Episode 229: Beyond the Myths of Psychosis: Understanding, Acceptance, and Paths Forward
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Article Author: Stijn Vanheule, PhD
Podcast Host: David Puder, MD
Podcast guest: Stijn Vanheule, PhD
Stijn Vanheule, PhD, is a professor of clinical psychology and psychoanalysis at Ghent University (Belgium), where he chairs the Department of Psychoanalysis. He has published extensively on psychosis and other mental health-related topics, as well as Lacanian psychoanalysis. He is also a practicing psychoanalyst in Belgium. An overview of his publications, which include 7 monographs and 220 peer-reviewed papers in academic journals, can be found here.
In September of 2024, Other Press published my new book, Why Psychosis Is Not So Crazy. This nonfiction work is written for mental health care professionals, patients and their families, and anyone curious about psychosis, psychology, and creativity.
Why Psychosis Feels Strange—Yet Is More Common Than You Think
The idea of experiencing psychosis might seem abnormal and strange. However, I explore how psychosis-like experiences are more common than many might think. Research shows that about 15% of the general population has had short-lived or isolated psychosis-like experiences (Verdoux & van Os, 2002) , such as holding strong irrational beliefs, seeing a ghost, or witnessing paranormal phenomena (Monshouwer et al., 2023). For 7% of the population, these experiences can be classified as “psychotic,” (van Os & Reininghaus, 2016) and in 3% of cases (Perälä et al., 2007), the situation may become severe enough to require psychiatric intervention.
Challenging Stereotypes: The Real-Life Course of Psychosis
When people think about psychosis, dramatic portrayals often dominate—decline, danger, and unpredictable behavior. But through my research and writing, I offer a different perspective. Evidence shows that most individuals who experience a psychotic episode recover well (van Os. et al., 2012). For example, 15% of cases involve one or two brief episodes with no lingering clinical symptoms. In 30% of cases, the course is episodic, with multiple episodes throughout life but no residual symptoms in between. Another 40% of cases are episodic as well, though with mild symptoms persisting between episodes. Only 15% of cases have a poor outcome, with ongoing symptoms and significant impairment.
Through this book, I hope to challenge misconceptions and provide a deeper understanding of psychosis—not as something to fear, but as an experience that can be understood, addressed, and often overcome. I argue that contemporary mental health care’s approach to psychotic experiences—as mere signs of illness that require management—is limited, because it overlooks their psychological meaning. Rooted in psychoanalysis, I suggest that psychotic symptoms are subjective expressions of serious existential challenges. The model discussed in Why Psychosis Is Not So Crazy connects psychosis to language use and the difficulties individuals face in interpreting life’s events within common-sense narratives.
How Our Minds Work: Primary-Process vs. Secondary-Process Thinking in Psychosis
In my view, psychotic outbreaks occur when common ways of making sense of reality break down, leading to discrete psychotic experiences. These experiences are subtle disturbances in a person’s sense of self and perception of reality, often causing confusion and disorientation. Unlike full-blown psychotic episodes, discrete psychotic experiences are more fragmented. They may manifest as trivial events demanding excessive attention, a loss of control over thoughts and language, strange bodily sensations, impulsive actions, or feelings of detachment from oneself. During these moments, narrative organization and a sense of agency are lost. Instead, consciousness becomes dominated by associative, primary-process thinking, which is experienced passively.
Freud described primary-process thinking as the fundamental mode of thought that operates at the level of unconscious mental functioning, characterized by a free and associative flow of ideas. It differs from secondary-process thinking, which is guided by logic, order, and rational connections, and governs conscious, waking thought. According to Freud, primary-process thinking becomes dominant in dream states and in conditions where the unconscious surfaces, such as during psychotic episodes. It organizes thoughts based on associative links, such as visual or auditory similarities, rather than logical connections. In these states, language and imagery connect freely, producing a surreal and often chaotic experience, much like the free association seen in dreams.
