Christian Jonathan Haverkampf, M.D.

In depression the past is too real, in anxiety the future is too real, in psychosis the inside is too real, in OCD causal connections are too real. This may be an oversimplification, but mental health and how a person experiences, thinks about, feels about and conceptualizes reality are tightly interlinked. On the other side, the same applies to mental health an imagination, and how an individual can distinguish between imagination and reality. Placing mental entities, such as thoughts, and physical entities, in the internal world and sensory perceptions of real objects in the outside world requires mental processing, which can be impaired in several mental health conditions from anxiety to psychosis (Haverkampf, 2012, 2017b). Reality is tied closely with communication, because it is also how information flows that defines reality.

It is easy to forget that a large part of therapy is to help the patient find a structure in internal and external worlds again and make the interface between the two workable again. Since all this depends on information flows, communication inside a person and between a person and the outside environment, a focus on internal and external communication patterns is an important part of therapy(Haverkampf, 2017a). One of the most basic steps is to help a patient distinguish mental events from real events in the outside world. This does not only apply to psychosis, but also to anxiety, social anxiety, depression and many other conditions or symptoms. It seems that if the ability to distinguish between inside and outside, between thoughts and feelings on one side and the sights of sounds of the outside world on the other, between internally and externally generated information is not fully functional or disappears altogether, that a person usually develops diverse mental health symptoms and ceases to function well in everyday life.

However, these conditions and the necessity to label information for internal and external sources also illustrate that information of similar content, whether internal or external is processed similarly and can have similar effects on other information content within the neuronal network. The ability to think about communication and communicate about it, which is often referred to as metacommunication, probably makes the distinction between thinking about the outside and the inside world necessary, keeping in mind that the sense of self is one’s perception of flows of information. The ability to not only work with or identify communication, but the ability to feel it, is what gives rise to the sense of self (Haverkampf, 2010).

Reality is the state of how things are, as they exist, no matter how one sees, hears or perceives it in other ways. It is what provides input to the senses and the nervous system, where some information about it can be processed. Without reality one could not think about things that are shared with others. Only because mountains and oceans exist in the real world and can be appreciated at different times by different people, is it possible to communicate about them with other people. The information one individual holds about a mountain may be different from the information held by another individual about the same mountain, but without the real existence of a mountain an interaction about it would be impossible.  In other words, reality plays an important role in the interconnectedness among people, and if, for whatever reason, the perception of reality is lost, or the ability to distinguish between what is real and what is imaginary is lost, the connectedness and the sense of being connected is often lost as well. The result can be severe feelings of loneliness.

To make oneself understood by other people and to be able to understand other people one needs an awareness of a common set of information and communication procedures, which is largely what is meant by a common and shared reality. Reality as usually been interpreted as something that is tangible, but it is really something one shares with others by necessity. While I may share an imagined story with others, I do so because I choose to. I may even imagine other people as guests in my reality, but I cannot banish them from reality itself and make them ‘unreal’. Reality and connectedness go hand in hand. In several mental health conditions, where the se sense of reality is lost, the sense of connectedness is lost also, and vice versa. A focus on communication can restore the connectedness and the link with the outside reality, as well as the link with the inside reality.

Hyperreality has traditionally been characterized as an inability to distinguish between reality and a simulation of reality. With technological advances that allow us to communicate in new ways, it has become progressively easier to simulate in ever richer ways various realities, such as in a film or a videogame, for example. This raises interesting questions about technology and mental health. On the other hand, it also reflects on how the brain has to actively distinguish between reality and the imagination.

Jean Baudrillard has mentioned two terms in his book Simulacra and Simulation to describe aspects of hyper-reality, the simulation and the simulacrum Simulation is characterized by a blending of reality and representation, where there is no clear indication of where the former stops and the latter begins. He suggests that simulation no longer takes place in a physical place with physical limits, but within oneself and may be facilitated by technological means. The simulacrum, on the other hand, is according to Baudrillard not a copy of the real but becomes truth in its own right. It begins with a basic reflection of reality, followed by its perversion, a pretence of reality where there is no original, and finally yielding the simulacrum, which has no relation with reality. The simulacrum is often described as a copy without an original.

Humans can be creative because of the close proximity of imagination and reality. In both cases, it is ultimately about the communication of meaningful information. Whether an imagined scene or a real one, it is the information and its communication which make them meaningful. However, they become less meaningful if the mind can no longer distinguish between them. In Communication-Focused Therapy (CFT), the work with communication patterns, becoming aware of and changing them, can help to practice the discrimination among them (Haverkampf, 2017c, 2017d). Interaction and actions in the real world are important to strengthen the sense for the real and the imaginary, which can also take place in a therapeutic setting as the communication between therapist and patient is real. A hyper-focus on a project, such as writing a novel, can lead to a situation where the imagined characters become ‘almost’ real, but in order to be able to write the novel, the novelist has to be able to still know that they are imaginary. While it requires the freedom to think, imagine and innovate in the internal world of the brain to change the outside world in helpful ways, it is the realisation in the mind of what is imaginary and what is real that allows us to do so.

Dr Jonathan Haverkampf, M.D. (Vienna) MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy, law and economics. He works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. Jonathan is the author of over two hundred articles and several books. He can be reached by email at jo****************@gm***.com or on the websites www.jonathanhaverkampf.com and www.jonathanhaverkampf.ie.


Haverkampf, C. J. (2010). A Primer on Interpersonal Communication (3rd ed.). Dublin: Psychiatry Psychotherapy Communication Publishing Ltd.

Haverkampf, C. J. (2012). A Case of Psychosis. J Psychiatry Psychotherapy Communication, 1(3), 61–67.

Haverkampf, C. J. (2017a). Communication-Focused Therapy (CFT) (2nd ed.). Dublin: Psychiatry Psychotherapy Communication Publishing Ltd.

Haverkampf, C. J. (2017b). Communication-Focused Therapy (CFT) for Anxiety and Panic Attacks. J Psychiatry Psychotherapy Communication, 6(4), 91–95.

Haverkampf, C. J. (2017c). Communication-Focused Therapy (CFT) for Psychosis. J Psychiatry Psychotherapy Communication, 6(4), 116–119.

Haverkampf, C. J. (2017d). Communication-Focused Therapy (CFT) for Social Anxiety and Shyness. J Psychiatry Psychotherapy Communication, 6(4), 107–109.

This article is solely a basis for academic discussion and no medical advice can be given in this article, nor should anything herein be construed as advice. Always consult a professional if you believe you might suffer from a physical or mental health condition. Neither author nor publisher can assume any responsibility for using the information herein.

Trademarks belong to their respective owners. Communication-Focused Therapy and the CFT logo with waves and leaves are registered trademarks.

This article has been registered with the U.S. Copyright Office. Unauthorized reproduction, distribution and/or publication in any form is prohibited.

© 2019 Christian Jonathan Haverkampf.

All Rights Reserved.

Unauthorized reproduction, distribution and/or publication in any form is prohibited.