#1283 Stijn Vanheule: Why Psychosis Is Not So Crazy

00:00 Ricardo Lopes: Hello everyone. Welcome to a new episode of The Dissenter. I'm your host, as always, Ricardo Lops, and today I'm joined by Dr. Sten van Hule. He's a clinical psychologist professor at Ghent University and psychoanalyst in private practice. And today we're going to talk about his book Why Psychosis Is Not So Crazy A Roadmap to Hope and Recovery for Families and caregivers. So Dr. Van Hula, welcome to the show. It's a big pleasure to everyone.

00:32 Stijn Vanheule: Yeah, um, I'm, I'm glad to be here, Ricardo, yeah, and thanks for the invitation anyways.

00:38 Ricardo Lopes: Yeah, of course. So, um, let me start by asking you this and also to introduce the topic to people who might not be familiar with the subject, and I would imagine most people would not be. Uh, HOW do you approach psycho psychosis, particularly from your standpoint as a psychoanalyst and Uh, I mean, how is it usually approached among, uh, clinical psychologists?

01:08 Stijn Vanheule: Yeah, so the mainstream opinion or the mainstream thinking about psychosis is especially thinking of it in terms of a severe mental disorder that is characterized by a couple of specific kind of symptoms, like people having hallucinations, meaning, They see or hear things that are not there or they feel things onto their body that are not there in reality, so that's the first characteristic. Then the second is delusions, meaning that people have opinions about the world, about themselves, about their relationships that actually do not hold true, um, often in the direction of suspicion, um, or, um, being elected to be very special, um. So that, that's usually the case um in, in a delusion and then there is often in the context of psychosis, behavioral changes, meaning that people can become very chaotic in what they do or very manic or very inhibited um or do weird things. This is usually how psychosis is defined. Uh, MEANING as a, as a kind of a, a severe problem where people, so to speak, go away from common reality, uh, which is often why it is experienced as disturbing both by a patient and by the people around them, like by the, by family, but also more broadly by society, um, we, we tend to have problems when people. Have specific opinions or behave in strange ways, there is something of an anxiety that, that arises. Um, AND so therefore, it, it, it, it's, it makes a problem for, for people, psychosis. Um, SO that's mainly the general idea about it. Um, OF course there's all kinds of specific criteria that psychiatrists and clinical psychologists use to diagnose it, uh, um,

03:17 Ricardo Lopes: and, and what is your view on those criteria and on how, uh, most, or at least, uh, mainstream clinical psychologists tend to approach psychosis?

03:32 Stijn Vanheule: Yeah, so, well, basically, um, as a psychoanalyst, I see it as follows. Um, THE way I described it provides us with the viewpoint of an outsider. This is how it looks for people, um, but as a psychoanalyst, I'm, I'm, I'm interested in the question, yeah, but what is it that brings it about such an experience? Uh, THIS is not something, uh, random. This is not just noise in the mind. This is not. Not just a brain entering in a most chaotic state. For me it's the question of a human being, a human being that obviously has been challenged to such a degree that their common way of making sense of, of themselves and of the world does not work anymore, um, and so therefore their way of functioning, their mind is switching. To, to different ways of, of making sense of things, um, and so as a psychoanalyst, that, that's my, my main question. Of course, there is this experience of reality that changes, but there's a base to a certain internal logic. It's, it's people being challenged to severe, in a, in a, in a very severe degree that creates such um a mindset, so to speak. And that challenge can be, is, is very complex and is very diverse. Um, IT might reflect something of people's social situation that has become very difficult or their relational situation that has become very difficult. It might witness to very severe things that have happened in people's lives, or of course it might also. Uh, REVEAL something of an, of an internal dynamic. So, um, I don't know that on beforehand when as a psychoanalyst when I start working with people, but the key idea here is that it's not random, um, it's, it's psychotic experiences are responses to, to triggers, to, to situations that have been overwhelming for a person and as a psychoanalyst, I tend to stress this. And um that, that's of course a bit different compared to mainstream psychiatric practice where the idea is more about, OK, these are weird experiences and we have to contain them, which is usually why people start thinking about medications in the first instance for people with psychotic um. Experiences to, to just calm it down, to kind of, to, to diminish the symptoms, to diminish the crisis experience that people have. And, and I'm not against medications, but for me the crisis experience is revelatory of something of, of how people live and how the challenges they are confronted with, and as a psychoanalyst, I want to value that component of the, of the psychotic experience.

