An Approach to Psychosis: the Mind-Work Process (4/6)

Many people have grappled with defining what mind-workers ought to do. Two “orts” emerge as favourites: rapport, as described by Carl Rogers, and support, as outlined by David Smail. My idea of the mind-working process starts from but does not end there. We will also have to consider other factors of crucial importance if the client is going to be able to take over and keep going the process of transformation for himself. These factors will be described in more detail in the next post: I’ll be using terms rooted in existential therapy but the key underlying concept is present in a strong form in my Faith tradition.

The Rogerian Triad

First there is the old faithful – the so-called Therapeutic Triad! I have used the word ‘therapist’ here because it is the one Rogers chooses. I’ve mentioned my doubts about the word in an earlier post of this sequence.

The Therapeutic Triad of Carl Rogers consists of genuineness (or congruence), empathy and warmth (or unconditional positive regard). Though it is very well known it perhaps needs a brief comment here. Carl Rogers in 1957 described the core conditions required of the mind-worker. To be genuine the therapist must be “freely and deeply ” herself. The therapist must also find herself experiencing “a warm acceptance of each aspect of the client’s experience as being a part of that client” if she is to experience “unconditional positive regard.” Empathy is “to sense the client’s private world as if it were your own.” For this to be effective the client must perceive “the acceptance and empathy which the therapist experiences for him.”

This triad can be summarised as Rapport, one of the “orts” which the mind-worker must bring to the mind-work to make the existential processes possible. This is what the mind-worker brings to the relationship but does not expect the client to apply to his own life.

(Incidentally, I will be using “he” or “we” for a client and “she” for a mind-worker in order to be politically correct, to avoid awkward constructions such as “(s)he” or him/her and to increase the likelihood of our reading at least some of these words from a client’s perspective.)  If these qualities were not seen by the client to be present the mind-work would never get going. Rapport may often do no more than make change possible.

Smail’s Triad

Then there is the new one on the block which takes things a bit further. This other “ort”, which can be labeled “Support”, is the Smail Triad, which he introduces in his book “How To Survive Without Psychotherapy” (1996). This is less widely known and will need a bit more introduction. It consists of Encouragement, Solidarity (or Comfort) and Clarification.

Warmth and Encouragement are related but not identical. Encouragement is essential. Smail defines this as:

. . . any kind of influence brought to bear by the therapist on the patient (sic) to try actively to make a difference to the factors that are causing him or her distress.

(A feature of so-called “psychosis” is passivity in the face of experience: encouragement is therefore very important in this context. Also such people have typically been facing deeply discouraging experiences for many years.) By encouragement the mind-worker responds positively to the efforts of her client to apply what he has discovered in mind-work. Praise is, for me, a key component.

Solidarity is, according to Smail, “one of the most potently therapeutic experiences to be had,” even though in itself it changes nothing. It is derived from sharing your deepest fears and most shameful secrets with a ‘valued other’ who does not immediately heap blame or scorn upon you, but who instead listens patiently and sympathetically to what you have to say.

It is something one human being gives to another by uncritically and supportively, but not blindly, standing beside him in his difficulties. It should but perhaps does not go without saying that this does not mean leaping in and drowning in there with him.

In the words of Smail (page 213):

Solidarity with others is both one of the most significant and, all things considered, the most available forms of power for ‘ordinary’ people.

For people with a label of psychosis it is significantly less available and we should not underestimate the corrosive effects of that unavailability upon a person’s well-being. Solidarity is also what stops the praise and encouragement from being experienced as patronising. The mind-worker stands alongside, not above, the client. To feel that we are not alone in our troubles and that some one appreciates our efforts has a power to keep us going and bring about success that should not be underestimated.

Though Solidarity and Empathy have much in common they also are not the same thing. Solidarity involves standing with somebody as he struggles to act. Though it implies the mind-worker knows how the client feels, solidarity also implies action whereas empathy might only sit nearby and commiserate with how difficult if must feel.

Clarification is also crucial. People in distress are often confused. Simple questions and straightforward feedback are often all that is needed to dispel the fog. Sometimes another map of the world needs to be gradually introduced, again as a colleague and fellow human being, not as a superior being from her pedestal.

