Allowing for Psychosis to be Approachable and Understandable as a Human Experience: A Role for the Humanities in Psychotherapy Supervision

Introduction

In conducting psychotherapy with people with psychosis, a key task facing therapists is to form a working, and safe, therapeutic alliance. This requires therapists to be authentic in the moment, to make sense of the bewildering and confusing elements of psychosis, and ultimately, to empathize with clients’ personal experiences of psychosis. Joining in these ways with people with psychosis can be challenging for a number of reasons. For instance, therapists may be fearful of being personally vulnerable, or may struggle to see psychosis as part of the continuum of human experience (Eigen, 1986). Failure to be able to join with a client may lead to any number of nontherapeutic processes much as it does in therapy with clients who do not have psychosis Florsheim, Shotobani, Guest-Warnick, Barratt, & Hwang, 2000; Orlinsky, Rønnestad, & Willutzki, 2004; Ravitz, McBride, & Maunder, 2011; Samstag et al., 2008; Zuroff et al., 2000.

A key task of supervision and a core element of training in psychotherapy is assisting therapists to join with people who have psychosis during treatment. Numerous authors have addressed important topics in supervision and the formation of a therapeutic alliance, such as the use of the supervisor-supervisee relationship as a starting point for understanding the therapeutic process (Searles, 1965), the importance of addressing therapist stigma in supervision (Buck et al., 2013), and the process of helping therapists to engage ambivalent clients and to manage feelings of vulnerability (Gold, 2004). However, less has been written about how to help therapists in training—especially students or those early on in training— understand that psychosis is approachable and understandable as a human experience. One way supervisors can help beginning therapists is by teaching them to consider their clients not merely as passive victims whose challenges are a matter of a life that has been interrupted by symptoms, but rather to view these symptoms as part an active meaning-making process, regardless of whether or not that meaning is adaptive.

It is not uncommon for supervision of student clinicians to include materials from outside psychotherapy to help diversify the supervisees’ ways of thinking and to enrich their experiences of clinical work and supervision (Bernard & Goodyear, 2009). In this paper we will explore how introduction of materials from the humanities might help supervisees consider psychosis as approachable and understandable and be better able to form therapeutic alliances with clients who have psychosis. We will explore how using novels and related literary genres instead of first-person accounts of suffering or illustrative case studies in group supervision helps trainees develop the ability to empathize with and relate to the experience of psychosis. We will first discuss the use of novels and related literary genres as illustrations of psychopathology. After this we will illustrate how these genres help in understanding and relating to the subjective experience of psychopathology. We will next examine the differences in using novels and related literary genres instead of nonfiction, first-person accounts of psychosis. We will describe specific methods of incorporating these materials, and then discuss the experiences of student clinicians exposed to them. Finally, implications for treatment, training, and future research will be discussed.

Using Novels and Related Literary Genres in Supervision

The idea of using literature¹ to teach people how to recognize psychopathology and to conceptualize clients has existed for decades (Mahoney, 1965; Silberger, 1973; Tucker, 1994; Wood, 1955). It has been proposed that literature allows clinicians in training to recognize and conceptualize psychopathology in a manner that is more expressive and less clearly laid out than the case examples and descriptions found in psychology textbooks (i.e., Douglas, 2008; Mahoney, 1965). For example, clinicians in training may see in a character a cluster of symptoms that might indicate a specific diagnosis, which can lead to the analysis of underlying psychodynamics. Additionally, psychoanalytic thinkers, in particular, have a history of using novels and other literature to illustrate underlying dynamics to trainees (e.g. Rodenhauser & Leetz, 1987). Silberger (1973) described using novels in training clinicians. Reading novels was a way to educate trainees about the psychodynamics of both the characters and the trainees. It was also an exercise in understanding others’ motivations and emotions. Others suggested that conceptualizing characters in novels provided student clinicians a nonthreatening opportunity to disagree with peers and supervisors about these conceptualizations and to develop their personal understanding of human behavior (Silberger, 1973; Wood, 1955).