The book elaborates that during psychotic experiences, the dominance of primary-process thinking disrupts the coherence typically provided by secondary-process thinking, leading to a breakdown in logical structuring of thoughts. This results in bewilderment and despair. Hallucinations and delusions further intensify the process, adding a sense of intrusion: strange communications from the outside world seem to haunt the individual.
Breaking Points: Traumatic Events, Existential Struggles, and the Onset of Psychosis
In my view, psychotic experiences are deeply tied to how individuals confront challenging and disruptive events, as well as existential struggles. These experiences often arise when individuals face situations that destabilize their sense of reality. Traumatic events such as conflicts, losses, or major life transitions—like the birth of a child, relationship difficulties, unemployment, or the death of a loved one—can overwhelm a person’s ability to organize their thoughts coherently, resulting in psychotic episodes.
In these moments, the normal frameworks people rely on—such as language and narrative structures—can fail, leading to a collapse of the sense of self and reality. I suggest that when individuals cannot symbolically frame or comprehend these disruptive events, their experiences may become so intense and vivid that they overwhelm the mind, creating a chaotic and disorienting state. Furthermore, these psychotic experiences often express profound, subjective truths related to the existential challenges individuals are grappling with. In this sense, psychosis serves as a manifestation of the struggle to find meaning or stability in the face of life’s uncertainties and existential voids.
The Power of Empathic Listening: Supporting Individuals Through Psychosis
Taking this into account, I emphasize the importance of a specific listening approach to help patients overcome these difficulties. A calm, receptive, and dialogical stance is crucial when engaging with individuals experiencing psychosis. I argue against displays of power or anxiety-driven reactions, as these only heighten fear and create distance. Instead, establishing a trusting and supportive environment is essential. Connecting through conversation helps the person articulate their concerns and experiences, enabling them to begin to re-establish their grip on reality.
This listening approach also involves accepting the fragmented and allusive nature of psychotic speech. Rather than dismissing these expressions as nonsensical, I encourage mental health professionals to approach delusions and hallucinations as symbolic references to the issues the person struggles to articulate coherently. Through this perspective, professionals can better support individuals in navigating their experiences and finding meaning amid the disorientation of psychosis.
On page 165, I characterize this as follows:
“If I look at a sculpture by Yayoi Kusama or step into the cinematic world of David Lynch, I do not fully understand everything that I am seeing. Even so, I am still captivated by their work. Their art stimulates new ideas and sensations that go beyond what I ordinarily experience. They take me out of my comfort zone and force me to view reality from a different perspective. This helps me (as it can help all of us) to escape from the force of habit. Art—and, in particular, “unpolished” art that is rough around the edges—gives expression to things we cannot say.
Psychoses have this same expressive status, with the difference that in a psychotic universe everything is wilder and more unbridled than in the creative work of an ordinary artist. And it is precisely there that the challenge is to be found. Like contemporary modern art, psychotic experiences stimulate dialogue and interaction. As soon as we are prepared to regard these experiences as expressive acts, we can come into meaningful contact with them—just as the visitor to an art gallery does with a sculpture or a cinema-goer does with a film. If we can do this, psychosis is no longer a defect, but rather an invitation to listen to a new language full of allusions and to be open to how someone deals with the groundlessness of his existence.”
The book argues that to help people recover from disruptive events and existential struggles in psychosis, mental health care should focus on creating supportive, inclusive, and dialogical environments. I emphasize the importance of not solely relying on medication, as it is not a cure and may not be effective for everyone. Instead, the focus should be on building meaningful connections and understanding the subjective nature of psychotic experiences.
Key strategies include:
Fostering dialogue and connectedness: Mental health professionals should provide space for open dialogue, enabling individuals to express and work through their experiences. This involves engaging patients and their support networks (family, friends) in conversation to address the underlying social and emotional issues revealed during psychotic episodes.
