Psychiatry & Psychotherapy Podcast - Beyond the Myths of Psychosis: Understanding, Acceptance, and Paths Forward

Episode Date: December 13, 2024

In this episode, Dr. David Puder sits down with Dr. Stijn Vanheule, professor of clinical psychology and psychoanalysis, to challenge misconceptions about psychosis and explore paths to understanding and recovery. They discuss psychosis as more than a clinical label, delving into its connection to existential struggles and creative expression. Dr. Vanheule explains primary-process thinking, how traumatic events can disrupt the mind's coherence, and the importance of empathic listening in therapy. Drawing on examples like Carl Jung's Red Book and Annie Rogers' creative processes, the conversation highlights the therapeutic potential of integrating psychoanalysis, creativity, and supportive environments. Whether you're a mental health professional, caregiver, or curious listener, this episode provides insights into how psychotic experiences can be understood, respected, and addressed through innovative approaches. By listening to this episode, you can earn 1.25 Psychiatry CME Credits. Link to blog. Link to YouTube video.

All right, welcome to the podcast. I am joined with Stain Van Hulow. He is a PhD psychology, clinical psychology psychoanalyst at Ghent University in Belgium. He wrote a recent book called Why Psychosis is Not So Crazy. He has over 220 peer-reviewed papers and seven monographs and has studied this extensively. And welcome to the podcast. Hi, David. So I think it's always good to start out with kind of like, what is your elevator pitch for why you wrote this specific book and what the book hopes to communicate? Yeah. So this is a book in which I try to explain to a very broad audience, meaning both of professionals, but like nurses and social workers, but also like families, and people who have problems with psychosis

to bring them a message about psychosis, a message about what is a psychotic experience and why is it not a fatal experience? Because I experienced in my clinical practice and also when I talk to people, that many people have a very negative idea about psychosis. And I wanted to shake that idea a little bit by adding a more subjective perspective,

like what is happening to someone, and why is it not the end of the world when you start struggling with psychotic experiences? Yeah, that is great. I always want to increase empathy, especially for things that seem very scary. And I think what I've experienced is that a lot of therapists, specifically, and there will be a lot of therapists who are listening to us,

are still somewhat intimidated maybe, working with patients with schizophrenia and psychosis and at least if they're early career clinicians, they may be that way. So I think this will be helpful. And it's a lot more common in the general population than maybe we would think. Tell me how common is it and beyond schizophrenia and beyond that level of severity? Well, the good thing is that there has been quite some epidemiological research in the past decades, and they show kind of an interesting picture, which on the one hand indicates that psychosis-like experiences are quite common in the general population, and it is estimated that about 15% of all people, once or twice or sometimes in their

life, will have a psychosis-like experience, which means maybe like thinking, that they see a ghost or an identified flying object, something like that. But then it's just a moment that they think that and it goes away. So 15% of the people have this kind of experience in their lives. And then it's estimated that about 7% really has something like a psychosis symptom, like hearing of voice, for example. And then it's still a smaller group, of course,

like about 3% that actually needs clinical help for psychosis experiences. And this could be like help by a therapist, by a psychiatrist, yeah, because they need clinical support for it. So interesting about it, I thought, is what, well, look, it's a bit of a continuum. And some people end up in a real psychotic crisis in which their lives is turned down. but on the other hand you also have like this kind of experiences in normal people and so yeah yeah and so it's it's like there's a break in in reality and you talk about how often this occurs after something very stressful or a large amounts of stress and tell me about that

Well, okay, you have to know, of course, that this book, I'm a psychoanalyst, so I have this specific viewpoint and a specific approach in therapy, and both at the level of theory. And here I'm trained in the Lacanian psychotic tradition, so both at the level of death theory, but also when I observe in my clinical practice, is that many people start having psychotic experiences and moments of ruptures. in their lives, moments when they have to change identity roles. Like maybe it's because something good happens to you, because you have your degree in a college, or maybe you have a first child, or you start a relationship with someone. That can be a trigger for some people,

but also negative experiences, of course, like a breakup in a relationship or severe conflicts in your job, or retirement, which are all like life-changing experiences, are often like the trigger for people to be a bit destabilized in how they experiences themselves and the world. And it's specifically at that point that something of a psychosis-like experience or a full psychosis can occur. Okay.

Okay. And so historically, we sometimes could go back to Freud and how we talked about primary process thinking, secondary process thinking. Can you define those? Can you share with us like how you feel that relates to this? Yeah. So indeed, Freud in his theory, distinguished between two modes of thinking that we kind of use. And one is the one that we use in daily life. And he called it. secondary process mentation or secondary process thinking. And Freud describes like, this is what we do in everyday life when we approach the world in a narrative

way, when we think of how events are linked to one another and then we try to understand what happens and the world starts to be comprehensible. So we build lines of reasoning and then we can start

imagining like if I have words If I have scenarios, I can think about my past because I remember it in a certain way as a narrative. Like I can remember what I did yesterday as a little story, but I can also imagine what I will do this night. So I can anticipate with the story. And in Freud's line of reasoning, this is one way in which we organize reality. And this is dominant when we are awake. And then Freud distinguishes another way of thinking, which is far more associated. and he calls it primary process.

And proper to primary process mentation or primary process thinking is that it builds on trivial details like maybe similarities between sounds or colors or repetitions, repetitions of numbers, of letters. And this brings about far more out-of-the-box way of thinking.

And Freud's point is that when we sleep and we dream, this is the way of thinking, this more primitive primary process thinking, that's what then comes to the fore, and that's because when we sleep, our secondary process control, like, is also asleep, and therefore the primary process thinking is fully awake. And then his idea, which was taken up by other psychoanalysts, is that in psychotic symptoms, we actually see that this more primary process associative way of thinking dominates the moment people have psychotic experiences. So it's a different way of relating to the world with thoughts and language. Yeah, I was thinking about the neuroscience link to this

and in primary process thinking, you can have a hyperactivity of the limbic system, reduced activity of the prefrontal cortex, disrupted communication between the two, which is what happens in dreaming, and it's common in psychosis that that happens as well, right? Yeah, yeah. Have you thought about the neuroscience of this at all? And kind of, you know,

because I think a lot of people may hear, like Freud and primary process, secondary process, they may be like, oh, gosh, are we really talking about stuff that, you know, science has proved to not be true, right? Where it's like, actually there's some good neuroscience,

correlates to this that we could look at. Yeah, this surely is this neurobiological side to psychosis and also to the two ways of thinking. But I'm not a neuropsychologist, and I also thought that maybe it's interesting to write a book without delving into the biology of psychosis, because I think that this is often the dominant discourse about psychosis and it maybe leads a bit attention away from the fact that it's especially a human experience, a subjective experience, meaning it's something that happens in your mind, in your consciousness. And my main question was, what is it doing with people?

