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

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  • Slide 1
  • Negative Symptoms A Critical Look and a Motivational Approach Isabel Clarke Consultant Clinical Psychologist AMH Woodhaven
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  • 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
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  • 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?
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  • 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 the face of the constant invalidation
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  • 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 Claridges Schizotypy research. Understanding the role of emotion where expression of emotion is not straightforward the feeling is real even if the story is suspect.
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  • 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
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  • 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.
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  • 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.
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  • 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
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  • 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?
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  • 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.
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  • 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.
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  • 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
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  • 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
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  • 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 individuals 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
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  • 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.
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  • 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.
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  • 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.
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  • Hope. CBT. Cognition and behaviour can change. You can take responsibility and choose. Not fatalistic. Central to Recovery. DBT: the life worth living.
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  • 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.
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  • 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.
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  • 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.
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  • 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.
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  • 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.
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  • 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.
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  • Response to Risk and challenge. CBT. Collaborative risk management is the most effective. Speci