Using Metaphors to Deal With Psychosis

Velo-cardio-facial syndrome (VCFS), also known as DiGeorge syndrome or 22q11.21 deletion syndrome, has a prevalence in the United States of approximately 1:2,000. Patients affected by this syndrome have an elevated risk for psychosis in late adolescence, which ends up affecting 30 to 40 percent of young adults with VCFS. This post describes hypnotic metaphors that have helped treat psychosis in this patient population.

In addition to psychosis, psychiatric disorders are present in most individuals with VCFS (Fabbro et al., 2012) and include anxiety, mood disorders including depression, ADHD of the inattentive type, learning disabilities primarily involving non-verbal skills, oppositional defiant disorder, specific and social phobias, and obsessive-compulsive disorder.

Individuals diagnosed with VCFS commonly experience cognitive deficits, with an average full-scale IQ of 73.3, and face limitations in communicative abilities in about 70 percent of cases. They also have numerous associated medical disorders, as described by Shprintzen (2008).

Over the past decade, I have worked with 10 adults with VCFS (age range 18 to 39), including four adults who dealt with psychosis. Their hallucinations had been only partially controlled with the use of medications. To aid in their treatment, I taught them how to use hypnosis that included the use of metaphors to help them handle their difficulties in dealing with their hallucinations, including distinguishing them from reality.

In approaching these patients, it is worth keeping in mind that optimal health care occurs when clinicians provide therapy compatible with their patients’ belief system. Thus, I believe this also is true when patients report hallucinations or delusions. In such cases, I have found it useful to consider the patients' beliefs as real, and to help them cope by providing suggestions that fit within their belief system, rather than telling them that their beliefs are false.

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Red Pill/Blue Pill

A 20-year-old with VCFS developed frequent episodes of paranoia, during which he felt his parents were replaced by evildoers, heard voices telling him things he did not want to hear, and became frantic when he felt unsafe.

He was a fan of the movie The Matrix, in which people are given the option to take a red pill or blue pill. The red pill allows them to awaken from the simulation in which they are living, while the blue pill would make them forget their awareness of the reality outside of the simulation.

I suggested that this patient be given an option to take a red Skittle (candy) or a blue Skittle while he was in a paranoid state. On some occasions, he chose to take the red Skittle, and his delusions then resolved.

Another technique that helped this patient temporarily was the suggestion that he put the voices on a radio, and then turn the radio off.

Discarding Voices

A 23-year-old with VCFS complained of recurrent voices that were telling her to do bad things. She did not want to disclose the content of these intrusive thoughts. Over several weeks I gave her many suggestions regarding how to reduce the impact of her loud internal voices, which she reported helped her cope with them for up to several days or a few weeks.

The suggestions included throwing the voices into the ocean, locking them up, turning down their volume, or telling them to pipe down. On one occasion, her voices agreed to speak telepathically so that they would not be so loud. I suggested that she tell the voices she would spend time with them in the evening, as long as they were quiet during the day. On another occasion, I suggested she invite positive voices and teach them to sing to drown out the negative ones.

I gave her an amethyst stone (and suggested that as an alternative she could use Chinese Baoding balls) that she could hold to help control the voices. Finally, I provided her with a reassuring recording I made for her in which I told her she could control her voices by telling them to speak silently. She said that listening to the recording helped.

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This patient also developed hallucinations regarding seeing spiders. I suggested she use the Baoding balls to run over the spiders, imagine spraying them with anti-spider spray, or offer to give the spiders haircuts, since they hate haircuts. These suggestions helped reduce but not eliminate the spiders.

Talking With Imaginary Beings

A 34-year-old patient with VCFS who lived with her parents spent much of her days talking on the telephone to imaginary friends. She told her mother that one of these friends had died. She was not receptive to being told by her family that her friends were imaginary. On some occasions, she said that she had heard knocking on her door in the middle of the night.

After working with me for several weeks, this patient asked me questions about how to deal with fallen angels and demons. She said she had never encountered such beings but was interested in the subject. I told her that in my experience with other patients, finding out what the beings desired and addressing their concerns has helped the beings depart.

I thought the discussion about out-of-this-world beings involving other patients represented progress, as it allowed this patient to explore the theme of interactions with imaginary beings in a face-saving way. Subsequently, although she no longer reported talking to imaginary beings, she began reporting that she had developed dark nightmares.

We discussed the possibility of her learning to control her nightmares by telling herself that she wanted to be protected in her nightmares by a superhero, which she said helped.

She then told me that in one of her recurrent nightmares, she was disturbed by the loud sound of a magnetic resonance imaging (MRI) machine. I suggested that she could drown out the sound by playing music in her dreams. Subsequently, her nightmares about the MRI machine resolved.

The Takeaway

As hallucinations and delusions can present in many ways, a clinician must utilize a creative and flexible approach with offered suggestions.

It is unclear whether the experiences with VCFS patients that I report in this post are generalizable to treating patients with psychoses that arise because of other reasons.