negative symptoms a critical look and a motivational approach isabel clarke consultant clinical...

Negative SymptomsA Critical Look and a

Motivational Approach

Isabel Clarke

Consultant Clinical PsychologistAMH 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

Ordinary, alert, concentrated, state of arousal.

Low arousal: hypnagogic; attention drifting etc.

High Arousal - stress

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

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).• 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 • Isabel.Clarke@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. ( 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