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
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 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.
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 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 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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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 firstname.lastname@example.org or on the websites www.jonathanhaverkampf.com and www.jonathanhaverkampf.ie.
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