Bupropion and Psychotherapy in the Treatment of the Sexual Side Effects of Antidepressants


Bupropion and Psychotherapy in the Treatment of the sexual side effects of Antidepressants

Dr Christian Jonathan Haverkampf, M.D.

Sexual dysfunction is a common side effect with many antidepressants, particularly the selective serotonin reuptake inhibitors (SSRIs). While the effects of the SSRIs are often very helpful in the treatment of depression, anxiety and OCD, sexual side effects are common but often not asked for by the prescriber. Two main strategies can be effective in treating sexual dysfunction. One is to add another medication, such as the dopamine and norepinephrine reuptake inhibitor bupropion. Another is to use psychotherapy, particularly one that is focused on communication. Psychotherapy is not used often in this context, although its effectiveness for sexual dysfunction in general has been established, and even cases of medication induced sexual dysfunction are frequently multifactorial.

Keywords: sexual dysfunction, selective serotonin reuptake inhibitor, SSRI, serotonin, dopamine, antidepressants, bupropion, medication, psychotherapy, psychiatry

Table of Contents

Introduction. 3

Bupropion. 4

Bupropion as an Add-On. 4

Psychotherapy. 6

Attitudes towards Sex. 7

Communication-Focused Approaches. 7

Behavioural and Cognitive-Behavioural Approaches. 9

References. 11



A significant number of patients undergoing treatment with selective serotonin reuptake inhibitors (SSRIs) report sexual dysfunction. However, sexual dysfunction is also a common symptom of the underlying condition the medication is used for, such as depression and anxiety.

SSRI-induced sexual dysfunction can significantly lower the quality of life of the patient. SSRIs alleviate symptoms of depression primarily by selectively inhibiting the reuptake of serotonin in the central nervous system. An increase in serotonin may, however, affect other hormones and neurotransmitters, such as testosterone and dopamine. This may lead to side effects of sexual dysfunction, as testosterone may affect sexual arousal and dopamine plays a role in achieving orgasm.

The most common sexual side effect is delayed ejaculation.  Other types of sexual side effects include reduced sexual desire, reduced sexual satisfaction, anorgasmia, and impotence.  A prospective, descriptive clinical study of 344 subjects found that the incidence of sexual side effects was highest with paroxetine, followed by fluvoxamine, sertraline, and fluoxetine. The incidence of sexual dysfunction was similar between fluoxetine and escitalopram. (Jing & Straw-Wilson, 2016)

The best clinical evidence supports starting treatment with an antidepressant that has a better adverse sexual effect profile, such as bupropion or mirtazapine, particularly in patients concerned about their sexual functioning and in those with sexual dysfunction at baseline. (T. Lorenz et al., 2016) However, bupropion usually helps little in clinical practice against anxiety, or may even worsen it, which is often comorbid with depression.


Bupropion has been used as an antidepressant for decades, though its use as an antidepressant is generally not considered first-line. It has a unique pharmacology, inhibiting the reuptake of noradrenaline and dopamine, potentially providing pharmacological augmentation to more common antidepressants such as selective serotonergic reuptake inhibitors (SSRIs). Preclinical and clinical data show that bupropion acts via dual inhibition of norepinephrine and dopamine reuptake and is devoid of clinically significant serotonergic effects or direct effects on postsynaptic receptors. (Stahl et al., 2004)

Bupropion undergoes metabolic transformation to an active metabolite, 4-hydroxybupropion, through hepatic cytochrome P450-2B6 (CYP2B6) and has inhibitory effects on cytochrome P450-2D6 (CYP2D6), thus raising concern for clinically-relevant drug interactions. Common side effects are nervousness and insomnia. Nausea appears slightly less common than with the SSRI drugs and sexual dysfunction is probably the least of any antidepressant. (Foley et al., 2006)

Several large multi-medication trials, most notably STAR*D, also support a therapeutic role for bupropion. It demonstrated similar effectiveness to other medications, though this literature highlights the generally low response rates in refractory cohorts. Bupropion is generally well tolerated, it has very low rates of sexual dysfunction, and is more likely to cause weight loss than gain. (Patel et al., 2016)

Bupropion as an Add-On

Bupropion is used in clinical practice quite frequently as an add-on to a serotonergic antidepressant therapy if sexual side effects due to the latter drug emerge. There is support for this prescribing strategy in the literature. However, there are also some contradictory findings, which may be due to the complexity of human sexuality and the diverse manifestations of sexual dysfunction. In a literature review, Zisook and colleagues found that controlled and open-label studies support the effectiveness of bupropion in reversing antidepressant-associated sexual dysfunction, whereas open trials suggest that combination treatment with bupropion and an SSRI or SNRI is effective for the treatment of MDD in patients refractory to the SSRI, SNRI, or bupropion alone. (Zisook et al., 2006) In a later literature review, Valeska and colleagues found that most of the studies have noted that bupropion has the advantage of a lower impact on sexual functioning, and that it is effective, when combined with other antidepressants, in treating emergent sexual dysfunction. (M. Pereira et al., n.d.) There were also some studies indicating that bupropion enhanced sexual functioning in general.

In a study by Ashton and colleagues with 47 patients receiving 75 mg or 150 mg of bupropion 1–2 hrs before sexual activity, bupropion successfully reversed a variety of sexual dysfunctions caused by SRIs in 31 (66%) patients. Side effects of anxiety and tremor led to discontinuation of bupropion in 7 patients. Otherwise, bupropion was well tolerated. (Ashton & Rosen, 1998) However, in another study by Clayton and colleagues, patients were randomly assigned to receive either bupropion SR 150 mg b.i.d. or placebo for four weeks in addition to the SSRI. The difference in global sexual functioning, based on the total Changes in Sexual Functioning Questionnaire (CSFQ) score, was not statistically significant between the two groups at week four, nor were differences in orgasm, desire and interest as measured by sexual thoughts, or self-reported arousal. There was a statistically significant difference between the two groups at week four in desire as measured by self-report feelings of desire and frequency of sexual activity. Desire and frequency showed a significantly greater improvement among those patients receiving bupropion SR compared with placebo. Frequency was significantly correlated to total testosterone level at baseline. (Clayton et al., 2004)

Bupropion has shown effectiveness in both sexes. However, as sexual side effects can manifest differently it is informative to look at individual populations. In a study by Sararinejad with 218 women (25–45 years old), who were randomized to receive 12 weeks of double-blind fixed dosed treatment with bupropion sustained release 150 mg b.i.d. or placebo, the mean for Female Sexual Function Index total score was higher in the bupropion sustained release group than in the placebo group (p = 0.001). Mean Clinical Global Impression Scale score for the bupropion group was significantly lower than that for the placebo group (p = 0.001). At the end of the trial the mean scores for desire, arousal, lubrication, orgasm, and satisfaction were significantly higher in the bupropion group. The highest improvement was observed in sexual desire, followed by lubrication. (Safarinejad, 2011) In a randomized clinical trial was performed on 40 schizophrenic patients, participants were randomly divided into two experimental and control groups. The study group was medicated with bupropion 150 mg/day and the control group was given placebo for one-month. The study group showed significant improvement in sexual function, leading to significant change in the score of sexual desire, erection and orgasm. (Rezaei et al., 2018)


Many approaches have been adopted for management of patients with sexual dysfunction associated with antidepressant treatment, including waiting for the problem to resolve, behavioural strategies to modify sexual technique, individual and couple psychotherapy, delaying the intake of antidepressants until after sexual activity, reduction in daily dosage, ‘drug holidays’, use of adjuvant treatments, and switching to a different antidepressant. (Baldwin, 2004) Unfortunately, the potential benefits of psychotherapy are often overlooked. Given that sexual activity is sensitive to many psychological factors and based primarily on communication if experienced with another person, psychotherapy should be a primary therapeutic approach for sexual dysfunction, whether caused by a medication or otherwise.

In clinical experience, sexual dysfunction is rarely due to a single factor, even in many patients who are on a medication that can cause sexual dysfunction. It is thus important to look at the treatment of sexual dysfunction from a more global perspective. Psychological interventions usually place a significant emphasis on communication, which is at the heart of sexual functioning, whether in the form of internal or external communication. (Haverkampf, 2010b) In a systematic review and meta-analysis of all available studies on psychological interventions for sexual dysfunction from 1980 to 2009, the overall post-treatment effect size for symptom severity was d = 0.58 (95 % CI: 0.40 to 0.77) and for sexual satisfaction d = 0.47 (95 % CI: 0.27 to 0.70). Psychological interventions were shown to especially improve symptom severity for women with Hypoactive Sexual Desire Disorder and orgasmic disorder, and evidence seemed to vary considerably across different disorders. (Frühauf et al., 2013)

Attitudes towards Sex

In a study of sexually functional males and females from the general population (43 males, 102 females) and clients attending a university clinic for the treatment of sexual dysfunction (1 14 males, 84 females), all groups of dysfunctional respondents were more likely than the functional group to report current negative attitudes towards sex. All groups of dysfunctional females were also more likely to experience deficits in both the sexual and non-sexual aspects of their current relationship, most particularly in relationship quality and range of sexual experiences. (McCabe & Cobain, 1998) This can raise the question whether sexual dysfunction leads to a more negative attitude towards sex or the negative attitude towards sex to greater sexual dysfunction. But maybe it is important to acknowledge that a clear line between sexual dysfunction and thoughts about sex does not exist. As mentioned above, sexual activity can be viewed as a form of communication (Haverkampf, 2010b), which is sensitive to many factors within and in the interaction with others. Messages containing meaningful information have a significant impact on a person’s thinking, feeling, and behaviours. (Haverkampf, 2010a) Communication-Focused Therapy®, for example, takes an approach that promotes awareness, reflection, and experimentation with respect to a patient’s communication patterns.

Communication-Focused Approaches

Communication with others can in itself have an antidepressant effect, depending also on the meaningfulness of the interactions. Since sex and intimacy are built on communication, both internal and external, they are very sensitive to changes in communication patterns. Depression can lead to less interactions, which then can also maintain the depression in a vicious cycle. Women with depressive symptoms, for example, have reported greater desire for sexual activity alone (masturbation) than the nondepressed women. (Frohlich & Meston, 2002) Thus, depression itself may be a barrier to the kind of communication that may be important for the enjoyment and initiation of fulfilling sexual activity with a partner.

Sexual activity occurs within a web of meaningful messages within and without the individual. A communication-focused approach means creating greater awareness in the patient for the communication patterns that have a large bearing on whether own needs, values, and spirations are satisfied or not. In one study investigating a community sample with 53 women and 34 men in long-term, heterosexual relationships, a majority of the men and women reported that they had experienced one or more sexual concerns or problems in the past 18 months. Both better communication in general, and disclosure of specific sexual likes and dislikes in particular, were  between sexual problems and concerns and sexual satisfaction. (The Relationships between Sexual Problems, Communication, and Sexual Satisfaction – ProQuest, n.d.)