Smail (page 42) feels that there is,

. . . in principle at least, not a great deal of difficulty in arriving at an acceptable account of how people come to be as they are and what are the origins of their distress. Where difficulties do arise is in knowing what is to be done with this information. The idea that ‘insight’ leads automatically to cure, while figuring largely in many patients’ expectations, has long been recognised to be problematic by therapists.

The glib assumption, that to be clear is to be able to change, places an unrealistic degree of responsibility upon the client. Part of Smail’s solution is to emphasise solidarity and encouragement: the rest of what he stresses may be summarised under the idea of taking proper account of the power of environment in creating and alleviating difficulties. The extent to which an oppressive environment cannot be changed sets limits on the degree of change we can bring about.

For me, the physical environment within which the mind functions can be both outside (society, unemployment, lack of cash, poor housing etc) and inside (brain structure, chemistry, hormones etc) the individual. The degree to which these variables can operate effectively to bring about change is affected by environment, but that is a topic too large for present consideration.

Transferring Ownership

The process of clarification provides us with the easiest bridge from the “orts” to the factors we mentioned earlier which enable the client to keep the transformation process going because the client has to have more ownership of clarification than of the other qualities in these groups of three.

Support, even in the context of a good rapport, can only make change possible but it doesn’t tell us how to make sure it will happen in the first place and then continue in the right direction in the absence of the mind-worker. These qualities do not become the instruments the client will use himself to bring about change nor are they the results of changes taking place. They are composed of the essential prerequisites that make positive change processes possible within a relationship. With the possible exception of clarification, if the client lacks them, he does not need to develop them if he does not wish to. However, he needs to sense most of them in the mind-worker.

The Good Samaritan

It perhaps goes without saying that most of these characteristics of the relationship, such as warmth, empathy, honesty, encouragement and solidarity are also emphasised in many spiritual traditions as essential to a proper relationship with other people. The golden rule, which recommends that we treat others as we would ourselves wish to treated, occurs over and over again across the world transcending barriers of language and culture.

The characteristics I will be discussing in the next post helped me combine practical insights specifically drawn from the Bahá’í Faith with the processes of therapeutic practice. They are key to someone’s being able to carry on the work after the mind-worker has gone.

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An Approach to Psychosis: Complicating Factors (3/6)

The Importance of Motivation

What perhaps is also worth mentioning is that if Ian had not been desperate to get rid of the voices he probably would not have bothered doing anything I suggested.

P.: What I’m picking up is that, initially, you didn’t have much trust in me and you wondered what on earth I was up to. You didn’t really believe in what I was suggesting you should do.

I.: No.

P.: So, in a sense, why do you think you tried it? And why do you think you stuck with it?

I.: Desperate. I wanted to get better, you see? I didn’t want to go on the way I was going. So, I was desperate. So, I tried what you were telling me to do. It was worth a try. It was something I hadn’t tried before. And it was something new, you know? And it worked.

P.: Were you surprised it worked?

I.: I was very surprised it worked.

P.: Right.

I.: It seemed so simple. All that eight years, you know? All the trouble, all the Sections [i.e. compulsory detentions under the Mental Health Act 1983], and all the rest of it, and all the time in hospital and all the talking didn’t count for nothing. Then all of a sudden it just seemed to click! And it come together.

P.: Made sense and gave you relief?

I.: It did give me relief, yeh.

It made very little sense to him beforehand. This is true for a great many people. The more engulfed they are by their experiences the less sense a mind-work approach makes to them. Only desperation or an equivalent motivation will drive them to try what we suggest to them. In Ian’s case we were lucky that he got some results before he gave up trying.

The Balance of Pain and Gain

There was also the issue of the pain involved.

P.: So you think that the pain you experienced as a result of sorting this out was a price worth paying for now having sorted it out?

I.: Yes. It was well worth paying. I didn’t think so at the time. I wanted to stop it, you know? Because it hurt too much.

This was not true later. When he was dying some years later of emphysema and heart failure, I visited him in the hospice and asked him the same question. We had worked on other deeper pain by then. He had changed his mind. The pain was not worth the gain he said then. He had learned to manage the voices by dealing with the pain when they got too bad and he had learned to manage the pain of difficult anniversaries by allowing the voices to surface again more strongly. The torment of the voices at those times was preferable to the pain, anguish and guilt he would otherwise experience. This makes it imperative to consider carefully whether we have the person’s informed consent before we use the depth approach.

