. Listen to the patient talk about their childhood, and if they struggle to do so, then ask them what it was like growing up in their family. Start to think with the patient about links between family dynamics and the content of the psychosis. Patients have known about these links for years in their unconscious. Starting to give them room to discuss and explore it will vastly decrease their psychotic symptoms—if they can tolerate it. One way to know that they cannot tolerate it yet is if their symptoms flare after talking about it, their thoughts become more disorganized, or if their thoughts “turn off” and they get excessively anxious. If that occurs, then work on the four points above first. If they can tolerate it, though, these conversations become the most transformative.
