Intent to Understand the Meaning of Psychotic Symptoms During Patient-Psychiatrist Interactions

Despite the availability of evidence-based psychosocial treatments for schizophrenia (1), including a range of individual psychotherapies (2), many of these treatments are not yet routinely available in outpatient settings (1). Although psychotherapy for psychosis has demonstrated efficacy, even for patients with medication-resistant conditions (3), psychiatric residents are seldom trained in, and therefore may not be aware of, specific psychotherapeutic approaches such as cognitive-behavioral therapy for psychosis (4). Given the lag in implementation of these specific therapies, residents need to have basic training and be familiar with principles to help guide their clinical interactions with patients who have psychosis, especially patients diagnosed as having schizophrenia spectrum disorders.

The therapeutic relationship is an essential element in all forms of psychotherapy (5), including psychotherapy for psychosis (6). Despite evidence (7) that clinicians can create an alliance with patients who experience delusions, and that such symptoms do not necessarily interfere with the formation of an alliance, other studies (6, 8) have found that less severe positive symptoms correlate with a stronger provider-rated alliance. In other words, psychiatrists often rate the alliance as weaker when working with patients who exhibit more severe positive symptoms. One reason psychiatrists may have relative difficulty fostering an alliance with such patients is because psychiatrists have views of reality that radically differ from those of their patients. In this article, we describe an attitudinal stance—“intent to understand”—that psychiatrists working with patients who have psychosis can embrace to improve the alliance. This article is not a manual of psychotherapy technique (9, 10). Rather, it addresses the broader challenge of engaging patients experiencing psychosis in an alliance that facilitates both pharmacotherapy and psychotherapy.

Research (11) on outpatient consultations between psychiatrists and patients suggests that, even though patients regularly bring up their psychotic symptoms, psychiatrists often avoid discussing such symptoms. For example, in one reported interview, a patient bravely asked, “Why don’t people believe me when I say I’m God?” The psychiatrist responded, “What should I say now?” (11). The psychiatrist was at a loss for words. Failure to address a patient’s pressing concerns, however, discourages a positive alliance and can lead to patients disengaging from or leaving treatment. But what should psychiatrists say in response to a patient’s delusional claims? Many psychiatrists have been trained to avoid dialogue about delusions because of fear of unwittingly colluding with the patient, thereby reinforcing the belief (12). In a study of nonverbal behavior in patient-psychiatrist interactions, Lavelle and colleagues (13) observed that in sessions with patients experiencing psychosis, 19% of psychiatrists showed behaviors indicative of a “flight” reaction (e.g., looking down or freezing). Because they know that arguments are unlikely to change the patient’s mind, psychiatrists may sidestep these conversations altogether (14).

Patients understandably want to talk about their psychotic experiences, especially because these experiences often represent central concerns in their individual psychology (15). For example, a young man who grew up in an academic family developed a delusion that he was being targeted by the Federal Bureau of Investigation (FBI) because he had mathematical powers that could be used to attack the U.S. government. In this case, his premorbid self-esteem had been grounded in his intellect, and his symptoms expressed, in an exaggerated fashion, a core element of his psychology. His delusion about his mathematical powers was a vestige of his self-esteem. Given the importance of the content of psychotic symptoms, how can psychiatrists respectfully converse with patients about psychotic beliefs without colluding with them (thereby encouraging the delusions) or provoking defensiveness by prematurely challenging them (12, 16)?

Efforts to improve the psychiatrist’s communication with patients experiencing psychosis have been developed, such as the training to enhance psychiatrist communication with patients with psychosis (TEMPO) (16) and the DIALOG+ tool, which provides a structure for evaluating patient satisfaction in multiple domains and identifies steps to improve the patient’s situation (17). These valuable approaches help to establish a patient-centered collaboration that, for the most part, seeks to improve adherence to a mutually agreed-on pharmacological regimen. With the exception of a simulated auditory hallucination exercise in TEMPO, however, these two approaches do not focus on an empathic understanding of the meaning of symptoms. Below, we extend the concept of improved communication to include the intent to understand, which we define as a persistent effort to empathically comprehend the emotional meaning of the patient’s symptoms.

