The summer before I began medical school, I worked as an orderly at a chronic care state psychiatric hospital in a rural area in the North East. I met many interesting and tragically lost souls that summer. I recall a 21-year-old man who had worked on a farm since he was 16, who had his first psychotic episode when he was 18, never finished high school, and never had much of a young adult life. Unless he had a dramatic change of fortune, he might likely spend the rest of his life in the hospital. I befriended an extremely intelligent man who had his first psychotic episode in graduate school. He spent many hours a day trying to understand other people by conducting an intricate astrological analysis of their intentions.

I asked myself, how does a person begin life with the natural exuberance of a child and end up in a state hospital? The patients in the hospital seemed strange, but I imagined there must be some bridge between the childhood they were born to and their journey to psychosis. As a psychiatrist, it became my life’s work to find the essential humanness in psychotic patients in an effort to ameliorate their suffering by understanding them as people and the life journey that made them who they came to be.

Although this may not be the majority opinion among psychiatrists, I believe that the primary cause of psychological disorders is that bad things have happened to a person. Some people react to adversity with symptoms of PTSD, while others develop Dissociative Identity Disorder (DID). Some are resilient, showing little sign of discernable illness. I have come to regard psychosis also as a complex trauma-related disorder with a biopsychosocial cause.

Although genes and epigenetic factors play a role, research in the last two decades has shown that childhood trauma dramatically increases the risk of psychosis in adolescence or young adulthood. For example, people with a history of sexual abuse as children are ten times more likely to develop a psychotic condition than people who have not faced such adversity.

Abused children form insecure attachments to caregivers and internalize mental representations of other people as untrustworthy and potentially dangerous. In adolescence, these fearful expectations interfere with the ordinary goals of a teenager making friends and working out their identity. Unable to meet ordinary developmental milestones in a real world they fail to navigate, they construct an alternate reality in which they must abide, at the great cost of suffering.

Although it may not seem so at first, there is an enormous overlap between psychosis and ordinary mental life. For example, some people regard hearing voices as a hallmark of a mental illness. But consider an experience that ordinary people commonly have – hearing someone call their name when no one is there, or hearing their phone ring when no incoming call registers on their cell phone. These are hallucinations of everyday life that illustrate how we often hear what we expect to hear and see what we expect to see.

Similarly, ordinary people often “talk to themselves,” as when we in our mind give ourselves advice (“Don’t cut corners! Do it right!”) or critique ourselves (“You idiot! How could you have said that?”) Such internal exchanges illustrate that the fundamental structure of the human mind is dialogical.

The most common auditory hallucination in psychosis is a cruel derogatory voice that attacks the person’s sense of worth. Such voices are intense versions of the evaluations we issue to ourselves internally, with an important difference. In ordinary mental life, we know the critical voice belongs to us; in psychosis, the voice appears to arise outside the self.

In my work, I combine an initial emphasis on CBT techniques with a subsequent focus on psychodynamic work. Delusions are literally false, but they are figuratively true, meaning they are meaningful expressions of a person’s history and current state of mind.

CBT focuses primarily on cognition. By examining evidence for and against a delusional belief, CBT can help patients discover that their thinking is influenced by a variety of cognitive biases, including a tendency to jump to conclusions and/or a self-referential bias, that may lead them to beliefs that are literally false.

Once the CBT work has encouraged a patient’s doubt as to the veracity of a delusion, the patient and therapist are in a position to explore, based on the patient’s life history, how the delusion is expressive of the patient’s life experience, in many cases, a history of trauma. Psychodynamic work focuses primarily on unconscious fantasy, affect, and symbol formation.

Delusions are quite varied in content. Paranoid delusions are common, in which a person believes a malevolent “persecutor” is seeking to harm them, thought to be a relative, neighbor, government agency, or group like the Mafia. Grandiose delusions are also common, in which a person believes they are all powerful, a genius, a billionaire, or a celebrity. In delusions of misidentification, the patient may believe that a family member is an imposter or that multiple people in the person’s environment are actually the same person in disguise. Some people may believe that their minds are being read, or that they can read minds, and/or that a machine or computer chip is inserted in their brain to control their thoughts and actions.

Delusions have a variety of sources. Typically, people develop delusions in an attempt to understand anomalous perceptions that arise in the course of psychosis and in their attempt to explain the inexplicable, as in, “How could my parents abuse me?” For example, children who have been abused may, as psychotic adults, believe that their biological parents were kind and loving people, while the abusive couple who claim to be their mother and father are actually kidnappers who stole the patient from his or her rightful parents at birth.

