A counselor’s approach to clients experiencing psychosis.
Psychosis is complex. A patient experiencing psychosis could overwhelm a counselor who is beginning their journey in the helping profession or even those who have hundreds of hours of practice. It is not only a counselor’s competence that matters but his/her temperament. Nancy McWilliams, in her book, Psychoanalytic Diagnosis, warns that this work demands emotional resilience, as patients’ intense projections can evoke countertransference. Counselors who struggle with the extremely slow pace of progress may not be suited for this population. It cannot be stressed enough that if a counselor should feel that they are not ready to take on such a client, he should refer them to more experienced clinicians or multidisciplinary teams, such as psychiatrists for medication management or inpatient care for acute episodes. Self-awareness ensures that counselors prioritize patient welfare.
1. If you cannot help the patient, do no harm. Consequently,
2. Use physical force only to prevent a patient from harming him or herself or someone else, never as punishment, or “negative reinforcement.”
3. Never humiliate your patient.
4. Get as accurate a case history as possible. Don’t limit yourself to a few minutes or even a few sessions.
5. Encourage work and social relations.
6. Most centrally, do your best to understand your patient as an individual human being.
Psychosis can have diverse origins. Genetic predispositions may increase vulnerability when combined with environmental stressors. Childhood trauma could disrupt psychological development, leading to psychotic symptoms as a defense mechanism. Abrupt cessation of the use of substances like cannabis, which modulates dopamine, may trigger psychosis in certain individuals. Other causes include neurological conditions, severe stress, or sleep deprivation. Harry Stack Sullivan emphasized the role of interpersonal disruptions, suggesting that psychosis could emerge from profound relational failures. Counselors must take time to assess these causes and understand them fully, and for this reason the assessment stage may involve several sessions.
The Emotional Makeup of a Psychotic Patient
Patients in the psychotic range often experience intense emotional turmoil. Sullivan noted that their inner worlds are marked by profound anxiety, shame, and a sense of alienation from others (Harry Stack Sullivan – The Interpersonal Theory of Psychiatry and Schizophrenia as a Human Process). Delusions and hallucinations may serve as attempts to make sense of overwhelming affect or to protect against perceived threats. McWilliams writes in Psychoanalytic Diagnosis, that these patients are terrified and “lacks a basic sense of security in the world and is ready to believe that annihilation is imminent”. For example, a psychotic patient might misinterpret a therapist’s neutral comment as a threat, triggering intense fear or hostility.
The Role of the Counselor: Supportive Therapy
The counselor’s primary role is to provide supportive therapy, which Karon describes as creating a “holding environment” where patients feel safe to explore their fragmented inner worlds. McWilliams elaborates that supportive therapy is “an approach that emphasize active support of the patient’s dignity, self-esteem, ego strength, and need for information and guidance”. She also highlights the importance of being a “non-anxious presence,” helping patients regulate overwhelming emotions. Supportive therapy is not about dismantling delusions but about building a therapeutic alliance with trust at its core. Counselors must balance empathy with structure, offering consistency to counter the chaos of psychosis. But they must also learn to identify progress in order to make changes in their own role as therapist. Bertram Karon articulates this beautifully here:
“The most frequent errors in the treatment of schizophrenia lie in refusing to be strong and active when the patient’s anxieties demand it, or, having played such a role, to refuse to relinquish it when the patient no longer needs it. It is the job of the therapist to allow the patient to grow; he cannot grow if the therapist refuses ever to accept him as an equal human being. If the therapist, upon whom he now depends, is unwilling to let him grow up, the therapist is repeating the traumas of his childhood and he cannot grow up. He may lose some of his psychotic symptoms, but he will always remain a dependent child tied to the infantilizing therapist”.
The Role of Trust, Acceptance, and Honesty
Trust is the cornerstone of therapy with psychotic patients. Karon emphasizes that patients, often betrayed by their own minds, need a counselor who embodies reliability and authenticity. Acceptance means acknowledging the patient’s subjective reality without endorsing delusions, a principle echoed by Silver, who advocates for meeting patients “where they are.” For example, gently acknowledging a delusion’s emotional significance while redirecting to reality. Sullivan’s interpersonal approach underscores that trust grows from consistent, nonjudgmental interactions, allowing patients to gradually lower their defenses. If psychosis is a defensive tool, then it is a great success when therapy helps one to lower those defenses.
Example:
“Oh my gosh, that sounds awful! It must have been a nightmare to feel that kind of fear!” (therapist is joining in the patient’s frame of reference and acknowledging his subjective reality). “Why do you suppose your best friend suddenly decide to want to beat you up?” (after the patient feels sufficiently understood, he is in a better place to reflect.)
