What is Real and What is Not. A Third Wave Approach to Formulating Psychosis

1
What is Real and What is Not. A Third Wave
Approach to Formulating Psychosis

• Isabel Clarke
• Consultant Clinical Psychologist
• AMH Woodhaven

2
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 persons
  relationship to both thought and feeling
• Mindfulness is a key component.
• Recognition of a split or incompleteness in human
  cognition which mindfulness can bridge.

3
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

4
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

5

• 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
• Brewins 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!

6
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.

7
Interacting Cognitive Subsystems.
Body State subsystem

Implicational subsystem
Auditory ss.
Implicational Memory
Visual ss.
Verbal ss.
Propositional subsystem
Propositional Memory
8
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.

9
DIALECTICAL BEHAVIOUR THERAPY Linehans STATES
OF MIND

• EMOTION
• MIND

REASONABLE MIND
WISE MIND
IN THE PRESENT IN CONTROL
10
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.
  Brewins PTSD research)
• Role of past trauma in psychosis and PD is now
  being properly recognised.

11
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

12
WAYS OF COPING WITH FEELINGS WHERE THE THREAT TO
SELF IS TOO GREAT

• 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

13
Typical formulation
PAST ABUSE LOSSES PARTNER LEAVING
WAYS FORWARD Dont 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
14
Psychosis formulation
The past
Fear Sense of threat
Being in crowds, busy places
Intrusive thoughts
This means Im bad and others want to hurt me
Hears voices
This also means Im bad and others want to hurt me
Escapes from thoughts By slipping into unshared
world
Withdraw, hide away Or Fight, becomes
aggressive
Tense, sweaty, heart races
15
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 Claridges
  Schizotypy research.
• Understanding the role of emotion where
  expression of emotion is not straightforward.

16
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!

17
Evidence for a new normalisation

• Schizotypy a dimension of experience Gordon
  Claridge.
• Mike Jacksons research on the overlap between
  psychotic and spiritual experience.
• Emmanuelle Peters research on New Religious
  Movements.
• Caroline Bretts 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.

18
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.

19

• Validating the persons experience, and 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 Claridges
  work on schizotypy.
• The persons important context of relationships
  needs attending to a lifeline.
• Creative expression

20
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 persons 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.

21
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.

22
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.

23
Shared Reality Unshared Reality

• 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

• Ordinary
• Clear limits
• Access to full memory and learning
• Precise meanings available
• Separation between people
• Clear sense of self
• Emotions moderated and grounded
• Logic of Either/Or

24
Therapeutic Alliance

• As this approach represents a new normalisation,
  it can greatly aid the therapeutic alliance
• The individuals 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.

25
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.

26
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
27
Session 2 cont. DIALECTICAL BEHAVIOUR THERAPY
Linehans STATES OF MIND applied to PSYCHOSIS

Discussion of Ways of coping suggested by this
approach management of arousal and distraction.
28
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.

29
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.

30
Contact details, References and Web addresses

• Isabel.Clarke_at_hantspt-sw.nhs.uk
• Hannah Wilson_at_hantspt-sw.nhs.uk
• 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. (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