Using Novels and Related Literary Genres to Deepen Understanding the Subjective Experience

Novels and related literary genres have been used predominantly to illustrate case examples, but when used in training literature may offer opportunities for student clinicians to gain understanding of the more human aspects of mental illness and to deepen their appreciation of subjective experience beyond labeling experiences as manifestations of particular diagnoses. Crawford and Baker (2009) discussed how literature allows for the perception of unusual behaviors, including those associated with psychosis, as existing on the continuum of human experience. Literature also presents a way to deepen understanding of subjectivity of another person through the processes it calls for which often mimic psychotherapeutic processes. Reading requires time and patience, the reader must surrender to the meanderings of the narrator and suspend the desire for certainty.

At a broader level, when reading fiction there appear to be several processes stimulated that open readers, including student clinicians, to a more genuinely empathic stance towards unusual human experiences. Kohut (1959; 1981/2010) described empathy as a process of deepened understanding of another through some shared experience; also describing how individuals are able to access own experiences that are similar (or map onto) the others’ experiences. One such process involves the reader making his or her own meaning of the experiences described in the text (Holland, 1975; Holland, 2009). Oatley (2011a) discussed how novels contain issues of character and emotion that tap into the reader’s personal constructs and how these issues are able to be accessed through indirect means. In reference to Shakespeare, Oately noted: “The something-beneath-the-surface that he depicts is an underlying pattern of how people are and what they’re up to. It’s a reaching towards deeper understandings of people’s inner being” (p. 9). He develops these thoughts and notes the novel is a model of the social world in which everyone is a part, yet the novel allows readers to access different roles and ideas that may not be obvious or comfortable in their own lives. It may be that this level of interaction with the text allows for clinicians to more fully join their clients who have experiences similar to those in the text. We suggest that Oatley’s work (2011a) helps beginning therapists readily identify with experiences that are labeled as psychotic, thus offering therapists a better position to form a working and safe therapeutic alliance.

A second way novels and related literary genres may open up the possibility for genuine empathy relates to how they allow the reader to consider emotional experience from an optimal distance. It has been documented that when reading fiction, the reader experiences emotions congruent to those presented in the story (Gerrig 1993; Oatley, 1999). Scheff (1979) takes this point further and discusses how fiction readers are able to experience emotions from their lives at a distance that allows us to be more open. Scheff (1979) noted that at times in life, everyone is overwhelmed by emotions, and either is overcome by them or blocks them out, preventing these emotions to be assimilated into experience. In reading novels, however, these emotions are presented as the experience of characters. This allows for a more comfortable distance in which readers can access and project their own emotions and experiences onto characters, and subsequently, deal more effectively with these emotions (Scheff, 1979). This seems to provide a type of experience that is distinctly different from reading case studies or novels and related literary genre as examples of psychopathology. Instead, this type of incorporation of fiction novels and related literary genre offers an experience in which a supervisee is able to connect emotionally with material that deepens understanding and humanizes aspects of psychopathology.

In addition to providing a space in which the reader can experience emotions at an optimal distance, reading fiction that humanizes experiences of psychosis likely also allows the reader to empathize with and relate such experiences to the reader’s own life. Interacting with fiction tends to create empathic emotions in readers, such as experiencing positive emotions at times that things are going well for the protagonist and negative emotions when things are going poorly for the protagonist (Mar & Oatley, 2008; Mar, Oatley, Djikic, & Mullin, 2011). Holland (2009) noted that the reader, when experiencing emotions in response to reading, also incorporates his or her own memories of emotionally charged experiences, which likely deepens the empathic connection between the reader and the literary character. Oatley (2011a, 2011b) noted that readers use their ability to know the minds of others through the narrative that is provided. This ability of understanding minds quite different one’s own is sometimes referred to as Theory of Mind (ToM). It has been demonstrated (Mar, Oatley, Hirsh, dela Paz, & Peterson, 2006) that those who read more fiction perform better on tasks measuring ToM.