So I wanted to stay more closely like to the psychological experience without adding this more, you could say, academic perspective, traditional. academic perspective where we indeed look for more causal lines of reasoning or the ground of this line of reasoning in biology. And this is exactly what I try to avoid a little bit in that book. Interesting. Interesting. So, yeah, okay. I appreciate that. I think the brain is infinitely complex, you know, and do we think about 10, 6 to 10 billion neurons, some with 50,000 connections? We can, so sometimes neuroscience can almost like make something that's so complex, so simple. But I think about the interplay between creativity and psychosis as well, about how often there's a link between highly creative people and having some high openness people, super high openness people, and having some sort of psychotic associations or things that we might consider psychosis, right?

but I might consider it more normal. Have you thought about that link? Yeah, absolutely, because also from a psychedelic perspective, you could say that people who are very creative tend to make use during the day of that more associative way of thinking, which is a bit beyond the traditional lines of thinking that we share, that is the common way of thinking. So it's out-of-the-box thinking is typical also for creativity.

and I think also for psychosis, but the main difference is that when people are creative and then it's usually located in the context. It's limited in time and space. When someone is writing a book, well, then you sit down at your desk with your pen and your paper and then you start writing. But the moment you put your pen down, it stops.

Maybe you think a little bit about it later, on, but actually the creation itself stops. And of course, there in psychosis, we have this endless going on of that associative process, and that's often what people with psychotic vulnerabilities are struggling with, that it doesn't stop. And then maybe in the night they can't sleep because the process doesn't stop. The associations go on and go on and go on. And so therefore, you could say that psychosis is like an overdrive, like,

creativity in some way or another, an overdrive. Yeah, and just for clarification how you view this, where do you view the boundary between maybe dissociation and psychosis or extreme panic and psychosis? Well, clinically speaking, it's often not so easy to make that distinction. It's exactly a conceptual distinction that we make, But the thing is that in the context of a panic attack, this will be like very temporarily. Then you expect that maybe the moment someone is having that panic attack,

that then suddenly they start thinking about specific scenarios where something very bad can happen. And then it's in a state of panic that some associations are made. But you won't have that very deep effect where people start to question. reality itself, does reality exist? Do I exist? How is reality organized? It's more that they have something of a time-out experience like, because what is happening in their mind is so extreme

that suddenly they seem to be out of reality, but reality itself does not become like a strange thing to them. So that's for panic, I think, and then for dissociation, well, that's, I think, a very difficult dilemma because classically we have been dividing in the world of psychiatry and clinical psychology like psychotic experiences and dissociative experiences indicating that dissociation is an effect of trauma while psychosis is most probably something that has to do with the brain but this is already also a bit shaken up in literature because we now observe that trauma is very prevalent in people with psychotic

problems. So that's a bit of a difficulty. But then to answer your question about the phenomenological characteristics of psychotic experiences versus dissociative experiences, I think that in dissociation, you will have this sudden shifts in reality where people are in a certain identity role, and then at other moments in another identity role, and that often this rather be as witness to to something, what I would call from a psychedelic perspective, of a repression. Like, there's something overwhelming that they don't want to know about, and that at this point, people switch between different modes of experiencing reality and dissociation whilst in psychosis.

It's not so much the question of a conflict, but rather that reality is overwhelming and starts to be unthinkable in using confidence. common sense lines of reasoning. Okay. Because when I think about psychosis, I tend to think in categories of like, is this a personality disorder

that is leading to some quasi-psychotic episodes? Like Borderline Persia sort of can have these quasi-sacotic episodes, or is this more of a primary psychosis like schizophrenia? Those are the two large sort of groupings that I have when I'm sort of trying to delineate. a patient in front of me, what am I dealing with? The person with borderline

precise disorder, I would kind of consider more of a dissociative, psychotic phenomenon that is presenting. So, is that how you view it, or you view it very differently? I think it, I view it quite differently, yes. I rather focus on

the idea of the psychotic experience as such, assuming that it's it might be very extreme that psychotic experience. And then you maybe end up with what, from a DASM perspective, is called schizophrenia. But on the other hand, the psychotic experience can be mild.

And then it's maybe more related to what we call personality disorders or some of the personality disorders. But I rather see it as a continuum, not as like distinct categories, but rather as something of the severity of the impact of the psychotic experience. Right, right. So, I mean, I have a lot of patients who don't fit into either of those two categories,

and they'll have occasional psychotic episodes. One of the categories I'm seeing is people who use a lot of psychedelics, and it's like their brain has opened up to a more common psychotic-like symptom. Yeah. And I'm curious, it seems like, they're more in that primary process, especially during the psychedelics, but even afterwards, it can kind of linger, and it can be very destabilizing. Well, I think that's quite well known that these drugs are one of the triggers also of

psychotic experiences and maybe also of clinical psychotic episode. And yeah, I think that's absolutely the case. So sometimes that, okay, so we may be. be getting away from kind of like the what you want to talk about or what the the value of this it's it seems to me that the um what we're talking about is some stressor will hit and someone may have some elements of psychosis even if they're not meeting criteria of schizophrenia absolutely yeah and it's not like necessarily this is um depression with psychosis because sometimes I'll see psychosis and severely severely depressed people especially older older adults who have very

severe depression they can they can get psychotic but you're but what I what I think is that there's another sort of type of patient that you're seeing maybe that like has some psychotic events and especially like as they're maybe even doing the work of therapy they can have some psychotic offenses they become more associative or more regressive i don't know any are we uh am i missing your your point here or missing i'm trying to understand it from my perspective i guess yeah yeah well when i think about psychosis i also especially think about the people who not the ones who have psychosis-like experiences during therapy, but rather like indeed people who start with problems

of psychosis like schizophrenia-like problems or delusional problems or bipolar ways of functioning, where often something of that psychotic flare will be present in how they function. And I think that the focusing on the psychosis part of the experience is most interesting. And especially since I also observe that many therapists don't work with it or are afraid of addressing this kind of experience. Whilst I think that often the psychotic experience is saying a lot of what, the person is especially struggling with.