06:30 Ricardo Lopes: But do you still approach psychosis as a mental disease, um, and I mean, more broadly as a psychoanalyst, what is your understanding of what mental disease is?

06:49 Stijn Vanheule: Yeah, so. Here I start from Freud and Sigmund Freud's opinion was that we actually all have psychopathological traits. Huh, a normal person does not exist. We all have our specific kinds of weirdness, huh, and so I see it as a dimension, huh, as, as a dimensional space in which you can have like very mild experiences of weirdness, uh, and that's what we usually call normal, but check normal people, it's not that they know who they are, it's not that they are always like very rational in what they do. Um, NORMAL people still have like all kinds of irrational thoughts. Um, THEY also suffer from doubts and uncertainties. They have weird dreams. They, they say stupid things to their partner, to their children. So even if you are, so to speak, normal, you have in Freudian perspective, you still are wrestling in a certain sense with like situating yourself in the world and in your, also with respect to your inner world. Um, BUT here the idea is that um we can. Move on that um dimension to the direction when things become a problem, when people start to experience these inner experiences or these relations to other people as potentially a problem. So when I doubt and I doubt a bit too much, Then maybe my life is troubled because I can't make decisions anymore or I, I start feeling anxious or I start feeling depressed, so it's when it moves, when it becomes more extreme, it becomes a clinical problem and a clinical problem is a problem for which you need help because you can't cope with it anymore yourself. So for me that's a clinical situation, that's, so to speak, a disorder that, that is when the internal order. It's disruptive to such an extent that you can't cope with it on yourself anymore, huh, so that's my, my broad idea of what what what is a disorder or what is a clinical problem and, and here we have to apply that continuum also to the experience of psychosis, um. There's many people who at a certain point of their lives have um like experiences that are very difficult to explain to other people, maybe some more paranormal experiences, um, or some vague experiences of reality that is, that, that is strange in a certain sense, but that does not mean that it is a clinical problem, huh, but it can evolve in such a way. That it becomes a problem, that it becomes intolerable for yourself, or that people in your, in your environment like in your family start being worried about you because in their opinion, you're doing weird things or or having weird thoughts, so that's a point where it might become clinical and clinical means that it's. It implies uh um a severe degree of suffering, uh, so for me that's, that's the criterion. If something of an inner experience or an experience of reality is so disturbing that it creates real suffering for people, then it starts to be clinical and then it becomes a problem where clinicians, uh, should attend to, like, that's also the point where, for example, a psychoanalyst could enter the scene. Uh, TO, to try to speak with people about what they experience and what is destabilizing them. So, for me, it's not like a categorical distinction between or you have a clinical problem or you don't. Um, OF course, as human beings, we tend to categorize and because that's what makes it a bit more easy for us, but actually, I, I see it as a continuum.

10:48 Ricardo Lopes: Mhm. So let me ask you this, and please let me know if you think that this is something worth considering when evaluating whether someone Um, I mean, whether something that someone experiences should be classified as a mental disorder or not. So, uh, do you think that perhaps there would be instances, and here I'm not exclusively referring to psychosis necessarily, it can be any other sort of uh mental phenomenon. I mean, do you think that there are at least some instances where Uh, people might express distress, but it is, it is not something that really has to do with their mental condition, but it's just because, uh, the, their behavior or perhaps some of the ideas they express are not normative in the society. So they, they are part of, I mean, and they, and they suffer psychologically, not because something is wrong with them, but just because they think and behave in ways that are not considered normative in their society.

12:05 Stijn Vanheule: Yeah, yeah, of course that's possible and that's what we usually call stigma, stigmatization, um. And stigmatization happens all the time in a society. It's a sociological mechanism, so to speak, where you have like the dominant ideas in a group, in a society, for example, or in, in, in, yeah, of course be in, in a smaller group where there is a certain consensus about what is, what is common, what is acceptable, and what is not. Um, AND what typically happens is when in a group some people start having opinions that are different than the common opinion that people tend to like think about what is wrong with that person, um, or what is strange about that person. Uh, AND then you get stigmatization where the one who is having different behaviors or different ideas is seen as, as, as, as weird, maybe also as dangerous, as unreliable, um, and when these thoughts are being developed about people, this is also exactly like a trigger for mental difficulties, huh, so when you're being stigmatized because you're somewhat different. This leads to a path that makes you more vulnerable for, for mental health condition, uh like for example, take homelessness, um, people can become homeless because they have bad luck in life, but once you're homeless. And you don't have a place to live, there is a quite a chance that society starts to think of you as being a very weird person because you don't have money, you don't have a house, so it is concluded that you must be very strange and that you must be like very difficult to deal with, that you must be lazy, uh, because you don't have a job. So there's