The Limitations of Diagnostic Labels

Also interesting is the point he made that the problems he discovered were different from what he thought they would be.

I.:. . . . the questions you asked were painful. And I didn’t want to answer them.

P.: And you didn’t see the point of answering them either, did you?

I.: No, I didn’t see the point in answering them because I didn’t recognise myself that the problem lay there. But once I could see where the problem was I could bargain with the voices.

P.: Yeh. And you had to know where the problem lay, roughly before you could bargain with them?

I.: And talking to you showed me where the problem was. So, I was able to deal with the voices in a positive way.

P.: But before you had gone through this whole process there was no way you would have realised that the problems were what they turned out to be.

I.: No. I thought it was just schizophrenia.

A Welcome Corrective

P.: And that was the end of it.

I.: And that was the end of it. I was schizophrenic and that was it. And I had nothing to look forward to except hospital and more medication. And I couldn’t stand the thought of that, you know? So that jumping under a train was looking very attractive. But it doesn’t look attractive now.

P.: Because life seems to have more to offer?

I.: Yeh.

Nonetheless in our subsequent conversations he oscillated between talking about his thoughts/feelings/voices and his illness.

What perhaps matters most is not whether these ways of describing a problem are true or false but whether they are useful or useless to the person at the time. Psychosis is too complex a phenomenon to be successfully explained in our present state of knowledge. My problem with the medical model is not that it is always completely wrong but that it is all too often offered as the only explanation when other explanations would be more useful to the person concerned.

Sleep and Food

Naturally, there are other factors that have a part to play in psychotic experiences and a person’s capacity to cope effectively with them. For example, Ian talked of his need for sleep and food.

He said, ‘Now I come back off the holiday. I was quite well for about a couple of weeks . . ..: . . . and then I went downhill very quickly because [the voices] wouldn’t let me sleep and I stopped eating. And I got very weak, you know. And the voices become louder and more persistent. And I started to believe them.’

We probably all know how important sufficient sleep and good food is for mental health, especially for people suffering from this type of problem. The physical and social environment is also extremely important. However, I am not attempting here a comprehensive list of such factors. That would be too ambitious.  I’m trying to give a sense of what constitutes an optimal approach for someone seeking to use conversations to help those who are struggling with these potentially disabling phenomena we call psychosis. The recovery model as a whole package depends upon many other things also being in place such as, where needed, social support, training, education and work.

Perhaps next time we should look more closely at the ingredients of collaborative conversation.

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An Approach to Psychosis: Surfaces and Depths (2/6)

Using Conversation: a Surface Approach

Ian talked of two main ways he felt he had been helped by the conversations with me. He felt he had learnt how to “bargain” with the voices.

P.: And you feel that [dealing with emotions: see below for more] was a very important aspect of what we were doing together?

I.: And the suggestion that I could bargain with the voices.

P.: Right. So in fact there were then two things. One was the emotions that you got in touch with about the separation from your partner, and there was also it was suggested to you that you could bargain with the voices.

I.: Yeh.

P.: Can you say a bit more about one or other of those? Why you felt they were important?

I.: Well, because I’d tried telling them in the hospital, you know, that I’d been trying to talk to the voices. And they kept discouraging me and said I shouldn’t talk to the voices. I should ignore ‘em. And I kept saying `Well, I should talk to them, you know, because I can get in touch with them.’ I’d felt that all along. And you supported it. And told me to talk to the voices, you know. With a bit of confidence.

P.: And what did you say to the voices? What was your approach to them?

I.: I said `I know that you’re unhappy. But I don’t know why you’re unhappy, but I’ll talk to Peter about it. And see if we can’t get to the bottom of it. And I’ll try to make you happy.’

P.: Yeh. And did you ask them if they could do something in return?

I.: Yes, I asked them if they could let me sleep.

P.: Right. And did they?

I.: Yes.

P.: Did they do it straightaway or . . .?

I.: No, it took a coupla nights.

P.: Right. But then after a couple of nights they did give you a break?

I.: Yeh. They give me a break, yeh.

P.: I need to ask you this as well. Did you think that that was actually going to be of any use before you did it?