As readers project their own experiences onto a character and integrate their emotions into a novel that portrays some of the human elements of psychosis, they create their own understanding of that phenomenon and perhaps feel in a way that is similar to individuals who experience psychosis. This deepened, personalized understanding of experiences of psychosis may then allow for a deeper connection with patients, and may create a stronger, more genuine therapeutic alliance in psychotherapy.

Fiction Versus Nonfiction, First-Person Accounts

Nonfictional, first-person accounts are also beneficial in supervision. An account of schizophrenia written by a person with the condition (e.g. Lampshire, 2012) offers beginning clinicians a deeply personal story related to the experience of mental illness. Typically, these personal accounts privilege the perspective of the individual, and therefore, work against marginalization of persons with mental illness. First-person accounts allow for a view into one person’s experience by presenting the meaning the author has made of his or her own experience. A view of what it is like for one person to experience mental illness is presented as a kind of educational experience, but the reader is not necessarily invited to relate to the text and to make original meaning of it. However, novels and related literary genres may serve in supervision in (at least) three ways. First, when reading a personal account of psychosis, readers may be hesitant to take the critical distance necessary to make his or her own meaning of the account for fear that to do so would be aggressive or invalidate the author. Fictional accounts invite reader to take the critical distance necessary for interaction with the text without the implication that the reader is questioning or invalidating someone else’s experience.

A second way novels and related literary genres differ from first-person accounts is that first-person accounts are explicitly presented as stories of mental illness and, often. recovery. Readers may be acutely aware that they are reading a narrative of mental illness, yet in novels the narrative may be presented without being labeled, which contributes to readers’ ability to relate to it. A reader’s personal interaction with the text in the form of constructing meaning allows him or her to understand a bewildering experience as a human one, rather than a clinical one. It removes the need for labeling an experience as psychosis and dismissing it as something specific to a symptom or diagnosis. This personal interaction with the fictional account encourages beginning clinicians to bring to their sessions a genuine and personal way of relating to patients who have psychosis.

A third way novels and related literary genres differ from first-person accounts is that fiction invites the reader to think about human experience as dialogical, presenting dialogue among a range of complementary, opposing, and unrelated elements within oneself and within others. Dialogical theory, which has roots in the works of Nietzsche (1886/1966), Dewey (1922/1988), and Bakhtin (1929/1985), suggests that the richness of self-experience comes from the interaction of a constellation of elements that make up the self that can be complementary or contradictory. The interaction, or dialogue, among these different elements of ourselves and the interaction of these elements with the elements of others make up our sense of self. With regard to reading as a way to understand the experience of psychosis: fictional literature seeks to understand the elements of the experience itself and the relationships between these while first-person accounts often focus on factual depictions of specific experiences. As such, the reader of fiction is free to focus on how different aspects of self-experience interact rather than on the specifics of an event.

Understanding the dialogical nature of experience may afford the fiction reader a deeper sense of some of the most confusing elements of psychotic experiences, which may be caused by self-disturbances in psychosis (Dimaggio & Lysaker, 2010). Lysaker and Lysaker (2002; 2008) proposed that diminished self-experience reflects a state in which intra-psychic and interpersonal dialogue has collapsed. They argue that if dialogue between elements of the self and others were interrupted, individuals may experience three different diminished self-experiences commonly seen in schizophrenia (Lysaker & Lysaker 2008). If very few self positions animate and interact, the result may be a barren state, in which the individual experiences him- or herself as empty. Alternatively, if one element of the self dominates, and there is diminished dialogue with any other elements of the self, a monological state can occur. The individual is fixated on this one element, and therefore, may experience a reoccurring scenario despite the context (e.g., always seeing oneself as being in danger and thus believing one is being persecuted). Finally, it is also possible that elements of the self are numerous and come and go without any sense of order. This could result in a cacophonous state in which individuals experience no coherence or sense of connection between one mental state and the next.