The artificial distinction between sex therapy and communication therapy has fortunately vanished to a large extent. If they are viewed separately, they can lead to conflicting effects. In an earlier study from 1981 on sex therapy and communication therapy, the experience of sexual interaction and the orgasmic experience improved in males and females in sex therapy, and in females in communication therapy. The male experience of sexual interaction deteriorated in communication therapy, while the male orgasmic experience initially increased and subsequently diminished again. Satisfaction with the total relationship increased in the males in communication therapy, and in the females in sex therapy. (Everaerd & Dekker, 1981) However, it must be remembered that a large part of sex therapy can be subsumed within the wider range of communication-focused approaches. Sex with another person happens within the framework of the interactions in a relationship. The quality of the communication between the partners has a significant effect on all areas of the relationship, but particularly on intimacy, which is very sensitive to flows of meaningful messages. In another study, male and female partners from 76 heterosexual couples independently completed measures of their own and their partners’ sexual preferences, as well as measures of sexual and general relationship adjustment, sexual difficulties, marital role preferences, depression, and social desirability. Results indicated that sexual satisfaction in both partners was associated with men’s understanding of their partner’s preferences and agreement between their preferences. General relationship adjustment of both partners was associated with women’s understanding of men’s marital role preferences. (Purnine & Carey, 1997)

A communication-focused is not a quick fix. New communication patterns and insights have to be practiced and engrained as part of daily life. This also requires an openness to changes in communication patterns. Often, rigidity in a problematic relationship dynamic and the fear to address issues within the relationship causes an exacerbation and entrenchment of the relationship difficulties and any sexual dysfunction that goes with them. In a study, couples who reported less relationship adjustment prior to treatment showed greater overall gains in coital orgasmic frequency than couples who reported better relationship adjustment. (Kilmann et al., 1986) The treatment conditions consisted of a communication skills format, a sexual skills format, and one of two combination formats.

Behavioural and Cognitive-Behavioural Approaches

Psychotherapy often focused primarily on the underlying condition rather than the sexual dysfunction. In a study by Hoyer and colleagues with 451 outpatients treated with CBT, sexual dysfunctions improved in a significant number of patients but only after successful treatment for the psychological disorder. Results for patients suffering primarily from depression were similar to those who suffered from other psychological disorders. (Hoyer et al., 2009) When patients are treated with an antidepressant, whether with an SSRI or otherwise, it is important to keep in mind that the depression can also lead to sexual dysfunction, and that it may not be easy to distinguish whether it is pharmacologically induced or a manifestation or by-product of the underlying condition. In a study with 55 male and 79 female patients with major depression, over 40% of men and 50% of women reported decreased sexual interest. (Kennedy et al., 1999)

In a review of the literature, Berner and Günzler found that twelve out of 20 trials in men used either a concept derived from Masters and Johnson or a cognitive‐behavioural treatment program. Overall, psychosocial interventions improved sexual functioning. In men with premature ejaculation, behavioural techniques proved to be effective. Most of the compared interventions proved to be similarly effective. (Berner & Günzler, 2012) The results of a study of 23 couples, in which the wife was suffering from secondary orgasmic dysfunction, indicated that a cognitive-behavioural sex therapy program was effective in changing a wide range of subjective satisfaction and behavioural measures. (Libman et al., 1984)

In a study by Lorenz and colleagues, exercise immediately prior to sexual activity significantly improved sexual desire and, for women with sexual dysfunction at baseline, global sexual function. Scheduling regular sexual activity significantly improved orgasm function; exercise did not increase this benefit. Neither regular sexual activity nor exercise significantly changed sexual satisfaction. (Tierney Ahrold Lorenz & Meston, 2014) In another study by the same authors, exercise prior to sexual stimuli increased genital arousal. Women reporting greater sexual dysfunction had larger increases in genital arousal post-exercise. For women taking SSRIs, genital arousal was linked to SNS activity. (Tierney A. Lorenz & Meston, 2012)

Disclosure: The author is founder of Communication-Focused Therapy® but reports no other potential conflicts of interest.

Dr Jonathan Haverkampf, M.D. (Vienna) MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy in Dublin, Ireland. He is the author of several books and articles on topics of psychiatry, psychotherapy, and communication, and is the founder of Communication-Focused Therapy®. He can be reached through www.jonathanhaverkampf.com and www.jonathanhaverkampf.ie and is a frequent guest on www.askdrjonathan.com.


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Communication-Focused Therapy® (CFT) for Psychosis


Communication-Focused Therapy (CFT) for Psychosis

Dr. Christian Jonathan Haverkampf, M.D.

Communication-Focused Therapy (CFT) is a psychotherapy developed by the author, which can be applied to several mental health conditions, including psychosis. Meaningful communication is at the heart of understanding psychosis. When a patient can no longer distinguish whether the information comes from the inside or outside world, we consider it a psychotic state. ‘Information’ can include anything from new thoughts to a sensory perception or sensations from inside the body. Since information transmission happens through communication, patients’ communication patterns influence the meaningful information they are exposed to, and the level of meaning they associate with themselves and the world. Psychosis is, in this sense, a distortion in meaning-making, which can be an impairment in everyday life. However, working on communication patterns can reverse the impairment and even bring out new resources to benefit the patient.

Keywords: psychosis, communication-focused therapy, CFT, communication, psychotherapy, treatment

Table of Contents

Introduction. 4

Reality. 4

Learning through Communication. 5

Resources. 5

Psychosis. 6

Misinterpretation of Sources of Information. 7

Misinterpretation of Messages. 9

A Diversity of Symptoms. 9

Connectedness vs Psychosis. 10

Communication-Focused Therapy® (CFT) 11

Communication is Life. 11

Autoregulation. 12

Understanding Psychosis. 12

Meaningful Communication. 12

Learning about Communication. 13

Observing Communication. 14

Experimenting. 15

Reflecting. 15

The Communication Space. 15

Connectedness. 17

Experiencing the World. 17

Identifying Meaning in the World. 17

Increasing Interactions. 18

Values, Needs and Aspirations. 19

Communication Patterns. 20

Questions. 20

Confirmation. 20

Reflection. 21

Support. 21

Explaining. 21

Theory Building. 22

Experimentation. 22

‘You’ and ‘I’ 22

Time. 22

Metacommunication: Structure. 23

Testing. 23

Boundaries. 23

Communicating Internally. 24

Communication Attributes. 24

Communication Structures. 24

Communication Dynamics. 25

Meaningful Messages as the Instrument of Change. 25

Knowing Where Information Comes From.. 26

References. 28


Psychosis means losing touch with reality in one’s perception of what is real. It is thus a failure in meaningful communication since what is meaningful ultimately becomes real. Medication is often the first-line treatment, and many schools of psychotherapy are reluctant to work with people experiencing psychotic symptoms. On the other hand, psychotherapy can be a much more delicate instrument than medication. It also needs to be remembered that both medication and psychotherapy bring about changes in the neuronal network. Psychotherapy changes the streams of information, and meaningful information brings about a change in the neuronal network because the inherent definition of meaning is that it can affect a change. (Haverkampf, 2010a, 2018a)

From a perspective of everyday functioning more specifically than medication, which can be highly specific for certain molecular pathways, but does not have the specificity for the interactions of the patient with the real world.

Underlying most psychotherapies is the belief in the effectiveness of interpersonal communication, the ‘talk therapy’ as psychoanalysis was called at the close of the nineteenth century. Since in psychosis there are patterns of communication with oneself and others that are causing symptoms and are not helpful to the individual, using therapy to change offers more than hope in the treatment and management of psychosis. Communication-Focused Therapy® was designed by the author to work on the communication patterns that play a role in the exchange of meaningful information.


When people speak of reality, they really often mean shared reality. Shared reality is the perceptions the majority of people have. It does not necessarily mean that this is the ‘true’ reality, but it is how the majority of people see the world.

The shared reality may not necessarily be the ‘best’ reality. Someone could be happy interpreting the world in a different way. Part of the shared reality is due to shared anatomy and physiology; another part is due to the exchange of information between people. Psychosis affects how information is processed. Besides medication, helping people to have a different perspective on the flows of information and process them differently is an important way to treat psychosis. Assisting patients in selecting for, exposing themselves to, and as a result, receiving more meaningful information, they can ‘build’ a reality which causes less suffering and better meets their needs and wants.

An essential feature of experiencing reality is to be able to discriminate where the information is coming from. If one hears voices, one misattributes internal thoughts as external, or if one feels pursued by a secret agent, an aggressive inner emotion gets projected into the outside world. Both these examples are a consequence of how patients work with internal and external communication. Better insight into communication and learning communication skills can help to better localize sources of messages and build a more stable view and sense of reality.

Learning through Communication

Learning to identify better the sources of information, inside one’s own body and in the outside world, can help to attach the correct meaning to a sensation or a voice one hears. This can be trained in the communication space of a psychotherapeutic setting. Practising communication and reflecting on it helps the patient to develop greater insight and sharpen his or her communication skills.

Learning about communication usually includes a theoretical psychoeducational component and a practical component. Engaging in communication can be important to increase one’s confidence and skills in the process. At the same time, better proficiency in communication also makes any other learning processes easier.


Patients who have psychosis often lose a sense of their resources because the structure of the self feels less stable and reliable. In the therapeutic interaction, through the communication process, a more stable distinction between the inside and outside worlds can be established, which strengthens the sense of self, and thus makes the own resources more accessible. The self is an experience of internal information flows (Haverkampf, 2010a, 2017b, 2017c). Therefore, it is not surprising that working on communication patterns can help arrive at a more stable sense of self.

Using communication more optimally can, for example, compensate for various cognitive impairments which are often a part of psychosis. Individual strengths can shine more if interactions with oneself and the world around improve. Resources can also be easier felt and relied upon if one communicates better with oneself. One aim of Communication-Focused Therapy® is to help the patient identify where information comes from, particularly if it represents a feeling or an emotion, what it means, and how one can react to it.


Psychosis is an abnormal condition of the mind that involves a loss of contact with reality. It is not a diagnosis but a bundle of symptoms. People experiencing psychosis may exhibit personality changes and thought disorder. Depending on its severity, this may be accompanied by unusual or bizarre behaviour, difficulties with social interaction, and impairments in carrying out daily life activities. Generally, psychosis involves noticeable deficits in normal behaviour and thought (negative symptoms) and often various types of hallucinations or delusional beliefs, particularly concerning the relationship between self and others as in grandiosity or paranoia (positive symptoms). Psychosis has such broad effects because it affects the flow of information, making interactions with others difficult. But it also affects the internal flows of information as discussed above, which can then lead to a misattribution of information. Internal information may then be mistaken as having an external source and vice versa. The paranoia of someone following me or a secret cabal of individuals influencing me is a projection fo the normal dynamics into the outside world. Our thoughts are questioned, obliterated, and threatened by other thoughts, as this is how normal rational thoughts processes work. The opposite happens when I am convinced that other people are influencing my thoughts directly.

Unfortunately, psychosis as a diagnostic term is often used after other reasons have been excluded. Therefore, it may be more illuminating to think of psychosis as a mental process involving changes in how information flows and how these flows are interpreted, which can occur in various psychiatric conditions.