14:02 Ricardo Lopes: yeah, it usually comes attached to some sort of a more. OR character failing, right,

14:08 Stijn Vanheule: and so then you have the stigmatization, but once this kind of framing is imposed onto you, it becomes very difficult to escape from it, so that's already a burden for, for people that creates this stress and it's exactly this kind of trap that keeps um people awful in a negative cycle when you have psychotic experiences, uh, for me, the psychotic experience. Psychologically speaking, is often not that weird because it's responding to something of an internal dynamic, to something of an experience that people have, and often this is it's very comprehensible why people have this kind of experience, but if also from an outside perspective at that very point stigma. IZATION starts, then you can enter into a negative cycle where it becomes very difficult for a person to escape from, um, from, yeah, from that problem because you're continuously confirmed in that problem rather than you experience that you are being helped to find a way out of it and that, that's often what, what makes it more chronic psychotic experience, but it should not be that. That way, uh, we can indeed organize care in such a way that it becomes an encounter with people where we start from an openness to their experiences and think of it as, OK, this is someone who is trying to make sense of a very difficult life. Situation or a very difficult moment in life, uh, on the one hand and on the second hand, we can think of, OK, but what is an environment that might have a healing potential for people, huh, and it's when you can create an environment where people are respected. Where they are valued, where they're not just seen as a problem, but just as human beings who are, who, who maybe have psychotic experiences but, but who have many other experiences, when you're treated as fully human, this is a, a context that is helping people to escape from or to find a way out of this crisis, but when you don't provide such a context, And rather start stigmatizing people, for example, by declaring, declaring them very sick, very ill, very chronically, never to be healed, uh, one psychotic, always psychotic, when you start having this kind of opinions, yeah, of course it, it becomes very difficult for people to escape, and so it's, it's, it's often us that create, that make it a very difficult problem for people who have the, the psychotic experience.

16:48 Ricardo Lopes: Uh, DO you think that even the diagnostic label itself can sometimes, uh, induce, uh, distress, or, I, I mean, or contribute to it being harder for the person to really improve their mental condition because I mean, if you get attached to this idea that becomes part of sort of your identity. That you are a psychotic person instead of, for example, just someone who in certain circumstances experiences psychotic episodes or psychotic reactions. I mean, couldn't that be problematic? Yeah,

17:32 Stijn Vanheule: absolutely, and at that point it's very important to attend to the language that we use when we speak about mental health difficulties. Like for example, a diagnosis like schizophrenia, which when you check it psychiatric manual is one of the psychotic disorders, um, this is a label. To which many ideas are already connected before you have it, yeah, so, often the idea of schizophrenia is connected to a deteriorating brain, to having to take medications for the rest of your life, uh, you will have difficulties in working and getting relationships, um, you will probably be chaotic and things like that. So there's a whole network of of expectations that is being created and. So, if we quickly give, or if mental health professionals quickly use that label to try to make sense of what a person is going through, this might have a devastating effect and therefore, it's interesting to see, of course, that there is a counter movement within psychiatry who questions these labels and who wonders, like, is it the best way to address things and um at that level. I'm more uh inclined to speak about um Psychotic, not as to not use it as a noun, but to use it as an adjective, meaning like you can have psychotic episodes, you can have psychotic um experiences, you can have a vulnerability to, to psychosis, and then we more see it as a process like thing, um, and not as a fixed state. And that's usually one of the problems that we're all responsible for, um, that we tend to, to think of it as a state, as a fixed state and not as something that is more process-like and for me that's the only useful way of thinking of it and what is kind of interesting is that when we at the societal level, think about um Less severe, so to speak, psychiatric disorders or psychiatric problems like, for example, anxiety and depression, we we tend to think of it as a process like we might all have at a point in our lives a depressive episode, uh, but we don't tend to think of it like, OK, once depressed, always depressed, no, it will be maybe a vulnerability in your life, and when you have had an episode and you enter. A difficult moment in your life later on that you might react again with psycho with, with depressive experiences, but we tend to think of it more as a process. But when we switch to psychosis where reality is experienced in a different way, we tend to to hold on to that categorical thinking and at that point, it is stigma that we do, we do stigmatization and that's something, of course. That is, that is not very fruitful, and that me also as a psychoanalyst, I see, OK, we at that point have to change something in our mental health system because that mental health system is still too strongly oriented towards the towards categorical diagnosis.

