“WHAT IS REAL AND WHAT IS NOT”

A THERAPEUTIC APPROACH TO PSYCHOSIS THAT TAKES EXPERIENCE

SERIOUSLY AND UNDERMINES STIGMA

Isabel ClarkeConsultant Clinical Psychologist

Moving on from the Illness Model

The illness model has the virtues of certainty and protectiveness

BUT Inadequate reflection of what is happening

Leaves out the universality of the other way of knowing

Leaves out or marginalizes the effects of life events, trauma and adversity

It does not encourage psychotherapeutic approaches – only marginally relevant.

It is damaging to mental health recovery.

The Blight of Stigma

Biological v. Social constructions of psychosis: Read, Mosher & Bentall 2004

Role of Trauma and adversity – e.g. Varese et al meta-analysis 2012

The self = work in progress Social Rank Theory (Gilbert 1992, Gilbert & Allan

1998). ‘Sealing over’ – effect on Recovery Brett, Heriot-Maitland, Peters et al - effect of how

experiences are construed. Social messages – epidemiological research. Meaning – The Hearing Voices approach

A Clinical Model based on ICS

When Emotion Mind/Implicational does not mesh properly with Reasonable Mind/Propositional

A different quality of experience results Anomalous experiences are accessible The everyday world becomes less

important, less graspable Might be frightening and disorienting;

might be fine in the short term A problem when the person becomes

stuck This is a universal potential given the

‘right’ conditions

States of Mind Diagram. Applied to Psychosis

REASONABLEMIND – SHAREDREALITY

EMOTIONMIND – UNSHAREDREALITY

IN THE PRESENTIN CONTROL

WISEMINDIn touch with both

Reasonable Mind Memory

Emotion Mind Memory

A therapeutic approach using this model

Validate the experience as their experience Validate the emotion (as opposed to ‘the

story’) Sit lightly to explanations – all explanations,

including medical and CBT ones! Model sitting with uncertainty, recognizing

mystery ‘Shared’ and ‘Unshared’ reality – a way of

talking about this Helping the person to take control of their

‘unshared reality’ is key – how to close off openness to invasion – from within or without

The “What is Real” Approach

Introduces and normalizes “Unshared Reality”

Balance between vulnerability and potential – positive side of high schizotypy

Practical ways to manage the threshold between the two 2 “realities”

Motivation to use coping to do this - counter giving up and opting out

Individual formulation based on coping strategy model – for some

Group Programme:

Openness to Unusual Experiencing

Acknowledging that psychosis feels different

Normalising the difference in quality of experience as well as the continuity

Reference Romme & Escher research Identifying and exploring pros and cons of

‘shared’ and ‘unshared’ reality Sensitivity and openness to anomalous

experience – continuum with normality: Gordon Claridge’s Schizotypy research.

Positive side as well as vulnerability – creativity, spirituality – effect on self esteem

Shared Reality Unshared Reality

Ordinary Clear limits Access to full

memory and learning Precise meanings

available Separation between

people Clear sense of self Emotions moderated

and grounded A logic of ‘Either/Or

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

A logic of ‘Both/And’

Understanding and taking charge of the Threshold

Brainstorm the factors leading to vulnerability Lack of sleep, food, stress, isolation Pressure of events – life transitions Effect of past trauma and adversity Drugs, alcohol Spiritual practice – with vulnerability/to excess

Choice – you can take charge – you do not have to shut it down completely

Motivation to use coping strategies in order to take charge

Session 2. The role of Arousal shaded area = anomalous experience/symptoms are more

accessible.

Level of Arousal

Ordinary, alert, concentrated, state of arousal.

Low arousal: hypnagogic; attention drifting etc.

High Arousal - stress

Session 2 cont. DIALECTICAL BEHAVIOUR THERAPY: Linehan’s STATES OF MIND applied

to PSYCHOSIS

reasonable mind

Ordinary thinking

Shared reality.

wiseMind –in touch With both

in the presentin control

emotion mind

or open to other ways

of experiencing

Non-shared reality

Shared and Non-shared Reality

Ways of coping suggested by this approach – management of arousal and distraction.

Ways of taking charge and making sense

Motivation to take charge – David Bowie e.g. Arousal Management – up and down Grounding Mindfulness - Haddock research

on Focusing and Distraction. How do people make sense of their

experiences? Discussion of different ways of making sense of them.