Misinterpretation of Sources of Information

As discussed, in psychosis leads to a misattribution of information to an outside or an inside source. Patients experience their thoughts as coming from outside in the form of voices or people on the outside as part of internal mental processes. They might experience the latter as people influencing their own thoughts. From the differently perceived localization of perceptions and messages, a different reality is constructed. Since the pieces often do not integrate as well into it as in the shared reality, gaps can result, which then lead to fears, which are often of an intense and existential nature. There is evidence for an association between hallucinations and externalization errors in source monitoring. Neuroimagining results support hyperactivation of voice selective cortical regions (e.g. the superior temporal gyrus, STG) as underlying the cognitive operations shared between externalization errors in source monitoring and hallucinations. (Woodward & Menon, 2013)

From a communication perspective, an interesting question is whether the meaning that is given to the information content influences the misattribution. In one study, results suggested that external source monitoring bias may not be central to the cognitive processes underlying hallucinations early in the course of psychotic illness, and the theory linking childhood trauma and external source misattribution was not supported. (Bendall et al., 2011) Also, in dissociation, there is support for the association between errors attributing the source of self-generated items and positive psychotic symptoms and the absorption and amnesia measures of dissociation. (Chiu et al., 2016) This would also point more to an information processing problem that is relatively independent of meaning.

Another pertinent question is whether the misattribution may be due to an existing tendency to externalize, which may at least explain the inside-out misattribution or projection. Earlier findings have been that patients with hallucinations and delusions are prone to misidentifying their own verbal material as alien in a task which does not involve cognitive self-monitoring. This suggests that these symptoms are related to an externalizing bias in the processing of sensory material, and not solely a function of defective self-monitoring. (P. P. Allen et al., 2004) In a later study, Garrison and colleagues found no evidence of an impairment or externalizing bias on a reality monitoring task in hallucination-prone individuals. They also found no evidence of atypical performance on an internal source monitoring task in hallucination-prone individuals. (Garrison et al., 2017) Reality monitoring is the ability to distinguish internally generated information from information obtained from external sources.  

Impairments in self-recognition (i.e. recognition of own thoughts and actions) have been repeatedly shown in individuals with schizophrenia. Information flows in many different areas in the body, and this can also involve sensorimotor processing. Dysfunction of sensorimotor predictive processing can lead to altered self-monitoring in psychosis. (Salomon et al., 2020) In another study, individual differences in auditory hallucination-like experiences seem to be  highly related to the external misattribution of thought. (Sugimori et al., 2011) This is important because sensorimotor information also plays an important part in building the sense of self. Self-monitoring biases and overconfidence in incorrect judgments have been suggested as playing a role in schizophrenia spectrum disorders. Gaweda and colleagues found that both ultra-high risk and first-episode psychosis groups misattributed imagined actions as being performed (i.e., self-monitoring errors) significantly more often than the control group. They made their false responses with higher confidence in their judgments than the control group. There were no group differences regarding discrimination between the types of actions presented (verbal vs non-verbal). (Gawęda et al., 2018)

The misidentification of self-generated speech in patients with auditory verbal hallucinations is associated with functional abnormalities in the anterior cingulate and left temporal cortex. In a study by Allen and colleagues, individuals with hallucinations made more external misattributions and showed altered activation in the superior temporal gyrus and anterior cingulate compared with both other groups. This may be related to impairment in the explicit evaluation of ambiguous auditory verbal stimuli, according to the investigators. (P. Allen et al., 2007)

There seem to be self-recognition deficits in populations on the continuum of psychosis who are still lacking the full-blown psychotic symptoms. Lavalle and colleagues observed significantly reduced self-recognition accuracy in populations on the pyschosis-spectrum compared to controls. (Lavallé et al., 2020) Biological areas in the brain that are involved in both self-referential processing and the integration of sensory information, such as the right middle temporal gyrus (MTG) and left precuneus, may be involved. A study found that within a first-episode psychosis group, the level of activation in the right middle temporal gyrus was negatively correlated with the severity of their positive psychotic symptoms. y (Kambeitz-Ilankovic et al., 2013)

One needs to regard psychotic symptoms as being on a sliding scale, like many other mental health afflictions. For example, psychotic symptoms can occur in situations when otherwise healthy individuals are under significant psychological stress. Using a robotic device to introduce sensorimotor prediction errors (SPEs) in healthy subjects can induce a psychosis-like feeling of a presence (‘FoP’) (Blanke et al. 2014).  induction of SPE can cause self-other confusion in the auditory domain. This deficit in self-other discrimination could be correlated to specifically reduced connectivity in the fronto-parietal cortex (‘FoP network’) related to sensorimotor self-representation. (Salomon et al., 2018)

Misinterpretation of Messages

Misinterpretation of a message is different from the misattribution of the information source, but they often seem to go hand in hand in psychosis. The conviction that someone is pursued by a neighbour, who is a spy, can be a misinterpretation of a feeling towards the neighbour as a (real) outside event, while a smile from the neighbour in the hallway can be interpreted as her satisfaction about having made a plan to harm the patient, which would be a misinterpretation of her original message of saying ‘Hi’.

A misinterpretation of messages usually occurs with respect to the universe of the patient, emotionally and perceptually. When focusing on communication in therapy, it is therefore essential to first get a sense for the universe the patient finds himself or herself in, both perceptually and emotionally. This information allows the therapist to build a better rapport with the patient since the patient will interpret the therapist’s messages within the context of this universe.

A Diversity of Symptoms

A host of symptoms can follow from the underlying communication dynamics of psychosis. Psychosis is often used descriptive term for the hallucinations, delusions and impaired insight that may occur as part of a psychiatric disorder. More correct would be to use it to describe the alterations in information recognition and processing. Some symptoms can be due to a misinterpretation in the source of the information or misinterpretation of one’s own position relative to the source of information, while others are clearly due to a misinterpretation of the messages.

Connectedness vs Psychosis

Psychosis is a state in which information is no longer categorized and compartmentalized in the same way. This does not necessarily mean an increase in connectedness. Rather the opposite, as the categorization of information, such as what happens in the outside world and what happens on the inside, is important to effectively communicate with oneself and others. When it becomes distorted or breaks down, the boundaries between oneself and the other person are affected, which reduces the accuracy of encoding and decoding messages. If I cannot distinguish if a thought or emotion is mine or someone else’s, my interaction with the other person will be affected. If I am wrong, a message from the other person, or myself, will be read incorrectly, and I am more likely to respond in a way, which does not help myself or the other person. For example, if my anger about someone else is misinterpreted as anger coming from the other person, I am more likely to misinterpret their brief stare or silence. They may reflect on what I said while I could interpret their communication as aggressive.

However, connectedness can also be heightened in a psychotic episode if barriers break down, which have been impairing a free flow of meaningful communication otherwise. For example, among shamans, several may owe their visions to psychotic episodes, which brought information into conscious awareness, which may not have been as easily accessible otherwise. Several artists also had psychosis, such as Van Gogh who had schizophrenia, whose paintings with their bright colours and eerily straight forward yet fantastically distorted images remind of accounts of psychotic episodes. It does not mean that they were actually created in a psychotic episode, but a greater sensitivity and less filtering of certain types of sensory and other information in psychosis could be associated with more pronounced internal and external connectedness. How this connectedness plays out in everyday life depends on existing communication patterns, both within the person and with others. It also depends significantly on the environment, as the case of the shamans illustrated.

Communication-Focused Therapy® (CFT)

The author developed Communication-Focused Therapy® (CFT) to focus more specifically on the communication process between patient and therapist and help the patient acquire more insight and better skills. The central piece is that the sending and receiving of meaningful messages is at the heart of any process leading to changes in thoughts or external situations. CBT, psychodynamic psychotherapy and IPT help because they define a format in which communication processes can bring about change without focusing on them. CFT tries to be more efficient in a therapeutic sense by focusing on them more directly.

At the start, when treating psychosis, it may appear challenging to engage in a constructive communication process. However, organisms, in general, tend to react to information if it reaches them somehow. Even in states that seem very closed off, the brain still receives and processes information streaming from the external world. Persistence, and in many cases antipsychotic medication as a supportive tool, often help to get the patient to a point where they get used to the constant messages, fears decline, and it becomes easier to initiate a response. It is important to remember that it is almost impossible to interact with someone who repeatedly sends out messages under normal circumstances.

Communication is Life

We continuously engage in communication. Cells in our bodies interact with each other using electrical current, molecules, vibrations or even electromagnetic waves. On a more macroscopic level, people communicate through a multitude of channels, which may depend on several technologies and intermediaries. It does not have to be an email. Spoken communication requires multiple signal translations from electrical and chemical transmission in the nervous system to mechanical transmission. Muscles and air stream determine the motions of the vocal chords. As a result, sound waves travel through the air, followed by various translations on the receiving end. At each end, in the sender and the receiver, there is a processing of information that relies on the nervous system’s highly complex networks. Communication, in short, happens everywhere all the time. It is an integral part of life. Specific communication patterns can, however, also contribute to experiencing anxiety and panic attacks.


Communication is an autoregulatory mechanism. It ensures that living organisms, including people, can adapt to their environment and live a life according to their interests, desires, values, and aspirations. This does not only require communicating with a salesperson, writing an exam paper or watching a movie, but also finding out more about oneself, psychologically and physically. Whether measuring one’s strength at the gym or engaging in self-talk, this self-exploration requires flows of relevant and meaningful information. Communication allows us to have a sense of self and a grasp of who we are and what we need and want in the world, but it has to be learned similar to our communication with other people.

Understanding Psychosis

In psychosis the internal and external worlds cannot be distinguished as accurately anymore. They seem to blend into each other. This can cause various symptoms that are then summarised as ‘psychotic’. However, each symptom should make sense in the context of the patient’s communication patterns as well as the life experiences and emotions the patient faces, which influence the content of the psychosis. Having an understanding for what is happening, is important because it also helps make the patient feel more secure.

Another feature of psychosis is a more or less strong divergence from the patient’s perceived world from the shared reality, maybe one aspect which allows artists with intermittent moderate psychosis to paint stunning works of art. This divergence is largely driven by emotions or thoughts which become disassociated from the fabric of the patient’s self and personality.

Meaningful Communication

When an individual suffers from psychosis, a first important step is to help the patient see meaning in the communication process, particularly a relevance to own needs and interests. This helps to build and maintain the motivation which is necessary for a communication oriented therapeutic process. It also helps the patient build a greater sense of efficacy when interacting with his or her environment.

Since communication patterns are usually significantly affected in psychosis, a message can be given different meaning. If the information background of a message changes, the meaning attached to it changes. When information is no longer tagged correctly as to where it comes from, whether from the inside or the outside of a person, its meaning will change because it is put into a different information context. For example, ‘hearing’ a thought as if it comes from the outside world, leads the brain to create a whole setting for this ‘voice’. As the brain is constantly trying to extract simplicity from the information it has, it will offer the simplest explanation for this voice, even if it has to create a new reality where the voice fits in. The result can be a fantastic story built around the voice. Understanding these internal communication patterns, even if they cannot be seen directly, helps a patient to better live with the voice. Patients with psychosis may even understand the voice as thoughts they are having. As these may be thoughts they would not be consciously aware of otherwise, psychotherapy also needs to help the patient gain a better understanding of the content of the voice, which can be a stark distortion of the underlying thoughts.