20:53 Ricardo Lopes: So what do we know about uh how psychotic episodes happen? I mean, what is it that triggers psychotic episodes in people?

21:05 Stijn Vanheule: Um, WELL, of course that's a complex story. Um, THERE is no one cause or one specific trigger that is, is there in, in all cases, but there is, uh, first of all, there is a component of biological vulnerability that is there, but, um, the thing is it, it has. Always been overestimated that component, um, like for example, genetics do play a role in our vulnerability for psychotic experiences, but long it has been thought as if genetics would explain like 50% of, of, of, of the chances that you develop a psychotic episode or not, but actually that's, it's much less. It's, it's, it's more around 1012 to 15% of your vulnerability is a biological component. That means that there's other components that play an important role, and for example, what we do know is there's quite some societal stressors that make people more vulnerable to psychosis, like for example, um, experiencing trauma as a, in your young age, and they could both be abuse or misuse or, or, or, yeah, being bullied as a, as a child. Um, THAT, that's something that makes you vulnerable or belonging to a minority group that is excluded in society, that's what makes you vulnerable. So there's a couple of social factors that play a role, um, but also, and that's also what interests me as a psychoanalyst the most. Um, AS human beings, we are internally confronted with, uh, dilemmas for which we don't have a definite answer, like, um, like, for example, how to relate in relation to sexuality and love, how to relate and as a parent in relation to children or as a child in relation to your parents, how to organize your life in such a way that it becomes meaningful, that, that the idea of dying is not devastating. These are also like very specific human questions that do return in the triggering of a psychotic episode, because it's often at turning moments in life that people start to have psychotic episodes, like it's, it's when, for example, when people graduate from school and have to switch to having a job, or when they start a relationship, or where there's a relationship breakup, or when they have a child. And they have to be a father or a mother, or when you had a job and you're fired, or you have a job and you try to do it so good, and you go in overdrive, or someone who's very close to you and. Dies like a parent or a loved one, these are all moments in life that made, that trigger us, that, that challenge us, and these are psychologically speaking, often the, the, the tipping points, the triggers that, Yeah, that provokes something of a psychotic experience and so for me as a psychoanalyst, it's always very important to not just look at the psychotic experience in the sense like reality is being experienced in strange ways, but always like, yeah, there is something that that is being experienced, so the content of a psychotic experience is often. Something of an elaboration already of the trigger that people have been confronted with, um, so for example, when people are being confronted with death in their lives, uh, and that is very difficult to them, there's quite a chance that there will be a morbid character in their, in their, in their psychotic experiences that it will be around threatening about murdering, about dying, about being dead already. Uh, SO that something of the thematics of the delusion of the hallucinatory experience echoes something of the dilemmas that people have been confronted with, huh? So that's my idea as a psychoanalyst, and it's only by attending very carefully to what people say about what they experience that we can get in touch with the triggers and the difficult aspects in their lives that, that they have been struggling with.

25:28 Ricardo Lopes: So what do you think or what would you say psychotic episodes express about uh the psyche of a particular person in particular circumstances?

