1. Psychosis and Spirituality
Isabel Clarke
Consultant Clinical Psychologist
Southern Health Foundation NHS Trust
Spiritual Crisis Network Director.

2. Some Questions What are the characteristics of spiritual experience ?
What are the characteristics of psychotic experience ?

3. Two Ways of
Experiencing -
The other
one!

4. Characteristics of the other way of experiencing
Metaphor come to life
Dissolution of boundaries

6. Cosmic significance – terrible or wonderful
Confusion about the self

8. Coincidence rules OK
Threat (cosmic)
Link with trauma

10. O the mind, mind has mountains; cliffs of fall
Frightful, sheer, no-man-fathomed. Hold them cheap
May who ne’er hung there.
Gerald Manley Hopkins (from ‘No worst, there is none, pitched past pitch of grief’)

11. Travel into the strange places of the mind
Not mind safely locked inside the skull;
No!: mind that envelopes us;
Mind that is sea we swim in
Travel across the threshold – the Transliminal – but never to let go of Ariadne’s thread!

12. Spirituality and Relationship
As people, we make sense only within our context of relationship –we are held in a web of relationship
Important others; our family; our social group; ethnic group etc.
Spirituality is about relationship with that which is beyond; with the whole – the widest circle of the web
At times of breakdown, that wider context becomes important

13. Different types of experience: psychosis and spirituality revisited.
Mental health breakdown is a common human experience
Comes from a combination of
Individual vulnerability/sensitivity
Life circumstances – losses etc.
Leading to unmanageable feelings
It often happens at times of transition
For some – the other dimension, across the threshold opens up
A way out of the impasse ?
Creative. Transformational ?
Disorienting. Terrifying ?
A journey into territory where there are no maps, no guarantees.
Think fairytale.

14. What is going on here? The levels of processing problem
Being human is difficult because our brains have 2 main circuits – they work together most of the time, but not always.
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 characterised by high arousal.
The other one filters our view to make it more manageable
The direct processing system is the default system – the one that dominates if the other gets disconnected – in which case we lose that filter – and land up
ACROSS THE THRESHOLD –THE TRANSLIMINAL

15. Getting a scientific grip on the transliminal
The split between realities comes from the split in us!
Interacting Cognitive Subsystems provides a way of making sense of this ‘crack’.(Teasdale & Barnard 1993).
An information processing model of cognition
Developed through extensive research into memory and limitations on processing.
A way into understanding the “Head/Heart split in people.
Having reviewed these trends within the cultural map of therapy, I will return to the central challenge faced in attempting to facilitate change where the patterns to be changed are rooted in early or major trauma, and are deep seated, or where psychopathology is severe, as with serious psychosis.
The split between thought and feeling underlies the logic of CBT. Behaviour, and so the course of life and relationship tends to be governed by feelings and habitual patterns (schemas). If these can be thought about, with the facilitation of therapy, they can be changed. It was then noted that the relationship between thought and feeling operated differently in different situations. Under high threat/high arousal/ high emotion, the reaction was automatic and not reflected upon at all (hot cognition). For revision to happen – it had to be appraised coolly.
Different CBT therapist-researchers have come up with a bewildering variety of ways into the levels of processing split - which I will not bore you with. Instead, I will bewilder you with Interacting Cognitive Subsystems, which provides a neat explanatory framework across these areas (I suggest).

16. (Implicational subsystem)
Linehan’s STATES OF MIND (from Dialectical Behaviour Therapy) – Maps onto Interacting Cognitive Subsystems
REASONABLE
MIND
(Propositional
subsystem)
EMOTION
MIND
(Implicational subsystem)
WISE
MIND
Though L does not refer to it specifically, the ICS split maps onto the basic DBT model of the mind, as follows: The idea of a shifting balance is central to DBT, so that the self is seen as moving between the minds. Wise mind is the same as the two central ss. in ICS working smoothly together; reasonable mind dominance suggests an avoidance of the emotional (because the physical state of arousal produced by memories is anticipated as too unpleasant). Emotional Mind is where the implicational is dominant, and a loop can be set up that excludes current reflection, and so revision of past patterns – whether of depressive rumination or impulsive action.
WISE
MIND
IN THE PRESENT
IN CONTROL 16

