Progressive Approaches to Psychosis, Part 1: Rethinking How We Understand Psychosis
For decades, conversations about psychosis have been dominated by pathology, risk, and symptom reduction. While medication and crisis intervention can be important parts of treatment, they are only one piece of a much broader picture.
Rather than approaching treatment with the question, “How do we eliminate symptoms?” a progressive approach to psychosis asks a different question: “How do we help people build meaningful lives while understanding these experiences with curiosity, validation, and respect?”
As a social worker, trainer, and author specializing in Dialectical Behavior Therapy (DBT) for psychosis, I've found that this shift fundamentally changes the therapeutic relationship and often improves outcomes.
Psychosis Exists on a Spectrum
Psychosis is not an all-or-nothing phenomenon. Psychosis is understood as unshared experiences that occur along a spectrum and are part of the broader range of human experiences.
For example, I’m originally from Houston, Texas, and one experience I regularly have when I return home to visit family is that, after seeing a roach, I sometimes get the sensation of it crawling on my skin for the next 5–10 minutes even after I look down and see that there is no bug there. This is an example of a tactile hallucination: a sensory experience that feels real but would not be shared by another person looking at my leg. While this experience is unpleasant and annoying, it does not significantly impact my distress level or functioning.
For people with a psychotic spectrum disorder, these unshared experiences typically occur more frequently, with greater intensity, and/or with more significant impacts on distress, daily life, and the pursuit of meaningful goals. At other points in their lives, these unshared experiences may be much more manageable or may even be welcomed and experienced as friendly based on a number of variables.
Recognizing psychosis as existing on a continuum helps reduce stigma and creates opportunities for earlier support, deeper understanding, and more compassionate, person-centered care.
Culture Shapes Psychotic Experiences
One of the most important findings in psychosis research is that culture influences not only how people interpret unusual experiences, but also how distressing those experiences become.
Research comparing voice hearers in the United States, India, and Ghana found that while people across cultures reported both positive and negative voices, Americans were much more likely to describe adversarial relationships with their voices. Participants in India and Ghana more often interpreted voices as spirits or familiar people and frequently described less distress (Luhrmann et al., 2015).
This reminds us that providers should avoid assuming every unusual experience is inherently pathological. Cultural humility is an essential part of competent assessment.
Language Matters
The words we use influence how people understand themselves. Clinical terms like delusions, paranoia, and symptoms can sometimes communicate judgment or imply that a person's experiences define them. Many providers and people with lived experience are instead moving toward more person-centered language, such as:
Distressing beliefs instead of delusions
Suspicious thoughts instead of paranoia
Psychotic experiences instead of symptoms
Creating a shared language with our clients is a powerful way to normalize experiences, reduce stigma, and build a collaborative relationship.
Looking Beyond Symptoms
People experiencing psychosis often face enormous challenges that extend far beyond hearing voices or experiencing distressing beliefs. Many also experience trauma, housing instability, unemployment, social isolation, discrimination, barriers to healthcare, institutionalization, and incarceration. Rates of PTSD, problematic substance use, and suicidality are also significantly elevated.
When treatment focuses only on symptom reduction, we risk overlooking the broader context shaping a person's life. A progressive approach recognizes that recovery isn't simply about reducing symptoms, it's also about addressing trauma, increasing access to resources, and helping people build meaningful lives.
In Part 2, I'll explore what people experiencing psychosis actually want from therapy and how providers can foster engagement, hope, and recovery through collaborative, person-centered care.
References:
Luhrmann, T. M., Padmavati, R., Tharoor, H., & Osei, A. (2015). Differences in voice-hearing experiences of people with psychosis in the U.S.A., India and Ghana: interview-based study. The British journal of psychiatry, 206(1), 41–44.