Skip to main content

Advertisement

SpringerLink
Log in

Navigating an Impasse in the Psychotherapy for Psychosis

  • Original Paper
  • Published:
Journal of Contemporary Psychotherapy Aims and scope Submit manuscript

Abstract

Despite pessimism in the field, persons experiencing psychosis can benefit from psychotherapy and recover. However, there are multiple factors that can interfere with the formation of a positive therapeutic alliance and lead to the premature termination of therapy, which is associated with poorer long-term outcomes. In this article, common therapist, patient, and intersubjective factors are identified that can inhibit personal growth and lead to stalled treatments. After reviewing these various roadblocks, four principles (e.g., an intersubjective orientation to realty, therapeutic openheartedness/vulnerability, “speaking the unspeakable”, and recognizing the pain beyond the psychosis) are outlined that can embolden the therapist to take judicious risks while avoiding common pitfalls when working with persons experiencing psychosis. These principles also enable the therapist to maintain an empathic connection to the patient and appreciate the pain beyond the psychotic symptom. The clinical implications and challenges of embodying these principles and implementing these interventions are discussed.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  • Bjornestad, J., Veseth, M., Davidson, L., Joa, I., Johannessen, J. O., Larsen, T. K., et al. (2018). Psychotherapy in psychosis: Experiences of fully recovered service users. Frontiers in Psychology, 9, 1675.

    Article  PubMed  PubMed Central  Google Scholar 

  • Brent, B. K. (2015). A mentalization-based approach to the development of the therapeutic alliance in the treatment of schizophrenia. Journal of Clinical Psychology, 71(2), 146–156.

    Article  PubMed  Google Scholar 

  • Britz, B. (2017). Listening and hearing: A voice hearer’s invitation into relationship. Frontiers in Psychology, 8, 387.

    Article  PubMed  PubMed Central  Google Scholar 

  • Buck, K. D., Roe, D., Yanos, P., Buck, B., Fogley, R. L., Grant, M., et al. (2013). Challenges to assisting with the recovery of personal identity and wellness for persons with serious mental illness: Considerations for mental health professionals. Psychosis, 5(2), 134–143.

    Article  Google Scholar 

  • Charles, M. (2012). Working with trauma: Lessons from Bion and Lacan. Jason Aronson.

    Google Scholar 

  • Davoine, F., & Gaudillière, J.-M. (2004). History beyond trauma. Other Press.

    Google Scholar 

  • De Boer, J. N., Brederoo, S. G., Voppel, A. E., & Sommer, I. E. (2020). Anomalies in language as a biomarker for schizophrenia. Current Opinion in Psychiatry, 33(3), 212–218.

    Article  PubMed  Google Scholar 

  • Etchegoyen, R. H. (1991). The fundamentals of psychoanalytic technique. Karnac.

    Google Scholar 

  • Federn, P. (1943). Psychoanalysis of the psychosis. In Ego psychology and the psychoses. Basic Books (1952).

  • Ferro, A. (1993). The impasse within a theory of the analytic field: Possible vertices of observation. International Journal of Psycho-Analysis, 74, 917–929.

    PubMed  Google Scholar 

  • Fromm-Reichmann, F. (1948). Notes on the development of treatment of schizophrenics by psychoanalytic psychotherapy. Psychiatry, 11(3), 263–273.

    Article  CAS  PubMed  Google Scholar 

  • Galvin, K. T., & Todres, L. (2009). Embodying nursing openheartedness: An existential perspective. Journal of Holistic Nursing, 27(2), 141–149.

    Article  PubMed  Google Scholar 

  • Garrett, M., Ahmed, A. O., Athineos, C., Cruz, L., Harris, K., Del Pozzo, J., et al. (2019). Identifying psychological resistances to using logic in cognitive-behavioral therapy for psychosis (CBTp) that limit successful outcomes for patients. Psychosis, 11(4), 287–297.

    Article  Google Scholar 

  • Hamm, J. A., Buck, K. D., Leonhardt, B. L., Luther, L., & Lysaker, P. H. (2018). Self-directed recovery in schizophrenia: Attending to clients’ agendas in psychotherapy. Journal of Psychotherapy Integration, 28(2), 188–201.