I.: No, because I didn’t think I could get in contact with the voices so easily. I thought it would take a lot longer, you know? But I found that it happened pretty quickly.

P.: Yeh. It was important was it that it happened quickly?

I.: Yeh.

P.: Do you think you would have had the patience to keep going if it didn’t?

I.: I don’t know.

This I would describe as a surface approach and bargaining in this way has been used by many others as well as Ian. Surface approaches range from recommending that people use earplugs or Walkmans as a distraction from the voices, through reading out loud as a way of disrupting the voices, to examining in detail the experience of the voices in its own right, which is called focusing (see below).

Using Conversation: a Depth Approach

Ian also mentioned how he had realised that the pain of breaking with his partner had contributed to his experience of the voices.

I.: I knew there was something wrong with me. But I didn’t know what it was. And I knew something was bothering the voices. And I think it was over the split up with my partner, you know, and the pain that that caused.

P.: Yeh. Which you hadn’t dealt with?

I.: Which I hadn’t dealt with. I just pushed it to one side.

P.: So is that why it was important to deal with that then, with that pain?

I.: Yeh.

P.: Can you explain that, rather than me putting the words into your mouth? Why do you think it was important to deal with the pain of that?

I.: Because I hadn’t come to terms with it, you know? I still loved my partner and I was still hoping that somehow we could get together, you know? But I’ve give up that idea now. And I’ve put her in the past.

P.: Right. So, do you feel that that sadness was something that had some kind of effect on the voices or . . .?

I.: Yeh.

P.: What kind of effect do you think it had?

I.: Because I was sad inside and because I was still hanging on, really, they kept plaguing me, you know? They were feeding on my unhappiness. And it was being unhappy that was causing the voices to be unhappy. But having talked about my partner and coming to terms with it and crying and feeling it, you know, and it really hurt and I didn’t want to go on with it at first because I thought it hurt too much but I knew that I had to go on with it, if I wanted to have peace of mind.

P.: Right. And that’s what kept you going was it?

I.: Peace of mind, yeh.

P.: Right. And presumably the fact that the voices did respond to your bargaining earlier on, did give you some hope that if you actually carried doing this process, that they’d leave you alone even more.

I.: Yeh. I thought that if I got it all out in the open, you know? And – er – I was able to think for the first time in eight years.

This is more of a “depth” approach. We were looking at what might lie behind the experience of the voices. Ian discovered that by acknowledging his emotional pain he could dispel the voices. Discounting emotional pain can lead to problems of other kinds as well as voices, but hearing voices is often the result of trauma and therefore connected with emotional pain.

Many people discover that working on what lies behind the voices can help them control the voices. Other people find this too painful and prefer to stick with surface approaches which are nonetheless quite powerful. There is evidence to suggest that distraction is not quite so good in the long run, leaving people with a lower sense of self-efficacy and a greater vulnerability to depression.

Focusing

Focusing, which is still a surface approach, is better if the person can cope with it. Self-efficacy is enhanced and subsequent depression less likely.

Focusing involves turning your attention to the patterns contained in the experiences you are having. When your experience is dominated by threatening and demonic voices, focusing is a scary business. However, if you can make yourself do it, it brings dividends.

The characteristics of the voices (in Ian’s case a bullying male voice) and the specific content (with Ian it was orders such as ‘Get out of bed you lazy bastard’) can help identify why the voices have taken this particular form: Ian’s first breakdown had been in the army when he was under the command of a particularly unpleasant sergeant-major. His army experiences proved important in understanding other aspects of his psychotic experience as well, but that is another and much longer story. So, it was very useful to get this early hint about that.

When they occur, how often, and under what circumstances,  can help us see what triggers them.

My only one session successful intervention was with a someone who heard sadistic voices insisting that he would be tortured if he did not find out where bombs were being planted. Until a couple of years before, his voices, which had been with him 25 years or more, were always friendly and helpful. We tried to work out what had changed. It turned out that about two years ago he had developed a strong interest in the Second World War and was reading avidly and constantly about the Gestapo and the Resistance Movement. We decided between us that he should experiment with desisting from any reading around this subject for the next four weeks and then we would meet against to compare notes.

