Transcript Spirituality, Religion and Psychosis

What is Real and What is Not.
A Third Wave Approach to
Formulating Psychosis
Isabel Clarke
Consultant Clinical Psychologist
AMH Woodhaven
“Third Wave” Cognitive Therapies
• Developments in CBT as it tackles personality
disorder, psychosis etc.
• Therapeutic relationship important
• Past history is significant
• Change lies not so much in altering thought to
alter feeling, but in altering the person’s
relationship to both thought and feeling
• Mindfulness is a key component.
• Recognition of a split or incompleteness in
human cognition – which mindfulness can
bridge.
“Third Wave” – term coined by Hayes
(Acceptance & Commitment Therapy)
• Kabat-Zinn. Applied mindfulness to
stress and pain.
• Segal, Teasdale & Williams. Mindfulness
Based Cognitive Therapy (relapse in
depression.)
• Linehan. Dialectical Behaviour Therapy
(BPD)
• Chadwick. Mindfulness groups for
voices.
• Hayes
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).
• Recognition of the role of Loss and Trauma
• The Recovery Approach.
All these lead to a blurring of diagnosis
LEVELS OF PROCESSING – A THEORETICAL
JUNGLE!
• First wave CBT comes unstuck over the gap between logical
reasoning and strong emotion. This leads to the recognition
of different types or levels of processing. e.g.s of theories
of this.
• Ellis: Inference and Evaluation
– Hot and Cold cognition
• Power & Dalgleish. SPAARS (theory of emotion).
• Mark Williams: overgeneral autobiographical memory.
• Metacognition.
• Wells & Mathews. S-REF
• Brewin’s VAMS and SAMS (just memory).
• Ehlers & Clark (following Roediger): conceptual v.data driven
processing.
• Perceptual Control Theory and the Method of Levels.
• AND INTERACTING COGNITIVE SUBSYSTEMS!
Features the theories have in
common.
• All suggest 2 or more separate types of processing
– the split in human cognition!
• There is one direct, sensory driven, type of
processing and a more elaborate and conceptual
one.
• The same distinction can be found in the memory.
• Direct processing is emotional and characteristed
by high arousal.
• This is the one that causes problems – e.g.
flashbacks in PTSD.
• The two central meaning making systems of ICS
provides a neat way of making sense of this.
Interacting Cognitive Subsystems.
Body
State
subsystem
Implicational
subsystem
Implicational
Memory
Auditory
ss.
Visual
ss.
Propositional subsystem
Propositional
Memory
Verbal
ss.
A challenging model of the
mind.
• There is no boss – our unitary sense of self is an
illusion!
• The mind is simultaneously individual, and reaches
beyond the individual, when the implicational ss. is
dominant.
• This happens at high and at low arousal.
• There is a constant balancing act between logic and
emotion – human fallibility
• Dysynchrony between the systems explains anomalous
experiences – psychosis!
• Mindfulness is a useful technique to manage the
balance.
DIALECTICAL BEHAVIOUR THERAPY:
Linehan’s STATES OF MIND
EMOTION
REASONABLE
WISE
MIND
MIND
MIND
IN THE PRESENT
IN CONTROL
Features of Emotion Driven Processing
• Emotion regulates relationship – both with yourself and
others
• It mobilises the body for action
• That physical mobilisation gives the emotion its punch
• The Implication ss. is constantly watching for
information about threat to or value of the self.
• Information about unacceptability leads to a
disagreeable level of arousal. (cf. Gilbert and
evolutionary approaches)
• Where physical arousal is prolonged it is unpleasant –
motivates people to avoid emotion
• Time is collapsed in Emotion driven processing – past
threat is added to current threat (cf. Brewin’s PTSD
research)
• Role of past trauma in psychosis and PD is now being
properly recognised.
The ‘horrible feeling’
• Human beings need to feel physically
safe and OK about themselves
• Emotion Mind/Implicational Subsystem
produces a sense of threat when those
conditions are not met
• Emotion Mind/Implicational memory
presents past events as present
(trauma)
• People develop ingenious ways of
avoiding facing the sense of threat
WAYS OF COPING WITH FEELINGS
WHERE THE THREAT TO SELF IS TOO
GREAT
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Give in - signal submission (depression)
Constant anxiety, worry and hypervigilance
Anger - attribute elsewhere.
Displacing anxiety - OCD, eating disorder
Drink, drugs, etc.
Dissociation - flipping between different
experiences of the self
• Cut out reasonable mind appraisal and access
another dimension – psychosis
Typical formulation
PAST ABUSE
LOSSES
PARTNER LEAVING
Nightmares: can’t sleep
Cut self
Attempt suicide
FEAR
RAGE
SADNESS
Friends and family alarmed.
Could lose custody of
children.
Feel worse
More time to brood
More difficult to cope
Avoid going out and seeing
people
WAYS FORWARD
Don’t let the feelings be in control: YOU ARE IN
CHARGE
Do things despite the feeling
Breathing and mindfulness to get back to the
present
Use the energy of the anger positively
Psychosis formulation
The past
Being in crowds, busy places
Hears voices
This also means I’m bad
and
others want to hurt me
Withdraw,
Tense, sweaty,
hide away
heart races
Or Fight,
becomes
aggressive
Fear
Sense of threat
Intrusive thoughts
This means I’m bad and
others want to hurt me
Escapes from thoughts
By slipping into unshared world
Taking Experience Seriously in
Psychosis
• Acknowledging that psychosis feels
different
• 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.
