Sponge or mirror: supporting a relative with psychosis

Picture a sponge left at the edge of a sink. Whatever spills near it, it soaks up, and it holds on to all of it until someone wrings it out. Now picture a mirror. Whatever stands in front of it, it shows back clearly, and when the person walks away, the mirror is as it was.

If someone you love has psychosis, you may recognise the sponge. Their fear at three in the morning becomes your fear. Their suspicion of the neighbours keeps you awake too. One difficult phone call colours the rest of your day. It feels like love, and it is love. It may also be what wears you down.

In Denmark, researchers asked 154 relatives of people in a first episode of psychosis (opens in a new tab) how they were coping. More than a third were struggling badly enough for it to count as a clinical problem. What set them apart was not how severe their relative’s symptoms were. It was how they experienced caring, and how much of their relative’s suffering they had taken on as their own.¹

Feeling with someone, and feeling for them

At the Max Planck Institute in Leipzig, the neuroscientist Tania Singer and her colleagues have studied the difference between the sponge and the mirror under other names. Empathy, in their terms, is sharing another person’s feeling while knowing that it is theirs. When that boundary dissolves, the feeling simply passes from one person to the other, which they call emotional contagion.² Compassion is something else: concern for another person’s suffering, joined to the wish to help.³

To find out what empathy and compassion do to the person who feels them, they trained a group of 25 young women. First the women practised empathy, resonating with the suffering of people in short clips from news and documentaries, injured or caught in disasters. They came to feel that suffering more keenly, and felt worse themselves. Then they practised compassion, meeting similar clips with kindness, warmth and concern. The negative feelings receded and positive ones grew, although the clips were as distressing as before, and brain networks linked to reward and affiliation became more active.³ Compassion did not make the suffering on the screen any smaller. It changed what the women carried away from it. They were volunteers, not carers, and the group was small, but the authors see in compassion a protection against burnout.³

Researchers who study families have their own name for the sponge: emotional over-involvement. It describes self-sacrifice, overprotection, intense emotional reactions, and a closeness in which the other person’s troubles become one’s own.⁴ It grows out of love, and it can grow out of grief. In 50 families followed from a first episode of psychosis, relatives who felt they had lost something of the person they loved were more likely to be over-involved.⁵

Grieving someone who is still here

It can feel wrong to grieve for someone who is alive, who sits at your kitchen table and answers when you call. Yet psychosis can take away much of the person a family knew while leaving them in the room.

The family researcher Pauline Boss named this in the 1970s: ambiguous loss. It is the loss of someone who is physically present but psychologically absent, as in dementia, addiction or long-lasting mental health problems. Because no one can promise that the person will return to the way they were, the grief has nowhere to settle; Boss describes it as frozen.⁶

Her way through is to stop choosing between the person who was and the person who is. “I intentionally hold the opposing ideas of absence and presence,” she writes, “because I have learned that most relationships are indeed both.”⁷ Among her guidelines for living with this kind of loss are finding meaning in what has happened, accepting that much lies outside your control, letting mixed feelings be normal, and discovering new hope.⁶ A mirror does not choose between who someone was and who they are. It shows who is standing in front of it today.

Listening without trying to win the argument

You don’t have to agree with everything your relative believes. You might be certain that nobody is watching the house. You might not accept that hearing voices is normal. And when a voice tells your brother that his friends have turned against him, you might reject that conclusion with everything you have.

But listening to what your brother hears, and talking with him about it, is not an attempt to win an argument. It is how you stay in the conversation at all.

The psychologist Xavier Amador built a whole approach for families on this idea and called it LEAP: listen, empathise, agree, partner. His institute sums it up in one sentence: “You do not win on the strength of your argument, you win on the strength of your relationship.”⁸ Dutch guidance for relatives (opens in a new tab) puts it in four words: aandacht helpt, opdringen niet. Attention helps; pushing doesn’t.⁹

Staying on your feet

Dutch guidance for relatives makes another point worth keeping in mind: to help someone else, you have to stay on your own feet. Taking time for yourself while someone you love is struggling feels unnatural. Sometimes you won’t want to do anything at all for a while, and that is allowed too. What started as a sprint may turn out to be a marathon.⁹

Some things are simply out of your hands: whether a medicine works, when the voices come back, what your relative decides to do. Carrying all of that is how the sponge fills up. Pushing it all away doesn’t help either; carers who cope by avoiding tend to feel worse.¹⁰

What seems to help lies somewhere in between. Psychologists call it psychological flexibility: you notice what you feel, let it be there, and keep doing what matters to you. In a Danish study of 101 carers, those who had more of it were less distressed, however severe their relative’s symptoms were.⁴ And it can be practised: in 13 studies, mindfulness courses eased carers’ stress.¹¹ In Finland, the clinicians who developed Open Dialogue call a similar skill tolerance of uncertainty: staying with a situation that isn’t clear yet, instead of forcing an answer.¹²

You do not have to do this alone

You can’t be someone’s support for years without having a working line of support for yourself. Talking to your family and friends helps, and it does so in multiple ways – sometimes by verbalising how the last couple of days went, what emotions they carried and how you’ve dealt with it. Do not expect a complete understanding from people around you though, it’s just natural if they don’t empathise with everything you’re going through. How could they, if they’ve never lain awake at night being afraid of tomorrow? This is a reason why support groups exist: there you meet relatives who know those nights from the inside. You can find groups in the Netherlands and Belgium on the Find support (opens in a new tab) map.

The sponge and the mirror at the beginning of this article are, of course, a simplification. Nobody is only one of them. On a good day you reflect; on a bad day you soak up everything in the room. The solution lies in finding a balance between them: to take in enough to stay close, and to let go of enough to stay yourself.