1. What is Real and What is Not. A Third Wave Approach to Formulating Psychosis Isabel Clarke Consultant Clinical Psychologist AMH Woodhaven

2. “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.

3. “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

4. 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

5. 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!

6. 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.

7. Body State subsystem Auditory ss. Visual ss. Interacting Cognitive Subsystems. Implicational subsystem Implicational Memory Propositional subsystem Propositional Memory Verbal ss.

8. 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.

9. DIALECTICAL BEHAVIOUR THERAPY: Linehan’s STATES OF MIND EMOTION MIND REASONABLE MIND WISE MIND IN THE PRESENT IN CONTROL

10. 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.

11. 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

12. 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

13. FEAR RAGE SADNESS Cut self Attempt 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 ABUSE LOSSES PARTNER LEAVING WAYS FORWARD Don’t let the feelings be in control: YOU ARE IN CHARGE Do things despite the feeling Breathing and mindfulness to get back to the present Use the energy of the anger positively Typical formulation

14. Psychosis formulation Fear Sense of threat The past Being in crowds, busy places Intrusive thoughts This means I’m bad and others want to hurt me Withdraw, hide away Or Fight, becomes aggressive Escapes from thoughts By slipping into unshared world Hears voices This also means I’m bad and others want to hurt me Tense, sweaty, heart races

15. 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.

16. 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!

17. 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.

18. 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 key Understanding the role of emotion and arousal – the feeling is real, though the story might be suspect. All this helps with building a therapeutic alliance.

19. 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

20. 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.

21. 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.

22. 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.

23. 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

24. 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.

25. 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.

26. 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

27. 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.

28. 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.

29. 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.

30. 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