Learning about Communication

The first step is to learn about communication, to see how it works, what its constituents are and the purposes it can serve, to talk about communication. Often it helps to go through examples that may be of special relevance to the patient. Analyzing them and looking at different options and different outcomes help to illustrate to the patient the importance of the process. Talking about communication also has the benefit that one can talk about something relevant apart from the content. Talking about communication allows to focus on something that not only underlies all the processes that produce content without talking about the latter, but also to move with the patient in a space where there are usually no discrepancies in beliefs or anything that is driven by content, which is largely superficial and dependent on the communication processes underneath it. Talking about communication also lets the therapist get a foot in the door of content. No matter how bizarre beliefs or views sound, there is some reason for the patient to have them, and to find one’s way into the deeper content is usually best via talking and learning about communication. Often, the more bizarre the belief sounds, the clearer may be the underlying thought content.

For the learning process, it is important that the therapist has a sense of the patient’s perceptual and emotional world. Understanding is here at the core, which involves the use of communication patterns that facilitate the exchange of meaningful information. Learning with the patient more about the communication patterns the patient (and the therapist) uses increases the amount of meaningful information that can be produced in the session. Insight into the patient’s communication patterns also enables the therapist to use communication styles and messages which are interpreted by the patient not as hostile, deferential or lacking in empathy. Early in the therapeutic process the interaction should help to build a strong and stable therapeutic relationship. An understanding of communication patterns is in this process more important than the content.

Observing Communication

Splitting up communication and identifying its components helps to observe the process and the variations, large and small, in it. Observing is a learning experience and helps develop an interest in communication and see the possibilities in influencing and shaping interactions with others. An interaction can exist in many shapes and forms, while the underlying communication processes adhere to common rules and laws. It helps the patient to appreciate the common underlying mechanisms, which can increase trust in the process and a sense of stability in the world, and, at the same time, to see an ecncounter as a dynamic group of interacting communication events.

Important is that the patient learns to look at the bigger picture and observe communication as it takes place, whether it involves the patient or not. This essentially requires being able to take a step out of the current interaction and to observe the dynamic without engaging in it at the same time. Over time, this becomes automatic enough that observation and engagement can alternate in one’s awareness so quickly that they seem to be simultaneous.

A patient can learn about communication if the therapist reflects and comments on what happens in the communication space the patient and therapist share. This teaches the patient patterns and skills through the expertise and experience of the therapist. However, it requires that the therapist has this expertise and experience. Especially for a psychotic patient, it is important to show this not just in theory, but also in practice through trying out new communication experiences which then translate into new perspective of the world and oneself.


Experimenting with communication in its different flavors can give the patient a greater sense of effectiveness with respect to the environment as well as oneself. It gives patients a greater sense of being in control, which is helpful because patients with psychosis often experience helpless and hopelessness, which can also cause some of the sudden emotional outbursts seen in severe cases of psychosis, such as schizophrenia.

A gradual increase in the scope or difficulty in the scope of experimentation probably works best. It can start with little everyday encounters and end with dating. People generally feel more vulnerable the more they feel they expose about themselves. For patients who have psychosis, this anxiety is much greater, because they sense that their perceived world and the shared reality diverge. Own emotions may also feel real, which makes their visibility to others even riskier. The fear of getting hurt at the core of one’s mental structure is universal. However, the hurt seems more devastating in a patient who has psychosis because the structure is already under considerable stress.


The newly gained knowledge and communication skills need to be processed, which can help increase the confidence and sense of effectiveness in the world. This should not be solely about control, but more about seeing oneself as a part of something bigger which is not something to be afraid of, but helps individuals to address and meet their needs and wants.

The Communication Space

Depending on the environment we move through different communication spaces in everyday life. The communication space is the space in which messages are being sent and received. If one is talking to someone over the phone who lives on a different continent, the communication space extends to this person, while not including the neighbor in the apartment next door, unless the walls are really thin.

To a patient suffering from psychosis the communication space can be extremely large or extremely small, but it usually diverges considerably from that of other people. Thoughts, for example, can be influenced from a large distance, or, at the other extreme, a patient could fully disconnect from the environment. To someone suffering from psychosis the internal world largely determines the communication space, while other people’s communication space is determined through an interaction with the environment.

In therapy, it is important to make the patient aware of the communication space he or she builds and what influences it. This is an important component of learning about communication and bringing about change through it. We all build our communication spaces in different ways. This does not only depend on individual communication patterns or structures, but also on other aspects of personality, individual life experiences, and more. The mental health condition, in this case the psychosis, should be viewed as something on top of it that affects the building of the communication space and the communication patterns in a fairly predictable yet somewhat crude way.

The communication space is built from communication patterns, yet it also influences communication patterns in a rather direct way. When I interact with another person, the communication patterns, and possibly also structures, I will be using, depend on the communication space I find myself in. As the communication space is subjective, it is only related to an actual physical space and situation, but it is not the same. Depending on how I feel I may perceive my external communication space as relatively large at a dinner party (good feelings, low social anxiety) or small (feeling self-conscious, distracted by internal thoughts). Although the external and internal communication space may both be large at times, they often grow at the expense of the other. When the experienced external and internal communication spaces in psychosis overlap less and less with the spaces as they appear to an observer, communication with the outside world becomes less efficient. There is more friction because the communication patterns an individual uses are adapted to the experienced communication space, which in psychosis, as also in several other mental health conditions, agrees less with the communication space another person uses to adjust their communication patterns and structures. Helping a patient identify these differences can already be very helpful. It is not necessary that people’s communication spaces agree all the time – they are not supposed to – as long as one can translate between the two and make modification. If a patient suffering from a psychosis sees her world as that of a microbe on an intergalactic sheep, it is still possible to talk about feelings thoughts and the conversation we may be having. As already discussed the content can pull the interaction, but reflecting together on the communication itself is often the technique that can lead to long-term stabilization.


The symptoms of psychosis can reduce the meaningful interactions a patient has with the world. The breakdown of boundaries between the outside and inside world and the changes in selecting and giving meaning to information, make communication between a patient with psychosis and someone else more difficult. These difficulties in communication can then have secondary effects, which lead to even more isolation and disconnect. The therapist can use communication patterns that lead to changes in the patient’s communication patterns, when they are combined with an overall strategy of creating more awareness and insight for the communication the patient has with the world and conducts internally.

Experiencing the World

Psychosis often leads to a vicious cycle which leads to less rather than more communication. Anxieties and a changed perception of reality can lead to a disengagement from it, which reduces the ability to distinguish internal from external reality even more. Practising and discussing new ways to communicate with the patient, including new communication patterns and better reflection on them, increases the patient’s ability to experience and bring about change in the world.

Next to improving interactions with others, better identification and understanding of meaning helps to anchor the patient better in the shared reality, making everyday life and planning for the future easier.

Identifying Meaning in the World

Fears brought about by the divergence of the perceived reality from the shared reality lead to social isolation and withdrawal, which reinforces feelings of fear and loneliness or frustrations. To break this cycle, it helps the patient find more relevance in aspects of the shared reality. This is usually not a process which happens from one day to the next, but over time leads to a closer alignment of the patient’s perceptions and intentions with the shared reality

Communication helps in identifying and finding meaning. Communicating with oneself and others raises one’s proficiency at identifying, finding and accumulating meaningful information. Organisms are already born with communication patterns they can use with themselves and the environment. These resources are encoded in the networks of cells within the organism, particularly the neuronal network. Through meaningful interactions, one accumulates more meaning, more connectedness with oneself and the world, which also provides a protective boundary against fears, guilt, self-blame and other negative emotions, depression and anxiety.

There are essentially two techniques to help the patient identify and interpret relevance and meaning in the world. One is by directly discussing the individual needs and how they can be met in the world, such as in a relationship or at the workplace. The second is by helping the patient have better internal and external interactions with the world, which make it easier to see relevance and meaning in the environment and provide the skills to attain them.

Increasing Interactions

Perceiving more meaning also makes interacting with others and oneself more meaningful. Communication patterns determine how one relates to the own environment and exchanges messages with it, which in turn affects the communication patterns. As long as this feedback loop works well, it contributes significantly to the patient’s autoregulation and a better adjustment to the environment. As the anxiety about interactions with others decreases, it should become easier to become more socially involved with others, at least to the extent that would feel comfortable to the individual.

In the beginning this often requires reducing situation- or person-dependent fears that are a consequence of the psychotic experience. Altered interpretations of information and its source lead to the perception of a less stable world, which seems to contain real threats, even if the latter is just own emotions or thoughts that have manifested as real to the patient. Meaningful interactions with the world can reduce the divergence of realities and fear because they stabilize the patient’s experience in the world. To be meaningful, the interactions should be an exchange of messages relevant to the patient’s interests, values or aspirations. This is why it is important to discuss with the patient and get a sense of the patient’s needs, wants and values. The next step is to help the patient find and make interactions that are helpful and meaningful to him or her. With the additional focus on communication, whether in a therapeutic session, internal thoughts or between the patent and others, interactions should become easier and less feared.

Values, Needs and Aspirations

Often, individuals suffering from psychosis become uncertain about what is really important to them and the fit between these values and interests and their current life situation. In all areas of life, having one’s needs, wants and values met, leads to a higher quality of life. If one values helping others in a specific way, it is important to find ways to engage in this activity, because it will result in a positive feeling. Harm to oneself and others is usually a consequence of some disconnect with one’s own feelings, needs, wants and values. Burnout or verbal abuse of another person may be examples.

The change in one’s relation with oneself and the environment, as well as the resulting change in the sense of self, make is usually harder for an individual suffering from psychosis to identify correctly the own needs, wants, values, and aspirations, partly out of fear that they could disturb a fragile feeling reality even more. In this situation, it is helpful to help the patient understand that connecting with them actually adds stability, rather than taking away from it. One way to reduce the fear of getting closer to and identifying key parameters about oneself is to help the patent emotionally reconnect. The emotions are the sum of vast amounts of information, such as a feeling of happiness as the product of perceptions of a situation and associated thoughts, and can, if they are owned by the patient, lead to a greater feeling of stability. Helping the patient to notice and identify them more accurately can lower fears and the make the inner world, and thus also the outer world in psychosis, seem more predictable. It is important to add in this context, that emotional instability is not so much due to a too much of emotions, but a consequence of impairments in a patient’s internal communication with the own emotions. The inability to read the emotions accurately leads to the sense of instability, or even the emotional and existential ‘void’ which is so prevalent in a patient with borderline personality disorder.

Communication Patterns

A more comprehensive overview of different communication patterns, elements, and structures is provided by the author elsewhere (Haverkampf, 2018b). A few will here be selected that may be particularly useful in patients with psychosis.


Questions are powerful instruments in changing communication patterns (Haverkampf, 2017a). There are many different types with vastly different effects. But what many of them have in common is that they have an influence on how information is selected and worked with. Many questions narrow the choice of communication patterns the other person can use in response. They often force the other to use a blended communication pattern and content they might otherwise not have volunteered at this point within the interaction. Questions can therefore also play a significant role to influence the timing of stages within an interaction.