Clue: what was happening when they first started?

Mike Jackson’s Problem Solving idea Positive potential sketched in

Grounding Mindfulness

Aim: To bring yourself 100% into the present, where you are in control.

Exercise: Take your attention away from your thoughts, away from your head and into your body.

Awareness of body Notice what it feels like to be a body sitting in a

chair Notice your weight on the chair Notice how your back feels against the chair Notice all the things you can feel Things that normally our mind does not notice

because they are not ‘interesting’

Individual work Therapeutic Alliance

As this approach represents a new normalisation, it can greatly aid the therapeutic alliance

Prepared to start from wherever the individual is Their experience is taken seriously and valued Encouragement to join the shared world, while

respecting their wish to retain access to the unshared (if wanted).

Risk and detention. Appreciation of the team’s perspective – people concerned about them

Their responsibility to manage those concerns.

Formulation Template

Try to escape from the emotion by avoidance, self harm, unshared reality etc.

Feel better short term

Bad longer term consequences.Aversive emotion worse.

Past: abuse, trauma etc.

Recent triggering event

Another maintaining cycle

feeding the emotion

HorribleFeeling

Using EFF with Psychosis

Approach with caution – based on an understanding of the States of Mind diagram

Exploring the emotion Might be accessible (fear in paranoia) Might be masked (psychosis as escape from

intolerable emotion) – caution needed The past – might need to be vague –

normalize its effect on the present Their coping strategies normalized – what

gets the person by but keeps them stuck

Psychosis formulation

FEARTHREAT!

THE PAST

Being in crowds, busy places:Body reacts to threat

Body reacts to threat: Intrusive thoughts

Withdraw, hide awayOr Fight, become aggressive

Escapes from thoughts By slipping into unshared world

Hears voices

More tension, sweaty, heart races

Unrealistic, worse, fears

RECENT TRIGGER

Breaking the Vicious Circles

Arousal management Grounding mindfulness Mindfulness of unusual

experiences/unshared beliefs – takes courage Fear and avoidance Facing that it is unshared – e.g. when grandiose

Facing emotion - DBT skills Self Compassion Relationship management

Spiritual Crisis Network Approach

There to offer a more hopeful, alternative, perspective – while stressing the role of NHS to manage risk

Small, unfunded, UK charity Website with email contact Supportive, validating responses Team of rota responders given training Awareness raising events and conferences A few local groups Ambitions to do more (e.g. Phone response)

SCN Email Responding Empathise with what they are going through

(might be a relative, friend or other supporter) Normalize – others have experienced the same

(majority of SCN responders have own crisis) Hopeful – in retrospect a transformative

experience for many, if difficult while in the midst of it.

Practical suggestions (next slide) Any suggestion of risk – strongly encourage

contacting NHS, taking medication as advised etc, while acknowledging they might be reluctant.

No outright advice or therapy recommendations

Grounding Advice Grounding when the experience is

overwhelming. Grounding activity. Grounding food.

Sleep Mindfulness activity in the now Importance of support Maintain ordinary relationships – even when this

feels irrelevant Managing arousal – breathing control to reduce

arousal and manage fear Mindful activity in the present to prevent it

slipping. Moderate spiritual practice Avoid substances

Contact details, References and Web addresses

isabel@scispirit.com

Clarke, I. (Ed.) (2010) Psychosis and Spirituality: consolidating the new paradigm. Chichester: Wiley

Clarke, I. ( 2008) Madness, Mystery and the Survival of God. Winchester:'O'Books.

Clarke, I. & Wilson, H.Eds. (2008) Cognitive Behaviour Therapy for Acute Inpatient Mental Health Units; working with clients, staff and the milieu. London: Routledge.

Wilson, H, Clarke, I & Phillips,R., (2009) Evaluation of an Inpatient Group CBT for Psychosis Program Designed to Increase Effective Coping and Address the Stigma of Diagnosis Psychosis. http://www.isabelclarke.org/clinical/icspsychosis.shtml

 Clarke, I. (2013) Spirituality: a new way into understanding psychosis. In E.M.J. Morris, L.C.Johns and J.E. Oliver eds. Acceptance and Commitment Therapy and Mindfulness for Psychosis. Chichester: Wiley-Blackwell, p. 160-168.

www.isabelclarke.org www.SpiritualCrisisNetwork.org.uk