Why Patients Choose Psychosis: A Psychiatrist’s Dilemma
The disconnect can be profound. A physician, armed with medical degrees and years of training, attempting to reason with a patient experiencing psychosis, only to find their reality dismissed, their expertise rejected. This fundamental clash, and the anxieties it provokes in clinicians, is at the heart of a growing conversation about how we treat – and more importantly, listen – to patients in the midst of a psychotic episode. The question isn’t simply about alleviating symptoms, but about understanding why some individuals repeatedly choose to remain within a psychotic state, even when offered the possibility of relief through medication.
The experience is illustrated starkly in a recent reflection by a physician, shared on Psychology Today, detailing an encounter with a young man named Ben who believed he was Jesus Christ. The physician, faced with the prospect of Ben becoming homeless, attempted to persuade him to take medication, framing the decision as a matter of life and death. But Ben countered with his own high-stakes logic: refusing the medication meant avoiding eternal damnation. The physician’s frustration stemmed not just from Ben’s beliefs, but from the realization that they weren’t truly listening to him, but rather attempting to impose their own reality.
The Cycle of Medication and Return
Ben’s case isn’t unusual. The physician notes that Ben has a history of cycling on and off antipsychotic medications. While the medications can suppress the more overt symptoms of psychosis – the belief that he is Jesus, for example – they often come with side effects, leading to weight gain, sedation, and a sense of detachment. Crucially, Ben consistently returns to a state of psychosis once he stops taking the medication, even when he acknowledges that the symptoms have subsided. This raises a critical question: why do some patients actively choose psychosis over the perceived drawbacks of treatment?
The answer, according to psychoanalyst Harold Searles, lies in a deeper exploration of what psychosis might offer the individual. Searles suggested decades ago that clinicians must confront the unsettling possibility that, for some, psychosis might be a more desirable state of existence than “sanity.” This isn’t to romanticize psychosis, but to acknowledge that it may serve a function – a way of coping with unbearable anxieties or a search for meaning that cannot be found in conventional reality. Searles’ work, dating back to 1976, continues to resonate in contemporary discussions about the patient experience.
Annihilation Anxiety and the Fear of Disintegration
The physician identifies a key obstacle to truly hearing patients: the clinician’s own anxiety. Beneath the defenses of a psychotic reaction, Searles posited, lies a “terror of disintegration,” a visceral fear of “going crazy,” “falling apart,” or experiencing a “mental breakdown.” This anxiety is universal, but it can be particularly acute when confronted by a patient whose reality fundamentally challenges our own. It’s a discomfort that can lead clinicians to prioritize restoring a “consensual reality” – a shared understanding of the world – over understanding the patient’s subjective experience.
This drive to restore a shared reality isn’t necessarily malicious. The physician readily admits that if all it took was a few months of medication to bring Ben back to a stable, functioning life, they would readily administer it. The fantasy, they confess, is of a grateful patient, relieved to be free from disturbing thoughts and able to move forward. But this fantasy overlooks the fact that, for Ben, the medication doesn’t offer liberation, but a different kind of confinement – a sedated existence devoid of meaning or purpose.
Beyond Symptom Suppression: The Need for Understanding
The challenge, then, is to move beyond simply suppressing symptoms and to cultivate a genuine curiosity about what psychosis represents for the individual. This requires a willingness to listen without judgment, without attempting to correct or invalidate the patient’s experience. It demands a bravery in the face of uncertainty, a recognition that “reality” itself is a fragile construct. The physician acknowledges that This represents difficult, that it requires confronting our own anxieties and questioning our assumptions about what constitutes a healthy mind.
The implications extend beyond individual clinical encounters. The inability to contend with the question of why some people choose psychosis points to a broader systemic issue within mental healthcare. As the Associated Press reported in 2026, even the “Jesus Shot” – an anti-inflammatory injection promoted for pain relief – highlights a willingness to seek unconventional treatments, and a potential distrust of traditional medical approaches. While the “Jesus Shot” itself has a controversial history, linked to a physician with a checkered past, it underscores the desire for alternative solutions and the potential for patients to actively seek out experiences that align with their own beliefs.
What Comes Next: Cultivating a More Empathetic Approach
The path forward isn’t about abandoning medication altogether, but about reframing our approach to treatment. It requires recognizing that medication is not always the answer, and that sometimes, the most effective intervention is simply to listen – to truly hear what our patients are trying to tell us, even if it challenges our own understanding of the world. It means acknowledging the possibility that, for some, psychosis may not be a disease to be cured, but a way of being that holds meaning and purpose. This shift in perspective demands a greater emphasis on empathy, curiosity, and a willingness to embrace the uncertainty inherent in the human experience. It requires, a greater degree of bravery on the part of clinicians – a bravery to confront their own anxieties and to listen to their patients with an open heart and mind.