Transcript WEST HAMPSHIRE NHS TRUST SOUTHAMPTON

Negative Symptoms
A Critical Look and a
Motivational Approach
Isabel Clarke
Consultant Clinical Psychologist
AMH Woodhaven
AIMS
• Putting so called ‘negative symptoms
into context by looking at Psychosis
holistically and from an experience point
of view.
• Negative Symptoms. Critical look at the
concept.
• Introduce the MI approach – an
example of a staff training intervention.
• ‘Common Core Philosophy’ – an approach
to the ‘medical model’ problem
Psychosis and Getting Life Back on Track
• The role of the psychologist in helping the
system to look beyond diagnosis
• Symptoms versus experience
• Take the person and their experience
seriously; goes with working collaboratively –
what would this mean?
• This means a whole system approach – working
with the institution as well as the individual
• Engagement with the system – what helps and
what gets in the way?
Symptoms? What Symptoms? A
critical look a the concept.
• The word assumes an illness conceptualisation
• The medical model as metaphor – one possible
metaphor among many
• Language and power issues………..
• Implications for the individual about the
choice of metaphor – a passive patient or a
human being coping with their life as they
experience it……
• …..in the face of the constant invalidation
Taking Experience Seriously in
Psychosis
• What is the nature of experience in
psychosis? How does this experience impact
on the individual?
• Normalising the difference as well as the
continuity
• Sensitivity and openness to anomalous
experience – continuum with normality:
Gordon Claridge’s Schizotypy research.
• Understanding the role of emotion – where
expression of emotion is not straightforward
– the feeling is real even if the ‘story’ is
suspect.
The Holistic Revolution in Psychosis
• Recognising the role of arousal
(Hemsley, Morrison)
• Importance of emotion (Gumley &
Schwannauer: Chadwick)
• Attachment and interpersonal issues (“)
• Self acceptance and compassion (“ +
Gilbert):Self esteem, (Harder).
• Loss and Trauma
• The Recovery Approach.
All these lead to a blurring of diagnosis
The Epidemiological and Cross
Cultural Perspectives
• Richard Warner ‘Recovery from Schizophrenia’.
• WHO epidemiological studies
• Overrepresentation of people from other cultures
in the Mental Health Services here: what is that
about?
• Studies of overlap with spiritual experience or
where acceptance of anomalous experience
leads to better outcome:
– Emmanuelle Peters,
– Mike Jackson.
– Caroline Brett.
Evidence for a new normalisation
• Schizotypy – a dimension of experience: Gordon
Claridge.
• Mike Jackson’s research on the overlap between
psychotic and spiritual experience.
• Emmanuelle Peter’s research on New Religious
Movements.
• Caroline Brett’s research: having a context for
anomalous experiences makes the difference
between whether they become diagnosable
mental health difficulties
• and whether the anomalies/symptoms are short
lived or persist.
A holistic, cross diagnostic approach to symptoms:
shaded area = anomalous experience/symptoms are more accessible.
Level of
Arousal
High Arousal - stress
Ordinary, alert, concentrated, state of arousal.
Low arousal: hypnagogic; attention drifting etc.
DIALECTICAL BEHAVIOUR THERAPY: Linehan’s STATES
OF MIND applied to PSYCHOSIS
Shared and Non-shared Reality
•
reasonable mind
Ordinary thinking
Shared reality.
wise
Mind –
in touch
With both
in the present
in control
emotion mind
or open to other ways
of experiencing
Non-shared reality
Questions and Theories about
Negative Symptoms
• What are they?
• Orthodoxy says they are they a core
form of the ‘illness’
• Are they distinct from depression?
• A product of medication side
effects?
– of environmental deprivation?
– Dysphoria about life change?
– Of loss of social position and hoped for
life?
Negative symptoms cont.
• Are they a protective response to the
experience of positive symptoms?
• A product of positive symptoms as these
interfere with engagement with normal
life?
