By Letticia Banton 

Ahead of TR Together’s upcoming live webinar on the Psychoanalytic Treatment of Psychosis, I read the book which has inspired the event: From Breakdown to Breakthrough: Psychoanalytic Treatment of Psychosis by Danielle Knafo and Michael Selzer (Routledge, 2024). As a newly qualified psychotherapist, I am starting to work with florid psychosis in private practice.

I valued the theoretically informed yet practical and down-to-earth style of this informative book. In this blog post, I share four insights that have informed my therapeutic practice:   

1. Working with psychosis may remind us of our own fragility

The authors suggest that one reason that therapists may feel hesitant about working with psychosis (besides a lack of training) is that our sanity is fragile, surmising (p168):

“The person with psychosis in treatment stands with the therapist on the borderland between a human ordered world and the chaos from which humans draw order. The therapist must accompany the patient into that terrifying territory, one that the vast majority of “sane” people mightily repress and avoid. One is reminded of madness. One is reminded that one can go mad. And one is reminded that one’s sanity itself is a kind of madness” 

Learning to tolerate and become comfortable with one’s own insanity, as part of the human condition, is perhaps the first step to working therapeutically with psychosis.

2. Ask yourself the important questions 

When I have been approached by a client experiencing psychosis, I have felt unsure about whether the client would be a suitable candidate for therapy with me, and if I would be a suitable therapist for them. So, I found the authors’ list of 10 factors for assessment a useful starting point: 

  1. No one is 100% psychotic. Assessing the client’s non-psychotic and conflict-free parts is crucial as they will become allies in the therapeutic process 
  2. Ask the important questions. What are the person’s expectations? What is known about previous treatment? How does the client perceive past treatment? 
  3. Both therapist and client need external support to manage isolation – are there family members, spouse, children, groups? What forms the therapist’s support system for this work? Supervisor, peers, analyst, family? 
  4. Has the therapist explored how the client’s ‘conditions’ intersect with their own need for safety? What needs to be negotiated with the client to establish safety in the therapeutic alliance? 
  5. What is the client’s capacity for an ‘observing ego’? 
  6. Does the client demonstrate some ability to empathise, toward themselves and the therapist? 
  7. What is the client’s highest level of functioning? How independent a life can they lead? 
  8. What is the client’s capacity for relatedness, engagement and curiosity for therapeutic exploration? 
  9. Is there evidence of a negative therapeutic reaction or destruction toward the therapy/therapist? 
  10. How does a client speak of their suicidal thoughts? Their delusions? If a client engages with curiosity in a dialogue with themselves there exists a greater potential to engage in the therapeutic work 

3. Go very slowly at the beginning

Working with a person with psychosis can be understood as working with an under-developed or unindividuated Self, where there is a lack of differentiation between self and other. Therefore, being in contact with the ‘Other’ of the therapist within the intimacy of a therapeutic space, can be a confusing, overwhelming and even terrifying experience for the client who may have no map for interpersonal relating. One role of therapy is to provide a holding environment which will enable the development of a person’s selfhood. This is likely to be slow work. While I am used to establishing a working alliance in the first 4-6 sessions, I was struck by the patience and compassion that the authors demonstrate through their case material to not impinge on the client’s sense of Self in the early stages of the work, and how this may take months and years. This included sitting in silence for weeks or finding ways to non-verbally and playfully communicate through eye contact and gestures to reach a pre-alliance stage of trust, safety and connection. This is necessary before ‘standard’ therapeutic interventions, such as offering insight or interpretations, are even considered because they could confuse or scare the client. 

4. Explore rather than eliminate symptoms

Knafo and Selzer emphasise that psychotic ‘symptoms’ can be viewed as adaptive measures and meaning-making systems which hold clues to the person’s problems and selfhood, rather than behaviours to be eradicated and eliminated through hospitalisation and medication alone. Through this lens, delusions and hallucinations can be understood as part of a person’s defensive structure. Throughout the book the authors demonstrate their skill in working collaboratively with clients to explore the unique meaning of their psychosis. In one standout and moving example, Michael Selzer describes his work with a client whose psychosis presented as ‘living with 17 small children’. In the first session, Michael steps on one of the children and the client shouts in terror at him. Michael proceeds to join rather than challenge the client in her reality and asks her to introduce the children so he can get to know them. Through this he also meets a non-psychotic part of the client that is caring and protective. I would highly recommend reading the book to understand how overtime through the therapy, the client’s children died one by one, the work focused on mourning and loss, and the client gradually came out of psychosis.

Join the live webinar!

Our upcoming webinar with clinical psychologist and psychoanalyst, Dr Danielle Knafo, is designed to build confidence in clinicians who are curious about working with psychosis. You can read about the upcoming event and register here: https://trtogether.com/events/psychoanalytic-treatment-psychosis