And the problem that many people who have psychotic experience have is that when they talk about it with their relatives, maybe, or friends, that it leads to misunderstanding because it creates a barrier when you talk about things that in the mind of the other cannot happen, but you do have this experience. This leads to a barrier. And so therefore, especially when they... start consulting a therapist, a psychologist, a psychiatrist. It's very important, I think, that we as professionals are available to kind of work with it.

And so therefore, we need something of an understanding of the subjective experience of this psychotic way of functioning. So I think for me, it's broad. Psychotic experiences can occur in many clinical categories, like also in people with addiction, in severe depression, in bipolar problems, but also in schizophrenia and delusional disorder. So I think of it as a broader category like, yeah. Okay, so there's like a curiosity of an openness, a calmness that you bring to this. And I think that that is so much better than if we have fear,

if we have worry, if we're scared of the other. How has that shifted in your sort of over the sense of your career, over the course of your career? Like have you become more patient, more calm with these types of patients? Or has there been a shift in that? Well, I do believe that I started to be more open and that I do try and fall more to be present for people and to stay in touch with them and to try to connect.

and in the book also I described this very early experience in my clinical work that maybe we can talk about with one of my early patients which helped me to kind of shift like okay but you have to be open you have to be present for that person otherwise it will not work yeah tell me the story of this patient okay so but that's the patient it's Mario I described him in the book and with the The young man with Down syndrome, right? Yeah. Okay. So he was like, it was indeed a young man, 18 years old, Down syndrome.

And he lived up, locked up in the house of his parents, locked up in meaning that he refused to leave his bedroom. And he stayed there all day, talking in himself, addressing someone and having like these kind of confused dialogues. and so I did outreaching work for an outreaching service for people with intellectual disability as well as psychiatric problems and so I started to treat him

and also have counseling sessions with his parents and what I observed in my work with Mario is that first of all it was indeed difficult to have contact with him both because of the fact that he had Down syndrome and didn't have a very rich vocabulary, but especially also because as soon as I started talking to him, he started hallucinating and he started talking to the voice

that was addressing him. So sometimes he was saying something to me then. He was like of listening and his eyes looking into nowhere. And then he was responding to the voice and then again to me. So it was very difficult to be in touch with him. And then I also observed later on that I did very well, I did everything I could to be like a good psychologist. I tried to be an expert psychologist and to kind of very knowledgeable about psychosis at that time. And I observed that actually I didn't, I did only really got in touch with him because of a little accident that happened.

And the little accident was that one day I arrived at the house of his parents with my car and it was raining and I stepped out of my car and I wanted to run to the front door. But I slipped and I felt on the ground. And Mario had been observing it from that bedroom and then suddenly he ran down from that bedroom and shouted like staying fallen. You got him out of his room, huh? Yeah, yeah. But it was not because of my knowledge, but because of my stupidity. And that led to a connection. And he had fun.

He made fun of me as the one who had been falling down. And then he also went to the bathroom, and he came down with a handkerchief for me. And this was very functional way of relating to the world, which was exactly the thing that he didn't do anymore up until then. for many months. So there I observed like, okay, but to be connected with someone

means that you have to be at the same level and it's not with impressing an individual who has psychotic experiences, for example, with your knowledge, which I try to do, I think as a junior psychologist at that point, that I wanted to be smart in relation to my clients.

But then I observed, no, no, I have to be available to them. And that's what I think, this is exactly what we need. And I do observe that in mental health care, we have a serious problem at that level because what we see is lots of escalation in relation to psychotic patients.

Yeah. Also in mental health care. And so this is the point that, well, I thought like, okay, but it's in trying to be connected to someone that the true value of therapeutic work, where it starts. Hmm.

Yeah. So it's like the, especially with this type of patient, maybe that more hierarchical, paternalistic approach would never work, right? It's like, yeah, I've kind of thought about this as like sometimes I find myself naturally taking a more like friend-like experience with someone who's very psychotic of like, there's a collaborating, more of a collaborating take, right? And I think you falling down and him, coming to help you, right?

Here's him having a role in this relationship, which you guys had built over months, it seems like he's probably really appreciated that you were attempting to listen to him and attempting to connect with him, right? Like, that was valuable for him. But suddenly we had a joint reality to be concerned about. Yeah. And this was something new, that there was a common ground, and the common ground was what accidentally happened with me.

But this was very important that it was not him having this strange experience and me being the normal caregiver who was there to help him. But then I was suddenly in a different role and he could step out of his illness role, so to speak. And then we could connect around that very event of me falling down. and that started off with creating something of a common ground. And that's very important when you want to work with someone who has psychotic experiences to find something of a common ground where we can talk, maybe also about the psychotic experiences in the next step, but maybe to first of all find something of that common thing.

Do you think it helped him long term? Did it change how he related to you after that incident? or did he improve his psychotic symptoms? Well, the psychotic symptoms indeed improved over time, but it especially created an openness, whilst before he had problems in saying to me what the voice that he was hearing was telling him, he started to be more open about it,

and he said what the voice said, and then he started laughing about it. And it was like, he was always like, he was also laughing with me. I was, and returning to me falling down, often when I came to him, and when he saw me,

he said, oh, Stan, you've fallen down. And then he started laughing with it. It was a little joke. And then the same joking nature returned when he started talking about what the voice was saying to him. And what was the voice saying to him?

For example, like feeling the breasts, touching the breasts. This was something that he was hearing. And then he said it to me, and then he started laughing because this was the thing that he was hearing. And I think that, especially for him also, there was a huge taboo before that. He would never say it to me or to his parents.

