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.

BodyState

subsystem

Auditoryss.

Visualss.

Interacting Cognitive Subsystems.

Implicational subsystem

ImplicationalMemory

Propositional subsystem

PropositionalMemory

Verbalss.

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

MIND

REASONABLE

MIND

WISE

MIND

IN THE PRESENTIN 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

• 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

FEARRAGE

SADNESSCut selfAttempt suicide

Friends and family alarmed. Could lose custody of children.

Feel worse

Nightmares: can’t sleep

More difficult to cope

Avoid going out and seeing people

More time to brood

PAST ABUSELOSSES

PARTNER LEAVING

WAYS FORWARDDon’t let the feelings be in control: YOU ARE IN CHARGEDo things despite the feelingBreathing and mindfulness to get back to the presentUse the energy of the anger positively

Typical formulation

Psychosis formulation

FearSense of threat

The past

Being in crowds, busy places

Intrusive thoughts

This means I’m bad and others want to hurt me

Withdraw, hide awayOr Fight, becomes aggressive

Escapes from thoughts By slipping into unshared world

Hears voices

This also means I’m bad andothers want to hurt me

Tense, sweaty, heart races

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 keyUnderstanding 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

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 transliminalBoth 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

• Emotions moderated and grounded

• 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

• 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

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

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

• Isabel.Clarke@hantspt-sw.nhs.uk• Hannah Wilson@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