To further address the importance of the concept of a dialogical self, several authors have linked dialogism to metacognition, or the ability to think about one’s own thinking and form integrated representations of oneself and others (Dimaggio, Hermans, & Lysaker, 2010; Dimaggio & Lysaker, 2010; Lysaker & Lysaker, 2002; 2008). Metacognition, more specifically, has been described as a range of mental acts that allows one to recognize aspects of subjective experience, to detect emotional states and viewpoints in others, and to be aware of one’s own internal states (Dimaggio et al., 2010; Dimaggio & Lysaker, 2010). Dimaggio and colleagues (2010) underscore the importance of metacognitive capacity in facilitating a conversation among the various elements of the self, as one must be able to self-reflect and be aware of internal experiences to be able to recognize and be aware of the complexities of a multi-faceted self. As Dimaggio et al. (2010) describes, if one is unaware of a particular element of the self, one will be unable to enter into a dialogue with this aspect of the self and other elements of the self. It may be that through reading novels and other literary genre that allow readers to understand and experience the self as dialogical, therapists as readers can develop a capacity to facilitate this type of inner dialogue through their own meta-cognitive processes in their work with individuals with psychosis, who likely experience a disruption in inner dialogue amongst self-elements.

We do not want to dismiss the use of novels as case examples and we support the use of first-person accounts of mental illness. However, we want to suggest that novels and related literary genres offer a unique window for understanding some of the most subjective experiences in psychosis. This may help establish therapeutic relationships with patients with the most profound challenges.

The Use of Literature in Supervision of Psychotherapy for Psychosis

Thus far, we have discussed the potential for novels and related literary genre to go beyond case examples or first-person accounts in psychotherapy trainee supervision by helping clinicians relate to the human elements of psychosis. In the next section we will describe our efforts use fiction in the supervision of doctoral clinical psychology students during a practicum that focused on individual psychotherapy for persons with psychosis. The format of the supervision, including the literary works used, will be outlined. We will discuss some of the responses students had to this learning experience and how they applied it to their clinical knowledge.

Format

The supervision group met weekly for one hour. Present were three to five trainees and three supervisors (two psychologists and one clinical nurse specialist). We used novels and related literary genres every six to eight weeks as an adjunct to the weekly group supervision of current cases. The novels and other materials usually were proposed by supervisors, though students sometimes suggested the work to be studied. All parties had a month in which to read the work and the only instruction given was to come to the group ready to share personal reactions to the piece and to try and relate it to clinical work. Discussions of the works were conducted in an unstructured format, and supervisees were invited to share their immediate reactions to the novels as a whole and to particular moments and passages that were salient to them. Case materials about patients seen in the clinic were introduced by both supervisors and supervisees, and parallels were drawn from passages in the fictional text to phenomena in psychotherapy material. Many works were used but two that stood out (these will be discussed) included Travels in the Scriptorium by Paul Auster (2006) and a collection of short stories titled Jesus’ Son by Denis Johnson (1992).

The process of these adjunctive supervision meetings was conducted in the spirit of dialogism. The discussion of literary works was not limited to just one idea or interpretation, but with the idea that there was not one ultimate truth to be gleaned. Multiple positions, complementary and contradictory, were discussed and equally valued. In addition, supervisors were invited to discuss their personal responses to the novel and their experiences of reading the piece. Case material was also present in the discussion as application of concepts and experiences of the novel were linked to various patients. The open nature of the discussion invited the use of humor and acknowledged that reading the different pieces was at times painful or confusing. Disagreements were tolerated and used to further discuss different aspects of the books and the ways in which the individual participants made meaning of the experience.

Reactions from Supervisees

To illustrate this process we will briefly detail the reactions of two supervisees (JH and RF) who participated in this literary supervision of psychotherapy with clients with psychosis. For each, we will first describe a particular work of fiction and then discuss how the reading of that work enriched psychotherapy with patients with psychosis.