As he believed the voices were real he did not have a great deal of confidence in this approach! He agreed to do it, I believe, in part to prove me wrong. He decided to pursue his other main interest at the time and  to read the National Geographic magazine instead.

He was plainly astonished but delighted when the sadistic voices disappeared and his friendly voices returned.

Focusing can be very effective especially when it is linked to practical action in this way on the basis of what you have learned.

Next time

In the next post we will be looking at some complicating factors.

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Cherie Blair Article in the Times

Cherie Blair has written a strong piece today drawing attention to the situation of the  Bahá’ís in Iran. She states:

The campaign against the Baha’i community reached a new intensity last spring when its seven-strong national leadership was arrested in dawn raids. More than a year after detention without charge or access to a lawyer, the prisoners’ families have finally been told a court date has been set for this Saturday.

We don’t yet know the charges. But Iranian news reports have suggested that the national committee stands accused of everything from “espionage for Israel” to “propaganda against the Islamic Republic”. Such charges carry very serious penalties in Iran, including the death penalty.

What is also very worrying are reports that the case will be heard by the same Revolutionary Court that recently tried, in secret, the US journalist Roxana Saberi. After proceedings lasting only one day, she was sentenced to eight years in jail.

The campaign against the Baha’i community reached a new intensity last spring when its seven-strong national leadership was arrested in dawn raids. More than a year after detention without charge or access to a lawyer, the prisoners’ families have finally been told a court date has been set for this Saturday.

We don’t yet know the charges. But Iranian news reports have suggested that the national committee stands accused of everything from “espionage for Israel” to “propaganda against the Islamic Republic”. Such charges carry very serious penalties in Iran, including the death penalty.

What is also very worrying are reports that the case will be heard by the same Revolutionary Court that recently tried, in secret, the US journalist Roxana Saberi. After proceedings lasting only one day, she was sentenced to eight years in jail.

It was only after the international outcry at this parody of justice and the severity of the sentence that she received another trial. This reduced her sentence to a two-year term that was suspended on appeal.

We need the same international pressure now, before the court case, to ensure the seven men and women receive a fair trial and a chance of justice. They must be given full access to their lawyers, who must have time to prepare their defence. The court proceedings must be open to independent observation.

For the full article follow the link at the top of this post. For more UK related background see bahainews-uk.

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An Approach to Psychosis: Mind-Work & Trust (1/6)

Some Background Thinking

I thought it was about time I tried to do a post on the work I did for most of my professional life. It could be tricky and might not work out at all.

I have been struggling for ages — at least ten years —  to capture in words the work I used to do. Words like therapist and therapy make me uncomfortable. Even the word counseling implies unequal distributions of wisdom. She who gives counsel is somehow superior to him who receives!

I have come to believe that what I did is best called mind-work. It includes mood-work, belief work and will-work: it should have included ‘soul-care’ but that would have been a step too far for a clinical psychologist’s job description even though ‘psyche’ means ‘soul’ to the Greeks.

Everyone does mind-work up to a point. It’s a bit like cooking though. Almost everyone prepares food at some point in his life but not everyone’s a chef. As a professional mind-worker I was a bit like the chef. I was an expert at the work at the same time as the people who worked with me as clients were experts about their own minds.

Because, to do mind-work, I drew on lots of other disciplines and traditions, including philosophy, psychology, biology, religion (especially Buddhism and the Bahá’í Faith) and the arts, I could sometimes feel like giving myself a fancy title such as psy-culturalist. This captures the richness of the traditions I could draw on and also captures the essential purpose of mind-work which is growth. It also meant I didn’t have to label myself a psychologist with its one-sided implication that I study the mind but don’t work with it, nor did I have to call myself a Clinical Psychologist with its implications of illness and therapy, which are insulting to the client.

Psy-culturalist, as a term, has a similar problem to Clinical Psychology. If we think about gardening, it’s a one-way street. Plants, as a general rule, don’t grow people. Mind-work, though, is both reciprocal and reflexive. I grow you and you grow me and we grow ourselves as well!

In the end then mind-work is a perfectly good description.

