May-May: ‘Have you ever helped someone who was unable to see? I’m sure you have. I certainly have. I would like some help myself from time to time. Not with my vision, but to perform a reality check. Because sometimes I think the intelligence services are tapping my phone, when I have been talking to a Russian tabloid over the phone for example. Would that be possible, or am I imagining it? I would like to talk about that sometime, with our pm for instance. Now that would be a little bit tricky – the man has better things to do with his time – but a reality check on a smaller scale too, could help. Think of the reality check John Nash performed in the film ‘A Beautiful Mind.’

John Nash in the film A Beautiful Mind

A Beautiful Mind is loosely based on the life story of John Nash. John Nash received the Nobel Prize in Economics, to be more precise, because of his work regarding game theory. There could be an outcome that isn’t ideal for either of the participants, caused by a lack of communication for example. At one point, John Nash develops paranoid schizophrenia. In the aforementioned film, John Nash is played by Russel Crowe. At one point he asks a female student whether she too, had seen the man who spoke to him a little bit earlier, because he wanted to know if what he experienced was real, or a hallucination.

A better understanding of the world through reality checks

In an article in De Volkskrant (a Dutch paper) dated 8^th of July 2013, aid worker Harry Gras says about one of his patients: ‘When I’m with him, he interrogates me for the first ten minutes of the visit. I am his perspective on the world. He assesses the severity of his psychosis by means of my answers.

My conclusion is, that this is a very intelligent patient! He’s figured out that he might be suffering from psychosis, and is searching for reality checks.

Sometimes I am in need of a reality check myself

I believe that that would be a great way to relieve tension and to ensure that my mental state doesn’t get the better of me. But frankly I don’t really dare ask the people  in my circle I would ask my sister, but she lives a little bit further afield, so I’d have to ring her, and I prefer speaking to people face to face.

What is your opinion Jim? Do people with a vulnerability to psychosis benefit from reality checks? And is it a matter of just biting the bullet? Would you be wiling to perform a reality check?

Jim Van Os’ answer:

“Dear May-May,

Thanks for your enquiry! I think that all of us are in need of a reality check 20 times a day  – at a certain level. To give an example: one day I walk through the hospital corridors and I see one of my

colleagues. I greet my colleague warmly, but he just gives me a glassy stare and keeps on walking without saying hello. The thought that pops up in my head: I knew it, he doesn’t like me, I upset him in that meeting we had recently.

Coincidentally, I didn’t have the best night’s sleep the night before, and spend the rest of the day brooding on the encounter with that colleague.

I contemplate paying him a visit  

And ask: How are things between us? Did you not greet me this morning because you dislike me? I don’t do this, but when I come home that night I tell my wife about my worries. She smiles and says: “You are always far too insecure about what other people think of you! Wouldn’t it be possible he wasn’t wearing his glasses, or that he was just lost in thought?”

This method of Socratic questioning makes me think, and after a short while I feel reassured. Later that evening I even wonder to myself how I managed to deem that encounter so negatively.

Our ‘problem’ – as humans – is that we can never be sure about the thoughts, emotions, and intentions of the people surrounding us – basically, how they relate to us. We simply cannot read their minds, and if we are even the slightest bit anxious, we read all kinds of anxious signals in their behaviour. In short, the world around us is full of ambivalence. And if you suffer from severe anxiety, you could even think that the driver of the car behind you was sent by the Intellingence Service in order to keep an eye on you.

Of course it would help us to share these worries with others

And to subject them to a reality check with Socratic questioning. Even if the concerns are of a psychotic nature, like yours are. Intelligent people like your sister see these psychotic concerns as a metaphor for ordinary human emotions, that are often rooted in relationships with other people and the relationship the person has with themselves. For instance, If you are insecure by nature, you are more likely to have these (whether or not psychotic) concerns. In that case reality checks are fine, but the underlying resistance needs to be addressed as well. For example, by creating a story with the person about a less insecure and more assertive individual.

This is important, because if we are not addressing the person’s resistance at the same time, there is a risk that the person needs ever more reality checks and/or becomes too dependent on them.

And evidently the truth is that what works well for one person, does not work at all for another

Undoubtedly it will be the case that from time to time that it isn’t sensible to perform reality checks, for example, when their effect is that the anxiety in a person is only further fuelled.

But in the round, reality checks are, in my opinion, a good way of starting a conversation through Socratic questioning, about the human concerns and emotions underlying the psychosis, allowing the person to find reassurance and develop resilience.

Photo: Tima Miroshnichenko via Pexels

Translated by SGM Taplin

---

Jim van Os is professor of psychiatry, chairman of the Brain Division at the University of Utrecht Medical Centre and one of the initiators of PsychoseNet.