25:43 Stijn Vanheule: Well, for me it's um it expresses existential dilemmas. Um, YEAH, uh, what to do as a human being. So it's actually, it's an existential ethical foundation of human being that is being triggered there. What should I do to do good in life, to do good, um, as a child in relation to my parents, as a parent in relation to my children, what should I do? And the thing is that as a human being, we are not entirely biologically programmed. We are programmed by biology, we do have instincts at to a certain level, like we don't have to consider very consciously how many times we will breathe, uh, in, in, in a time span of, of one minute. This happens automatically because the body regulates itself, huh, but at the level of our psychological functioning, we don't have. Instinctual regulation for everything and that's the very point that psychoanalysis calls the drive, uh, the, the dimension of the drive and what is the drive? It means that we are triggered by situations and our body reacts in an effective way to situations, but it's not that biology is guiding us in how to, how to deal with these situations, and that's exactly at that point we are there as a questioning human being, as an existential. Creature who is, who is knowledgeable about the fact that we are and that we are there, but we wonder how we should deal with situations and when we wonder how we should deal with situations as human beings. We tend to look at the answers that have been formulated around us, the answers in our context by our families, by our parents, by our societies, through the books that we read, through the education that we got, and we tend to relate to these ideas in a dialectical way. Like, I agree with some of the ideas and I disagree with other ideas, and as a human being, I search my way. Into these dilemmas and as long as I can do that, I have something to hold on to, but my idea about psychosis is that we as human beings also have the potential, the, the, the, the, the possibility of ending up with no answers at all with, with the dilemma, yes, but with finding no solutions anymore. With seeing no perspective anymore and at that point that's for me the triggering of a psychotic episode when we as speaking beings who use words and narratives to make sense of ourselves and of the world might end up in a situation where there's no word that is organized potentially organizing. Uh, REALITY anymore is, is, is available and at that point, reality goes crazy for people because it becomes inexplicable. It becomes no longer possible to frame something of reality, and framing is something that we always do with words. With ideas and ideas are rooted in words, that's how I think of it as, as, as a psychoanalyst, um, and so therefore, also talking therapy is very useful in working with people with psychotic experiences, the possibility because it's a way of thinking how maybe words can be used to digest something of that very difficult experience.

29:16 Ricardo Lopes: Right, but, but I mean, it's one thing for the narratives that we have at our disposal in our socio-cultural context to not work for us anymore in particular cases or in particular circumstances, but, uh, I mean, is it possible or do you think that it's possible that perhaps some of these, uh, norms or some of these normative. Ideas that we get from our society as to how we deal with, for example, death, loss, romantic breakup, or, I mean, even some of our more personal failings, like, for example, failing in being a proper father, a proper mother, or whatever your understanding of that is in your, according to the society you live in. I mean. Do you think that perhaps some of these, let's say, expectations or norms of thinking could induce or at least could aggravate uh psychotic episodes because we are failing to conform to conform to the expect the expectations put upon us by our society.

30:36 Stijn Vanheule: Yeah, so at that point we will make within Laconian psychoanalysis, meaning psychoanalysis in, in, in, in line with the works of Jacques Lain, we make this distinction between neurotic and psychotic struggling. HM, yeah, and what is typical of neurotic struggling with like the societal norms is that we are always in doubt. Am I doing the good thing because people or society might expect this. And this and that from me, but, and, and then I struggle with do I want to comply with it or not, uh, and, and it results in internal conflict, uh, uh, but we are always like in a continuous internal dialogue with all the expectations around us, and that's typical for neurotic experiencing. What is typical for psychotic experiencing rather is that, um. At a certain point, these narratives around me don't make sense anymore, that it, it's, it's more the experience as if they, um, they don't speak to me anymore. Um, I know they are there, but yeah. They don't help me, they don't inspire me anymore, and I rather start to feel empty handed, as if I'm alone. I'm the one who needs to solve the situation because there's no idea, there's no one who can really help me with this dilemma, so it's really the experience of being really alone in the world um that is often so typical of, of, of people with psychotic experiences. And then you have to see of course that when bad things happen in people's lives, for example, imagine that you're being abused as a child by your parent, huh? So here you have something that you experience, uh, and societal norms tell you that this cannot be the case because a father or a mother is supposed to take care of you, but you are in a private situation where this is not happening, so it becomes very difficult to make sense of that. Experience that you're having given the referential framework that you have and that's a point that might make people more vulnerable because you are confronted with situations that literally do not make sense, huh, and so that's really triggering for a young mind to deal with that, um, and so that's how I see why trauma. Yeah, severe trauma is often indeed triggering to psychosis.

33:11 Ricardo Lopes: Yeah, but then definitely the reference points we get from our cultural context uh can play a role in psychosis.

