1. What is real & what is not? Isabel Clarke Consultant Clinical Psychologist

2. 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.

3. The Project We have been running this group for a couple of years, and are convinced it has an impact We are using the grant to evaluate and write it up We hope that the approach will be adopted more widely – so that people with psychosis can be given a more balanced and hopeful message than at present.

4. 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 transliminal Both 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.

5. The Everyday TheTransliminal Ordinary Clear limits Access to full memory and learning Precise meanings available Separation between people Clear sense of self Emotions moderated and grounded Numinous Unbounded Access to ordinary knowledge/memory is patchy Connections abound - or all is meaningless Self: lost in the whole or supremely important Emotions: swing between extremes or absent

6. Taking Experience Seriously in Psychosis What is the nature of experience in psychosis? Normalising the difference as well as the continuity Sensitivity and openness to anomolous experience – continuum with normality Understanding the role of emotion – where expression of emotion is not straightforward.

7. Evidence for the 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. Wider sources of evidence – e.g.Cross cultural perspectives; anthropology.

8. 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.

9. 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.

10. 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

11. Session 2 cont. DIALECTICAL BEHAVIOUR THERAPY: Linehan’s STATES OF MIND applied to PSYCHOSIS Discussion of Ways of coping suggested by this approach – management of arousal and distraction.

12. 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.

13. 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……..

14. Work in progress We have recruited an excellent researcher for one day a week for 6 months She has attended the programme and researched the literature. We are considering combining a couple of questionnaires (a coping style questionnaire and the standard CORE) with the ideographic goal setting measure and a satisfaction questionnaire, modified to measure impact on self image. Service user and carer interviews might be admissable without Ethics involvement.

15. 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. (forthcoming) 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.scispirit.com/Psychosis_Spirituality/