Children who have been abused form conscious and unconscious mental representations of themselves and other people that emerge in delusions. Abused children know that they are unsafe. In one line of development leading to a paranoid delusion, they believe that they are still unsafe in the present because they are subject to the malevolent intent of a “persecutor,” as noted earlier. A second line of development leads people who were helpless as children to embrace an unconscious grandiose fantasy that leads to a grandiose delusion that they are all-powerful, a genius, a wealthy person, or a celebrity, with no need of love or care.

Another common type of delusion (as noted above) is exemplified by the belief that another person or computer chip is controlling their thoughts. This may arise as the patient’s explanation from their altered subjective experience of their thinking their thoughts and experiencing their feelings, which may seem hollow, or two-dimensional compared with the robust “I” they formerly felt themselves to be at the center of their experience. In such cases, when a person’s subjective experience of their own mind does not feel familiar to them, they may conclude that someone else has inserted thoughts into their mind.

The most powerful therapeutic element in psychotherapy is a trusting relationship between patient and therapist. The therapeutic alliance becomes an arena that can contain the challenging work of psychotherapy.

People suffering from psychosis have typically grown accustomed to being dismissed as mental patients with a diagnosis of schizophrenia, rather than being treated as complicated individuals suffering from what has befallen them. It is essential that the therapist listens to what psychotic people say with the intent to understand the psychological meaning of their psychotic symptoms. This attitude sets the work of psychotherapy in a dignified frame in which the patient feels they are taken seriously by the therapist and are worth the therapist’s time and attention.

Depending on the patient’s wishes, problems, and capacities, a variety of techniques can be employed. As noted above, I tend to integrate a CBT and psychodynamic approach. Other approaches including Acceptance and Commitment Therapy (ACT) can also be helpful, as well as mindfulness practice for some patients. In addition, a range of other psychosocial interventions such as supportive housing and supervised employment can be helpful.

In my opinion, which I cannot say is a majority view, most conditions that psychiatrists and psychotherapists treat are different ways of reacting to one’s sorrows in life. Although the phenotypic expression and diagnostic criteria for PTSD, Dissociative Identity Disorder (DID), substance abuse, chronic depression, and so on give the impression that these conditions are separate disorders (“diseases”), research shows that people with these diagnoses all have an increased incidence of traumatic experiences in their personal histories. These conditions are all trauma-related disorders.

Researchers typically define trauma with a checklist of adverse events that most people would consider traumatic, but what is traumatic for one person may not be for another. For example, I once consulted in the treatment of a shy 16-year-old with loving parents who had his first psychotic episode after students at a school social gathering stole the laptop on which he had saved a collection of rap songs he had written, hoping his music would gain him acceptance by his peer group. The idea that his peers would steal from him rather than accept him was devastating. Theft of a laptop does not appear on any standardized scale for trauma. Although some individuals who become psychotic were physically or sexually abused by their parents, in some cases, as was true for the adolescent whose laptop was stolen, despite loving parents, complicated circumstances of development that can only be unraveled in psychotherapy lead to a psychotic breakdown, sometimes in what might be seen as the trauma of a thousand paper cuts.

Given the high incidence of child abuse in people who develop psychotic conditions, I regard psychosis as a particular type of trauma-related disorder. While the underlying cause of most psychiatric conditions may be painful experiences in life, why one person develops PTSD and another becomes delusional is an important question for research. People with a history of being abused who are diagnosed with schizophrenia may have a genetic makeup that predisposes them to react to trauma with hallucinations and delusions. Genes undoubtedly play a role in psychosis, but it is highly reductionistic to regard schizophrenia as essentially a genetically determined brain disease that invites only pharmacological treatment.

Research shows that the earlier a person with psychotic symptoms can be engaged, the better. Accordingly, and rightly, many constituencies fund first-episode psychosis teams to intervene before a psychosis becomes chronic. That said, in my experience, it is still possible to reach people who have been ill for many years with ambitious psychotherapy.

Psychosis disrupts a person’s life, whether for a short time or decades. After an acute psychotic episode, some people hope that they can “seal over,” put the psychosis behind them, and pick up their life where they left off. Other people regard the psychosis as a message sent to them by themselves urging them to attend to the unfinished business in their growing up. They want to understand what the psychosis can teach them. Psychotherapy can aid in this integrative process.

In addition to dealing with a painful childhood, people who have suffered a long-term psychosis have the added burden of facing the reality that they have lost years of their life to psychosis, a realization that may entail enormous grief.

