On overview, agency, and psychological work in psychosis
What kind of psychological work is possible when a person with psychosis is contactable, but not yet ready for structured psychotherapy? This article explores a neglected clinical phase focused on overview, agency, and rebuilding the capacity to act.
There is a phase in work with psychosis that often remains invisible. An in-between phase. The person is severely mentally ill; psychotic symptoms are present – sometimes voices, sometimes disorganised thinking, sometimes a profound fragmentation of experience. And yet, it is possible to sit together in a room. It is possible to speak. There is contact. Still, something is missing that makes psychotherapy, in the usual sense, often judged as premature or too demanding.
This is not acute psychosis in the sense that all shared reality has collapsed. Nor is it a situation in which structured psychotherapy, such as cognitive behavioural therapy for psychosis, can easily be conducted. Nevertheless, many people remain in this state for long periods of time. And the question arises: what kind of psychological work is actually possible here?
This text attempts to give language to precisely that kind of work.
A clinical in-between phase
When psychotherapy in psychosis is discussed, attention often shifts between two extremes. On one end, very basic contact work, sometimes referred to as pre-therapy, where the primary task is simply to establish shared reality. In such work, this may involve pointing to something both people can see in the room, naming what is happening here and now, mirroring bodily actions, or repeating the person’s words verbatim without interpretation, in order to create the most basic common ground. On the other end, there are more structured forms of therapy, such as CBT for psychosis, focusing on symptoms, interpretations, coping strategies, and psychological distance from psychotic content.
The clients I meet are often situated between these two levels. They are contactable. A structured conversation is possible. Yet they lack overview of their situation. They lack a stable position as an actor in their own life. Initiatives do not arise from a coherent “I”, but from voices, impulses, fragments, or from the situation itself. Much happens, but little is chosen.
This is not merely a transitional state on the way to “real therapy”. It is a phase in its own right. And it needs to be taken seriously.
When psychological content disappears
In practice, this in-between phase often means that the person is not offered psychological treatment. The assessment may be that they lack sufficient capacity, that psychotherapy is not feasible at present. CBT for psychosis is deferred to a later stage, as a future possibility.
What remains is often care coordination, case management, or resource-group-based support. These approaches have solid empirical support and are often crucial at an organisational level. They provide continuity, reduce chaos, and hold different interventions together. But they primarily address external overview: appointments, contacts, calendars, coordination.
What is often missing is psychological overview. Someone who works together with the person to understand the situation as a whole. Someone who helps plan in steps, explore alternatives, and examine what actually works. The result can be a psychological vacuum. The person is present in the system, but without direction.
Overview as a psychological function
Overview is not information. It is not simply knowing what is going on. It is a psychological function: the capacity to hold several elements in mind at the same time, to perceive connections, to distinguish now from later, to think in steps.
When overview is absent, everything is experienced as simultaneous. Everything is equally urgent, or equally irrelevant. Planning becomes impossible. Control is experienced as lost. No amount of external coordination can replace this internal function.
Psychological work at this stage therefore largely consists of helping the person develop overview. Not through long explanations, but by breaking things down, structuring experience, and maintaining simple maps over time. This is not administration. It is psychotherapy at a fundamental level.
Agency – becoming an actor
Here, the concept of agency becomes central. Agency is closely related to being an actor: the one who initiates, rather than merely reacts. It is important to distinguish agency from motivation. Agency does not require strong will, drive, or even hope. Agency can be minimal.
In psychosis, agency may consist of saying no. Of articulating a thought aloud. Of choosing between two options. This may sound trivial, but it is not. Without agency, there is no psychotherapy – only events that happen to the person.
Many psychotic conditions are characterised by a subjective loss of agency. Thoughts, actions, and words feel controlled. The task of psychotherapy here is not to interpret content, but to gradually re-establish a position of agency.
The psyche as a workshop – producing alternatives
One way of understanding this is to view the psyche not only as an arena in which things occur, but as a workshop in which something can be produced. Voices and psychotic processes often function as a monopoly on initiative. They are not merely content; they actively generate proposals for reality.
As long as they are the sole producers, there are no alternatives. No choice. No competition.
It takes only two shops for a market to emerge. In the same way, it is enough for the person to produce a single alternative for something new to happen. A “I don’t want to”. A thought spoken aloud. An action initiated. At that moment, competition between initiatives emerges – and with it, agency.
Psychotherapy at this level is therefore about helping the person become a producer of psychological material: thoughts, expressions of will, actions. Not analysis. Not restructuring. But production.
Thought, will, and action
Emotions are often difficult to use as a starting point in this work. Not because they are absent, but because they are often identified retrospectively. In affective flattening or disorganisation, emotions may be unreliable as a driving force.
Thoughts, however, can be initiated. Will can be expressed, even in minimal form. Action can occur on a very small scale. Here, a classic philosophical statement becomes unexpectedly practical: I think, therefore I am. Not as metaphysics, but as an anchor. The fact that thinking occurs cannot be taken over by voices.
By working through these channels, reality can be created through language and action. Not to change the world, but to establish a position as an actor within it.
Empirical exploration in everyday life
This work also has an empirical dimension. Not in the form of complex behavioural experiments, but as everyday exploration. What happens if I say this? What happens if I do this? What happens if I refrain?
This is reality-testing through action. A way of reconnecting experience with consequence. It is learning on a micro-level, and it builds both overview and control.
The relationship to CBT for psychosis
CBT for psychosis is an important and often helpful form of treatment, with a clear evidence base. At the same time, it often presupposes precisely the functions that are lacking in this in-between phase: overview, perspective-taking, and the ability to hold more than one thought in mind simultaneously.
For many people, a more fundamental form of work therefore needs to come first. Not instead of CBT for psychosis, but before it – as a preparatory phase in which overview, agency, and a position as an actor can begin to take shape.
What this kind of work can achieve
This is not a cure. It is not a quick solution. But it can create direction. A sense of some degree of control. A possibility for the next step. And sometimes, that is precisely what is missing.
Psychotherapy in psychosis sometimes has to begin before therapy. Not to lower ambitions, but to meet the person where they actually are.