A woman and her voices: The case for a functional contextual view of psychosis.

A woman and her voices: The case for a functional contextual view of psychosis.

“Insanity – a perfectly rational adjustment to an insane world.”

– R. D. Laing, Scottish psychiatrist

When I teach “Abnormal Psychology,” one of the first things I do is tell the students that we will no longer be referring to the class as “Abnormal” psychology but rather, “The Psychology of Human Suffering.” Much of the course focuses on helping students see how those who suffer in ways that happen to be associated with a diagnostic label are not fundamentally different from those who suffer in ways that are yet to be pathologized.  A main message is that mental health is not an “us” versus “them” problem. Rather, we all struggle and suffer. Some forms of suffering we happen to label with names that are written in a book called the DSM and others we label with names that aren’t in that particular book. Usually toward the end of the semester, students are generally on-board with this alternative to the traditional medical model view of mental illness.

But then comes the final chapter of the course: Schizophrenia and psychosis. The reaction is predictable and goes something like this: “OK, I can get that people who experience what we call ‘Depression’ or ‘Panic Disorder’ or even ‘PTSD’ aren’t fundamentally different than me, but psychosis?!? Those people are really crazy! Right?” Of all the psychiatric diagnoses we put on people, the one that we still cling to as being fundamentally “crazy” or as being a “brain disease” is psychosis, usually defined as people hearing or seeing things that others don’t hear or see. It’s a very common presumption, even probably among we mental health professionals. Even look at the phrase we frequently use to describe the phenomenon; we describe people who have these experiences as “SMI patients” (i.e. “serious mental illness”). This presumption of pathology is so tenacious that it’s been difficult for me to help my students question it in the same way they have come to question some of the other presumptions they have.

So I was delighted a few weeks ago when I came across this inspiring and refreshing TED talk through my Upworthy feed this week. In it, Eleanor Longden, international speaker, doctoral candidate in Psychology, and voice hearer, describes her experience hearing voices and how unhelpful she found the pathologizing approach taken by the mainstream establishment. She talks of how the psychiatric and psychological establishment was solely focused on trying to figure out what was “wrong” with her, and then, following their assumption of pathology, try to “fix” her (i.e. make her voices stop or at least make her stop acknowledging that she hears voices) by doing whatever means necessary. The result was that they were largely unsuccessful and even made it worse.

I found Ms. Longden’s story both inspiring and very consistent with some of the assumptions of Acceptance and Commitment Therapy (ACT) and contextual behavioral science in general . Contexual behavioral scientists, which would include ACT therapists, would not view hearing voices as inherently problematic. Rather, from perspective contextual scientific perspective, the experience of hearing voices needs to be examined in the same way we would explore any other behavior –contextually. While hearing voices is not inherently pathological or even problematic, they ways that people react to voice hearing often makes things worse.  The focus is less on the voices themselves as problematic, but instead how the voices are responded to and function in a person’s life.

Research seems to support this contextual non-pathologizing view of psychosis. To date there are at least 8 empirical studies, including 3 randomized controlled trials, demonstrating the effectiveness of ACT for people who experience psychosis. In ACT, the focus is not on decreasing a particular symptom, such as the hearing of voices, but rather on increasing flexible, adaptive functioning across a wide variety of contexts, including contexts in which the person may be hearing voices. And the data suggest that this approach tends to increase quality of life, and decrease a whole host of problematic outcomes, including rehospitalization, by some pretty astonishing rates.

If you are interested in learning more about ACT for psychosis, the protocol is available for free on the Association for Contextual Behavioral Science (ACBS) website. You do need to be a member of ACBS to get access to the protocol, but ACBS has “values based” dues which start at $10 per year. Those dues also get you access to the Journal for Contextual Behavioral Science as well as all the incredible wealth of resources and information available on the ACBS website.

Does Ms. Longden have a unique experience that falls outside the normal range of the bell curve? Probably. Does her experience of hearing voices result in suffering for her? At times. But does treating her experience as some disease, some pathology that must be stamped out at all costs help her live a fuller and richer life? Unfortunately not.  ACT and Contextual Behavioral Science offer an alternative that holds incredible promise for helping us all live meaningful, productive lives as Ms. Longden is doing.


January 31, 2020, 8:30 am – 4:30 pm · Portland, OR · Details

This workshop is intended to be part 1 of a two day workshop, but can also be taken on its own. This workshop is useful for therapists who want an update on the current clinically applicable research on how shame functions, including an overview of how and when shame tends to be adaptive versus maladaptive. This day has two primary goals: 1. To provide an overview of research on shame and self-criticism that can guide clinical practice and 2. To allow therapists to experience the model from the inside-out so as to develop greater personal self-compassion and a deeper intuitive understanding of compassion-based intervention strategies. Read more

February 1, 2020, 8:30 am – 4:30 pm · Portland, OR · Details

This workshop is intended to be part 2 of a two day workshop, but can also be taken on its own. If you already have a thorough understanding of the functions of shame and a good understanding of Acceptance and Commitment Therapy, then it is you will probably be OK taking just the second day of this workshop. The workshop proceeds to discuss how ACT processes can be focused on addressing chronic and pervasive shame-based difficulties, with a particular focus on flexible perspective taking. Demonstrations of how to use perspective taking and compassion-fostering strategies with clients will be provided and attendees will also practice in small groups. An overview of chair work in the context of ACT will be provided. Read more

February 29, 2020, 9:00 am – 12:15 pm · Portland, OR · Details

Exposure is one of most the effective treatments for anxiety, trauma, and obsessive compulsive and related disorders (e.g., OCD, PTSD, panic disorder). A transdiagnostic intervention, exposure involves the repeated and systematic engagement with avoided stimuli that cause anxiety. Unfortunately, exposure remains underutilized by clinicians (e.g., Scherr, Herbert, & Forman, 2015), mostly due to misunderstandings of how exposure works and perceived difficulty of using it with clients. This half-day workshop will address these gaps by drawing from research on enhancing clinician understanding of and ways to overcome barriers to delivering exposure therapy (Farrell et al., 2016). Using didactics, role-play, and experiential exercises, participants will learn flexible application of exposure for a variety of clinical targets. Read more

April 17 and 18, 2020, 9:15 am – 5:00 pm · Portland, OR · Details

Do you ever “get stuck” as a therapist? Do some of your clients press your “hot buttons”? Do you ever find yourself struggling and thinking about “what do I do next” or feeling anxious, scared or stressed in therapy? In this workshop we will work on clarifying your therapist values and defining what is “difficult” about “difficult” clients. Through discussions, demonstrations and roleplays we will then work on these difficult clients and look at the processes from a compassionate ACT perspective. Read more