Medication is an essential component in the treatment of psychosis for many patients. I combine pharmacology and psychotherapy in my work. Although some localities try to minimize the use of neuroleptic medication (which can have significant side effects), no mental health system in the world has found a way to entirely avoid prescribing medication in the treatment of psychosis. The prescription of medication has for the last 50 years dominated treatment, but compared to dramatic gains in some areas of medicine, progress in improving clinical outcomes in psychiatry has been modest. Despite pharmacology’s best efforts, only one in seven psychotic patients achieve a robust recovery.

Research shows that the impact of neuroleptics on symptoms and how a person feels is highly varied. For example:

• People with psychosis who suffer from intrusive recollections of trauma report that the medication blunts the emotional impact of their trauma recollections in a way that they welcome, because feeling less overwhelmed, they are better able to function and engage in psychotherapy.

• For some people, neuroleptics allow a person to live in the community rather than being confined to a hospital. It is not uncommon for patients taking neuroleptics to report that they still entertain their delusional thoughts but that the thoughts don’t bother them as much as they once did.

• For some people, neuroleptics may burden a person with side effects while being of little therapeutic use.

• In some cases, people report that neuroleptics so blunt their feelings that they live hollowed out, deprived of their emotional connection to life.

• Still, others report that neuroleptics increase the frequency and intensity of traumatic recollections.

In public psychiatry, it is often the case that one person (a psychiatrist) prescribes medication, while another person (when available) conducts psychotherapy. All too often there is little communication between the pharmacologist and the psychotherapist. Close collaboration would help fine-tune medication to an individual patient’s needs.

Delusions, hallucinations, dreams, fairy tales, myths, and other creative works of fiction arise from the same source – human imagination. Evolution has endowed us with a need and capacity to symbolize and make sense of our experience by telling stories about what has happened to us.

Consider the continuum between a daydream in ordinary mental life and a delusion. In a daydream, a person is the sole author of an imagined sequence of events that allows them to escape from a current reality into an imagined world more to their liking. For example, a person sitting in a classroom who is having trouble understanding a poorly presented lecture may fear that they will receive a bad grade because the instructor is a poor teacher, rather than through some fault of their own capacity as a student. Faced with this “reality,” an aggrieved student might conjure up a daydream in which the principal of the school gets rid of the bad teacher and reassigns the class to another instructor.

In a delusion, a person is the sole author of an imagined sequence of events that allows them to escape from a current reality into an imagined world more to their liking. For example, to escape from a “reality” in which they blame themselves for failing in school, a person might assert in a delusion that a shadowy group, jealous of the person’s superior intelligence, is secretly drugging the person to undermine their performance in class. In paranoid psychosis, a person typically believes that a persecutor is the cause of their suffering. This imagined world is terrible, but preferable to a reality in which the patient’s parents are the source of their suffering.

The difference between ordinary daydreaming and a delusion lies in the daydreamer’s ability to voluntarily step in and out of the daydream as they desire, while in psychosis the person is locked into a permanent daydream that they cannot escape. Or, just as we may daydream of winning a prize or achieving a goal, in a grandiose delusion, a person may imagine a world in which they are a celebrity who has already achieved all the goals they might otherwise struggle to achieve.

In the case of adolescents and young adults who develop a psychotic illness, their growing up leads to breakdown. Every psychotic person has a backstory that underlies their psychotic symptoms. Sometimes the backstory is easy to see and readily treated, while other times, it is more difficult to discern.

For example, as anyone who can recall having awkward moments in adolescence knows, an important developmental task for teenagers is to find their authentic identity among peers, a developmental task that for most adolescents involves consolidating their sexual identity and sexual preferences while trying out their identity in social relationships, including dating. I once consulted in the treatment of a 19-year-old man who reported that every night, a couple entered his body and had sex inside him, which he found greatly disturbing. Just as many young adults daydream about sex at night when the activity of the day is done, it occurred to me that his delusion about what went on at night might be akin to such a daydream.

When the therapist explored this possibility with the patient, he acknowledged that it had always puzzled him how two people could get into and out of his body without leaving a trace (at which point he considered that the delusion might be literally false). When the therapist asked the patient if he guessed who the couple might be, it occurred to the patient for the first time that he imagined that the woman in the couple resembled a girl he had fallen in love with when he was fifteen, who had left him for another boy.

The patient offered his own explanation of his delusion. Once he saw the woman in the delusion as a proxy (a symbol) of the girl he considered to be the love of his life, he went on to say that his idea of her having sex inside his body might be his way of keeping her close, or vicariously imagining fulfilling his sexual fantasies about her, when in reality she was lost to him. It took him four months of weekly psychotherapy to come to this conclusion, which left him feeling sad but no longer preoccupied with his delusional night visitors.