This was the thing that he was hearing. And maybe it's because of the connectedness that was created in the first step that this openness actually occurred. Yeah, I think that's really important. I think it's been there's been a couple of patients where it's like you don't really get the full story of the psychosis until years of connectedness, you know? Yeah. It's one patient I had felt like he was in the Truman show, right?

So like everyone was watching him, cameras were on him, and it wasn't until maybe a year of olanzapine. And, you know, a lot of relationships. space before he started telling me that this was like what he had been experiencing for so long. Yeah. How would you interact with someone who felt like they were in like a Truman show, like they felt like the whole world was built to watch him, basically? Well, of course we must know that many people, many psychotic patients have this experience. So many of them refer to the film, the Truman Show.

and this as such is already very interesting and I would also like immediately think about the parallel between that movie and some philosophical reflections that we have had in Western philosophy like Descartes he also wondered whether there was a god that was deceiving us and that maybe reality is just a big game where we are and it's God deceiving us. So that's a philosophical thought within our tradition.

And then, of course, when someone at a very subjective level starts feeling this, for me it's not just craziness or, but also like, okay, but this is something of human reflection that there occurs in a very extreme form. So I do find it also interesting, the fact that a human being can have this kind of imagination. So out of that curiosity of what someone is living through, I would listen to him in the first instance and ask him like, okay, but tell me what is happening. And how is it for you? How do you think it is organized? Explain me. It's not something that I think or I believe. But I do hear that you say that for you, this is the case. So explain it to me so that I maybe can understand a bit what

what it is that you are observing or that you're living through. So I would invite him to say more about it. Also, out of the idea that it's a very specific way of thinking that human beings can have, and that can, of course, go in the direction of starting to be very painful for them. But I would try to create that common ground in the listening as such to the story. And then, of course, we will hear something of what it does with people.

So some people might, will be very suspicious because of that. And they will tell us that they are very suspicious because they are deceived all the time. And then I think it could be a good idea to echo something of it that indeed, that I hear, that he's suspicious. And that I can imagine that if you think that reality is, organized like that, that you start to be suspicious, that's not surprising maybe. So I would express something

of how I'm a bit in touch with that experience without confirming that he's right in his experience or that he's wrong in that experience, but rather to take it really as a subjective experience

of an individual in relation to reality. Yeah. It sounds like, it sounds like how I think about we you know if this is like new for people to kind of consider it this way this is how you would do good dream analysis too right it's like you you're curious about it you see where their associations come from what emotions are there yeah but the difference would be for me with dream analysis the way I do it in psychoanalysis as well that in dream analysis I would focus more specifically as an analyst to specific topics in the dream.

And I'll invite the patient to say more about something very specific. So if someone would have had like a Truman show like Dream and he says that he was sitting in a boat and he was sailing like it is the case of a human show in the movie. And that's specifically in the dream. I would maybe invite my patient to say a bit more about the boat. what does it make you think of the fact that you're in a boat in the dream? And I wouldn't do that in the context of a psychotic experience. I would then go for the holistic approach of the story and not so much the analytical details of it, which I would do in the context of dream analysis.

But what is similar, of course, is that I would take the subjective experience as a subjective experience, like very seriously and and invite people to to talk about it and to devote time to talking about it. Okay. Very good. Yeah. Let's talk about Young. That's probably the most, it's a fascinating kind of thing to talk about his psychosis, talk about the break with Freud, how you think that that related to it.

So do you want to share with my audience kind of like how you think, the break and his stress from that led to some of his psychotic writing that were detailed in the Red Book. Yeah, yeah, yeah. So the thing is that with Jung, I'm not a Jung specialist for, I must say it, I'm a psychoanalyst,

but I'm not a Jung specialist. But at a certain point, I got very intrigued by Jung, the man. Because Jung has, produced a very curious set of books. And the first one of that curious book that was published was the so-called red book. And the red book is a very big leather volume where Jung had been writing in Gothic letters and he added like small paintings and mandalas to it. And it looks like a medieval manuscript. And for Jung, that manuscript is something of a good.

big revelation. It's not something that he has consciously taught out and then written down, but there is something of an inner truth that has been revealed to him, and he has written it down. And then I started searching about the book, and it all indeed starts with

the relationship between Jung and Freud. Jung was, like, for Freud, a very promising colleague to work with. He was a bit younger than Freud, and he was not a Jew, and he was a psychiatrist. And that was interesting for Freud because he as a Jew

was excluded from academic positions in Austria. And also he was not a psychiatrist. He had a neurological training and Freud believed that Jung was like the one who could follow him up in psychoanalysis and they had a very intense exchange of ideas.

But then, of course, Jung had his very own ideas on certain topics. And then there was a break between Freud and Jung, and it's especially at the moment of that break between both, that Jung actually started having psychotic experiences, like he started hearing voices that told him like vague things, and in the end, he said he decided to start listening to what he was experiencing and assuming that something was being told to him,

and that then became, he first wrote it down in little black books, And then he brought it together in that red book, of which he also says that the crucial ideas of his later theory are all in that red book. So not so much as a product of rational reflection, but rather of creative revelations that he has had. Yeah, so interesting. So it was like the break, the final break with Freud occurred around age 38, his red book coming up. age 38, age 39. You know, in like one vision, he sees Europe flooded with blood. Yeah.

Often an image associated with the coming of World War I. Do you think there's any beyond sort of like, how do you make sense of like the people who might see links to like, oh, okay, he's seeing things in the future, you know, prophecy, you know, kind of like this like, beyond just a psychotic event, right? Yeah, yeah. Well, personally, I'm rather, I think, a very rational person in that perspective,

and I wouldn't see it as prophecy. I don't think that Jung was a seer, so to speak, who could foresee specific events, but at the same time, I do think that he was probably a very clever man and that he was maybe linking already things that had to do with politics in Europe together with also conflicts with Freud and that something of that dramatic thing provoked this vision that indeed he once had in the train.