Creating safe and welcoming environments: Establishing safe, unforced environments where individuals can freely explore their experiences and interests is crucial.
Offering therapies that foster expression: Approaches that allow individuals to express their experiences creatively (e.g., art, music, storytelling) help in making sense of their psychotic episodes. Such methods are vital for reconnecting with reality and developing a coherent sense of self.
In making the latter point, I refer to Annie Rogers, a psychoanalyst, clinical psychologist, and professor known for her work in the field of psychoanalysis and trauma, particularly focusing on the experiences of psychosis. She has integrated her own personal experiences with psychosis into her professional and academic work, offering insights into how individuals can navigate and make sense of psychotic experiences. Rogers emphasizes that overcoming psychosis involves finding a new language that resonates with the individual’s own voice and experiences. This process allows for the expression of previously unimaginable thoughts and feelings, creating a space where the illogical aspects of one’s experience can be articulated. In this way, aspects of primary-process thinking are articulated in terms of secondary-process thought. Rogers discovered her new language through psychoanalytic therapy, which provided her with the space to explore her experiences creatively.
However, Rogers suggests that not all primary-process thinking that occurs in the context of psychosis can be expressed in terms of secondary-process memories and narratives. In her view, a “nub of nonsense” will always remain present. This remainder also deserves expression, which can be achieved by playing with forms, images, or even sounds that match the associative nature of someone’s psychotic experiences. For example, she experimented with drawing, printmaking, poetry, and photography, embracing absurdity and whimsy. She used this approach to give expression to elements that remained elusive, accepting that some aspects of her experience would defy logical understanding yet still hold meaning in a symbolic or aesthetic sense.
Jung’s Path to Meaning: Using Creativity to Translate Psychosis into Psychological Theory
Another example discussed in Why Psychosis Is Not So Crazy concerns Carl Jung, who began experiencing acute psychotic episodes shortly after his rupture with Sigmund Freud. Jung's relationship with Freud started as a promising partnership in advancing psychoanalytic theory but ultimately unraveled due to conflicting theoretical perspectives. Freud viewed Jung as a potential successor, partly because of Jung's respected academic background and non-Jewish identity, which Freud hoped could mitigate some of the anti-Semitism facing psychoanalysis. However, their differing views on the unconscious, sexuality, and spirituality created a divide, leading to a painful separation. This split left Jung in an existential crisis, during which he experienced psychotic episodes marked by powerful, often terrifying visions and auditory hallucinations. These psychotic experiences seemed to erupt as his mental anchors, previously supported by his friendship with Freud, were shaken.
Interestingly, in response to these disruptive experiences, Jung began making notes and drawings to document what he was going through, thus embarking on what he called a “spiritual journey” recorded in The Red Book, an illuminated manuscript blending calligraphic text, esoteric paintings, and mandalas. Jung saw this work as a personal myth-making process, helping him integrate and express his internal chaos. The manuscript includes symbols and imagery that reflect the depth of his visionary experiences. Over time, he translated these experiences into foundational concepts in psychology, such as the animus and anima, introversion and extraversion, and even the idea of a midlife crisis. By recording and reflecting on these visions, Jung managed to integrate the unconscious insights of his primary process into his conscious self through secondary-process thinking, thereby developing theories that bridged personal and collective unconscious elements.
Later in his life, Carl Jung began constructing Bollingen Tower on Lake Zürich—a small, medieval-inspired castle that he designed as a sanctuary for self-reflection and solitude. He saw the tower as a symbol of rebirth and a concrete expression of his psychic life, describing it as a representation of the maternal womb. In Why Psychosis Is Not So Crazy, I draw a parallel between Jung’s use of Bollingen Tower and Annie Rogers’s concept of working with what she calls the “nub of nonsense.” For both, this involves giving form and expression to elusive, illogical elements that resist conventional understanding. Jung’s Bollingen Tower became a personal sanctuary where he could immerse himself in mysticism, allowing primary-process thoughts—marked by symbolic and illogical elements—to exist within a structured physical space. Within the architectural confines of the tower, his “madness” found a safe realm for irrationality and self-expression.