In the above example, the therapist doesn’t show agreement with the patient’s understanding of events. The therapist acknowledges but refrains from wounding the patient’s pride by dismissing his story.
A More Authoritative Stance
Nancy McWilliams suggests that unlike with healthier patients, counselors must adopt a more authoritative stance with those in the psychotic range. This does not mean authoritarianism but rather “by behaving like a professional expert but a human equal, the therapist can make a frightened client feel safer” – (Psychoanalytic Diagnosis). Karon notes that patients may test limits or project hostility, requiring counselors to maintain calm authority while remaining empathetic. This balance helps patients feel contained, reducing anxiety and fostering a sense of safety within the therapeutic relationship.
Educating the Patient
Harry Stack Sullivan wrote that we have information about our experience only to the extent that we tended to communicate it to someone, or, thought about that experience as if we were to communicate it through speech. Therefore, what we believe to be repressed is simply these experiences which were unformulated (1940, p. 185). D B Stern elaborated that unformulated experiences are not some hidden truths that are waiting to be discovered, but that they are a ‘pre-conceptual state of meaning’ that exists before they are formulated into explicit thoughts, feelings or narratives. Patients in the psychotic range experience tremendous cognitive confusion. They are confused about emotions, thoughts and fantasies. They may have grown up in confusing environments. A mother that professed her unconditional love may have physically abused the child black and blue. McWilliams writes, “psychosis-prone people often need explicit education about what feelings are, how they are natural reactions, how they differ from actions, how everyone weaves them into fantasies…” (Psychoanalytic Diagnosis). Therapists help to make the connection between ‘unconscious’ or repressed feelings and unformulated experiences.
Louise-Ann Silver recommends demystifying psychosis, explaining symptoms in accessible terms without overwhelming the patient. For example, counselors might describe how stress can influence symptoms, framing psychosis as a manageable condition rather than a personal failing. The therapist could also normalize frightening thoughts and feelings as natural components of being an emotionally responsive human being (McWilliams). For example, the client might make a remark about how she hates dogs. The client maythen become terrified that he has a murderous streak. The therapist could put him at ease by saying that it’s quite common for people to want dogs out of the way in many countries. And looking at the client’s history, there is no reason to think that he is actually in danger of acting out his thoughts. Of course, with healthier clients, the interaction will go quite differently.
Psychoeducation also includes discussing medication adherence, coping strategies, and the therapeutic process. Karon emphasizes that education should be collaborative, inviting patients to ask questions and express fears, which reinforces their agency.
Case Example: Kirk Allen in The Jet-Propelled Couch
In The Jet-Propelled Couch – Part 1 (Harper’s Magazine, December 1954), Robert Lindner introduces Kirk Allen, a physicist referred for therapy due to impaired work performance at a government research facility. Allen, raised by a neglectful mother and a native governess in an isolated Pacific island setting, found solace in science fiction novels. By adolescence, he developed a delusion of teleporting to an interplanetary empire where he was a heroic lord, writing thousands of pages of detailed biographies, maps, and histories. This fantasy, rooted in childhood loneliness, intensified under the stress of his scientific work, leading to psychotic disconnection from reality. Sullivan’s theory of interpersonal disruption applies, as Allen’s early relational failures fueled his escapist delusions.
In Part 2 (January 1955), Lindner describes the therapeutic process. Conventional psychoanalysis failed, as Allen’s fantasy offered unmatched gratification. Allen did not think he was sick at all. Facing a stalemate, Lindner innovatively entered Allen’s delusional world, studying his records and engaging discrepancies—e.g., inconsistent astronomical data—prompting Allen to “journey” to resolve them. This built trust, aligning with Louise-Ann Silver’s principle of meeting patients where they are. By exploring Allen’s real-life history—neglect, sexual awakenings, and isolation—Lindner slowly shifted focus from fantasy to reality. Over time, Allen’s investment in the delusion waned, and he admitted pretending to sustain it, fearing Lindner’s disappointment. This marked therapeutic success, as Allen reconnected with reality. Lindner’s ‘joining’ risked countertransference but facilitated the breakthrough, embodying Karon’s “holding environment.” The case underscores the need for trust, authoritative structure, and creative engagement. Lindner’s approach required exceptional temperament, highlighting McWilliams’ call for self-awareness in referring out when unfit.
Referenced books:
Unformulated Experience – From familiar chaos to creative disorder, Donnel Stern
Psychotherapy of Schizophrenia: The Treatment of Choice, Bertram Karon and Gary Vandenbos
The Interpersonal Theory of Psychiatry, Harry Stack Sullivan
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