But as I noted in the book that I wrote, it's kind of interesting to see that the blood is flooding just onto the Alps where Freud was living. Yeah, you pointed that out. I found that really curious. Yeah. So I think it's not. unrelated to his conflict with Freud because when you see the the logic of events there is first

this rupture with Freud and then he starts having the psychotic experiences and then of course these psychotic experiences they say something but I wouldn't read them as prophecy about the future it's maybe a way of guessing about the future but what about what about like a deep knowing it It seems like from a lot of his psychotic things, there was a sense of like a lot of his future ideas came, like a deeper sense of knowing, the archetypes, stuff that we'd appreciate, like, oh, there's some real beauty in that.

Like, how does his creativity in the midst of his psychosis lead to ideas and how do you see that that is productive? Because not all people who have psychotic symptoms, it doesn't always lead to something productive, you know, in the future. No, but there is a surprising big portion of people who have been very creative in their work. Oh, 100%. But also a couple of people in the arts who started off from psychotic experiences. So in my view, the psychotic experience is already a way of thinking.

And I, um, some people, managed to kind of do something with it, with the fact that there is a thought, it's a way of thinking, it's a primary process thinking around specific events that occurs in the psychotic experience. And I do think that people can, that you can learn something from it, that maybe tell something about you in your context, and that you can learn something about it, that is not crazy, that is not just very idiosyncratic, but, that it's not just very idiosyncratic, but maybe relevant to other people. Like in Jung's case, he took it very seriously.

He studied the content of what was revealed to him in the psychotic experience. And of course, Jung was a human being. So it's not surprising that something of the conflicts that are typical for human beings occurred there in that experience. And so he took it seriously. But maybe because he was also already like a psychiatrist, and a psychoanalyst, and he was aware of the fact that psychotic experiences might communicate something, because before he had the experiences, he already wrote about it, that we should

listen to the content of what psychotic patients say. So he applied it to himself, and then kind of saw probably that it articulated something about typical human struggle, and I think this is what he took from it and then in his very own language which is a specific Jungian language like about

the archetypes but he's saying something about what human beings are struggling with that's how I see it okay appreciate your your thoughts so I'm reading that Jung's relationship

with this one patient Soprene, maybe I'm pronouncing it wrong, where there was some professional boundaries potentially crossed led to part of the rupture with Freud. Freud was seemingly critical of this relationship. So it seems like there's quite a bit of stresses going on in Young's life, right? So how do you see that in the timeline? Is that part of it? I think some of his visions started earlier, like for you know around 34 he was having some marvelous visions that he was reporting to Freud and letters so was there it seems like in your book you you say the psychosis started after the rupture was was it was it more pronounced after the rupture or how would you sort of or did

you have more freedom to express it after the rupture or you know was it happening in the midst of the sort of the conflict what's your thought of that yeah yeah Well, I think that the rupture with Freud brought more the distressing aspect of this kind of experience to the fore. So that's more closely connected to how we as professionals usually encounter psychotic experiences, like disruptive elements that suddenly pop up in people's minds. But of course, like, there are traces in Jung also when he describes his childhood, that he had a very wild imagination and meaning. like a very wild primary process thinking that he tended to apply to the world.

And maybe I can think that maybe this was also annoying Freud. Because Freud to be very like, although he was speculative in many domains, he wanted to have a very logical theory because he wanted that it should be able to test the theory. He wanted to discuss with scientists and not with people who tended to go in the direction of spirituality and religion. That was not the way Freud wanted to go, but you see that Jung is more in that direction, of course. Okay.

Yeah. So from your read on this, he was having more access to that primary mode of thinking because of the stress of the rupture in the relationship. and that was like sort of magnifying things. So if you were his patient, or if he was your patient, how would you explore that with him? Wow, that's a difficult question. Like let's say he's bringing to you, these visions,

he's bringing to you these stories. What do you do with that? Yeah. I would first of all invite him to say more about it. And to contextualize it, like, what is it that you've written down? What is it that you've been drawing? And what is the content of it, on the one hand, but also like to situate it in time and space, like, when did you make it?

And at which, how can you be situated in a chain of events? What has happened last night or last week that now you have been making specifically this? What is it telling about the past week or maybe about the past weeks and what has happened? Is it responding to something? So I would try to contextualize it and invite him to say more about it because my hypothesis would be that it is indeed like it's an answer to something. It's an attempt to solve something of a problem and therefore he has been creating it. And I would try if it was a patient to bring it into the trans-franche relationship, into the therapeutic space, and to see how maybe the conversations with him

provide some ground to kind of contain the experience that maybe what is starting with the writing down of the experience with Gothic letters and paintings that it's not taking over his entire life, that maybe it can stay limited because maybe the problem that he's responding to is something that because we talk about it and we discuss it, maybe we can also produce ideas that help him to deal with that problem that he's been confronted with.

Because for me, the creative writing would already be an answer to something of a problem and therapy can also provide something of an answer to the problem a person has been confronted with. So I would, that's, I think, how I would try to work with him. Okay. And so what was the first question that you had there? Okay, so if I was, if I was young and I heard you asking me in that, I would be like, you know, I feel like you're critical of my, my, these, you know, these visions.

I feel like in just the way that you're asking that, there's a sense of critique. Like you're trying to show me that this is not real. Yeah. And then I would say that, that I'm not saying it's not real, but rather that it's not everybody has these experiences. Can we, can we try a roleplay here? And I'll be young and pretend I'm young.

I just say to you or this, okay? Like the way that you, you know, the way that you say that staying is, I feel like you're saying this is, you're, you continually are trying to look for some sort of like analytical reason behind this. And I feel

like there's a form of critique in that. Yeah. Well, my answer would then be that I'm curious about the experience because When you say about it, when I look to everybody who's coming here, it's not that it's so common that people have this thing, that people have this religious revelations. And so for me, it's something new.