Using questions in the interaction with someone experiencing psychotic symptoms should be done carefully. While it can be a challenge to preemptively analyze how a question could be interpreted by the other, it makes the interaction easier to try to stay with the patient and get a sense for how they are likely to experience the world and this interaction in particular. The advantage of using questions is that they are less overtly directive, which can help when talking with a paranoid patient. On the other hand, being more directive can help a patient who experiences a loss of structure in the world and within themselves. However, in order to provide this level of support it is important to have a proper sense of the world and the own person through the patient’s eyes. Psychotic patients are often grateful for the interaction with another human being. Important is to build enough insight that any remaining structures that provide the patient with stability are not under attack from the start.


Repeating the information the patient has said but with adding to it, and thus slightly altered meaning, can be helpful to strengthen the healthy resources the patient can still access in a psychotic episode. This can also be done outside the psychotic episode. Building on strengths and resources that are rooted firmly in the patient’s mental world creates greater resilience when the psychotic thought patterns try to loosen the connection with external and internal realities.


Reflective communication patterns are mainly directed at inducing reflection in the other. This is often done by introducing something novel, such as particular observation by the therapist, which appears relevant to the patient’s basic parameters, namely the needs, values and aspirations. Reflection should help build on the healthy structures the patient uses to gain a greater sense of stability and support the grounding in reality which facilitates better communication with oneself and others.


Supportive communication patterns give the patient the opportunity to narrate and explain about his or her world in a safe and non-judgmental atmosphere. At the same time, the therapist is present with a reflection on the own feelings and thoughts that are triggered by the patient’s narrative. Supportive communication uses communication patterns that make it easier for the patient to engage, while providing the openness the patient needs to do so. Statement that show genuine interest and caring can go a long way. Here it also helps if the therapist is alert to meaning within the patient’s words. As the decoding of meaning depends on the information one already has, getting meaningful information form the patient and trying to understand as much as possible about the world of the patient are important.


Explaining something to the patient may seem one-directional and untherapeutic, but it is of particular importance when working with patients suffering from psychosis. A good explanation about something the patient is struggling with or about the interaction with the therapist, for example, can be helpful in giving the patient a greater sense of stability and safety. This, of course, requires that the therapist has enough insight to be meaningful and relevant to the patient in the explanations and to be understood. Explaining can sometimes work like a question, because the additional information can lead to further information from the patient. Particularly in psychosis, a clear and mostly unambiguous communication is essential. Good communication can help the patient put more structure into the experienced real world.

Theory Building

Considering and reflecting on options demonstrates openness. Particularly in the case of psychosis, in which patients experiencing the world becoming a smaller rather than a larger place, learning that openness in terms of looking for explanations is nothing to be afraid of can be helpful in containing the destabilizing effect of psychosis.


Experimenting with communication patterns is one of the most important tools in therapy. When the patient experiences that the therapist experiments with new communication patterns, it also makes it easier for the patient to experiment. Adjusting existing communication patterns or synthesizing new ones so that they are more effective and adaptive is an important step for the patient. The therapist can support this by being open, reflected and playful in communicating.

‘You’ and ‘I’

Communication patterns that highlight the individual realms of patient and therapist are important to help the patient to distinguish between the own inner and the outer world and to integrate the presence of the other into these worlds. At the same time, the important of communication as a bridge between ‘you’ and ‘I’ which can make a ‘we’ in defined areas helps the patient to experience the power of communication, which can work against feelings of helplessness and control from outside.


 Patients suffering from psychosis are already under tremendous pressure. It is important not to rush it and allow communication patterns that may not be directed to a specific goal and to create the space in which relaxed experimentation without fear of failure can take place. Time can take on different qualities when a patient is in a psychotic episode, which should be taken into account. As with any communication dynamic, pattern or attribute, it is important for the therapist to use a combination of picking up the patient where he is and doing something new, which can bring about a change and help the patient to move to a better state.

Metacommunication: Structure

Communication patterns have structure and the communication patterns together give rise to structures. As mentioned under support, it is usually helpful for the patient to get greater insight into how communication works. This makes it also to build on it. Raising awareness in the patient for communication structure may include some explanation, but often it may be more a combination of reflecting with the patient on past communication experiences, and how they worked, and reflecting on the communication taking place in the current setting.


Testing out communication patterns can also be important particularly for patients with psychosis. For example, to know where the information one hears in a voice is coming from, being able to test communication patterns is important. In the session this is often facilitated, when the therapist displays openness and explores with the patient helpful questions to find answers that satisfy needs and aspirations. Testing out communication patterns is frequently done by talking about situations that did nor did not work and investigating with the patients what made them work or not work. Practicing this investigative thinking can be helpful in improving everyday situations. It has also the benefit that it entrenches a way of communicating internally that can keep a greater stability in a psychotic episode.


It is difficult to communicate without boundaries. If there is no marked off space one can claim for oneself and outside of which there is the other person’s space, it is easy to make other people’s unhealthy thought and emotional dynamics one’s own and see own thoughts and emotions as those of others. When the distinction between the internal and external world fades in a psychotic episode, helping oneself and making decisions become impossible. If structures and categories disappear, ‘Yes’ or ‘No’ become even more of a challenge. A disconnect from vital internal information to make decisions, add to the indecisiveness.

Important communication patterns in building boundaries are those that help the patient become more aware of and identify the basic parameters, that is the own needs, values, and aspirations. As they are always present and do not change much over time, identifying them can often have a stabilizing and healing effect for the patient. But they also help establish boundaries, because they reinforce the sense of being distinct from others and unique in them. At the same time, boundaries make it easier to also explore what one has in common with others without having to be afraid to lose those attributes that are important to oneself.

Communicating Internally

Making it easier for the patient to talk about internal communication can also help in having more influence over the internal communication. One usually has more influence over communication one can communicate about. This ability to engage in meta-communication is something that is usually lost in a more severe psychotic episode in schizophrenia, for example. However, in more moderate psychotic episodes this can be possible provided one has practiced it beforehand and experienced it as useful.

Communication Attributes

Different communication patterns can have common attributes. For example, openness can be expressed through questions, statements, inviting gestures, and so forth. Particularly when working with patients suffering from psychosis, clarity is important, but so also is adjusting the amount of information that is being communicated. Providing spontaneous feedback, for example, while a generic communication pattern, can come with many different attributes. It can be information rich, have added information in the form of particular emotional undertones, invite or not invite a response, and so forth. Working communication patterns and attributes usually develop out of the interaction with the patient, which contains auto-regulatory mechanisms.

Communication Structures

More complex behaviors in life, such as socializing, doing therapy, or conducting a meeting in work, are ruled by communication structures, which specify the group of communication patterns that are most likely to be used during the event, and in what sequence and under which circumstances. More awareness of these structures can often provide additional support to patients when they feel overwhelmed and confused by the communication dynamics of the moment. It also helps the therapist to have these structures in mind when the patient discusses everyday situations that did not seem to work.

Communication Dynamics

Therapy has meaningful messages travelling in both directions most of the time. Even the most abstinent therapist can only have a positive effect on the patient because he or she communicates. When working with patients who are experiencing an episode of psychosis, the information flows have to be adjusted to the situation. Problems usually arise in any communication situation when the external and internal dynamics diverge too far from each other (Haverkampf, 2010b)

The needed communication dynamics depend on the individual and on the situation. In many mental health conditions, the self-regulation capabilities are impaired, and it is difficult for a patient to adjust the parameters of the dynamics, including intensity, directionality (for example, back-and-forth or one-way), repetitiveness, novelty, and more, to the current needs. In psychosis, the partial disconnect mentioned above makes it more difficult to perceive the own need and to communicate to others the adjustments that are needed. The therapeutic setting should be a place where this can be practiced.

Meaningful Messages as the Instrument of Change

Communication is the vehicle of change. The instruments are meaningful messages which are generated and received by the people who take part in these interactions. In a therapeutic setting, keeping the mutual flow of information relevant and meaningful brings change in both people who take part in this process. The learning curve for the patient may be steeper in certain respects because he or she spends less time in this interaction style than a therapist.

The main objective is that patients can make communication work for themselves on their own. Looking at communication patterns and how meaning is generated in a therapeutic session should not only help with a concrete situation or problem in the moment but provide the tools to work with a multitude of situations or problems in the future. The key to build motivation and use communication processes, is to understand that meaning, information about information which is relevant to and resonates with the recipient of the message, is very much at the heart of it. Becoming better at sending and receiving, interpreting and working with meaning can make the world for an individual suffering from psychosis more stable and broadens the scope of change that can be affected on the world and oneself. Better insight and skills around communication and meaning take some time but can have a lasting beneficial effect for and individual suffering from psychosis.

Knowing Where Information Comes From

In the end, the patent should also have a better sense of communicating and knowing where information comes from. Not only does this help this reduce the divergence between the experienced world and the shared world, but it also helps to use information and communication better. Being able to identify a source of information can make it easier to identify meaning and respond to it. This helps build a stronger sense of self, better relationships and imparts greater confidence in dealing with everyday life as well towards fulfilling own aspirations. Greater insight and skills into communication can accomplish this.

Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. The author can be reached by email at jonathanhaverkampf@gmail.com or on the websites www.jonathanhaverkampf.com and www.jonathanhaverkampf.ie.


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This article is solely a basis for academic discussion, and no medical advice can be given in this article, nor should anything herein be construed as advice. Always consult a professional if you believe you might suffer from a physical or mental health condition. Neither author nor publisher can assume any responsibility for using the information herein.

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Communication-Focused Therapy® (CFT) for Depression


Communication-Focused Therapy® (CFT) for Depression

Christian Jonathan Haverkampf, M.D.

Depression is a mental health condition that affects a large part of the population at least once over their life span, significantly reducing life quality and impairing work and relationships. Psychotherapy and medication are the main treatments for the condition. Communication-Focused Therapy® (CFT) is a therapy developed by the author, focusing on communication processes to treat depression. Improvements in internal and external communication and awareness for a patient’s needs, values and aspirations appear to be effective against several symptoms of depression and increase motivation and compliance for therapy. This article provides an overview of a conceptual framework from a communication perspective and several approaches for treating depression with psychotherapy.

Keywords: depression, communication-focused therapy, CFT, communication, psychotherapy, psychiatry, treatment

Table of Contents

Introduction. 4

Depression. 6

Flattening of Emotions. 6

Negative Interpretations. 7

Communication-Focused Therapy® (CFT®) 9

Communication Patterns. 10

Questions. 11

Timeline. 11

Getting Information. 12

Connecting. 12

Integration. 13

Analyzing Communication Patterns. 13

Emotional Signals. 14

Motivation. 15

Insight into Communication. 15

Building the Sense of Self 17

Meaning. 18

Resonance. 18

Relevance. 19

Communication Exchange. 21

Integration. 21

Values, Needs and Aspirations. 22

Internal Communication. 22

Meaningful Messages as the Instrument of Change. 23

Broader Experience. 23

References. 25



Depression is a general lowering of emotional experiences, while in the lighter forms, it may just be a reduction of positive emotional experiences. A dialling down of internal and external communication, such as thoughts, feelings and activities, usually accompanies it. Loss of energy, motivation, and initiative, loss of enjoyment and interest in pleasurable activities, and loss of concentration are just some of the possible attributes of depression.

