1. ‘What is Real and What is Not’ An Inpatient Group Programme Designed to Combat the Stigma of Psychosis Isabel Clarke Consultant Clinical Psychologist Hampshire Partnership NHS Foundation Trust

2. About Stigma Not just a ‘side effect’ – a ‘main effect’ on mental health Social Rank theory (Gilbert & Allan, 1998) Diagnosis = low social rank = subservient response and hopeless self beliefs (see Birchwood, Meadan, Trower & Gilbert in Morrison, 2001). And what is diagnosis anyway? – offering an alternative perspective on this and on so called ‘psychosis’

3. Anomalous Experiencing Revisited: Transformative Potential Mike Jackson’s problem solving theory Loosening constructs - both/and thinking Link with re-experiencing trauma Encounter with whole can seduce - effect on self Importance of context and holding Clinically encouraging people to join shared world; work in shared world Failure of society to provide adequate containment to allow transformative process - Spiritual Crisis Network

4. The Context “ 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

5. “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.

6. The Holistic Revolution in Psychosis Recognising the role of arousal (Hemsley, Morrison) Importance of Emotion, Attachment and Interpersonal issues (Gumley & Schwannauer: Chadwick) 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

7. Levels of Processing theories 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. –Hot and Cold cognition (Ellis) – and many more! All these theories 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.

8. Linehan’s STATES OF MIND (from Dialectical Behaviour Therapy) – Maps onto Interacting Cognitive Subsystems EMOTION MIND (Implicational/ subsystem) REASONABLE MIND (Propositional Subsystem) WISE MIND IN THE PRESENT IN CONTROL

9. The ‘horrible feeling’ Human beings need to feel physically safe and OK about themselves – about their place in the primate hierarchy Emotion Mind produces a sense of threat when those conditions are not met Emotion Mind/ Emotion Mind memory presents past events as present (trauma) People develop ingenious ways of avoiding facing the sense of threat

10. Ways Of Coping With The Horrible Feeling Giving in - signalling 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 Cutting out reasonable mind appraisal – clicking into another dimension – could be a ‘problem solving’ stage Or getting lost in that dimension

11. Two Ways of Knowing Good everyday functioning = good communication between the two levels of processing ( e.g.implicational and propositional in ICS) At high and at low arousal, the implicational (more holistic) ss becomes dominant This gives us a different quality of experience – one that can be either valued and sought after, or shunned and feared

12. The Everyday The Transliminal Ordinary Clear limits Access to full memory and learning Precise meanings available Separation between people Clear sense of self Emotions moderated and grounded A logic of ‘Either/Or Numinous 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’

13. Taking Experience Seriously in Psychosis Acknowledging that psychosis feels different Normalising the difference in quality of experience as well as the continuity Positive side as well as vulnerability Helping people to manage the threshold – mindfulness is key Sensitivity and openness to anomalous experience – continuum with normality: Gordon Claridge’s Schizotypy research. Understanding the role of emotion – the feeling is real even though the ‘story’ is questionable

14. 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. (New chapters by Brett and Jackson in Psychosis and Spirituality: consolidating the new paradigm – along with new qualitative research) Wider sources of evidence – e.g.Cross cultural perspectives; anthropology. Richard Warner: Recovery from Schizophrenia.

15. 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.

16. What is real & what is not?: about the programme. A 4 session group programme for an Acute inpatient setting Run by staff supervised by or co-facilitated with the clinical psychologist (Mental Health Practitioners, nurses, AOT staff, etc.). Builds on the Romme and Escher ‘Voices Group’ tradition It is different from other CBT approaches in normalizing the difference in quality of experience in psychosis, as well as thinking style.

17. Normalizing anomalous experiencing Everyone is somewhere on the schizotypy continuum 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. Signing up for the group. Validate their reality Introduce the idea that their reality is only one way of looking at it: shared and unshared reality (negotiate the language).

18. 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.

19. Characteristics of unshared reality. Idea of the line/ the threshold. Importance of being able to manage the line Motivational aspect – pros and cons. Coping skills to manage the line When is unshared reality most powerful; in charge? Arousal as a means of being in control; Stress management Being alert and concentrated – watch out for drifting states Grounding in the present Wise mind and mindfulness Focusing/mindfulness v. distraction

20. 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

22. 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.

23. 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. We are prepared to open the programme to people who are quite floridly psychotic – not so easy to obtain measures from this group. Even with only 4 sessions, consistency of attendance and retention are a problem CSIP grant enabled us to employ an Assistant one day a week for 6 months in order to evaluate the group

24. Measures CORE – routine measure and to gage level of pathology Mental Health Confidence Scale Visual Analogue Goal Setting Scale – administered as part of the first session. Satisfaction Questionnaire at the end gave us some idea of impact on individuals

25. Questionnaire Results Because of high rates of attrition and difficulties obtaining questionnaires in some cases, only 15 complete data sets were achieved Significant self rating of achievement of goal for group attendance Mental Health Confidence Scale: overall results not significant. Only the ‘Coping’ subscale showed significant improvement;’Optimism’ and ‘Advocacy’ subscales did not reach significance - the trend was in the right direction

26. Satisfaction Data Question 1: What was most helpful about the group? – Universality cited: Nice to hear other people open up… Being able to talk and understand each other Q2: What was least helpful about the group? Other people talking too much Should be earlier and more intense

27. Q3: Has it made you think differently about anything? If so, please tell us about this. It made me think about things in my thoughts I feel clearer about what’s real and what’s not, what to share and what is personal Yes without a doubt. I feel better about myself Q4: Please tell us what, if anything, has changed in the way you think about your mental health issues since attending the group. Yes, I am thinking of more positive things about my life I have now realised that I in-fact do have a problem

28. Q5: Please tell us what, if anything, has changed in the way you view yourself since you attended the group. Feel less isolated about the way I see things I have become more confident Q6: What kind of things did you learn in the group? Using mindfulness To be open, to think about what you are thinking, to be self-aware Open Comments: wanting the group to have been longer.

29. Wider Influence AOT became interested as the group drew in previously unengageable clients – co-facilitated A 12 session community version was developed – with the help of a focus group of service user graduates Attended by AOT and CMHT clients This is being more thoroughly evaluated and will be written up Service user report of impact in the chapter on the approach in the Second Edition of Psychosis and Spirituality.

30. Contact details, References and Web addresses Isabel.Clarke@hantspt-sw.nhs.uk AMH Woodhaven, Calmore, Totton SO40 2TA. Clarke, I. (Ed.) (2010 Forthcoming) 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. 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. Wilson, H., Clarke, I. & Phillips, R.(in preparation) Evaluation of an Inpatient Group CBT for Psychosis Program Designed to Increase Effective Coping and Address the Stigma of Diagnosis Psychosis. www.isabelclarke.org www.SpiritualCrisisNetwork.org.uk