    Article  Google Scholar 

  • Hamm, J. A., Buck, K. D., Vohs, J., Westerlund, R. J., & Lysaker, P. H. (2016). Interpersonal stance and dialogue in psychotherapy for schizophrenia: A supervisory approach. The Clinical Supervisor, 35(1), 42–62.

    Article  Google Scholar 

  • Hamm, J. A., Ridenour, J. M., Hillis, J. D., Neal, D. W., & Lysaker, P. H. (2021). Fostering intersubjectivity in the psychotherapy of psychosis: Accepting and challenging fragmentation. Journal of Psychotherapy Integration. https://doi.org/10.1037/int0000271

    Article  Google Scholar 

  • Hasson-Ohayon, I., Gumley, A., McLeod, H., & Lysaker, P. H. (2020). Metacognition and intersubjectivity: Reconsidering their relationship following advances from the study of persons with psychosis. Frontiers in Psychology, 11, 567–575.

    Article  PubMed  PubMed Central  Google Scholar 

  • Hasson-Ohayon, I., Kravetz, S., & Lysaker, P. H. (2017). The special challenges of psychotherapy with persons with psychosis: Intersubjective metacognitive model of agreement and shared meaning. Clinical Psychology & Psychotherapy, 24(2), 428–440.

    Article  Google Scholar 

  • Humphrey, C., Berry, K., Degnan, A., & Bucci, S. (2022). Childhood interpersonal trauma and paranoia in psychosis: The role of disorganised attachment and negative schema. Schizophrenia Research, 241, 142–148.

    Article  PubMed  Google Scholar 

  • Knafo, D. (2020). Alone in a crowded mind: When psychosis masks loneliness. Psychoanalytic Psychology, 37(2), 108–116.

    Article  Google Scholar 

  • Kreyenbuhl, J., Nossel, I. R., & Dixon, L. B. (2009). Disengagement from mental health treatment among individuals with schizophrenia and strategies for facilitating connections to care: A review of the literature. Schizophrenia Bulletin, 35(4), 696–703.

    Article  PubMed  PubMed Central  Google Scholar 

  • Leonhardt, B. L., Kukla, M., Belanger, E., Chaudoin-Patzoldt, K. A., Buck, K. D., Minor, K. S., et al. (2018). Emergence of psychotic content in psychotherapy: An exploratory qualitative analysis of content, process, and therapist variables in a single case study. Psychotherapy Research, 28(2), 264–280.

    Article  PubMed  Google Scholar 

  • Lincoln, T. M., & Pedersen, A. (2019). An overview of the evidence for psychological interventions for psychosis: Results from meta-analyses. Clinical Psychology in Europe, 1(1), 1–23.

    Article  Google Scholar 

  • Lysaker, P. H., Gagen, E., Klion, R., Zalzala, A., Vohs, J., Faith, L. A., et al. (2020). Metacognitive reflection and insight therapy: A recovery-oriented treatment approach for psychosis. Psychology Research and Behavior Management, 13, 331.

    Article  PubMed  PubMed Central  Google Scholar 

  • Lysaker, P. H., & Klion, R. E. (2017). Recovery, meaning-making, and severe mental illness: A comprehensive guide to metacognitive reflection and insight therapy. Routledge.

    Book  Google Scholar 

  • McCabe, R., & Priebe, S. (2008). Communication and psychosis: It’s good to talk, but how? The British Journal of Psychiatry, 192(6), 404–405.

    Article  PubMed  Google Scholar 

  • Nabors, L. M., Yanos, P. T., Roe, D., Hasson-Ohayon, I., Leonhardt, B. L., Buck, K. D., & Lysaker, P. H. (2014). Stereotype endorsement, metacognitive capacity, and self-esteem as predictors of stigma resistance in persons with schizophrenia. Comprehensive Psychiatry, 55(4), 792–798.