33:20 Stijn Vanheule: Yeah, yeah, absolutely, yeah, yeah, um, I don't what we typically see then in psychosis is that often, um, uh, when people develop so-called delusions or start having hallucinations that they pick up elements from the culture. Um, LIKE, for example, nowadays, many people will have delusions that go in the direction of AI as if they have the feeling that an AI is taking control of their, over their brain. Um, THAT thoughts are being put into their mind and they don't think these thoughts themselves, but still the thoughts are there, so it must be that it's not my intelligence but an artificial intelligence that is entering my mind, uh, so what we see in psychotic experiences is that it echoes, that it goes into, uh, an innovative dialogue, so to speak, with, with, with the culture around us. And it's, for example, now we see lots of experiences that pick up something of, of, of, of information technology, but that's also why in many psychotic experiences, God is there and Jesus is there and Allah is there and Muhammad is there, uh, and Buddha is there. Why is that? It's because, of course, these are the cultural references that we use. That we have been using for ages to think about the dilemmas, but then it's not so much as an idea that I'm in a dialogue with, it's more like. There's something of a complete innovation that is coming from an idea that I'm confronted with. It's not so much a thought, but it becomes a reality with which I'm interacting, and that's typical of a psychotic experience. You are starting to experience new realities, and some of the figures and some of the ideas that are circulating in our culture become real creatures with which I am interacting.

35:17 Ricardo Lopes: Right, so, uh, how shoulder psychotic experiences be dealt with, particularly in a clinical context to help people overcome their distress?

35:32 Stijn Vanheule: Yeah. So we have to see that often in a clinical context, people enter in a state of crisis, huh, um, they don't know what to do anymore, they cannot make sense anymore of these things that are happening to them and often in their context, people are also in panic, uh, like their, their, their partner is in a panic because what is happening to my, to, to, to my, to my boyfriend, to to my, to my, to my husband. Um, PEOPLE don't know, there is panic. So the one thing that first of all needs to be done in a mental healthcare system is to create a context that can contain the crisis. That incarnates something of the calmness like give people space and time, let them land, let them arrive, let them be welcome in a, in, in a context, so provide them with time and space and with human beings that are there around them. Human beings that are willing to listen to them, that are willing to take it seriously, that are willing to recognize their experience, and that does not mean that we have to say to people, oh, it is true what you experience, so we don't have to like give a judgment whether it is true or not true. The thing is they experience it and the question is, but why, what, what, what triggered it? What brought them in such a state of crisis, uh, and so it's providing such an atmosphere that is very important and to, to help people to, to, to go beyond something of that experience. Um, SO it's by creating a certain atmosphere, and for me the most important thing to do there is to create, to try to create encounters with people, huh, and encounters with people is like meeting again, speaking again to one another, um, and also doing things together, eating together, drinking coffee together, and maybe doing activities together. Like going for a walk, painting a little bit, playing some music, listening to some music, discussing novels, uh, but also maybe discussing their life situations, uh, and to kind of like really valorize them as sense-making human beings. That's the kind of context that we should create for people and then we can think of. What can maybe help people to enter such a state, uh, and it's only at that point, for example, that medication could be considered for people. I don't think it's a standard solution that works for everybody or that makes sense for everybody. For some people it might help, and for some people it might help that they have medication that makes them less anxious, huh. Uh, AND other people, something that makes them an antidepressant or an antipsychotic medication, but to be very careful with that, it's not the the, the solution, the medications, but it can help in reaching a certain calmness inside, a certain openness again to, to attend to the experience, because that's for me what needs to be done and the next step is like looking how to express something of it, huh, and we can both do that in words. Huh, like in talking therapy, like we usually do in psychoanalysis, but we can also do that in creative expression, and that's also what I stress in the book, uh, psychotic experiences are so Different compared to other human experiences that it's not everything about them can be told just in plain words and in narratives. Something is often better expressed in creative ways like through painting and singing, um, uh, as, as other modes of, of human expression are often very useful, um, also in that context.

39:22 Ricardo Lopes: Right, yes, because nowadays we tend to have these very biological, very strong biological framework in psychiatry specifically, and many times people think that even the Professionals themselves that the only way, or, or, or maybe not the only way, but the, the primary way of helping people who suffer from psychotic episodes is through medication.