Both Carl Jung and Annie Rogers employed creativity inspired by primary-process thinking not only as a personal outlet but also as a way to break through the isolation of their psychotic experiences and connect with a broader audience. Jung externalized his chaotic, symbolic visions through The Red Book and the construction of Bollingen Tower, translating his internal struggles into tangible, aesthetic forms. This creative process served as a bridge between his inner world and the external world, fostering connections with others who could see the psychological and spiritual value in his insights. Similarly, Annie Rogers used her art to transform her once-isolated experiences into something that could resonate with others. By sharing her work, she invited others to engage with and appreciate her subjective reality.
In both cases, their creative expressions became powerful mediums for building social connections, validating their psychotic experiences, and offering others a way to understand the misunderstood and deeply personal nature of psychosis. Through their work, they opened doors for audiences to explore the richness and complexity of psychotic experiences from a place of empathy and engagement.
Together, Jung’s and Rogers’s methods illustrate that therapeutic work with psychosis can benefit from embracing both primary and secondary process thinking. This dual approach allows patients to express and integrate their fragmented thoughts and experiences in a constructive way. By combining psychoanalytic therapy with active support for creative expression, patients can find coherence and meaning. This, in turn, reduces isolation and provides them with tools to reconnect with reality and others.
Holding Space for Complexity: The Power of Presence in Psychotherapy for Psychosis
Effective therapeutic work with individuals suffering from psychosis also requires therapists who can skillfully manage both their own and their patients’ anxiety. This is crucial because psychotic experiences are often deeply overwhelming and disruptive—not only for the individuals experiencing them but also for those providing care. For therapists, this means maintaining a calm, composed presence that allows them to stay engaged and receptive without becoming overwhelmed by the chaos or fear that psychosis can provoke. Moreover, I believe therapists should approach psychotic experiences with creativity, exploring the meanings and paradoxes embedded in such episodes. By providing space for unconventional expressions—whether through symbols, metaphors, or other forms of primary-process thinking—therapists can help patients give voice to experiences and thoughts that might otherwise feel unmanageable.
This creative engagement enables patients to construct a narrative or symbolic language that bridges their fragmented internal experiences with a more coherent reality, paving the way toward recovery. In essence, this therapeutic approach requires flexibility, openness to the surreal and illogical, and a willingness to engage with each patient’s unique symbolic expressions. By doing so, psychotic experiences can be integrated constructively rather than suppressed, allowing for a healing process that respects the individual’s subjective reality.
To illustrate the importance of openness and flexibility in therapeutic work with patients suffering from psychosis, I discuss my therapeutic work with Mario in Why Psychosis Is Not So Crazy. Mario was a young man with Down syndrome who experienced severe psychotic episodes, which led him to withdraw almost entirely from his surroundings. Isolated in his attic room, Mario became locked in an imaginary world, engaging in conversations with an invisible companion. This disrupted his contact with reality and made it difficult for him to connect with those around him.
As a junior clinical psychologist at the time, I observed that a fruitful transference relationship with Mario was only possible when a genuine encounter occurred—one that was not obstructed by my own ego or ambitions:
“One rainy day, about three months after I started visiting him, I arrived at his house for a new session. Afterward, I was scheduled to attend an important meeting, and, with this in mind, I was wearing my best suit, hoping to make a good impression. With my thoughts already half on the meeting, I got out of my car and walked quickly up the garden path toward Mario’s front door, forgetting that this path was covered with moss that had now been made super slippery by the recent downpour. I felt my feet slowly sliding away from under me and, notwithstanding my best efforts to maintain my balance, soon found myself lying flat on my back in the grass, wet and spattered with mud! Mario had witnessed this whole unedifying episode from the loneliness of his attic room. As I struggled to get back to my feet, cursing my stupidity, he opened the front door and called out, “You okay?” Once I was finally inside, he disappeared for a few seconds and returned with a towel, which he pressed to my chest. “Here, clean yourself up.”