Barriers to Dialogue With Patients Experiencing Psychosis

Several factors may impede dialogue about psychotic symptoms: the seeming incomprehensibility of symptom content, psychiatrists’ fear of collusion, expectations of the futility of engagement, and a strictly biomedical model of psychosis. With respect to the first barrier, psychotic symptoms often defy common sense and consensual reality. Their meaning is often not readily apparent. Psychiatrists may have difficulty understanding experiences that strikingly differ from their own. For example, a young man who was experiencing delusions was referred to treatment after a suicide attempt. Prior to the attempt, he said he had had an “out-of-body experience,” in which he had traveled to outer space and returned to his body as a “triangle” in the center of his chest. He asked the psychiatrist for help in “extending [himself] out” to his fingertips; he wanted to become more embodied.

The psychiatrist was uncertain what to say in response to the patient’s claim of having traveled to outer space and returned as a “triangle” in his chest. By traveling to outer space, is the patient making a claim that his spirit left the planet, or is the space travel a metaphor for his psychosis—a journey leading to a radical sense of alienation? A psychiatrist with an intent to understand might regard the delusion as the patient’s attempt to put into words how it feels to experience a faded sense of self-presence, common in psychosis (18), in which he feels dissociated from his body. Working from within the patient’s metaphor, the psychiatrist might say, “Do I have this right? You feel as though you have been on a journey that has changed you, and even though you have returned to earth, it doesn’t seem like your spirit has fully returned to your body. You want help feeling more connected to your fingers and toes, the way you used to feel before all this started.” When the psychiatrist says, “you feel as though,” she does not agree with his claim to be a space traveler, but rather marks her understanding of the delusion as a metaphor—an “as though” statement rather than a truth claim.

The fear that a conversation about psychosis might represent inadvertent collusion (12) rests on the questionable assumption that merely having the conversation will grant validity to the patient’s claim and will be experienced by the patient as tacit agreement. In fact, because patients have likely already been told many times that they are wrong or “crazy,” they may expect to be received similarly by the psychiatrist. Their fears of being dismissed may drive them to implore their psychiatrist to believe their claims. If a patient asks whether the psychiatrist agrees with a delusional claim, the psychiatrist might say, in so many words, “There has been a lot going on in your life. I am just getting to know you, and I don’t want to jump to any conclusions about your situation. I would like to take the time to get to know you better, to hear your main concerns.” The psychiatrist might point out that she needs to gather more information, given that the patient’s claims are, by the patient’s own account, unusual. We know of no evidence for the belief that inquiries about symptoms increase the patient’s psychotic preoccupations; instead, the inquiry may establish the psychiatrist as an ally in making these distressing experiences more manageable.

Psychiatrists rightly want to avoid challenging the patient’s beliefs prematurely, thereby exacerbating conflict and defensiveness (14). As patients lay out their ideas, they often share their observations and interpretations of their experiences. When patients show a degree of pathological certainty (19), the psychiatrist may not know how to steer a conversation toward promoting curiosity and openness. Accordingly, the psychiatrist may withdraw and attempt to shift the conversation away from the symptom. This response may be intensified with patients experiencing paranoia, who may be agitated and fearful and, sometimes, desperately seeking agreement or validation.

Finally, psychiatrists’ theories of psychosis may influence their willingness to engage in conversations with patients about psychotic symptoms. Those adhering to a primarily biomedical model may feel it is not helpful to talk with patients about symptoms that they believe represent merely a dysregulated biochemistry and dopaminergic dysfunction (20). In this model, the primary intervention is pharmacological; therefore, the psychiatrist may not see the utility of engaging with patients about their beliefs.