39:53 Stijn Vanheule: Right. Yeah, and, and, and that's a bit our societal um delusion, you could say. We live in a technological society, and we tend to believe that if there is a problem, there must be something of a, of a mechanical solution to it, like my, my, my car is not driving very well. I go to the garage and I ask people like, check it, monitor it, and, and change the, the little element in my car that is causing the. Disturbance, we are mechanical thinkers and we tend to think that psychiatrists and psychologists should be some kind of engineers of the soul who do the same thing with a human being that is in crisis, as if they can look into the mind and look into the brain and then change that little mechanism and preferably we want something concrete, something technical as a solution, but that's just a societal dominant narrative, um. And of course there is something of our human functioning that obeys that mechanical, biological logic, but there's much to our functioning that is different, that, that goes beyond that simple model, and when we want to take care of people with psychosis, we have to go for that broader perspective and therefore, we need like a broader idea about human functioning in which, Sense making, speaking, using words, using narratives, uh, is also taken into account the fact that we live in a cultural context, the fact that um if we live in unhealthy circumstances, this will have an effect on our, how we feel, these are all things that need to be taken into account and not just focusing on the question of, OK, a medica giving, giving a medication for, for it as the solution.

41:43 Ricardo Lopes: Right. So, uh, I mean, I want to ask you this question and I actually have two more questions also because we're running out of time here, but, uh, people have this very common understanding of what, uh, uh, so to speak, psychotic person, uh, is like, where they think that it's not possible at all to communicate with them. Because they are out of their mind, they are insane or something like that. I mean, but, but, but how can people communicate with someone who suffers from or experiences psychotic episodes?

42:23 Stijn Vanheule: Yeah, well, there are at least 3 things that we can always do that everybody can always do if you are a professional or if you're appear to someone, if, if it's someone in your, of your friends. There's 3 things that we can always do, and the first of it is very easy and very difficult, and this we can listen. And listening means like with an openness of mind, attend the other, and we could maybe if we would write other here with a capital O in the sense like someone in who they are and how they are different. Compared to what we think they are and that we accept it and really listening to people means like being open to what that very person is saying and often we don't listen because we already have an opinion about people and that's the difficulty also when we classify someone, oh, but he's a psychiatric patient. Yeah, uh, then we don't listen anymore because we already frame it, so actual listening is like creating an openness of mind in yourself and really attending to what someone is saying, huh, and so it's in a non-judgmental way attending to someone. That's the first thing we can all do, simple, listen. The second thing you can do is that we can recognize the impact of the experience. Maybe it's not something that I myself have experienced, like a voice saying um weird things to me, huh? Maybe I didn't experience it myself, but if someone tells me that this has happened to them, I can recognize the impact of it. Uh, IT'S not saying like, OK, but this is not possible, hearing a voice that I don't hear that it's not being judgmental here again, but it's recognizing that it must be disturbing to feel that or to hear that, huh? Personally I didn't experience it, but if what you say you have experienced. That must be like devastating, so recognizing something of the impact of an experience is also something we can always do. And the third thing we can always do is that we can do things together with people beyond. That psychotic experience, we can always drink a coffee together, we can always chat a little bit about, about, about cycling uh on TV or, or, or, or a TV show or sports uh or the weather or uh the quality of the, the, the bread. That the bakery is selling, so there's always little things we can talk about, and this is also very important because um often when people start to have psychotic experiences there starts to be a distancing both in that people lose their feeling of connectedness with the world, but also that, that the world takes a distance from them. And it's often by doing little things together that we keep a connectedness, so we can always invite someone to go for a walk, for example, or to go for a coffee, uh, and that's creating a connection, and these are three things we can always, all of us do, both if you're caregivers in an informal sense or professionals or friends to people. This is something we can always do, and that will help people to digest their psychotic experience.

45:50 Ricardo Lopes: Yeah, you know, I'm not a clinical professional, of course, but I, I mean, in dealing with people that many times other people label as crazy or insane or out of their mind or something like that, I mean, I frequent, frequently find that many times it's if you just listen to the person, it's If you try to put aside your, let's say, cultural filters in terms of what you consider normative and so on, it's not that hard to understand why a person who manifests a particular mental experience or distress or something, why, at least in their particular case, in their particular circumstances, that makes sense. And many times I think we're also too weak when it comes, when it comes to uh ostracizing or stigmatizing or alienating someone just because they express particular ideas when perhaps uh I, I mean, I'm not necessarily trying to minimizing here uh the distress the distress caused by psycho. Experiences and other kinds of mental experiences, but perhaps sometimes it's not even that the person has any kind of mental problem. It's that it's just that they're different in their way of thinking and they are not heard actually heard by other people. I mean, I don't know if you also have that kind of experience or not, but

