December 19, 2022

By Mark Ragins, MD

I’m the kid who pestered my parents and teachers by always asking “why?”

By the time I finished college, I was fascinated by psychosis, but I found that there were very few books about the topic. The books that were available talked about illnesses, dopamine, genetics, medications, deinstitutionalization — and not much else. They never seemed to ask, let alone answer, “why?”

  • Why is someone experiencing psychosis when no one else in their family is? Why do people hear voices?
  • Why can’t they tell the voices are not real?
  • Why are there so many varieties of experiences?
  • Why can’t we understand what they’re experiencing or help them more?

I had a lot of questions — and no convincing answers — when I headed off to medical school to become a psychiatrist. Since then, I have spent the last 30 years gaining a deeper understanding of this symptom. Here is what I’ve learned.

Myths that Hold us Back

The main reason we don’t know have the answers, or even ask the important “why?” questions about psychosis, is due to a set of myths. Many people falsely believe:

  • That the content of psychosis is meaningless. There’s no point trying to understand what they’re experiencing.
  • People with psychosis are dangerous and people should be careful around them.
  • We need to keep our distance to avoid feeding into a person’s delusions or we might become part of their delusional world.
  • People with psychosis can’t recover. The best we can hope for is them staying on their medications, stabilizing and not hurting anyone.

Each of these myths has been ingrained for over 100 years in both our medical model and our society, but none of them are usually true.

Embracing a Variety of Methods

I spent most of my career working at Mental Health America of Los Angeles’ Village in Long Beach, Calif. — one of the most successful mental health programs ever during its peak. I decided to write the book that I wished I’d had when I was young, Journeys Beyond the Frontier: A Rebellious Guide to Psychosis and Other Extraordinary Experiences.” It’s filled with true stories of people I’ve met, the explanations I’ve come up with for all my questions and strategies to help people more effectively.

1. Understanding the Person – Not Just the Symptom

I’ve learned that prolonged psychosis is not the product of a single illness. It’s the result of many different pathways and causes, each of which should be approached, understood and helped differently. Psychosis is also not just a biological process impacting how someone experiences reality. It’s a combination of three dimensions — experiencing reality, self-identity and relationships — all falling apart as their life unfolds.

My guidebook includes eight “journeys,” impacting all three dimensions, including:

  1. Loss and grief
  2. Psychotic reactions
  3. Difficulties in making sense of the world
  4. Childhood trauma
  5. Losing balance
  6. Drugs and alcohol
  7. Psychiatric illnesses
  8. Brain damage and other neurological and medical conditions

If we’re going to really get to know people, and how they got where they are, we’re going to need to use a comprehensive model, not just a symptom checklist.

2. Replacing Fear and Avoidance with Respectful Curiosity and Caring

For almost all of us, psychosis is beyond our comfort zones and frontiers of understanding. Many tend to fear people with psychosis, avoid them, try to keep them contained and controlled. Our first efforts should instead be around humanizing and engaging people with psychosis.

If we can actively explore their experiences and lives, seeing the experience from “their side,” we can begin to partner with them and help. We can focus more on the story of their life, instead of just a diagnosis that they “lack insight” into. Medications don’t have to be used only within an illness-centered approach. They can be used in a recovery, person-centered approach that helps people grow and develop.

3. Focusing On Building Connection and Relationships

Social isolation can potentially cause symptoms of psychosis in anyone, regardless of neurobiology. Accordingly, medication and therapy are not the only effective treatment options for people with schizophrenia – studies show that regular social interaction can significantly reduce psychiatric symptoms.

Often, staff are limited by their professionalism and cannot make personal connections effectively. However, they can help by observing the “3 C’s”— being curious, caring and committed. We need programs to be welcoming places, with a culture of acceptance, instead of clinical fortresses.

4. Using Growth and Hope to Build Recovery

While the medical model usually focuses on reducing psychotic symptoms and treating a person’s illness, it often neglects the other two dimensions — a person’s self-identity and relationships. This is a missed opportunity as many people are likely to be more motivated to pursue their own goals, such as quality of life goals, rather than symptom reduction or illness treatment goals.

When we focus instead on housing and employment, even while a person is symptomatic and may always be, people are far more likely to grow and recover. We can nurture their hope and motivation by taking their dreams and goals seriously, helping them visualize the better future they want and giving them the concrete support and resources they need to succeed.

Moving Forward

My book goes beyond exploring, understanding and connecting with people with psychosis to show how this three-dimensional approach (experiencing reality, self-identity and relationships) can help us meet many of the serious challenges we face today, including suicide, violence, substance abuse, poverty and homelessness, family relationships and employment. It also describes a variety of programs that focus on person-centered recovery that exist primarily on the edges of our system.

We need to demand the provision of, training in and funding of, the most successful interventions, rather than just the “medically necessary” services.

Now that I know what can lead people to experience psychosis, ways to help them recover and even why most people perceive psychosis inaccurately — I’m left with one more question: Why can’t we remove our blinders and move forward using what we have learned?


Mark Ragins, MD was the Medical Director for 27 years at the Mental Health America Village in Long Beach, Calif. In 2017, he became the only campus psychiatrist at CSULB, and in 2022, he joined the Department of Health Services mobile clinics and street medicine teams working with unhoused people on the streets throughout LA county. His recent book, “Journeys Beyond the Frontier: A Rebellious Guide to Psychosis and Other Extraordinary Experiences,” is based on the true stories from more than 30 years of clinical work with some of the most underserved people in our communities. Mark has won a number of awards including the American Psychiatric Association’s Arnold Van Amerigan Award in Psychiatric Rehabilitation, the Psychiatric Rehabilitation Association’s John Beard award for his outstanding lifetime contribution to psychiatric rehabilitation and National Alliance on Mental Illness (NAMI) California’s recovery practitioner of the year.

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