Mind-work for the most part involves forming a relationship (much more on that later) that allows words to be used in a process of collaborative conversation (the title of a book chapter I contributed to This Is Madness) to enhance meanings in a way that enables all participants to grow. As I see it every human interaction is an opportunity for mind-work and as many interactions as possible should be used as such. Even the groups of people who traditionally have been seen as experiencing meaningless lives, such as those with a diagnosis of schizophrenia or dementia, are not to be excluded from this meaning-making growth process. My work has mostly been with the former group and what follows discusses some implications of that. For me though, everybody means something and to deny that is to dehumanize us.

Perhaps it is important to clarify something. I use the word mind to cover a wide variety of possibilities. Consciousness is only one of them. Many important processes take place outside the circle of light shed by conscious attention. Mind is also where the body is experienced and shares a two-way relationship with the brain, so the realms of the physical are not excluded. The mind is a node in a sociocultural network and is affected by many wider systems which it maps and responds to in a variety of ways. No mind is an island! There is also strong evidence that the mind can operate independently of the body/brain (See Jenny Wade’s Changes of Mind, Ken Ring’s Lessons from the Light and David Fontana’s Is There an Afterlife? as well as posts on this site about the afterlife hypothesis for more detail about that.)

There are differences that should not be obscured. A psychologist is paid for her mind-work: her client is not. That is one difference which can create an undesirable power-differential if great care is not taken to counteract that tendency. Another difference lies in the fact that the client is the expert, as I have said, in his own mind: the psychologist is the expert when it comes to the nature of the work in some of its aspects. That is the only other difference. Both can grow as a result of the mind-work they do together.

That should be enough to set the scene for the exploration of my way of working that follows.

The Client’s Perspective

In 1996 I interviewed someone who had gone through a series of conversations with me about his voices. He was a former miner and an ex-army man from the Welsh valleys. He was articulate but down-to-earth. What he told me enriched my way of doing things considerably and shed a great deal of light into previously dark places. We made a video together, from which the photo  below is extracted but without showing his face, and he was very keen that it be used to help others understand this kind of problem better. At the time of the videoed interview we had been working together for about six months. There was still a long way to go but much of interest had happened. I will call him Ian to protect his identity.

Perhaps most importantly, he emphasised the role of trust.

P.: And it was in November that we first met, wasn’t it?

I.: Yeh. Jenny [his residential social worker not the author of the book recommended above!] had started talking about you, you know? And it was coming up to the meeting with you. And I can remember going to the meeting with you that first time. And I can remember thinking who’s this bloke asking me all these questions, you know? And I didn’t trust you. But Jen was persistent that I could trust you, so I decided to trust Jenny and to talk to you.

P.: And you actually asked if Jenny could come to sessions, didn’t you?

I.: Yeh, I asked if Jenny could come, yeh.

P.: Right. And I think she came about the second or third time you came.

I.: Yeh.

P.: And did you feel more comfortable with her there?

I.: I did, yeh.

P.: And did that make you feel more able to begin to trust me at least personally if not what I was doing?

I.: It took about a month to start to trust you. And that was with Jenny backing you up.

This cannot be stressed too much. Trust takes a long time to build and is easily lost. In Ian’s case Jenny who had worked with him for years and vouched for me assisted the development of trust. In a “delusion” exercise I use in workshops we can see how a period of unsympathetic and confrontational treatment at the hands of other people makes it harder for someone to believe we are not going to be the same. We need to prove our trustworthiness over a period of time. We need to be prepared for hostility at worst and the cold shoulder or evasion at best in the early stages of our relationship. We would be wise not to assume that such behaviour is the result of “paranoia.” It is at least as likely, if not more so, to be a natural reaction to months if not years of other people’s outspoken incredulity.

What also was important to the success of my work with Ian was all the effort Jenny put in in-between times.

I.: It took about a month to start to trust you. And that was with Jenny backing you up.

P.: And that was by being there in the sessions and by talking to you between whiles wasn’t it? You used to have meetings and discussions with her between times.

I.: Inbetweentimes, yeh. And we’d talk about what we’d talked about, you know? And she supported you in what she said.

She helped him remember what I had said or correct his distortions of it. She encouraged him to make use of the suggestions we had come up with. She helped him make sense of what was happening to him in the terms I had described it. Isolated mind-work sessions will achieve little if they are not reinforced and supported by a lot of work in-between.

We will hear much more from Ian in the next post.

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