    Article  PubMed  Google Scholar 

  • Potik, D. (2014). Self psychology conceptualization of postpsychotic depression and recovery among paranoid schizophrenic patients. Bulletin of the Menninger Clinic, 78(1), 70–86.

    Article  PubMed  Google Scholar 

  • Ridenour, J. M., Knauss, D., & Neal, D. W. (2021). Promoting an integrating recovery style: A mentalization-informed approach. Journal of Clinical Psychology, 77(8), 1786–1797.

    Article  PubMed  Google Scholar 

  • Rosenfeld, H. (1987). Impasse and interpretation: Therapeutic and anti-therapeutic factors in the psychoanalytic treatment of psychotic, borderline, and neurotic patients (Vol. 1). Tavistock/Routledge.

    Google Scholar 

  • Sandler, J. (1976). Countertransference and role-responsiveness. International Review of Psycho-Analysis, 3, 43–47.

    Google Scholar 

  • Sass, L., & Byrom, G. (2015). Phenomenological and neurocognitive perspectives on delusions: A critical overview. World Psychiatry, 14(2), 164–173.

    Article  PubMed  PubMed Central  Google Scholar 

  • Startup, M., Wilding, N., & Startup, S. (2006). Patient treatment adherence in cognitive behaviour therapy for acute psychosis: The role of recovery style and working alliance. Behavioural and Cognitive Psychotherapy, 34(2), 191–199.

    Article  Google Scholar 

  • Suchet, M. (2015). Impasse-able. Psychoanalytic Dialogues., 25(4), 405–419.

    Article  Google Scholar 

  • Tarrier, N. (2008). Schizophrenia and other psychotic disorders. In D. H. Barlow (Ed.), Clinical handbook of psychological disorders: A step-by-step treatment manual (4th ed., pp. 463–491). The Guilford Press.

    Google Scholar 

  • Tillman, J. G. (1999). Psychosis as the sickness unto death: Treatment impasse, consultation, and resolution. The American Journal of Psychoanalysis, 59(2), 119–125.

    Article  CAS  PubMed  Google Scholar 

  • Will, O. A. (2021). On “caring” in psychotherapy. Psychiatry, 84(1), 2–15.

    Article  PubMed  Google Scholar 

Download references

Funding

There are no funding sources to report.

Author information

Authors and Affiliations

  1. Erikson Institute for Education, Research, & Advocacy, Austen Riggs Center, 25 Main Street, Stockbridge, MA, 01262, USA

    Jeremy M. Ridenour & David W. Neal

  2. Eskenazi Health, Sandra Eskenazi Mental Health Center, Indianapolis, IN, USA

    Jay A. Hamm

  3. College of Pharmacy, Purdue University, West Lafayette, USA

    Jay A. Hamm

  4. Chillicothe VA Medical Center, Chillicothe, OH, USA

    Jaclyn D. Hillis

  5. Department of Psychiatry, Harvard Medical School, Boston, MA, USA

    Emily C. Gagen

  6. Massachusetts Mental Health Center, Boston, MA, USA

    Emily C. Gagen

  7. Department of Psychiatry, The Institute of the Living at Hartford Hospital, Hartford, CT, USA

    Aieyat B. Zalzala

  8. Richard L Roudebush VA Medical Center, Indianapolis, IN, USA

    Paul H. Lysaker

  9. Department of Psychiatry, Indiana University School of Medicine, Indianapolis, USA

    Paul H. Lysaker

Authors
  1. Jeremy M. Ridenour
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jay A. Hamm
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. David W. Neal
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Jaclyn D. Hillis
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Emily C. Gagen
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Aieyat B. Zalzala
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Paul H. Lysaker
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Jeremy M. Ridenour.

Ethics declarations

Conflict of interest

No potential conflicts of interests to report.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Ridenour, J.M., Hamm, J.A., Neal, D.W. et al. Navigating an Impasse in the Psychotherapy for Psychosis. J Contemp Psychother 53, 235–243 (2023). https://doi.org/10.1007/s10879-022-09571-6

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10879-022-09571-6

Keywords

Search

Navigation