47:34 Stijn Vanheule: Yeah, absolutely, and we, we must also see that there's quite some very creative minds that we have had or that we have in, in our culture and society that um that started a way of thinking or that, that way of thinking was connected to something of psychosis and of insanity. Um, LIKE in philosophy we have Wittgenstein, uh, we have N Nietzsche. These are important philosophers who, who thought through very difficult problems. We have important mathematicians, we have, uh, like also in my domain, domain of psychology, like in, in the book I discussed the case of Carl Gustav Jung, who clearly also had psychotic experiences but who tried to. To like transform these experiences into something of an insight into the human mind but also like uh in, in an attempt to be creative, um, and to live accordingly to the, to these experiences in, in, in, in, in, yeah, in very creative inventive ways we have many artists who have had psychotic experiences so I see it also at, as, as a. Potential source of, of innovation and creativity both in an individual life where we must see that if someone goes through a psychotic crisis, this is not the end of their lives, no, it, it, it, it is the potential of for them to find something else and I don't know beforehand what it will be, but obviously it's a breaking away of something of a, of what used to be an internal. Consensus or an internal equilibrium, but they're going away, they're moving from it, and it might lead them to a different path that is maybe better for them, but also at societal level, people with this kind of experiences, yeah, can bring new ideas. Uh, IN a world where we tend to circle around in, in always the same ideas, and so there is something of that creative power connected to psychosis that, that should be valued.

49:41 Ricardo Lopes: So my last question then, and it's related to what I've just asked you, I mean, what do you make of the idea of insanity, because we tend to use this word, we tend to label people as insane. As if, I mean, they're out of their mind and we can't even speak to them in a rational way at least anymore. I mean, uh, are there actually insane people? Should such a label be used?

50:14 Stijn Vanheule: Well, the thing is that um these labels like crazy and insanity. Um, THESE are lay terms to refer to certain situations and often we use them to refer to situations in which the crisis becomes so intense and big that we cannot understand it anymore, huh, um, and here it's interesting to see that many people who have psychotic experiences and who enter a crisis also have an experience of insanity because they, they have the impression that the world has gone insane. That the world is crazy, that very weird things are being done to them, or they might fear that some instances are making them crazy. So craziness and insanity is a reference to, um, a potential mental state of functioning where I lose control, huh? And when outsiders tend to stigmatize people, huh, they also tend to use that word like they're someone is crazy or someone is insane. But actually that's only denominating that they themselves are afraid that they themselves cannot make sense of, of a person's functioning anymore, but rather than thinking of it as a challenge that is inviting me to search new ways of finding a connection with someone. At a societal level, we tend to withdraw into the stigmatization and to continue like just framing someone as insane. So framing someone as insane or or as crazy is not the solution at all because it's, it confirms the, the stigmatization. It's, it's, it, it's in the moving beyond, it's in the thinking of it as not so crazy, that's why it's also in the title of my book, Why Psychosis is not So Crazy, because we think, we tend to think of it as very crazy and very strange, but the more. You listen and attend to people, the more you will discover that it's not coming out of the blue and that it's actually saying something, something about themselves, but often something about their context as well, about their societies as well. So it's a source of truth to, to people, and if we don't listen to it, that is very stupid.

52:33 Ricardo Lopes: Yeah, so let's end on that note, Dr. Van Hole, and the book is again Why Psychosis Is Not So Crazy A Roadmap to Hope and Recovery for Families and Caregivers. We'll be leaving a link to it in the description of the interview. And would you like to just tell people where they can find you and your work on the internet?

52:57 Stijn Vanheule: Um, WELL, um, like the book is, um, worldwide available. You can find it, you can ask it to your local bookseller, that book, um, they, they can, um, search it and, and, and give it to you or sell it to you, I guess. You can ask your libraries to order it or you can find it online, that book, um, but, um, I'm also an academic, so I'm a professor at Ghent University. Uh, MANY of the papers I've been writing, um, are also online available. If you use my name as a search term and you look for, uh, Stein von Hule on, on what has he written on psychosis or on psychoanalysis, you will find multiple links to, to my work.

53:42 Ricardo Lopes: Great. So, Doctor Van Hue, thank you so much for taking the time to come on the show. I really loved our conversation. Thank you so much. Yeah,

53:51 Stijn Vanheule: thank you, Ricardo.

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