Isabel Clarke Consultant Clinical Psychologist

 The illness model has the virtues of certainty and protectiveness  BUT  Inadequate reflection of what is happening  Leaves 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.

 Biological v. Social constructions of psychosis: Read, Mosher & Bentall 2004  Role 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 approach

 When 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 universal potential given the ‘right’ conditions

REASONABLE MIND – SHARED REALITY EMOTION MIND – UNSHARED REALITY IN THE PRESENT IN CONTROL WISE MIND In touch with both Reasonable Mind Memory Emotion Mind Memory

 Validate the experience as their experience  Validate 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 without

 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 some

 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 esteem

 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  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’

 Brainstorm the factors leading to vulnerability  Lack of sleep, food, stress, isolation  Pressure of events – life transitions  Effect 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 charge

Level of Arousal Ordinary, alert, concentrated, state of arousal. Low arousal: hypnagogic; attention drifting etc. High Arousal - stress

Ways of coping suggested by this approach – management of arousal and distraction.

 Motivation to take charge – David Bowie e.g.  Arousal Management – up and down  Grounding 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 in

 Aim: 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’

 As 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.

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 Feeling

 Approach with caution – based on an understanding of the States of Mind diagram  Exploring 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 stuck

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 TRIGGER

 Arousal management  Grounding mindfulness  Mindfulness of unusual experiences/unshared beliefs – takes courage  Fear and avoidance  Facing that it is unshared – e.g. when grandiose  Facing emotion - DBT skills  Self Compassion  Relationship management

 There to offer a more hopeful, alternative, perspective – while stressing the role of NHS to manage risk  Small, unfunded, UK charity  Website with 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)

 Empathise 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 recommendations

 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 substances

  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.  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  