Literary Work: Jesus’ Son

Jesus’ Son by Denis Johnson is a collection of short stories, which taken as a whole can also be viewed as a novella owing to the ostensible continuity of the first-person narrator and the consistent themes across stories. The eleven stories portray a fragmented and graphic narrative of a protagonist involved in a lifestyle of drug abuse and various criminal activities. The protagonist has fleeting and intense social interactions with others about whom he has limited ability to understand.

The book’s format and intense emotional content led to JH’s experience of reading the book to be compelling, but at times shocking, confusing, and painful. JH initially found the fragments found in each story difficult to synthesize into a picture of an individual across time, but with each consecutive story, JH found that his mental representation of the narrator as a single person began to cohere. In the final two stories, the protagonist moves from a place in which he has limited agency and ability to make sense of his life to one in which he is able to reflect and face personal challenges; this change can be associated with increases in his willingness to connect with and attempt to understand others in more complex ways. It occurred to JH as he read the book that his experience of moving from story to story closely matched his experiences with patients in therapy as they related narrative episodes from their lives that often lacked coherence or a linear time sequence.

In the supervision group discussion of Jesus’ Son, JH noted that it struck him that others were left feeling frustrated by the fragmentation of the narrative or offended and made uneasy by some of the graphic and at times antisocial content of the events that transpired in the book. He found it useful to think about and discuss how the group’s reactions, both the similarities and differences in personal responses, were consistent with the experience of sitting in a room with the disorganization, pain, and often graphic and agonizing content of the stories of the group’s patients’ lives.

At the time JH had been meeting with a patient whose lifestyle had a number of similarities to that of the narrator in Jesus’ Son, and who. in session, would provide JH snippets of narrative information that lacked a coherent, temporal structure and tended to involve only the most thinly described accounts of the others. These sessions often left JH confused and discouraged at the difficulties he was having in forming a therapeutic alliance with this patient. After reading and discussing Jesus’ Son, JH found that his thoughts and reactions to the book enriched his conceptualization of the patient’s psychopathology and increased his own understanding of what was occurring in the room, thereby improving JH’s ability to join the patient and establish a working alliance. Much as JH the reader was inclined to impose order and make connections between the narrative fragments in Jesus’ Son, JH as therapist was able to recognize and empathize with the fragmentation experienced by this patient.

JH described some of the parallels between the patient and the book, noting that in some sessions the client would offer brief accounts of childhood abuse; in others, he would describe unembellished accounts of drug and alcohol abuse involving an ever-changing cast of superficial acquaintances. Yet, at times he would exclusively focus on delusional explanations of unusual bodily sensations without any reference to specific events in his life. Consistent with the early stories in Jesus’ Son, the content of the barren narrative episodes this patient offered reflected a subjective state characterized by a limited ability to recognize his own mental content, which extended to the point of being unable to identify sexual arousal to corresponding objects of desire, an experience shared by the protagonist in the book. Rather than providing JH with a better ability to identify a particular cluster of symptoms, the exercise of reading and discussing Jesus’ Son seems to have facilitated growth in his capacity to sit with someone who offers an impoverished and fragmented personal narrative. It enhanced his ability to manage his own distress and confusion, and ultimately, to form a working alliance with clients, including the client discussed.

Literary Work: Travels in the Scriptorium

Paul Auster’s novel Travels in the Scriptorium chronicles one day in the life of Mr. Blank, a man who is uncertain of his identity and, at times, his existence. While wondering who he is and how he came to reside in a spartan room, Mr. Blank often fails to take action to answer these questions that occupy his mind. For instance, unsure whether he is locked in this room or is free to leave, he does not test the doorknob to see if it will yield. As a host of characters personally call on him throughout the day he fails to inquire about his own circumstances. Although Mr. Blank’s passivity may be attributable to memory problems, he seems to resist knowing, as his private reflections, and information gleaned from others, often evoke feelings of anguish and guilt that he cannot assimilate. Seeking solace from painful feelings, existential questions, and people whom he cannot understand, Mr. Blank repeatedly turns to a manuscript that offers a fictional, albeit more comprehensible, world than the one he occupies. As RF read the book, she noticed that she too experienced relief when reading the passages from the manuscript. Like Mr. Blank, she reflected that she enjoyed respite from difficult feelings, specifically the confusion and frustration that she frequently felt as she tried to answer the questions: Who is Mr. Blank? Who are these mysterious people who visit him? How to make sense of this world?

