a THERAPEUTIC APPROACH TO PSYCHOSIS THaT TAKES EXPERIENCE SERIOUSLY AND UNDERMINES STIGMA Isabel Clarke Consultant Clinical Psychologist Moving on from the Illness Model The illness model has the virtues of certainty and protectiveness ID: 434668
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“What is real and what is not”a THERAPEUTIC APPROACH TO PSYCHOSIS THaT TAKES EXPERIENCE SERIOUSLY AND UNDERMINES STIGMA
Isabel Clarke
Consultant Clinical PsychologistSlide2
Moving on from the Illness ModelThe illness model has the virtues of certainty and protectivenessBUTInadequate reflection of what is happeningLeaves 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.Slide3
The Blight of StigmaBiological v. Social constructions of psychosis: Read, Mosher & Bentall 2004Role 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 approachSlide4
A Clinical Model based on ICSWhen 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 u
niversal potential
given the ‘right’ conditionsSlide5
States of Mind Diagram. Applied to Psychosis
REASONABLE
MIND – SHARED
REALITY
EMOTION
MIND – UNSHARED
REALITY
IN THE PRESENT
IN CONTROL
WISE
MIND
In touch with both
Reasonable
Mind Memory
Emotion
Mind MemorySlide6
A therapeutic approach using this modelValidate the experience as their experienceValidate 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 withoutSlide7
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 someSlide8
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 esteemSlide9
Shared Reality Unshared RealityOrdinaryClear limitsAccess 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’Slide10
Understanding and taking charge of the ThresholdBrainstorm the factors leading to vulnerabilityLack of sleep, food, stress, isolationPressure of events – life transitionsEffect 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 chargeSlide11
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 - stressSlide12
Session 2 cont. DIALECTICAL BEHAVIOUR THERAPY: Linehan’s STATES OF MIND applied to PSYCHOSIS
Ways of coping suggested by this approach –
management of arousal and distraction.Slide13
Ways of taking charge and making senseMotivation to take charge – David Bowie e.g.Arousal Management – up and downGrounding 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 inSlide14
Grounding MindfulnessAim: 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’Slide15
Individual work Therapeutic AllianceAs 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.Slide16
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
Horrible
FeelingSlide17
Using EFF with PsychosisApproach with caution – based on an understanding of the States of Mind diagramExploring 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 stuckSlide18
Psychosis formulation
FEAR
THREAT!
THE PAST
Being in crowds, busy places:
Body reacts to threat
Body reacts to threat: Intrusive thoughts
Withdraw, hide away
Or Fight, become aggressive
Escapes from thoughts
By slipping into unshared world
Hears voices
More tension, sweaty,
heart races
Unrealistic, worse, fears
RECENT TRIGGERSlide19
Breaking the Vicious CirclesArousal management Grounding mindfulnessMindfulness of unusual experiences/unshared beliefs – takes courageFear and avoidance
Facing that it is unshared – e.g.
when
grandiose
Facing emotion - DBT skills
Self Compassion
Relationship managementSlide20
Spiritual Crisis Network ApproachThere to offer a more hopeful, alternative, perspective – while stressing the role of NHS to manage riskSmall, unfunded, UK charityWebsite 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)Slide21
SCN Email RespondingEmpathise 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 recommendationsSlide22
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 substancesSlide23
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