Suddenly, he was no longer the one with the problem: it was me! This turned out to be an important breakthrough. Many young professionals, which I was at that time, hold rigid views about their role as a professional. They strive to be seen as an expert and impose their own agenda onto their patients. Or, even worse, they want to be a savior or act as if they are the patient’s closest confidant. In my case, I probably tried to be the clever and heroic therapist who would achieve a breakthrough. However, to my surprise, significant changes were not achieved through my earnest efforts, but rather when I let go of my desire to be the hero and instead focused on being present and attentive for Mario.
Being present and attentive in the moment may sound easy but is very difficult. In daily life, we are often preoccupied with our own thoughts and miss what others are saying. However, if therapists remain deaf like this, they make a serious mistake. Regardless of their level of education or professional experience, all mental health care workers have blind spots they should be aware of. It is part of their job to examine their own attitudes and behaviors. Through discussing this event with my own psychoanalyst, I came to realize that the secret fantasy of being the smart savior was one of my blind spots. It was only by recognizing and acknowledging the caricature of the savior in myself that I was able to let it go.
(…) A key lesson I have learned is that to be effective as a therapist, one must set aside any personal agenda and strive to be fully receptive to what patients are expressing, both verbally and through their symptomatic behaviors. Understanding these expressions can be difficult, as speech may be chaotic, patients’ experiences may be far from reality, and silences can be overwhelming. While this can be frustrating, it becomes less so when you accept that it is inherently difficult to truly comprehend the subtle meanings another person is communicating. Even with detailed attention to an individual’s problems, a missing link will always be present in our understanding. It is by accepting this lack and taking it as our starting point that a true encounter is possible.”
References:
Jung, C. G. (2009). The Red Book: Liber Novus (S. Shamdasani, Ed., M. Kyburz, J. Peck, & S. Shamdasani, Trans.). W. W. Norton & Company.
Monshouwer, K., ten Have, M., Tuithof, M., van Dorsselaer, S., Bak, M., Gunter, N., Delespaul, P., van Os, J., & de Graaf, R. (2023). Prevalence, incidence, and persistence of psychotic experiences in the general population: Results of a 9-year follow-up study. Psychological Medicine, 53(8), 3750-3761. DOI: https://doi.org/10.1017/s0033291722002690
Perälä, J., Suvisaari, J., Saarni, S. I., Kuoppasalmi, K., Isometsä, E., Pirkola, S., Partonen, T., Tuulio-Henriksson, A., Hintikka, J., Kieseppä, T., Härkänen, T., Koskinen, S., & Lönnqvist, J. (2007). Lifetime prevalence of psychotic and bipolar I disorders in a general population. Archives of General Psychiatry, 64(1), 19-28. DOI: https://doi.org/10.1001/archpsyc.64.1.19
Vanheule, S. (2024). Why psychosis is not so crazy: A road map to hope and recovery for families and caregivers. Other Press.
van Os, J., & Reininghaus, U. (2016). Psychosis as a transdiagnostic and extended phenotype in the general population. World Psychiatry, 15(2), 118-124. DOI: https://doi.org/10.1002/wps.20310
van Os, J., Murray, R. M., & First, M. B. (2012). Course and outcome of schizophrenia. In J. A. Lieberman & R. M. Murray (Eds.), Comprehensive care of schizophrenia: A textbook of clinical management (2nd ed., pp. 1–16). Oxford University Press.
Verdoux, H., & van Os, J. (2002). Psychotic symptoms in non-clinical populations and the continuum of psychosis. Schizophrenia Research, 54(1–2), 59-65. DOI: https://doi.org/10.1016/s0920-9964(01)00352-8