All explanations for depression seem to depend on the framework of the school of thought that produced them. An early answer from ego psychology was that depression is the emotional expression of a state of ego-helplessness and ego-powerlessness to live up to certain strongly maintained narcissistic aspirations. (Bibring, 1953) This explanation is in some ways not so far from what we can observe in depression in every clinical practice, even if we rarely use the terminology anymore. Patients who are depressed indeed mostly feel helpless and powerless, which are practically requirements of the sense of feeling depressed. When we find ourselves in a situation where there seems no escape or where we have to decide quite literally between a rock and a hard place, we are more likely to feel depressed, unless we develop a new alternative and open a door we have not seen before. Unfortunately, depression makes it seem harder to innovate and be creative. One of the techniques of Communication-Focused Therapy® (CFT) is to restore the ability to see a broad range of options and innovate in depression. The path there is through work on communication patterns, as communication is how we all get our needs, values and aspirations satisfied.

Depression usually impairs the emotional communication one has with oneself and with others. (Haverkampf, 2017e) Experimental data has been showing quite consistently that depressive subjects exhibit disrupted emotional processing.  (Delle-Vigne et al., 2014) This emotional disconnect from oneself leads to a less complete sense of self and lower confidence in oneself and the world. (Haverkampf, 2012) The disconnect then leads to significant secondary impairments in everyday life.  It affects the interaction patterns one has with other people and oneself, leading to various relationship and workplace problems, and from here to further depression and anxiety. Thus, a neverending vicious cycle can pull the individual suffering from depression ever further down. Fortunately, in most people, depressive episodes are self-limiting as self-regulatory mechanisms usually kick in once it has reached a level where the quality of life is severely compromised. What then happens is that a shift or change in the internal and external communication happens that pulls the individual out of the depression. This latter process is what Communication-Focused Therapy® aims to bring about in patients where these auto-regulatory processes are absent or maladaptive. (Haverkampf, 2010b)

The symptoms of depression are the result of maladaptive internal and external communication patterns. A disturbance in the flows of meaningful information flows within the nervous system and between the nervous system and the outside world leads to a disconnect, resulting in less perceived meaning in the world and worse decisions because there is less available information. The informational deficit about oneself and the world leads to depression and anxiety, which causes even more withdrawal in a vicious cycle.

The link between communication patterns and mental well-being is an essential insight for its enormous ramifications on understanding and treating depression. However, one needs to view it as a large puzzle, where the pieces all fit in in the end. These puzzle pieces can come from many areas of an individual’s everyday life. In a study on monogamous romantic relationships, for example, mutual constructive communication was associated with decreases in depressive symptoms for males. In contrast, demand-withdraw communication correlated with increases in attachment avoidance and depressive symptoms. (Givertz & Safford, 2011)

An essential step in overcoming depression is becoming curious about how one communicates with oneself and others. Using constructive inquisitive communication patterns can have a healing effect (Haverkampf, 2017i). In therapy, the therapist can encourage observing the communication patterns a client operates and the assumptions made in them about intentions, wishes and needs, values, and other factors that determine the quality, quantity and future of human interactions. Since all psychotherapies to date, use human interaction as the main instrument in the healing process, even if they do not focus on it, most therapies can have a beneficial effect. Unfortunately, the focus is often not on communication patterns, which can, at least from a theoretical perspective, render them less efficient. While it is true that learned behaviour and past experiences influence the severity of the symptoms, they do so via internal and external patterns of communication. In any instance where therapy works, it is a change in information flows and communication behaviours that brings about changes in symptoms and quality of life. (Haverkampf, 2010b, 2017a)


Depression is a state of low mood and aversion to activity that can affect a person’s thoughts, behaviour, feelings, and sense of well-being. A depressed mood can be a normal temporary reaction to life events such as loss of a loved one, a job loss, but also ‘positive’ ones, such as winning in a lottery or having sudden and spectacular success. All these events represent changes globally, requiring internal modifications to adjust internal and external communication systems to the new reality. A job that is now suddenly more practical requires a different internal dialogue, such as less analysis and more exploration. It may also require different external communication patterns with colleagues rather than work in front of a computer screen. If these changes have only occurred partially or not, the information exchange patterns do not fit the situation. This lack of fit can lead to feelings of being overwhelmed, withdrawal, emptiness and feelings of depression, or in some cases (hypo)manic states.

The sum of the basic patterns of external and internal communication, an individual’s personality, remains relatively stable over time. (Haverkampf, 2010a) This also applies if a mental health condition, such as depression, improves. In a sample of depressed outpatients receiving a 5-week trial of pharmacotherapy, changes in neuroticism and extraversion scores were modestly or not accounted for by changes in depression scores. (Santor et al., 1997) However, how individual communication elements and patterns are used in given situations can be subjected to change, leading to significant changes in personal satisfaction, contentment and happiness.

Flattening of Emotions

Depression leads to a disconnect. A patient is no longer able to access positive emotions to the same extent as before. However, at the same time he or she may also become disconnected to a varying degree from ‘negative’ emotions, such as sadness. In all cases, the individual suffers from missing out on important information about the own person. This then leads to negative feelings, possibly also fears and anxiety, because meaningful information is missing. To some degree it is possible to counteract this with activities that are meaningful to oneself. One may even say that in the best a depression weeds out thoughts and activities that are less meaningful. And in most cases short and especially the reactive depressive episodes are self-limiting. But in the more severe and longer lasting depression the disconnectedness from emotional signals accelerates the downward spiral of decreasing emotional connectedness and increasing ability to correctly send and receive meaningful messages. (Haverkampf, 2010c, 2013)

Reconnecting with emotional signals can be helpful in depression. This should not add to the pressure on the patient ‘to feel better’. In Communication-Focused Therapy®, this is usually done by using the communication patterns in the session or memories of past interactions and experiences in the world to inquire into the feelings that were associated with them. However, the main technique is concerned less with individual emotional episodes, but with enabling a patient to become more aware of and influence communication processes and information, which lead to particular emotional signals. (Haverkampf, 2017a)

Negative Interpretations

Elevated levels of repetitive negative thinking are present across a large range of Axis I disorders and appear to be causally involved in the maintenance of emotional problems. It has also been argued that repetitive negative thinking is characterized by the same process across disorders due to the inherent similarities (Ehring & Watkins, 2008). A depression leads to more negative interpretations of messages from the environment and from within oneself. As one attributes the cause of negative experiences to oneself and engages in self-blame, feelings of guilt, failure and incompetence emerge. At the same time, the own person, others and the world as a whole appear to be less meaningful and less relevant. This loss of meaning can potentially lead to dangerous situations of self-harm or even suicide. To prevent this requires an insightful and caring use of communication between therapist and patient.

It is important to realize that it can be the same information which reaches the patient, but which is associated with more negative emotions and thus more hypotheses of negative consequences. A depressed affect can so lead to an increased selection of information associated with negative emotions, which can then lead to an even more depressed affect. This vicious cycle usually does not pose a problem because positive information becomes more appealing, which pulls the individual out of the negative affective state. In a depression where emotional and other communication is inhibited already, it is more difficult for the autoregulatory mechanisms to work, making a spiralling into an increasingly depressed affect more likely.

Analytical internal communication patterns can be helpful in many areas of life. However, in depression they are often used for the wrong purpose, possibly in the attempt to extricate oneself from the symptoms of depression. In a study by Rimes and Watkins, thirty depressed participants and thirty never-depressed participants were randomly allocated to ‘analytic’ (high analysis) or ‘experiential’ (low analysis) self-focused manipulations. As predicted, in depressed participants, the analytical self-focus condition increased ratings of the self as worthless and incompetent pre- to post-manipulation, whereas the experiential self-focus condition resulted in no significant change in such judgements. (Rimes & Watkins, 2005)

Negative thinking can often be triggered by some internal or external information, frequently an intrusive, which may be easier to shrug off for a non-depressed person. In this instance, it is as if the depressed person tries to preempt any disappoints or possible negative emotions from an adverse outcome, by already realizing them intracranially and fighting them with compensating emotions. However, this only leads to further negative thoughts and downward spiraling ruminations. One solution is to identify thoughts as mere thoughts and not real, another to build a sense of oneself as being able to deal with whatever may be coming one’s way, particularly the own emotions.

Repetitive negative thinking can, on the other hand, be distinguished from other forms of recurrent cognitions, such as obsessions, intrusive memories or functional forms of repeated thinking. (Ehring & Watkins, 2008) This illustrated how certain symptoms of a mental health condition can be grouped along the internal and external communication patterns they are associated with, and that they can be categorized into a moderate number of sets.

Communication-Focused Therapy® (CFT®)

Communication-Focused Therapy® (CFT®) was developed by the author to focus more specifically on the communication process between patient and therapist. The central piece is that the sending and receiving of meaningful messages is at the heart of any change process. Communication processes are at the same time the instruments of change and their target. Any therapy has to lead to change. This can include changes in acceptance levels, new insights, learning processes and more. All these aspects are determined by communication processes and some are communication processes themselves. For the acceptance of a certain situation or emotion, for example, with the aim of reducing conflicting emotions and anxiety, one needs to learn about the situation or emotions and identify them and then put them into context with information from memory and use internal and external communication flows to reflect on them. If fear inhibits the information retrieval from memory this will not fully work. CFT aims, among other things, at reducing the fear of information retained in memory or communicated from others. This requires more meaningful information rather than less which can be communicated more freely as the fears or other inhibiting factors decrease. The freer and more open the communication processes become, the easier it is for autoregulatory processes to counter unhelpful diversions from health affect states. However, this requires insight, reflection and experimentation in therapy.

Many popular forms of psychotherapy, such as Cognitive-behavioral Therapy (CBT), psychodynamic psychotherapy and Interpersonal Psychotherapy (IPT) define a format in which communication patterns take place that can bring about change. However, they do not address and work with the communication processes directly. In psychodynamic psychotherapy, there is the concept of transference and counter-transference which focuses on the result of communication processes. CFT in contrast attempts to focus on the process itself. (Haverkampf, 2017a)

CFT attempts to analyze how information is exchanged, the various channels involved and how meaning is generated. Messages do not have to be contained in words, they can also be transmitted by facial gestures or any behavior of the send. To contain meaning they have to be relevant to the recipient and have the potential to bring about a change in the recipient. Working with and analyzing patterns of internal and external communication helps to make the exchange of meaningful information work more effectively, reducing anxiety, emotional, mood, psychotic and other disorder in the long-run. (Haverkampf, 2018b) This does not mean that medication and other forms of therapy do not have their places in treatment, it does not change that at all. However, CFT provides a theoretical and empirical framework that can enrich these other therapeutic approaches, while also being used on its own.

Communication Patterns

Humans interact on millions of communication channels at one point in time. Cells have their communication channels, and every information coming into the system and leaving it uses communication patterns. The reason why certain patterns have to be used is so that the other person can understand the message. A language can be seen as a form of communication patterns on a more complex level. We all communicate in patterns. However, unlike learning a language, people spend little time observing and reflecting on the other communication patterns they use all the time.