It's something a bit surprising to hear it from someone. But at the same time, I'm curious about it. And I'm not saying it's nonsense, but rather like, okay, but why is it you that is having? it, that experience, and well, something along these lines, I would try to engage with him. Okay, we got to get you more into this like roleplay here, okay? And there's no right answer, right? See, I'll pause for the roleplay, and I'm actually leading with some transference, right? Because I'm thinking that there would be some Freud transference because of the disruptiveness of

the relationship, right? So I would be transferring as Young that you are like Freud and critical of him because there were some letters that kind of like, you know, you feel like Freud is like the super ego of Young in these letters the way that Young is responding to it. So in one letter I read, it was like Young was like, I know that you're not going to be happy with this. you know it's like so it's like Freud is like the super ego structure of uh in in the midst of his like sort of internal thinking right so I was I was thinking I would lead with some of that transference towards you and be like you know as you as you are yeah talking to me about this I feel like you're critical of me yeah but I think there the difference would be that when Freud was working with you Freud did have an agenda oh 100%

Yeah, and as a therapist, of course, like, I wouldn't want him to be rational per se. That's his own choice. And I would rather, like, associatively think when someone would come with something like a medieval manuscript to the fact that indeed, there are lots of medieval manuscripts in the world. There are many libraries with this kind of manuscripts. And there's lots of religious manuscripts that are kind of interesting, both in the sense of the stories that they are recounting, but also in terms of the aesthetics of how it has been made,

and that this is interesting because in a consumption culture like today, we don't make this anymore. So if someone takes the effort to do something along these lines, I think it's a bit surprising, but at the same time, I'm curious about it. So that would be the attitude along which I would listen to to you when you with your new manuscript come to me. Okay. That's good.

Well, we don't have to continue this. Maybe the audience will be like, hey, we want a full role play, like step by step, you know. I was actually thinking it would be fun to write a book where it's kind of like a more of an artistic, You know, like if Jung was in therapy, right? Yeah.

And he would bring out some of the letters from Freud and be like, this is what he wrote. Do you see how critical he is of me? Like, I'm trying to be open and explore. And all he wants to talk about is this libidinal theory of early sexual development, where I think there's so much more beautiful. Like we need to invite more archaeologists into our endeavor to understand human nature. We need to look at icons of the past. Well, it could be a great novel, a great novel indeed to kind of address how a therapist

could work with someone who has this psychotic-like experiences or psychotic experiences. What would you have said to Young if you would have said that, just what I said right there? Well, I would say that maybe Freud did have his own agenda. Freud was probably not a neutral listener. He wanted to promote his theory. He had his own stakes. He had his own specific things that he wanted to realize and that maybe Jung was looking for more for someone who was closer to his hypothesis

and to his dogmatic starting points. And that maybe there was a problem for Freud to be open to what Jung was expressing and that maybe that's what he felt in relation to Freud. So maybe it's like in the throwing off of that dogmatism, that structure, right? It's almost like his brain kind of like had too much freedom to explore for, you know,

and the psychosis kind of picked up quite a bit in the midst of that. And also the pain of the separation in the pain of the disconnection. But probably what you hear that I would try to do is, like, recognize you. Recognize him as someone who is doing something, who is thinking, who is trying to produce something, who is trying to do something creative to make an own point. That would be my starting point.

And I think that if I would try to do it like that, that maybe. be in the young patient, something of an openness could occur. Like, we should especially avoid that he feels judged by me as a therapist. Right. Okay. It's not that he would have to think that I'm a believer. Maybe he would feel that I'm a bit critical about when he says something of the spiritual revelations, that it could be that he, it could be that he, feel that I'm not like fully at the same line but I'm not judging it and I think that that's

very crucial yeah yeah okay and we can we can move on to kind of like other other points that you that you've made and reflections you've had are there other cases famous cases of psychosis that you've kind of thought through and thought about how they might relate to this kind of holistic view of how to approach psychosis? Well, in the book, there's a couple of people who are a bit or quite famous whose work I'm discussing, like there is Annie Rogers, a professor of psychology, who has had psychotic experiences. There is Yaiou Yusama, the artist who started painting, starting from hallucination, already as a young child and who, well, makes art installations with the hallucinatory experience.

There is, of course, Ellen Sachs who wrote a memoir about her own psychotic experiences. So I try to go rather broad in the field of, well, within our culture, who are people who have been talking quite openly about psychotic experiences that they have had, and who also have this, who have been exploring this twist that psychosis is not, or the psychotic crisis is not the end of a life, but maybe like the start for something new. And that can also be functional in how you afterwards relate to the world. Yeah, I met Evelyn Sachs, I hope I'm saying that right. She gave a lecture when I was at the New Center for Psychoanalysis.

Yeah. And I read her book and it was impactful decades ago. Anything about her story in particular that spoke to you or that was interesting to you? Well, I would also recommend it to everybody who has not read a memoir to read. because it shows so beautifully that although she has this problem that has been diagnosed as schizophrenia, and I think that clinically speaking, the diagnosis is correct. But at the same time, she shows that what she was experiencing is indeed kind of always linked to specific triggers in her life. Like it's when she has her degree or a first sexual encounter with a boyfriend. It's often at these

moments that she starts having the psychotic experiences. And when we only look at the psychotic experience, it's only the strangeness that stands to the form. But in her memoir, she makes clear because it's the accounts of the, when she talks about psychotic experience, it's embedded within events in life. And that's how that memoir is so beautiful in how you see that the rupture occurs as an answer to something.

so therefore I thought that was very useful and also the difference in how different clinicians have been reacting to these psychotic crisis of Ellen Sachs so where she has both had this very brutal encounters in in some psychiatric hospitals

but at the same time has also had like very good clinicians both like biological psychiatrist and at a certain point like a clientian analyst who was working with her and trying to delve into the psychotic experience. Yeah, I was amazed by how profound that work was and how stressing it must have been also for the therapist to work with her. But it's such a beautiful story of how something is possible if we try to be there for the psychotic patient and don't immediately think only about the strangeness of the experience.