Engaging Psychotic Symptoms

Patients often arrive in the consulting room with a desire to speak about their symptoms, hoping the psychiatrist will be a thoughtful partner who can help them figure out what is going on in their lives. Despite Jaspers’ (21) assumption that true delusions cannot be empathically grasped, in his classic phenomenological treatise he acknowledged that persons experiencing psychosis sometimes entertain “delusion-like ideas,” in which the precipitant of the symptom allows for empathic understanding (e.g., a son whose mother has just died believes she is still alive). Whereas some delusions are easy to comprehend, others are more challenging. When meanings are obscure, it is critical that the psychiatrist maintain the intent to understand. We define this stance as a persisting clinical attitude, an ongoing inquisitive state of mind, and verbal and nonverbal communication of the psychiatrist’s hope to understand the patient better over time. The respect and humility conveyed in the stance of seeking knowledge and understanding are potentially infectious and may inspire the patient to adopt a similar open-minded position. This concept is similar to what clinicians who practice cognitive-behavioral therapy for psychosis have termed sitting on the “collaborative fence” (22), where the clinician abandons the expert role and coinvestigates with the patient possible interpretations of the patient’s experiences.

The intent to understand is essential for several reasons. This stance communicates that the psychiatrist takes the patient’s symptoms seriously, allowing the patient to feel valued and respected. The psychiatrist’s wish to understand facilitates a collaborative process that can promote the therapeutic alliance. For persons experiencing psychosis, fostering an alliance has been empirically related to greater treatment adherence, more positive attitudes toward medications, increased medication adherence, decreased hospitalization rates, symptom reduction, and better quality of life (6, 23–25). Finally, the intent to understand encourages the development of an integrative recovery style, in which patients try to understand the meaning of their symptoms in the context of their life experiences (26).

To make a diagnosis, psychiatrists must listen to patients in ways that de-emphasize the patient’s individuality while highlighting definable characteristics that are commonly shared by all members of a diagnostic group. Although diagnoses offer useful information, they do not provide an understanding of the patient as a person. The psychiatrist must also listen to the patient as a participant who has a unique life experience expressed in symptoms that cannot be collapsed into a list of diagnostic criteria. When listening for meaning, the psychiatrist must listen as one might listen to a story, an allegory, a work of fiction, or a metaphor that is assumed to have a discernible meaning. A delusion may at first appear to be a nonsensical claim about the world. However, as Spitzer (27) points out, to the extent that delusions express the internal state of an individual extended into the outer world, they cannot be objectively falsified, because a person’s subjectivity can be known only by that individual. Regardless of the contribution of biology, delusional narratives are the patient’s attempt to account for past and current experiences. They also serve the purpose of imposing order on a mind that might otherwise be unbearably painful and chaotic (28).

Delusions Whose Meaning Is Readily Understood

A woman who was sexually abused by her father as a child is evicted from her apartment because she failed to pay rent. She stated that she did not need to pay, because her rent was “covered by the Feds.” She claimed to be an undercover FBI agent investigating a child abuse ring in her town. Although no one else in the town could identify the people who were abusing children (just as no one had believed her childhood claim that her father was abusing her), she thought that she was able to pick up nonverbal cues that revealed which townspeople were perpetrators (ideas of reference). Her “job” was to report these people to “the Feds,” who (unlike her mother, who had told her she must be “crazy” to make up such lies about her father) were invested in preventing child abuse and in bringing perpetrators to justice. Listening for meaning allowed the clinician to recognize the sexual abuse that shaped the patient’s delusional narrative and engendered her “paranoid” mistrust of others. Through this narrative, she was trying to take up the unfinished business of her adolescence and seek justice.

