Stephanie Hepburn is a writer in New Orleans. She is the editor in chief of #CrisisTalk. You can reach her at .
When mental health professionals discuss psychosis, they often highlight the person’s lack of insight into their psychosis as a barrier to care. However, Dr. Paul Grant, director of Research, Innovation and Practice at the Beck Institute Center for Recovery-Oriented Cognitive Therapy, says what’s happening is a difference in perspective.
“There’s often a disagreement, in terms of what they’re experiencing, between the person and their doctors and family,” he said.
Grant advocates for families and providers to adopt this terminology shift to improve relationships and treatment engagement. He says the term “lack of insight” can seem judgmental and impede trust, while “disagreement” acknowledges the person’s viewpoint.
“It’s very hard to have a good relationship with someone when using language that diminishes their perspective.”
In 2007, Grant and mental health pioneer Dr. Aaron Beck began working with Dr. Arthur Evans, who, at the time, was commissioner of Philadelphia’s Department of Behavioral Health and Intellectual Disability Services. (Today, Evans is the CEO of the American Psychological Association.) According to the Beck Institute website, the partnership was designed to improve outcomes for the city’s most vulnerable and at-risk populations and create a replicable treatment model.
The partnership largely focused on individuals from North and West Philadelphia given a diagnosis of schizophrenia that they may or may not have agreed with. Often they didn’t.
Grant and Beck quickly realized cognitive behavioral therapy, which Beck developed in the ‘60s, tailored for psychosis wasn’t going to work. “People didn’t want to talk about their psychosis or any approach that tried to reduce it,” said Grant.
They shifted to a whole-person cognitive behavioral therapy approach known as recovery-oriented cognitive therapy, often called CT-R.
The treatment actively helps clients achieve their goals, fostering positive self-identity and resilience. Medication, perhaps even getting more treatment, can fit into this broader context, says Grant, but ultimately, the goal is to help individuals have “the life they want.”
Instead of confronting someone’s belief or focusing on their symptoms, Grant advocates for an approach led by the person’s interests. He stresses the importance of genuine human connection, contribution and empowerment — universal needs that form the basis of his engagement strategy. “We’re trying to meet the person where they’re at and have meaningful interaction with them that brings out their best self.”
Those in psychosis can feel misunderstood and rejected, contributing to isolation and loneliness. Society often correlates conspiracy theories and delusions, says Grant, but there’s a critical difference between the two: a community believes in a conspiracy theory whereas a delusion is a belief held by only one individual.
“They’re completely alone in their delusions. That’s incredibly isolating and upsetting — people don’t want to talk to them about it, they turn away, they go, ‘Come on, stop with that stuff.’”
Instead of shutting someone down, Grant delves into what might be underlying the delusion. If someone claims to be Jesus, he would ask, “What’s the best part of being Jesus?” He says perhaps the person wants to foster community and help others. “Can we help them do that where they are, whether in the community or state hospital?”
While there was a persistent, long-held belief within mental health and society at large that talking to someone about their delusion encouraged, reinforced the belief, many experts, including Grant, say ignoring delusions doesn’t diminish them. “If the person thinks they’re Jesus, from 0-to-100%, I think we’re already at 100.”
His objective is to understand and validate someone’s experience. He explains a grand belief doesn’t require a grand solution — at the core is the desire to contribute and be respected, appreciated. “These are basic human needs everyone has. When those are met, we see things begin to calm down.”
He goes right to their interests, not whether or not they’re taking medication.
Similarly, Grant shared by email that he doesn’t find focusing on symptoms a useful target of care. People may continue experiencing symptoms and are “living life to the fullest,” while others may not have symptoms but “don’t get their life back.”
When a person feels respected and participates in activities that bring them meaning, they may no longer be as bothered by the voices and know what to do “when they capture their attention and are getting in the way of the life they’re pursuing.”
“They still might hear voices and have ideas but their relationship with the experiences is different — they are more empowered.”
He notes that the person could score just as symptomatic on the Positive and Negative Syndrome Scale. “If you ask the person, ‘Do you still think you’re the Famous Rock Star’s son? They’d say, ‘Damn right.’ But, they don’t usually think about it — it doesn’t come up so often — and they can refocus.”
When someone has been diagnosed with schizophrenia, providers and families often focus on medication adherence. However, unlike a medical diagnosis, Grant says a diagnosis of schizophrenia has limitations in guiding effective intervention, with diagnosis alone providing insufficient actionable information. “It doesn’t give us anything that we can do.”
Instead, he emphasizes the need to understand the challenges someone is having with communication or motivation. “Are they bothered by voices or saying really grand things?” He encourages understanding the meaning behind the person’s beliefs. “What is it doing for them to say this? What do you think they want?
“More often than not, they want to get on with their life.”
Grant challenges the binary view of “insight” as either toggled on or off. Psychosis can be episodic or continuous, but even if continuous, the intensity of symptoms can fluctuate. When the solution only focuses on medication, the fallout can be twofold — the client may pull away from treatment, and family, especially parents, can become frustrated, leaving them saddened that medication hasn’t returned their loved one to how they once knew them and grieving the future they thought their loved one would have.
“No one gives parents a playbook if their son or daughter suddenly starts to feel paranoid and hear things — it’s very hard.
“I would say to those families that their child is still in there.”
While families may grieve this loss, at the same time, their loved one might feel as if they don’t measure up to their family’s idea of who they should be, furthering the chasm between them.
When people stop engaging with their family, friends, treatment or care team, they’re more likely to fall through the cracks of the behavioral health care system and into the criminal justice system. That’s why, says Grant, there must be connectivity to mental health care for those with psychosis at every potential intercept point.
The Sequential Intercept Model, developed by Drs. Mark Munetz, Patricia A. Griffin and Henry J. Steadman, traces how individuals with mental health and substance use issues come into contact and move through the criminal justice system. The model also illustrates how and when those with psychosis may come into contact with mental health services, providing opportunities for diversion.
Grant and his team have worked with mental health crisis services, community residential programs, hospitals, reentry services, mental health courts and assisted outpatient commitment programs to try to create a safety net for people who experience psychosis.
He sees the 988 Suicide and Crisis Lifeline as an opportunity to use recovery-oriented cognitive therapy concepts, especially for repeat callers who may be experiencing psychosis and don’t want to engage with mobile crisis or crisis receiving and stabilization services.
Grant envisions contact counselors using a recovery map to help explore callers’ interests, goals and challenges. “That way, when the person calls back, you know how to engage them, get them talking.
“Maybe last time they spoke about being a good family member or their education; the counselor could talk about ways they could do that.”
He suggests family members get out of the caregiver mindset and into spending time with their loved one. Not challenging their experience but instead doing what they enjoyed doing together before. “What is your family like at its best? What were you doing? When did you do that last?”
Families are a wealth of knowledge, notes Grant. They can share activities the loved one once enjoyed, even if it’s been decades. Sometimes, family members worry the person will be sad when returning to the activity. “In my experience, they often aren’t — they learn they didn’t lose their abilities, they enjoy themselves.” He adds that spending time together fosters support. “When you’re connected to your family, you have connection.”