17. Interacting Cognitive Subsystems.
Body
State
subsystem
Implicational
subsystem
Auditory
ss.
Implicational
Memory
Visual
ss.
This is a diagram of some of the processing subsystems in the brain, according to Teasdale and Barnard - based on research on cognitive processing. .
I am going to concentrate on the two large ones here - p and i.
p = verbal based logical reasoning - with a verbally coded memory store.
i = holistic, overall meaning processing. Direct connections with sense modalities (in contrast to p) and a memory store coded in every sensory modality - vivid and immediate. The connection with emotional response made possible by the direct connection with state of bodily arousal.
For complete processing, for “construing” in a Kellyan sense, you need both working in close communication. Because the systems are distinct, it is possible for this communication to become overloaded or skewed in some way.
This helps to explain a lot of what goes wrong for human beings.
Verbal
ss.
Propositional subsystem
Propositional
Memory

18. Important Features of this model
Our subjective experience is the result of two overall meaning making systems interacting – neither is in control.
Each has a different character, corresponding to “head” and “heart”.
The IMPLICATIONAL Subsystem manages emotion – and therefore relationship.
The verbal, logical, PROPOSITIONAL ss. gives us our sense of individual self.

19. Two Ways of Knowing
Good everyday functioning = good communication between implicational/relational and propositional
At high and at low arousal, the implicational ss becomes dominant
This gives us a different quality of experience – one that can be either valued and sought after, or shunned and feared
This suggests that some things are precisely knowable, and others are not – though they can be experienced. I think ICS gives us a neat way into this, so I am going to return to the 2 central organising subsystems.
Our everyday mode of being and knowing is achieved by smooth communication between these two higher order subsystems.
However, as we have seen, they can become desynchronised in certain circumstances. It could be that when this happens, and the relational subsystem is in the ascendant, we have access to a quality of experience that goes beyond the personal and appears to offer relationship with the whole. This could be identified with a transpersonal, or spiritual quality of experience – but also the psychotic.

20. A Challenging Model of the Mind
The human being is a balancing act as the two organising systems pass control back and forth: there is no boss.
The mind is simultaneously individual, and reaches beyond the individual, when the implicational ss. is dominant.
This constant switch between logic and emotion gives us human fallibility
The self sufficient, billiard ball, mind is an illusion
In our implicational/relational mode we are a part of the whole.

21. ‘That’s How the Light gets in’ (and the dark)
The Relational part of our mind is embedded in relationship; in the whole (the older part)
The newer, self conscious, part holds our individuality
Temporary control passing backwards and forwards between the two organising ss is experienced as normality
When the ‘relational’ takes over for any length of time, the character of experience changes
The person is no longer grounded in their individuality – boundaries dissolve – they are open to any influences – positive and negative.

22. 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
Boundaries dissolve
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’

23. Managing the threshold
Awareness of vulnerability – of openness to transliminal experience
Grounding when the experience is overwhelming. Grounding activity. Grounding food.
Mindfulness to manage the threshold
Challenge of facing unshared reality mindfully – both pleasant and unpleasant
Transliminal state of mind = most accessible at high and low arousal
Managing arousal – breathing control to reduce arousal; mindful activity in the present to prevent it slipping.

