What We Can Learn From Therapists Who Treat Psychosis

In the popular folktale, Chicken Little, a chicken finds himself afraid of the sky falling when an acorn falls on his head. He warns the other creatures who greet him with skepticism and or join him in his journey. As a child, my mom shared her version (one of many passed down) and I laughed at the foolish animal. As an adult, my view has changed. Chicken Little's sky truly was falling.

Validation is a mainstay in relationships. We all need to be seen and heard. Being met as a fellow human with an acknowledgment of credibility is critical. But, what if someone is expressing something that does not line up with our understanding of the world?

As humans with our individualized perspectives on life, this is an everyday experience. We have disagreements about what is true all the time.

Here's what I have learned about validation as a therapist treating psychosis.

We don't have to share the same views to see and hear each other.

I have met many people with beliefs that others would call unusual or bizarre. Some people have been diagnosed as having delusions. Validation is just as central in their therapy as is for anyone else.

I would never want to mislead someone or collude with a troubling belief. Still, it is possible to validate a person and their experience without encouraging a delusion. It is essential.

The Nature of Reality

Even in psychosis, a person's experiences are real to them. Having an unshared belief can be a lonely, frightening, and painful thing. They may share their worries or excitement with others only to be repeatedly shut down or ignored. When reaching out for therapy, the last thing someone needs is to be further invalidated and argued with. Or, potentially worse, to receive that stare, the one people give when they don't believe something but also don't want to say so.

The nature of reality is more fragile than many would like to admit. Who is to define what a delusion is? Psychotherapists and other mental health professionals are certainly not Gods. There have been cases where individuals have been wrongly diagnosed with delusions, and people who have a pre-existing psychotic disorder might be particularly susceptible to not being believed.

Yet, we do have this consensus reality, and troublesome beliefs often accompany a variety of well-defined conditions including psychotic disorders. While no one can say for sure what is real, we make a best guess based on observation and consensus reality. When a person is suffering due to a condition that affects this ability, we must acknowledge it, even as we also acknowledge that what they are sharing is their reality.

Psychotherapy for Unusual Beliefs

While in traditional cognitive behavioral traditions, Socratic questioning and cognitive restructuring begin early on forming a central part of the therapy, this is less the case in offshoots specific for psychosis such as Cognitive Behavioral Therapy for Psychosis (Wright and colleagues, 2014), or recovery-oriented cognitive therapy (Beck and colleagues, 2021). Rather, curious questions just to understand what someone believes and partnering with them mark the beginnings of these therapies.

It is possible to show empathy for someone's reality, even when it is not shared, and to express a desire to understand better. The therapist is likely to delay answers to questions: "Do you believe me?" "What do you think?" In recovery-oriented cognitive therapy, the focus is on the person's recovery as defined by their values rather than immersion in our shared reality. Often underlying needs and values can be found in what someone is sharing. For example, a person who shares a belief that they are the president of the United States might have dreams of feeling relevant or other hidden beliefs that they are not. In therapy, a focus on this need or dream over the content of the delusion can go a long way further.

In cognitive behavioral therapy for psychosis, sometimes there are additional interventions such as behavior experiments and cognitive interventions.

Regardless, the process is complex, and respect is central.

Rather than using the term delusion, one that has sadly become an insult, the therapist might endorse the term unusual belief, reminding us that almost all of us have at some point or another had an unusual belief even if we do not have a psychotic disorder.

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What We All Can Learn

Perhaps there is something here for all of us to learn about validation. We don't have to share each others' realities or beliefs to appreciate each others' experiences. Seeking to understand is not just important in therapy or when a person is experiencing mental illness, it's perhaps key to every relationship we have.

If we could look past the factual disagreements we have to see each other's aspirations and needs, we have a better chance of connecting and meeting those. For example, my friend and I might disagree about what happened in an argument. We could go on an epic odyssey to prove each other wrong while in the process tearing apart our relationship. Or, we could hear each other out. Maybe the important piece isn't who cancelled plans first, but that one or both of us felt overlooked. At the end of the day, that's the piece that matters.