Delusions Whose Meaning Requires Persistent Effort to Understand

Some delusions require the clinician to be familiar with a range of phenomena that patients may experience, including alterations in self-experience that commonly occur in psychosis (9). For example, a young woman claimed that her “soul had been smoked away” by aliens. She believed that a group of aliens had damaged her mentally by removing half of her brain and replacing it with a computer chip, an operation that had forced her to drop out of college. She believed the aliens to be in league with her older sister, with whom she entertained a long-standing sibling rivalry. The computer chip allowed her to go through the motions of everyday life, like an automaton, but it prevented her from feeling alive (i.e., she felt “soulless”). Her psychiatrist understood the delusion as her attempt to verbalize a phenomenon in psychosis known as diminished ipseity (29), in which the subjective sense of a vital “I” at the center of experience dissipates. The patient aptly characterized this altered state of diminished agency as having had her soul “smoked away.” Her metaphor captured the feeling of her mind having “gone up in smoke” or having been vaporized. Her delusional narrative modulated her sense of personal failure by attributing the catastrophe not to her own academic limitations or psychiatric struggles but to her sister’s nefarious conspiracy to take her down (i.e., “I would have been a success in life were it not for my sister”).

Clinical Pointers in the Intent to Understand

Respond Courteously and Respectfully

Prior to offering an opinion, it is important to understand how open the patient is to input and what might exacerbate resistance and potentially damage the alliance. For example, in the middle of a psychiatric interview, a patient stated, “I don’t like to be questioned. Everyone I’ve talked to about this woman who broke into my car believes me!” These types of statements can alert the psychiatrist to the fact that the patient is likely feeling vulnerable and frightened, as if to say, “I can relate to you only if I know that you hold the same beliefs as I do. I cannot feel safe unless we are of one mind.” The psychiatrist might say, “There are ways you are connecting some of your ideas that I couldn’t quite follow. I want to understand, but I was worried that saying this might upset you because you told me that you don’t like to be questioned.” Courtesy requires respect for the dignity of the other person and an attitude of humility, which allow the psychiatrist to carefully consider how to express her opinion in order to strengthen the alliance and promote recovery for the patient.

Listen for Affect

Although patient and doctor may disagree about claims regarding the material world, it is often possible to agree about what the patient feels (30). Terror is among the most prominent affects in psychosis, although feelings of grief, guilt, worthlessness, jealousy, rage, and despair are also common. If the psychiatrist can identify the core feelings that the delusional narrative both expresses and attempts to modulate, a window of empathic understanding can open (31). For example, a man believed that a tribunal of four older men who could read his mind had promised him a lucrative business deal if he could last a week without having any negative thoughts about them. In a session following a week in which he felt he had met their demands, he exclaimed angrily, “I did what they want, but they still didn’t give me the contract!” The psychiatrist said, “You have tried your best and waited so long. When you feel angry because you have been treated unfairly, it just makes matters worse, because you think they know you are having angry thoughts toward them, which gives them an excuse to not honor the contract.” In response, the patient wept openly.

Work to Connect the Symptom to the Person’s Life Story and Potential Trauma

Psychotic symptoms often emerge in response to trauma or adverse experiences (32). For instance, a young woman believed that her professor was sending her private, romantic messages through his clothing choices. Eventually, this ballooned into a delusion, as she accused him of wanting to have an affair with her. Over the course of therapy, the patient and psychiatrist were able to recognize that this preoccupation with her professor had emerged after the breakup of her first romantic relationship. Unable to bear the grief of rejection, she had escaped the pain by focusing on her professor’s sexual “interest” in her. Psychotic symptoms happen at specific moments in life and are often instigated by trauma or loss. Finding the link to the patient’s history helps to contextualize the symptom, which strengthens the patient’s sense of identity while encouraging an integrative recovery style (26).

Conclusions

Although some psychotic symptoms may at first appear difficult to understand, maintaining a persistent intent to understand can, over time, strengthen the therapeutic alliance by fostering a human connection that is based on the patient’s fundamental emotional concerns. Furthermore, this active and engaged stance allows the psychiatrist to stay in conversation with patients who are trying to sort out their confusing symptoms, rather than to ignore or sidestep conversations altogether. A positive alliance can improve collaborative decision making about medication. For interested patients, it may serve as a prelude to more ambitious psychotherapy. For these reasons, psychiatric education should include training in the intent to understand psychosis.