24. Web of Relationships Sense of value comes from rel. with the spiritual
In Rel. with
earth:
non humans
etc.
In Rel. with
wider
group etc.
primary
care-giver
Self as
experienced
in relationship
with primary
caregiver
16 I would go further and suggest a theory of mind that says we create and our created by our relationships, and by the quality of our relationships; I see the individual as held in a web of relationship.
ICS, by suggesting that the verbal and emotional parts of our cognitive organisation work in partnership, opens the possibility of a theory of mind that holds two potentialities; one for the purely individual experience, and the other where human beings are organised in the context of relationship. In this way, the individual mind is not self sufficient, but makes sense within a web of relationship which both creates and is created by experience and action in relationship. The quality of those relationships shapes us in the core of our being.
Clearly, the person's early caregiver relationships, which influence all later intimate partnerships, are important, but the web extends wider; to the social group; the tribe or nation; the ancestors and those who will come after us; the non human creatures with which we share the planet, and to the planet itself. This model provides a way of understanding that "ground of being" that has been cited, or the mystery of the ultimate; of God (however designated) as the widest and deepest relationship of the web. This suggests a way into a universal human experience, but not one that can be precisely designated – it remains a mystery.
Sense of
value comes
from rel. with
the spiritual

25. Unpacking the Web
We learn about ourselves from the way the important people around us treat us from babyhood on.
The function of emotions is the organisation of relationship: relationship with others, but also our relationship with ourselves.
Emotions communicate directly between people, bypassing the verbal-logical (they are catching). 13
To start with the INTER personal by returning to the other feature of the mind as understood by therapists; its extension beyond the personal, whether within the immediate or broader context of relationship.

26. Looking Beyond the Individual – to understand Spirituality
We are defined by relationships that go beyond our current human bonds
These include relationship with our ancestors and those who will come after us
Moving out to relationship with our group, nation, other peoples, humanity
Our relationship with the non human creatures is deep and significant for us
14 Looking beyond the perspective of immediate relationship, the introduction of mindfulness into therapy introduces wider and deeper concepts of mind that go beyond the personal. Some therapists are more aware of this than others. Mindfulness also emphasises the reflexive aspect of therapy (more recognised in humanisitic and psychodynamic, and traditionally, less in CBT – the therapist needs to have a practice of mindfulness, and does the exercise along with the patient where it is used in therapy.

27. Further dimensions of relationship
Relationship with place, with the earth, our planet
Relationship with that which is deepest and furthest – which is beyond our naming capacity, but is sometimes called God, Goddess, Spirit etc.
Relationship is something we experience – so it can be beyond propositional knowledge – we can feel more than we know.

28. Psychosis, Spiritual Crisis and Relationship
Psychosis can be seen as getting lost on the wrong side of the threshold – the place of relationship
But we need our propositional to manage immediate human relationships – and life in general
It is no accident that it is those people diagnosed as psychotic who are often most concerned with the spiritual
I suggest we need to respect their connection with that valued part of human experience – while developing ‘threshold management’

29. Psychosis – Potential for Transformation
Traditions such as Psychosynthesis and Spiritual Emergence/Emergency recognize the transformational potential of the transliminal.
Meeting and integrating shadow - an aspect of transformation
These traditions tend to distinguish between ‘psychosis’ and transformational crises
More and more this is seen as a false dichotomy – Spiritual Crisis Network (.org.uk)
Mike Jackson’s Problem Solving – problem solving model, encompassing potential and dangers.
Role of stigma in trapping people.

30. Taking Experience Seriously in Psychosis/Spiritual Crisis
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’ can be suspect.

31. 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 result in diagnosable mental health difficulties
whether the anomalies/symptoms are short lived or persist. (and now Heriot Maitland)
Wider sources of evidence – e.g.Cross cultural perspectives; anthropology. Richard Warner: Recovery from Schizophrenia.

32. The ‘What is Real and What is Not’ programme
A way of working with psychosis that normalises the spiritual dimension.
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” – need to be honest about the risks.
“Sensitivity” – normalisation based on Claridge’s work on schizotypy.
The person’s important context of relationships needs attending to – a lifeline.
Creative expression

33. 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

34. 34

35. Contact details, References and Web addresses
AMH Woodhaven, Calmore, Totton SO40 2TA.
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.
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,
Wilson, H, Clarke, I & Phillips,R.,(in submission) Evaluation of an Inpatient Group CBT for Psychosis Program Designed to Increase Effective Coping and Address the Stigma of Diagnosis Psychosis.