I think of the book, one of the most stark examples of poor mental health care that she received was being kind of like in this psychiatric hospital in restraints for a very long period of time and how traumatic that was to her and how difficult it was for her to move past that into a place of acceptance of like, I do have psychosis. Yeah. That was one of the things that really stuck out with me. I was reading it just kind of like how horrific that seemed. And I've seen this with a number of patients who are describing their psychiatric

hospital visit. It just kind of like becomes a new trauma of sorts, you know? Even if it's like maybe the professionals were well-meaning, you know, as well-meaning as they could have been given this situation, it seems awful. And I've actually, there was one patient I had who was homeless and his mom would bring him to me and we would give him injections. And he thought I was, he hated it. He thought I was part of the CIA's sort of operation to harm him. And once he got maybe a year into being on good doses of an antipsychotic he was back in school doing well straight days and um he was um writing books for his class on the psychiatrists linked up with the CIA against the person you know

type of thing but like you know in a very sort of um thoughtful way not necessarily like psychotic way and we were able to put words to what happened between us and how hard it was. But I wonder, like, Evelyn Saksino was on, I think, chlozapine and zyprexia, she mentioned in a TED Talk. Do you having this approach with more of the therapy, do you see it as the thing that should be only used, or are you also open to, you know, patients being on antipsychotics, Clozapine?

Like, do you think therapy is enough? no no of course not i think it's in in most cases it's a combination of both that is that is useful um like both the medications and therapy i think it's in the combination and i'm not a psychiatrist so i'm not allowed to prescribe medication um but i'm not i'm not struggling against i'm not fighting against medication, but I do share some concerns about medication. So I do think there is a tendency to over-medicate people with psychotic problems. And once they are on one antipsychotic, and maybe it doesn't work the way we want, and in the end they take several ones. So that's why I often observe in patients here in Belgium that many of them take like four or five,

different psychophomological products in the end. And there I would be a bit concerned. Oh, absolutely. And so therefore, I think if we use pharmaceuticals, we should use it in a very rational way, and in minimal doses, as minimal as possible. But sometimes it's very good that someone has this medication, of course. And I would never advise to stop people,

just like that, I would also say to people, you have to discuss it with your psychiatrist and if you want to stop, you should do it very slowly and really in a very considerate way

with guidance from a psychiatrist. But I also believe that therapy is not working for everybody with psychotic problems. Some people will get more psychotic because of having psychotherapy. So I think we should be,

very smart in when we observe that it is destabilizing people, that it's better not to continue with it. But the same is true for medication. So there is no one cure for psychosis and often it's in the combination of

both social support, psychosocial support, and good health care, physical health, pharmacological care and psychotherapy. If we can combine these things together I think that's a better way of thinking about a strategy to approach psychosis. And if we can leave one of these away and the person is still functioning well, of course,

we can drop it. And maybe you can drop the psychotherapy or maybe we can drop the medication. I don't know. We will have to see patient per patient what is working. So have a very functional way of thinking about it. And I think the reason why I think in categories, like I said, like borderline per se, disorder can have quasi-psychotic episodes. They often have a history of self-harm.

They often have a history of passive suicidality. They often have a history of, you know, deep interpersonal conflicts leading to ruptures, leading to high stress, leading to self-harm. These patients, new standards are to not leave them on antipsychotics forever. And I see that this is what clinicians have been doing. I came out with an episode recently that talked about this. So actually new recommendations from a lot of organizations are like, a week of antipsychotics, but don't leave them on it forever. And so in my partial program,

when these patients get hospitalized, then they come into my partial program, I'll take them off of Risperol pretty quickly. If they fit that category of borderline precise, or if they fit the category of like schizophrenia, you know, delusions, auditory hallucinations, being the predominant symptoms, right? And the, you know, usually starts 20s, late 20s, and usually it leads to them being very isolated, you know, at home, in their bedroom, homeless for years before they actually get good treatment, right? So this is like schizophrenia, and they're not showering, they're not taking care of themselves. These patients, I believe, are probably going to need to be on some dose of antipsychotic. Now, if the first medication

like Risperidol, Sparidone, olanzapine doesn't work, you know, then, then, you know, then, you then my sort of way that I've talked about on the podcast is get blood levels, make sure the blood level is optimized. There's numbers that we use to kind of see if it's optimized. Before we switch, if it's not working, the chance that a second one is going to work is like pretty low. And so I've done a lot of episodes on clozapine for treatment resistance schizophrenia. I think it's very important to kind of delineate schizophrenia from the personality disorders and then further delineate something like a bipolar because bipolar people when they get ramped up they can get psychotic they don't need to be on antipsychotics forever lithium is probably the best choice

if that one works for long term and so i'll have people on lithium and then if they're getting more manic they'll be on i'll put them on you know an antipsychotic on top of that for a couple weeks to bring them down and i'll bring them down off off that antipsychotic as soon as i can but i think what you're seeing and what I'm, I am as critical as, as you are, is they'll get put on one anti-sacotic. Now, Closopin is, it's hard to monitor, so we don't want to, a lot of people are afraid of putting them on it. They don't want to have, you know, I have, I have clenches. I had just one clinched in the other day saying, if I could never prescribe clozapine again, I would. Just because you have to check the blood levels and, or the, you know, the complete

blood panel to see if they're white blood, what their white blood cells, what their neutrophils are doing. So a lot of people don't want to do that. So what people do in practice is they stick on a second antipsychotic, which is really just sedating.

And the other thing I noticed, which I'm very critical of, is they get put on multiple anticholinergic medications, which lead to like a decrease in their brain function, Sensorian makes it very hard to do therapy. Yeah.

And so I've done episodes as well on like anticholinergic burden and the necessity to decrease the anticholinergic burden so they can do psychotherapy. Yeah. And so it's a, that's a general summary of my perspective. Yeah, yeah, yeah. But I can really follow you with that very like logical way of thinking about using these medications, and that's exactly the kind of psychiatrists that I would like to collaborate with. And of course, I can follow that from your perspective, you would want to make distinctions

between the categories much more than I would do as a psychotherapist, because for me, it's often not so different the way I would speak to someone who's suffering from a bipolar problem with psychotic experiences connected to it compared to someone who more fits. a schizophrenic profile. For me, it doesn't make such a difference. I rather see there, I would focus always on the individual and the question, of course, of psychotic experiences and the impact of psychotic experiences.