Cognitive Theories;
• Theory of mind deficit argument (Pickup &
Firth 2001)
• Cognitive deficit arguments. E.g. Putnam &
Harvey.
Medication side effects
• Dopamine is involved in the reward system of
the brain
• It is particularly associated with anticipation
of reward – therefore motivation
• Antipsychotic medication reduces dopamine
activity and therefore affects motivation
Arias-Carrion, O. & Peoppel, E. (2007) Dompamine, Learning and
Reward Seeking Behaviour. Acta Neurologicae Experimentalis 67:
481-488.
• Some antidepressant and antipsychotic
medication affects sexual response.
Sensitivity Argument
(Watkins, J. (1996) “Living with Schizophrenia. An holistic
approach to understanding, preventing and recovering from
negative symptoms.”
• Psychosis = high on the schizotypy spectrum
and so more sensitive and “open”.
• Leading to the need to regulate stimulation.
• This can lead into an avoidance cycle; social
isolation and withdrawal
• Psychotic reality takes over.
• Psychotic reality can be more attractive than
a stimatized and marginalized role in the
shared world
Therapeutic Approaches
1. To Sensitivity
• Validate the sense of vulnerability
• Negotiate graduated exposure to more social
interaction.
2. To the attraction/escape value of the
alternative reality.
• Validate the attraction – take a motivational
approach
• Encouragement to find and pursue valued
roles in the shared world – with support
Therapeutic Approaches cont.
3. To loss of direction in life:
•
Both unrealistic hope and despair paralyse
•
acknowledge loss of hoped for future
•
emphasise immediate, small scale achievement
•
foster medium term achievable goals
•
stay with the individual’s vision and choice. –
working with strengths and interests
•
Individual goal setting work. – negotiate valued
goals and monitor their progress – a therapeutic
approach for the staff group and a nice research
project
Introducing this model of working to the
Staff Group
Using Motivational Interviewing.
• MI principles: 1. EXPRESS EMPATHY
• Acceptance facilitates change
• skilful reflective listening is fundamental
• ambivalence is normal.
– Addiction: Approach/avoidance
– Psychosis: Hope/Despair.
2. DEVELOP DISCREPANCY
• Awareness of consequences is important
• a discrepancy between present behaviour and important
goals will motivate change
• the client should present the argument for change.
3. AVOID ARGUMENTATION
• Arguments are counterproductive
• defending breeds defensiveness
• resistence is a signal to change strategies
• labelling is unnecessary - get away from illness
language – and arguments about diagnosis
SUPPORT SELF EFFICACY AND SELF ESTEEM
• Belief in the possibility of change is an important
motivator.
• Every communication should increase self
efficacy/self esteem.
Common Core Philosophy
(This applies across diagnoses).
•
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Hope
Working with strengths.
Normalisation.
Common humanity, common vulnerability.
Collaboration.
Accepting reality.
Idea of Balance and Finding a Middle Way.
Proactive, collaborative response to risk and
challenge.
Hope.
• CBT. Cognition and behaviour can
change. You can take responsibility and
choose. Not fatalistic.
• Central to Recovery.
• DBT: the life worth living.
Working with strengths.
All look at the whole person, not the pathology.
• CBT. Behavioural approach to challenging
behaviour: focus on behaviour to increase
– what the person can do as opposed to
what they do wrong.
• Recovery: regaining or developing valued
roles.
• DBT. Encouraging mastery.
Normalisation.
• CBT. We all have dysfunctional thinking
patterns and challenging behaviours
sometimes. We can apply the approach to
ourselves.
• Recovery. Building a life outside the
services; employment focus.
• DBT. Biopsychosocial model applies to
some degree to everyone.
Common humanity, common
vulnerability.
• CBT. Therapists monitor the effect of challenging
behaviour on their own arousal systems and thought
patterns, and sidestep reproducing the pattern or
responding from the raised state of arousal.