When discussing Travels in the Scriptorium in supervision, RF found that though there were common reactions to the novel such as confusion and frustration, people responded to it with a range of emotions and interpretations. With this ambiguous springboard for discussion (as opposed to a formulaic case study or a first-person account of psychosis), a variety of perspectives emerged as members of the group interacted, wrestled, and played with the meaning of the novel. Reading the novel and exchanging ideas with others helped RF to better understand psychosis, and it reminded her that some psychotic experiences are similar to experiences she has had, though in an attenuated form. The group identified common experiences of persons with psychosis that Mr. Blank also faced, such as struggling to understand powerful negative affect, questioning one’s existence and aspects of the environment that others take as a given, and experiencing people as unknowable and transient. Beyond enhancing RF’s understanding of psychosis more generally, the text and discussion also proved fruitful for empathizing and working with a particular patient who experienced a strong sense of fragmentation and discontinuity over time and avoided attempts to make meaning of his life.

After immersing herself in the novel, it became easier for RF to connect with the patient’s sense of feeling like a different person each day and his difficulty in integrating these self-experiences into a unified, complex representation of himself. While RF could empathize with the confusion and discomfort of fragmentation, it also became less difficult for her to appreciate why the patient resisted integration, because she could understand that as with Mr. Blank, remembering and examining life often involved confronting painful experiences and emotions. RF grasped that not to know—not to turn the metaphorical doorknob—affords comfort, even if the original dilemma remains unresolved. When the patient engaged in avoidance in session, RF reflected that she now often considered avoidance as a temporary attempt to alleviate painful emotions rather than label the patient’s behavior as resistance. She noted that though she was capable of recognizing this process before reading the novel, what ultimately helped her connect more deeply with this process was recognizing the experience within when interacting with the text. Recalling the relief she felt when moving from a confusing narrative to the more coherent manuscript helped her appreciate the relief that comes from escaping a bewildering or distressing experience, even when escape means one enters another reality that is less than idyllic (e.g., chaotic, fragmented, destructive). This knowledge helped her to better understand the patient’s experience without medicalizing it, which contributed to the building of a working therapeutic alliance.

Concluding Remarks and Future Directions

One of the key and difficult tasks of engaging in psychotherapy with clients who have psychosis is to join with the patient and form a working therapeutic alliance. This task is a topic in the supervision of beginning clinicians in their work with clients with psychosis. In this paper, we have offered the view that incorporating novels and related literary genres into supervision may help therapists join with clients who have psychosis by enhancing the therapists’ ability to empathize with and make meaning of phenomena that resemble the often bewildering and frightening experiences of psychosis. We further suggest that exposure to novels and related literary genres may help prevent therapists from surrendering to the view that psychosis is not understandable as anything other than a collection of abstract symptoms or from infantilizing patients by offering of paternalistic direction or protection from life demands.

We do not suggest that the reading novels and related literary genres is superior to reading case studies or first-person accounts, but we seek to identify the unique merits of fiction in gaining an understanding of the phenomenological aspects of psychosis. It is likely that engaging with literature in this manner might enhance supervisees’ understanding of first-person accounts of psychosis.