So for me, as a psychotherapist, as a psychoanalyst, it doesn't, that's not the clue of how I think about the problem, but I do believe that, of course, if you approach it from a different way of thinking, biological model, some categorical distinctions are more relevant and very open to combining both ways of thinking about same person. I think, I don't know if I would purely say mine as a biological, because I think I am leaning more towards this approach of being patient with someone who's outright refusing

medication. And there's a couple patients on my panel that have anisinomia. So they do not believe that they are psychotic. Yeah. And they've created a lot of frustration for

a lot of providers because they don't believe that they need to be on medication. They refuse it. And they may be not sick enough to be hospitalized. So they're kind of in this in-between place. And so I've tried to build connection over time

and then get to a place where maybe they are open to it, but this is very difficult work. Especially if they're not showering, not taking care of themselves at home for a number of years. This is probably the biggest pain point I would see if people are trying to help this kind of unique population that just are not getting better. stuck. Do you have any insight on this group, what you would say to a provider is trying to help

this type of person? Well, I would always try to look for the common ground. What could be a common ground that creates something of a connection between a therapist, the clinician, and the person, because it's only if there is something of a common ground that may be an openness for, further interaction and maybe discussing, like, for example, the possibility of medications. It's only because of that, that it will happen. And yesterday I was talking with a psychologist working in a prison, and they were talking also about a psychotic man in prison, and he's connecting with no one. but they were describing

that there was one thing that he has an interest in and that's in getting crisps getting crisps yeah well chips chips chips yeah to just little things to eat but they should give it in the back

to him because he's very suspicious and so if chips are being offered to him then he's willing to interact with with people and so maybe if it's a interested in chips, then maybe you can start talking about that. Does you want salted chips or paprika or different taste? And so to really start like maybe around very simple things, if there is something of a common dialogue possible, to try to build some trust in relation to him.

And of course, I'm not sure whether that will work in the longer term, whether that will lead to something of a trust in an interpretive relationship. But I, I think it's the only point we can start from as a therapist to try to look for what could it be. There's a little thing where we don't have to discuss about that the patient does not need to be suspicious that I might be doing something to him when I do this very thing. And often it's very difficult to find it and a very minimal element. But it could be like maybe there's a joint interest in a specific dog band because he's wearing a t-shirt with Nirvana. and maybe we can ask if he's a fan of Nirvana because I also know some of the songs of Nirvana

and maybe that could be a connection with someone. Right. And I think... I think that can be somewhat counterintuitive to some providers who are like, well, if all he wants to talk about is conspiracy theories, should I engage him in that? I have this one client. He spends all day online reading conspiracy theories.

That's all he thinks about. And conspiracy theories, you know, not like, you know, there's some things that are like, okay, the CIA finally released these files. Like, that's not the stuff that I'm talking about. It's the stuff of like, it's the level of absurdity is much higher, right? Yeah. But for me, just engaging him in that and allowing him to talk about what he, you know, some of it doesn't quite make sense. Like he thinks he thinks he's a genius in it, you know, but it's like it does, it may not make as much sense as he. talks about, right? But yeah, it's like looking for that one thing

that he's curious about and allowing him or her space to kind of like talk about it, connect through that, right? I love that. That's a good point. And also, if someone only wants to talk about conspiracy theories, the question of course is

like, what is it metaphorically saying about his life? What is the sense of, concern and if he thinks he's a genius in some respects, well, what is it saying about him, about what he needs, what he wants, what is he missing in his life, what has been missing in relation to his friends and his family and his job, if he has a job, that brings him to having this conspiracy theory as something of a solution, because for me it would be an attempt to solve something, something that is far more problematic for him. than spending all day with these conspiracy theories.

So I would always, in the back of my mind, wonder, yeah, but what is he trying to treat which subjective problem? Is he trying to treat with that conspiracy theory? And to maybe open to when it's about threats, when he feels threatened by something, to kind of stress, of course, like being threatened is for people in a very difficult situation. everybody would respond with anger or anxiety to being threatened.

And this could be something of a common thing that we could draw from a conspiracy theory, not the content of the conspiracy theory, but if you feel threatened as a human being by someone else who is wanting to harm you, that's, of course, very damaging and very, and there is something maybe of a common ground that can be found. For example, in terms of the emotional response that we see, in the patient and that we might make sense of in a certain way. Yeah. Yeah, very good.

Okay, so I think some of the things I'm pulling away are to look for the meanings, exploring the paradoxes, to put words to things, to bring a calm presence, to remain engaged and receptive without being overwhelmed by the can. or the fear that the psychosis can induce to have patience with the process. Kind of as we wrap up our time together, are there any other sort of final pearls or final things you'd like to share as we seek to help these people? Well, maybe two things. the connectedness is

but you summarized that but I believe that looking for something of a connectedness is crucial and then also looking and checking with people how something of their concerns can be translated in

different activities so I do believe for example that artistic expression is often a good idea because artistic expression appeals to creativity appeals to something of the primary process thinking, but also is something that creates a social bond.

So I observed that, for example, that people with severe psychiatric problems, like for example, maybe they are interested in playing music in making up a rock band, and if you can play music in a rock band, and you can perform with your rock band, the music, then you are being,

appreciated maybe by an audience and for many people who are living in a very isolated state because they are so deeply into their psychotic experiences this way of appreciation again creates a connection that maybe also leads to discussions with people about the music because maybe someone says wow your cover of let's say nirvana that was very very good one your guitar sounded like very crazy and and then maybe they you can talk about that. And so something of the creativity is for me an underestimated thing. And I think that's supporting people in it.

But of course, the creativity in the field that they are interested in maybe someone is interested in gardening and someone else in rock music or in painting or in poetry. But to be very open in which domains of human creating that people are open to that connect to their talents and passions that this is also something to put to the fore and also as clinicians or me as a therapist I would always be very attentive to

what are people capable of in terms of what might create a link with other people and also be an outlet of something of the thing that they have in them and that they do want to express like something of the psychotic experience

so supporting that is also very important and also a topic of course that I discuss in the book. Great, fantastic. I love it. Thank you so much. I appreciate your time. Appreciate your willingness to come share with us here. Thank you, David. Yeah. These were great questions and your invitation for the role thing with Jung. Yeah. Yeah. Yeah. That's good. It's fun. Well, we will leave it there. for today. Thank you for your time. And I would love, at some point, I would love to come to Belgium. It would be beautiful to visit. Yeah, you're welcome. It's on my bucket list.