In biology, an emerging picture of interconnected networks has replaced the earlier view of discrete linear pathways that relate extracellular signals to specific genes, raising questions about the specificity of signal-response events (Kholodenko, 2006). In synthetic biology, researchers integrate basic elements and modules to create systems-level circuitry (Purnick & Weiss, 2009). The communication of the cells with each other and with the environment determines how effective they are in, for example, eliminating tumor cells. The important basic material is ‘information’, which is then activated and given influence over other factors through meaning, whether that is meaning in in an intracellular or an interpersonal context. Communication patterns and structures facilitate this process. (Haverkampf, 2018c)

Two cardinal symptoms of depression are ruminations and selecting negative information. Many therapeutic approaches focus on the negative, for example, and try to unlearn them. This may work in the short-term but often fails in the long-term if the internal and external communication patterns do not change. An external pattern may be how one could ask for information that could dispel the negative thoughts or an internal testing of the information. Changes in communication patterns means modifications in which and how information is sent, how it is received and how meaning is extracted from it. All these steps can either be adaptive or maladaptive. Depression comes with maladaptive communication patterns which then cause even more maladaptive communication patterns. The way out is to create awareness for, reflect and experiment with these communication patterns, at first in a therapeutic setting and then in the real world.


As has been pointed out by the author already elsewhere, questions are powerful communication patterns in effecting change in other communication patterns (Haverkampf, 2017i). In depression, they can mobilize resources and redirect thinking towards a different focus, and they can also help end ruminations and looping thoughts. Over time, the patient should become a personal expert in asking the right questions.

Questions represent a large group of communication patterns with very diverse combinations of communication elements. One needs to fine-tune questions to the present communication dynamics and the aim of the questioning. Using them is to cause a branching off in the communication dynamics, which then brings about change in everyone in the session. One should not forget that a question can also change the one asking it, even if one has used a particular type of question hundreds or thousands of times. Questions are so embedded in the social and interactional everyday life that we mostly are not aware of them more than the microtasks we carry out when driving a car. The author has written elsewhere much more in-depth about the question as a communication pattern that can be a potent therapy tool.


Patients with depression often spend a considerable amount of time ruminating about the past. Those who also suffer from anxiety may also ruminate about the future. What frequently gets lost is thinking about the present, even though that is the point-like interval of time which is the only one that is ever real. To avoid the reality of the present can be due to various reasons. The depression can make existence so unbearable that one escapes into a different ‘time zone’, and that it is not real may even be wished for in the hope that this also makes the pain less real.

The use of observations, feedback and questions can help the patient to stay in the patient. Several other communication patterns can also achieve this goal. Whenever a communication pattern leads to greater internal and external connectedness, it helps to anchor the patient more firmly in the now. However, this does not lead to more intense suffering because it is the disconnectedness that usually causes suffering. Patients with severe depression do not feel sadder, but they often feel nothing. Truly experiencing an emotion like sadness, when one feels ready for it and while being connected with others and oneself, can be an essential step in dealing with and overcoming a loss or other saddening event. And nothing can be as connectivity promoting as communication itself.

Getting Information

Questions help the patient in changing communication patterns. Still, they can also produce information, which lowers uncertainty, brings new insight or leads to something new in the world, which is enjoyable and improves the overall mood. Often, patients with depression return to the same thoughts or situations because they do not see alternative actions or ideas, which may be enjoyable and lead to a better mood.  Ruminations result not from too much but too little useful information, yet finding the right information again depends on communication patterns.

When things look at their darkest, and everything around seems empty like a desert, it helps be aware of all the meaningful information that is already easily accessible.  Connecting within oneself and others can lead to insights that help in countering the depressed rumination. A therapist’s task is to help the patient build communication patterns that are more effective towards connecting with oneself and others. Doing so allows a patient to find more meaningful information in places such as the own life experiences, which are a treasure trove of information. If I ask what is important to me and what I value, I just have to look at situations in the past and probe how I felt, what I thought and whether my actions and interactions in these situations benefitted me. One only has to be more open to information that can be helpful, and one aim in therapy is to help patients become better at this without fear.


Communication patterns that help the therapist and patient connect in the session can also help the patient connect with others and with themselves. As already pointed out, the internal and external communication is a reflection of the other. The ability to communicate with the outer world also increases the ability to communicate better on the inside. Communication-Focused Therapy® supports patients in becoming more aware of, reflecting on, and experimenting with communication, which leads to the flexibility and openness in communication that is very effective against many forms of depression.

Communication patterns to facilitate connecting may again include questions and other communication patterns that enable the flows of meaningful information. Patterns may be repeating a modified message, providing information about a feeling or thought triggered in response to the patient’s communication, making an observation that offers a new perspective, and so forth. It is more than small talk because the therapeutic communication patterns not only test and build relationships but should also provide greater insight. The latter also includes insight into the communication patterns themselves.


By talking about the communication between patient and therapist it is possible to help the patient see how communication can be influenced and shaped so as to lead to new insights and to make new connections between pieces of information. This integration of different strands of information flows are important in helping the patient to feel more integrated as a whole. For example, talking about communication can help the patient to associate an image with emotions, which in turn may connect with past memories. This integration, however, requires that it is first possible to talk about these thoughts and feelings, and secondly that it is possible to talk about communication in ways which helps the patient to make associations between the different flows of information.

Analyzing Communication Patterns

The first important step in therapy is to create awareness for the flows of information, and their patterns. (Haverkampf, 2018c) These dynamics happen largely outside of consciousness, but they are not random. Rather, they are a result of biology and the internal and external communication experiences of an individual over time. Complex organisms receive, combine transform and send millions of bits of information in the smallest fraction of a microsecond. To navigate within this sea of information successfully is the primary objective of every organism, humans included. Health conditions in general are a result if these processes no longer work adequately. Mental health conditions often also include a significant impairment in the external communication between a person and the environment.

The human brain is in a particularly good position to work with information, and one objective of therapy should be to help it work better with information, whether this is coming from emotional signals, sensory organs, or retrieved from within the neural network itself. Communication processes and information can be made conscious. We might not be able to identify the information stored in a neuron, which would not anyway, because that information only makes sense within the context of the neural network. However, we can become aware of information stored in the neural network, even if it is a tiny detail or something that does not seem to fit into an existing pattern.

Particularly in interactions with other humans and other living organisms, communication patterns have evolved that facilitate the exchange of meaningful information in an efficient way. They need to be largely automatic, such as a gesture in response or a change of voice, and it may be even more distracting to follow them all, but it is possible to discern and work with some universal patterns. For example, the sequence of a specific type of question and a specific type of answer can be universal, such as the nod of a waiter signaling attention, followed by a guest using the palm of her hand and finger to scribble in mid-air, which indicates that she wants the bill. A complex business negotiation, however, would also use the basic communication element of question and answer and build it into more complex patterns. Spiraling negative thoughts in depression, on the other hand, also use otherwise adaptive communication elements, however, they do so in unhelpful communication patterns. The problem is not the ability to worry and think, but how this is done, the pattern, which is not constructive and unhelpful.

Emotional Signals

The emotional signals contained in a message are important because own emotions one becomes aware of can contain a lot of information. The brain uses a lot of information to form an emotion. To yield an emotion of sadness requires not only the information that a relationship has ended, but also the information about the relationship itself and potentially the relationships before, including information from interactions with one’s parents, and so forth. In a therapeutic setting, all this information can be helpful to adapt strategies, or to design new ones, and help the patient to integrate all this information into his or her life.

The communication between therapist and patient gives clues about thought patterns and beliefs, which affect how messages from others are interpreted and how own messages are assembled and communicated. It also helps to get an idea for how a patient constructs meaning. What someone sees as meaningful and relevant is largely determined by own needs and wants, but also past experiences. When the patient begins to form new communication patterns or adapts old ones, it is helpful to help in identifying patterns that have worked well for him or her in the past. Sometimes new ones have to be constructed from scratch, if a patient has been socially isolated for a while, for example. It is then useful to rely more on the therapeutic interaction as a model to train new communication patterns. In some patients who have suffered from depression for a long time with social isolation this may be necessary, but also important to maintain the patient’s motivation for the therapeutic work.

The importance of awareness is that it gives the patient a greater sense of hope and control when the depression causes hopelessness and despair. The journey patient and therapist take together in exploring and experimenting with communication in itself has a major antidepressant effect. It requires openness and insight which cannot be manualized. Communication has, however, universal rules which can be understood and worked with.


Decreased motivation is a central symptom of depression which often makes therapy more difficult. It is no different in a communication focused approach. Experiencing what is possible in therapy can raise motivation significantly, but this requires at least some motivation to begin a therapy and makes it through the early stages. A communication focused approach may have the advantage here that it has material to work with from the time the therapist opens the door and makes eye contact with the patient. Another advantage on the motivational side is that a communication focused approach places emphasis on the interaction between patient and therapist, and thus the relationship, which helps to motivate the patient to wait and see what the therapy has to offer.

Insight into Communication

In many instances, reflecting on one’s communication patterns and strategies with oneself and others in concrete situations leads to insight about them. This is quite practical in nature. Observing communication patterns and trying out new ones is an important part of therapy. Since communication has different components one can focus on its components:

Person A

  • Selecting information for a message
  • Encoding the information in a message
  • Sending the message through a communication channel (using the speech system to say the words)

Person B

  • Receiving the message through a communication channel (using the auditory system)
  • Decoding the message into information
  • Processing the information further

One will observe quite often that a message it not received accurately. For example, one may say “the weather is nice today”, and the other person may interpret this as a signal that one wants to go on a hiking tour. The easiest way, of course, is to ask the other person again if one is in doubt. However, patients with depression or anxiety are less likely to get the full information.

The communication patterns a depressed patient uses may have served some function in the past, as they could have protected from some negative emotional consequence. However, in the present they no longer promote an optimal outcome, one that takes into account both the own needs, values and aspirations. On the other hand, it is also easy to see how awareness, reflection and experimentation with new communication patterns can resolve the problem, reduce the anxiety in A and lift the mood of B. That is what a communication-oriented therapy should do.

Maladaptive communication pattern can lead to the perception of more negative consequences and less meaning in the world. The former can be a filtering and interpretation deficit, the second often follows the first in the form of a disconnect or disengagement from the world. Insight does not have to lead to a change of current communication patterns, but in many cases also the development of new ones. In practice, this may also include considering situations which can facilitate better communication patterns, as the communication patterns one uses also depends on the communication patterns of the people one interacts with. This is also the basic dynamic when an individual is constantly exposed to other people who are stressed, anxious or depressed. Especially in infants and children who are still in the process of acquiring and forming communication patterns, an anxious parent, for example, can pass on some of the maladaptive communication patterns to the child. Depending on any helpful communication patterns already in memory and the effectiveness of autoregulatory processes, the child may adopt less of the maladaptive communication patterns than it might otherwise.

Observing and insight into internal and external communication patterns are both important. An individual suffering from depression is less likely to see messages as relevant and meaningful if the communication patterns that make up the feeling of being oneself have been compromised. The feeling of being oneself is itself the own observation of internal flows of information or communication. There is thus a strong link between internal and external communication patterns, which also explains how individuals can spiral into a vicious cycle of depression where engaging with the world can make the internal sense of dread and depression even greater, and vice versa. For example, a depressed person who pushes himself or herself to be more outgoing in a social situation often feels worse in the end.