• Recovery. Trainers devise their own WRAP plans.
Encouragement of employment of those who have
recovered in the services (experts by experience).
• DBT. Therapists note own therapy intefering behaviours,
dialectical dilemmas and emotion mind.
Collaboration.
• CBT – at the heart of the approach: goals
of therapy are arrived at collaboratively.
• Recovery; service user sets the agenda.
• DBT. Client must agree to work on
reducing self harm as a first priority, but
the life worth living is their own vision.
Accepting reality
• CBT.Person has to accept that there is a
problem for the problem list. They have to
accept that they have a role in dealing with it to
form a collaborative alliance.
• Recovery. The concept of the turning point
means the point at which the individual
recognises whatever limitations are imposed by
their problems, and accepts what has happened
in the past – this makes taking ownership of their
future possible.
• DBT. Acceptance is a core concept.
Self Monitoring
• CBT: Thought Diaries.
• Recovery: WRAP.Identify wellness, and
then triggers and early warning signs for
relapse. Relapse is a normal part of
recovery.
• DBT: Diary cards.Chain analysis.
Response to Risk and
challenge.
• CBT. Collaborative risk management is the most
effective. Specifying behaviours to increase and
reinforcing them is the most efficient way to
decrease challenging behaviours.
• Recovery. WRAP – individual responsibility for
maintaining wellness and specifying what should
happen in case of breakdown.
• DBT. Skills training, featuring mindfulness, to
master action urges.
Idea of Balance and Finding a
Middle Way
• CBT. Continuum work. Dysfunctional thinking is usually
extreme – CBT works towards finding the middle ground.
• Recovery. Balance between learning to live with
symptoms and a relapsing condition, and making the
most of life.
• DBT. Always looking for the dialectic, and for the wisdom
in both poles while seeking a way through. There is no
one right way – the process carries on.
•
Behavioural approach to challenging behaviour –
balancing the obvious, behaviours to decrease with
emphasis on behaviours to increase.
Unique features
• CBT. Individual formulation of difficulties.
• Recovery. Service users, not
professionals, in charge.
• DBT. Skills training and mindfulness.
However – the similarities are more striking
and numerous than the differences.
Implications for staff role.
• Staff need to hold hope and vision for the individual even when they
cannot yet see it.
• Staff need to concentrate their efforts on identifying and working with
the person’s strengths and interests.
• Staff need to see the person as they might fit into society to help
them maximise their prospects. They need to listen to the person
and take seriously what they say.
• Staff need to be aware of and manage their own emotional
reactions.
• Staff need to develop their skill in working collaboratively.
• Staff have a vital role in enabling the person to accept what has
happened and its consequences, and take responsibility for
continuing problems.
• Staff must keep in mind the need to balance working with strengths
with realistic support with problems.
• In managing risk, staff need to seek the full collaboration of the
service user.
Principles for working with staff
• Respect their professionalism – take every
opportunity to raise their morale and self
esteem
• It is your role to be the expert – you do have
something to offer.
• Offer it in a spirit of collaboration
• The Medical Model problem – I go for “both –
and”
Contact details, References and Web
address
• [email protected]
• AMH Woodhaven, Calmore, Totton SO40 2TA.
• Clarke, I. & Wilson, H.Eds. (2008) Cognitive Behaviour Therapy for
Acute Inpatient Mental Health Units; working with clients, staff and
the milieu. London: Routledge.
• Clarke, I. ( 2008) Madness, Mystery and the Survival of God.
Winchester:'O'Books.
• Clarke, I. (Ed.) (2001) Psychosis and Spirituality: exploring the
new frontier. Chichester: Wiley
• Durrant, C., Clarke, I., Tolland, A. & Wilson, H. (2007) Designing a
CBT Service for an Acute In-patient Setting: A pilot evaluation study.
Clinical Psychology and Psychotherapy. 14, 117-125.
•
www.isabelclarke.org