2 Ways of experiencing
• ICS gives us a normalizing way of
understanding the experience of difference.
• When the imp.ss and the prop.ss are working
together, that gives us an ordinary, grounded
quality of experience.
• When they become desynchronized, the imp.
temporarily takes over
• This feels different; in extreme forms leads
to openness to anomalous experience.
• This quality of experience is also sought and
valued!
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.
• Wider sources of evidence – e.g.Cross cultural
perspectives; anthropology. Richard Warner:
Recovery from Schizophrenia.
Being Porous: therapeutic
approach
• Some people are more open to this type of experience
than others – cf. Schizotypy
• People high on the schizotypy spectrum are 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.
• Sensitivity and openness to anomolous experience –
continuum with normality
• Positive side as well as vulnerability
• Normalising the difference in quality of experience as well
as the continuity
• Helping people to manage the threshold – mindfulness is
key
Understanding the role of emotion and arousal – the feeling
is real, though the story might be suspect.
• All this helps with building a therapeutic alliance.
• Validating the person’s experience, and
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helping them to manage the threshold
between the two ways of experiencing.
Mobilising and nurturing strengths
Persuasion to join “shared reality” –
motivational work. Realistic about the risks of
“unshared reality”.
“Sensitivity” – normalisation based on
Claridge’s work on schizotypy.
The person’s important context of
relationships needs attending to – a lifeline.
Creative expression
Helping someone get their bearings by mapping
the 2 states.
• These sorts of experiences can be very confusing and
disorienting – it helps it someone can come up with a
map.
• Explain that there are 2 states, and some people are
more open than others
• Find a way of describing this that works for your
client (e.g. ‘Your Reality’ and ‘Shared Reality’
• Draw out two columns
• Sort out the person’s story into the two – being very
tactful where you are suggesting that it lies in the
non-shared side – hint: Non-shared reality has a
‘both-and’ logic – 2 incompatible things can be true at
the same time!
• This can be used as a framework for future sessions.
What is real & what is not?: about
the programme.
• A 4 session group programme for an Acute inpatient
setting.
• Run by a clinical psychologist and one or two others –
trainees, nurses, OT etc.
• Builds on the Romme and Escher ‘Voices Group’
tradition
• Is different from other CBT approaches in
normalizing the difference in quality of experience in
psychosis, as well as thinking style.
• This normalization attacks stigma by associating
psychosis with valued areas such as creativity and
spirituality.
• Attempts to mitigate the damage to self concept of
the traditional, diagnosis, based approach.
This approach is based on my work on
Psychosis and Spirituality
Both spiritual experience and psychosis are
different in character from everyday
experience.
Instead of psychosis and spirituality, I propose
two ways of operating: two modes of
experiencing:
• The everyday
• The transliminal
Both of these are available to all human beings.
(but some people can access the transliminal more easily
than others – sensitivity; vulnerability; high schizotypy).
Both are incomplete.
Shared Reality
Unshared Reality
• Ordinary
• Clear limits
• Access to full memory and
learning
• Precise meanings available
• Separation between people
• Clear sense of self
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• Emotions moderated and
grounded
• Logic of Either/Or
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Supernatural
Unbounded
Access to propositional
knowledge/memory is patchy
Suffused with meaning or
meaningless
Self: lost in the whole or
supremely important
Emotions: swing between
extremes or absent
Logic of Both/And
Therapeutic Alliance
• As this approach represents a new
normalisation, it can greatly aid the
therapeutic alliance
• The individual’s experience is taken seriously
and valued – at the same time as working on a
better relationship to shared experience
• It is possible to get away from illness
language – and arguments about diagnosis
• The schizotypy continuum is a good normaliser
– association of high s. with creativity etc.
The group programme: Session 1.
• Introduce Romme and Escher
• Extending from voices to other experiences
that people in general do not share.
• Idea of openness to voices and strange
experiences. Schizotypy spectrum. Artists
etc. David Bowie example.
• Examples from the group – what do they want
to get out of the sessions. Fill in goal form.
Session 2. The role of Arousal
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.
Session 2 cont. 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
emotion mind
or open to other ways
of experiencing
Non-shared reality
in the present
in control
Discussion of Ways of coping suggested by this approach –
management of arousal and distraction.
Session 3: mindfulness & 4: making
sense.
• Introducing Focussing. Haddock research on
Focussing and Distraction.
• Mindfulness and focussing.
• Mindfulness exercise.
• ****************************************
How do people make sense of their
experiences? Disussion of different ways of
making sense of them.
• Clue: what was happening when they first
started?
• Feedback, summing up and completing the goal
sheet again.
The Challenge of Evaluation in
the Inpatient Setting
• People in crisis are not keen to fill in a lot of
questionnaires – and are not very good at it.
• Even with only 4 sessions, consistency of
attendance and retention are a problem
• Qualitative methods would be ideal – but, the
Ethics Committee……..
• Plans to develop a longer version of the
programme for AOT and the community and
evaluate – in collaboration with service user
graduates.
Contact details, References and Web
addresses
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[email protected]
Hannah [email protected]
AMH Woodhaven, Calmore, Totton SO40 2TA.
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Clarke, I. & Wilson, H.Eds. (2008) Cognitive Behaviour Therapy for
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Acute Inpatient Mental Health Units; working with clients, staff and
the milieu. London: Routledge.
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.SpiritualCrisisNetwork.org.uk
www.isabelclarke.org