Building the Sense of Self

Seeing relevance in a message requires knowing what one needs, wants, as well as one’s values and aspirations. In short, it means knowing some basic parameters about oneself. When the self becomes more meaningful, the motivation and desires to learn or try out something new, including therapy, increase. To give the sense of self texture requires awareness and identification of the own needs, values and aspiration, thereby attaching more subjectively perceived value to it.

The sense of self is awareness of certain communication flows in one’s own body. These information flows can be sensory, emotional or other signals from cognitive processes or from memory. This is the reason why internal and external communication patterns play such an important role for the sense of self because they influence these information flows. If a patient uses an external communication pattern which interferes with social exchanges, the information flow from the outside world in this respect will be reduced which has as effect on the sense of self. Thus, exposure to meaningful communication and improvements in communication can be very effective in treating the symptoms of depression. Negative perceptions of oneself are reduced and the interactions with the environment improve, which in itself has an antidepressant effect. As the moods lift concentration, focus and memory problems tend to decrease because things feel more relevant consciously and subconsciously.


Individuals suffering from depression often see less meaning in the things they do. In therapy an important part is to rediscover meaning, and find it in the things that are relevant to the patient. Relevant is anything that is close to his or her values, basic interests, aspirations, wants, wishes and desires.

Meaning requires that one can decode a message and extract some novel information form it which can potentially lead to change within oneself, a new thought, state or emotional signal, for example, which can then also lead to a change in the world. Helping patients to reassess and readjust communication patterns can be particularly helpful in therapy because the resulting change in perceiving and thinking usually also leads to a change in perspective (Haverkampf, 2018d), which then in turn also lead to changes in thinking, feeling, acting and interacting.


Resonance is when synchronicity or similarity leads to a potentiation of a signal or piece of information. In a therapeutic setting, resonance can be important because it identifies information that may be important or relevant. A depressed patient who has lost a grasp of what is potentially enjoyable and meaningful can rediscover it when resonance is detected. When the therapist becomes aware of resonance in how a patient is communicating about something, it is often helpful to point that out. If there is true resonance, the patient will usually acknowledge it quite quickly. In other cases, the therapist may also identify it as a projection of something that is important to the therapist only. But if the patient sees a resonance, it can be helpful in getting more insight into the own needs, values and aspirations.

Resonance is when new piece of information becomes more meaningful because of the information that is already present (Haverkampf, 2018a). The interaction between therapist and patient is meaningful to the patient if what is happening resonates with the values, basic interests or aspirations of the patient. In therapy, often the technique of the ‘fishhook’ (Haverkampf, 2010b) may be used. One asks the patient to describe life in general, such as the events of the weekend. The more the patient learns to work with resonance, the easier it will be for her to find insight in these everyday events by using an increasing volume of information effectively, including emotional signals, perceptions, cognitive thoughts and more.

In therapy, patient and therapist look for resonance because it is necessary for the communication of meaning, which brings about a change in the patient. Often resonance can only be guessed by either patient or therapist, and it takes some amount of communication to find resonance. A good starting point is listening to what the patient is communicating, since it reflects the information the patient already has, and which represents the foundation for resonance. The question “how was life yesterday?” or “what did you do yesterday?” can be more powerful than a complex intervention, because it can serve as the starting point to greater insight if one is aware of information resonance.

Depression makes old and new information, particularly emotional information, less accessible, which lowers any potential resonance. However, in many patients suffering from mild or moderate forms of depression accessibility may not be greatly reduced. Rather, it is a question of whether a patient can still believe there is ‘something’ below the unpleasant state. Resonance can help to rebuild a connection with interests, needs, values and aspiration, whose pursuit can be enjoyable, below a surface of depressed feelings. Reflecting with a patient on everyday activities can help to find spots of resonance. If the therapist then uses an inquisitive and interested communication pattern to get information on what about this activity is valued, needed or aspired to by the patient, the patient’s internalization of this pattern can help to form more adaptive communication patterns which can help against and prevent a depression.


Depression makes everything seem less relevant as it reduces the spectrum of information that is available, including emotional signals. Less available information leads to less resonance, and thus less meaning which is extracted from messages form internal and external sources as well as less openness to new messages. Looking at a tree may, for example, not be as enjoyable anymore. The visual information about the tree still arrives in the brain as it always did, but the information stored in memory about the good feelings associated with a tree is tuned down. The actual tress has not changed, but it has become less relevant to the person.

Less relevance also means less focus, which could support an evolutionary explanation of depression. In times of stress, it can be helpful if one sees less relevance in the situation and withdraws. However, this may not feasible in the world we live in today. One cannot just leave one’s job form one day to the next. Rather, a common response to stress is often to work even harder, which can the lead into burnout. However, the more one thinks about relevance on a smaller level, the easier it becomes to adjust larger constructs, such as ‘one’s job’. As mentioned before, it is the details which help to identify one’s needs, values and aspirations. On the smaller scale, the brain reorients focus to task-relevant stimulus information. Egner and Hirsch showed that, in response to high conflict, cognitive control mechanisms enhance performance by transiently amplifying cortical responses to task-relevant information rather than by inhibiting responses to task-irrelevant information (Egner & Hirsch, 2005). This also shows that the brain focuses on picking out potentially relevant information rather than by suppressing non-relevant one. Of course, what is relevant is subjective to the individual, but it must be based on existing information about the needs of the individual, one’s internal state and the state of the world.

From a broader and more long-term perspective, relevance is a connection one has with things, people and situations. If something is relevant to what one needs, wants, values or aspires to, one is more likely to be open to information associated with it. If one values being in a relationship, for example, one is more likely to be receptive to messages from a partner, if they are seen as relevant to the maintenance of the relationship. Although, one may not have enough information to judge what is relevant, and therefore focus on the wrong messages, or one may not understand a message. All this can be remedied with better communication patterns which lead to better information, and exposure to meaningful communication.

Changing a situation or one’s perception of it requires taking stock of one’s needs, wants, values and aspirations and then to make a change. If one is working in a job which does not seem relevant to oneself, an option, aside from quitting and finding another one, is to assess if a change in the work or one’s perspective of it is possible that could align it more closely with one’s needs and wants. This can be worked out in therapy. But whatever action one takes, just the doing it already helps against depression.

In therapy, rebuilding relevance through new communication patterns which bring a different focus and more useful information changes how the own person and the world are seen. It also puts the focus on better sources of meaningful messages. For example, if a patient gains the insight that he values staying in touch with a particular group of friends because they share his interests, he is more likely not to decline a lunch invitation by someone who is a part of that group. At lunch, this friend may tell him then what the other members of the group have been up to, which may help the patient with his own career choices as he shares their interests. Raising the level of resonance, and thereby the relevance one sees in oneself, others, activities, things and so on, is very effective in the treatment of depression and other mental health conditions because it lets through more and better information to make better decisions and raises the mood as the world as a whole seems more meaningful now.

Communication Exchange

Meaning is built within the communication processes in the therapy. The interaction between two minds can give rise to a dynamic, which carries the flow of meaningful messages and brings the process forward. Motivation for the process is usually maintained if the messages feel relevant and meaningful to the patient in the present. If emotions or thoughts about the past are brought to the center of attention, they are important to the extent that they are still relevant in the present. This relevance depends on the emotions they can induce in the moment.

The exchange of messages can be influenced by both partners to the interaction. The depression can be felt by both, since it interferes with the construction and free flow of messages. As long as the therapist is open and receptive to the patient’s messages and tries to understand the communication dynamics and the patient sees the process as relevant, it can move forward. Since the patient and therapist have different neuronal networks and past communication (life) experiences they can induce change in each other through the communication of meaningful messages.


As change in the communication pattern occurs, the information flows within the individual also change. Since the self is a reflection on these communication flows, it can bring about a change in how a person experiences the own self. In the long run, the identified meaning is integrated into the self, which, depending on the meaningful information perceived, can make the self itself more meaningful and valuable. One derives meaning from interacting with oneself and with other people, and this is also how people build their sense of self. Thus, while personality stays largely constant, the sense of self can get a boost form exposing oneself to the right communication environment.

Values, Needs and Aspirations

Depression blurs what feels important to a patient, and the fit between values, needs and aspirations and the current life situation is usually reduced. Whether in professional or personal life, getting what one needs, values and aspires to makes happiness, contentment and satisfaction more likely in the long run. If I value helping people, I know what makes me happy and gives me satisfaction. Communication, whether internal or external, is the instrument, that makes individuals aware of these basic parameters and helps them to pursue them.

The basic parameters, values, needs and aspirations, change little over time. One may alternate between being hungry and not being hungry within hours but eating as a basic need does not change and nor does someone who is happy with being a vegetarian. To some extent these basic parameters seem to be built into our biology, and it is not the therapeutic task to change them but to arrange the world around in such a way as to be able to live one’s values, needs and aspirations. Working with and improving communication with oneself and others usually accomplishes that.

Internal Communication

Exploring interests, values, needs and wants requires becoming sensitive to one’s own thoughts, emotions and physical sensation, to be open and receptive to the information coming in from one’s body and mind. It is about feeling what makes one feel good and what does not. At the same time, it has to make sense and should fit together. If specific values and needs appear to be in conflict with each other, a combination of emotions and rational thinking is often helpful. For a depressed patient, this may not be an easy task, but to bring more structure and sense into a seemingly chaotic and disconnected world, can be helpful.

Internal communication can be practiced in therapy. Since there is a correlation between the communication with others and one’s own internal communication, rehearsing and going through communication patterns in therapy, is often helpful to the patient outside of therapy, not only for the interactions with others, but also for the interaction with oneself. Values and needs can be clarified by talking to someone else and engaging in soul searching on one’s own. An important experience in therapy should be that one can clarify one’s needs and values by reflecting and communicating about them.

Meaningful Messages as the Instrument of Change

Communication in its various forms needs to be the target of therapy because it can be fined tuned and a change here can bring lasting change. The author has described this elsewhere (Haverkampf, 2017a, 2018b) Communication-Focused Therapy has been developed by the author for several psychiatric conditions. (Haverkampf, 2017f, 2017b, 2017d, 2017c, 2017g, 2017h). In depression, the desired change is for a broader emotional experience, seeing more relevance in oneself, one’s thoughts, emotions, and in the world as a whole. Adjusting, discarding and forming new communication patterns can lead to a reduction in symptoms that is more permanent than techniques the focus less on communication.

The actual instrument of change are the meaningful messages which, provided they are encoded, sent and decoded, induce the change. As information in a message resonates and is processed with the already existing information, meaning is created which leads to changes in the future.

Broader Experience

If there is more meaning in oneself and the world, it is easier to focus on aspects of oneself and of the world. This expands one’s experience of oneself and of the world around. Seeing more relevance and more sources of novelty and change in the world, increases one’s experience of the world and makes this experience richer. However, it also requires that one engages with the world, which may be difficult due to anxiety cause by fears and other unresolved emotions. However, working with communication early in the therapeutic process often reduces any anxiety quickly as the patient learns to become aware of and experiment with communication and appreciates and gains insight into the predictability of communication.

Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. You can reach author by email at jonathan@jonathanhaverkampf.com or on the websites www.jonathanhaverkampf.com and www.jonathanhaverkampf.ie.




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