There are limitations to our discussion. First, this paper has primarily dealt with teaching beginning clinicians how to join with clients who have psychosis; we do not have the space in this paper to discuss how this is also a transformative process for experienced therapists, including the senior authors of this paper. These authors have been practicing psychotherapy with clients with psychosis for several years, engaging in this type of supervision continues to add to their understandings of what it is like to be in the world as someone experiencing psychosis. Group discussions are illuminating and present different views and challenges each time discussions take place, and thus even with rereading the novels several times, new ideas, concepts, and a deeper understanding of how one can join with these patients emerge. Therefore, we believe this can be a beneficial activity to engage in outside of the context of supervision and can be a process by which psychotherapists desiring to understand the subjectivity of psychosis and to join with their clients can work toward these goals.

Second, we acknowledge that our views largely draw on the idea that psychosis can be understood as existing along the continuum of human experience. Our use of novels and related literary genres indeed seems predicated on the idea that individuals experiencing psychosis are not inherently different from anyone else, and that some of the strangest and most bewildering experiences can be made sense of while reading literature and engaging in other reflective activities. As such, our view differs significantly from some phenomenologists who would suggest that some of the experiences of individuals with psychosis are ontologically different from those of individuals without psychosis (e.g., Parnas & Handest, 2003).

While we have focused on reading novels and related literary genres as a way to deepen empathy between therapists and clients with psychosis, it is important to note that reading fiction may also facilitate a deeper appreciation of subjective experience and the motivations of clients experiencing different types of psychopathology. For example, Dimaggio, Fiore, Lysaker, Petrilli, Salvatore, Semerari, and Nicolo (2006) have discussed the importance of understanding the intentions and motivations of individuals with narcissistic personality disorder in order to form an empathic working alliance (working with individuals with narcissism can pose a unique set of challenges to understanding and the formation of an empathic bond). It is likely that by clinicians reading novels and related literary genres, the processes outlined in this paper could bring a better sense of the subjective experiences of a range of different human dilemmas that bring clients to the therapy room.

Psychiatry and the allied fields of mental health, and in particular psychotherapy, have a long history of close ties with the humanities. That bond appears to have weakened over the last few decades as medicalized views of mental health treatment have emerged (Fidler et al., 2011). In this paper we explored the potential of the introduction of the humanities, in particular novels and related literary genres, into the supervision of psychotherapy for psychosis, which may offer unique ways to understand the experience of psychosis. Certainly, this has implications for including other elements of the humanities, such as paintings, poetry, film, and drama. We posit that creative expression in many forms can be used to capture elements of human experience that may be difficult to express in more conventional ways. Consistent with this thought, Fidler and colleagues (2011) discussed the importance of different modes of the humanities for learning about psychiatric work, describing that use of the arts allows for discussion about what makes us human in a discipline that is starting to remove these types of discussions in favor of descriptions of symptoms and strict medical explanations. As Fidler et al. (2011) noted introducing student clinicians to different methods of creative expression may help supervisees expand their own understanding of human experience. Much like the discussion of case studies or case material in supervision, we posit that by viewing and interacting with works of creative expression, supervisees will be engaging in an exercise of making meaning of experiences that may allow for them to more fully join with clients.

It is important to note that while we believe we have presented a method that may be helpful in creating and deepening empathic connections between clinicians and their clients with psychosis, we do not suggest that reading novels and related literary genres alone is a comprehensive or sufficient strategy in joining with clients. There are other aspects of the therapeutic encounter beyond the clinician needing to develop an appreciation of the patient’s experience as understandable and part of the human continuum that may hinder the ability to form an empathic bond. For example, countertransference issues can be an important element impacting the clinician’s ability to join with the patient. Thus, while we believe reading fiction can facilitate a deeper understanding of the subjective experience of psychosis as relatable, we recognize that it is not enough if it is not part of a larger effort by the clinician to examine his or her own reactions, intentions, and ultimately dialogical elements of the self that interact in the therapeutic encounter.

It is our view that psychotic experiences are an element of human experiences that can be understood and accessed by those who have not had first-hand experience with psychosis. We believe that one way to access these types of experiences is through reading novels and related literary genres that invite the reader to grapple with these existential dilemmas, and that through engaging in this type of exercise, clinicians can come to more fully understand and create a working alliance with their clients.