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

Some years ago I posted a series of attempts to describe my work in the NHS as I experienced it. Since then I have been also attempting to use poems to approach the same experiences from a different angle. Because my poems tend to come from a darker place than my prose it seemed only right to publish the poems alongside the more positive feel of the republished mind-work posts. It felt as though that would be more balanced, more true to the experience as a whole. So, what I am doing is following up a prose post with a poem after a day or two, but they need to be read together to get a more complete picture of what was involved in the work I did. Above all else I would hope to convey the reality of this area of experience more completely by tackling it this way, and do more justice to the courage of those who suffered. They are stronger than we realise for bearing the unbearable so bravely.

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

Carl Rogers

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 relatively 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.

David Smail

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 it 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 be 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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Glimpses of the Spirit

Spiritual truth is hard to spot in the tangle of distractions we call ‘ordinary life.’ The photograph at the head of this post gives a rough illustration of the point. It is not immediately clear that this is a picture of the Shrine of the Báb taken as we walked down Hatzionut Street on a recent visit to the Baha’i Holy Places. The golden dome is almost completely hidden by the twigs and branches to the right of the lamp post.

When you are there, and can walk the gardens, pray in the Shrines, have deep conversations in the Pilgrim Centres in Haifa and at Bahji, the world of the spirit is almost as clear as day. When you return home, even as you travel, you can feel ‘shades of the prison house‘ of material reality beginning to close around you again.

It becomes harder to hold onto the glimpses you have had. What’s more we are of course meant to express in our daily lives on our return the spirit we have glimpsed. We are meant to use our actions to rebuild a failing world of competition and self-seeking into a new civilisation built on co-operation and a sense of common humanity. We are doing so, it seems to me, in a situation that is rather similar to the building site that existed before the glory of the current Arc on Mount Carmel was fully realised. We are seeking to move from something like this . . .

. . . . . to something more like this:

As our understanding of what this building process means has increased, we have learnt ever more clearly the exact nature of the sustained and sacrificial work that it entails. I have attempted to convey the essence of this elsewhere on this blog (see links below).

Even then, even if we do reach this kind of near perfection as a society, we will still have to struggle to maintain it in difficult conditions – the steep slopes and baking heat of obstacles and tests – just as these workers are doing on the slopes of the mountain at this time.

The experience of this three day visit has also thrown some other aspects of this work into sharp relief. For example, a patient attention to detail combined with the ability to think outside the box can be essential. The picture below, from the inside of one of the buildings on the Arc, illustrates this well. The green wedge you see, believe it or not, is a window.

The problem that needed to be solved was how to shed additional light into the meeting room behind it without infringing on the essential privacy of the meeting that was taking place and at the same time without falling short of the high standard of beauty that prevails. Huge expanses of frosted glass would not have been a fitting option. A slit window with this exquisite tapering glass was the answer.

But you cannot take it out of the context of the huge and complex constellation of buildings and gardens that make up the whole. There must be thousands of these inspired choice points throughout the Arc. It clearly took much more than the pedestrian processes of our rational mind to create the beauty we find on Mount Carmel right now.

The same is true for all our efforts to realise the vision of a new civilisation based on compassion, justice and unity. And if these buildings and these gardens have taken so many years to create, and they are confined to a relatively small area of stone and soil, how much longer and how much more slowly are the gardens of the hearts of billions of people across the entire globe going to take before they are similarly transformed into this kind of beauty and harmony. Maybe, if I can just hold this thought, it will enable me to be a bit more patient with the faint traces of progress that sometimes frustrate me as I look at all the effort we are striving to put in.

A poem I wrote when I first saw the mixture of finished terraces and building site many years ago might be a good place to end on now that I have returned from a visit where the work of building is complete but the effort of maintaining what has been created will never end.

Carpenters of Minds

Half the containing lip is cut away. The water overflows,
a sheer curtain drumming onto white pebbles. Crimson roses
tinge the terrace with fragrances. Songbirds cast their melodies
like spells upon the air. The steep pitch of the steps throws
my gaze into the bay of Haifa, etched with craft. God knows
how hard it was to hew out of such harsh rock this paradise
of fountains, birdsong, flowers, stones and sacrifice –
a symphony it took at least three thousand years to compose.

Wordsworth was clear: getting and spending we lay waste our powers.
Now I’ve returned an impressionable mind to these rain-pelted shores
I wonder what those words are worth to me. In this brief pause
I half-sense some hope of beauty in this building site of ours.
But who are the masons, the carpenters of minds, who will raise
up the New Jerusalem from this dust? “Why you, of course!” He says.

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

Some years ago I posted a series of attempts to describe my work in the NHS as I experienced it. Since then I have been also attempting to use poems to approach the same experiences from a different angle. Because my poems tend to come from a darker place than my prose it seemed only right to publish the poems alongside the more positive feel of the republished mind-work posts. It felt as though that would be more balanced, more true to the experience as a whole. So, what I am doing is following up a prose post with a poem after a day or two, but they need to be read together to get a more complete picture of what was involved in the work I did. Above all else I would hope to convey the reality of this area of experience more completely by tackling it this way, and do more justice to the courage of those who suffered. They are stronger than we realise for bearing the unbearable so bravely.

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, a spiritual perspective and work.

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

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Patients in Adversity (2/5): Thought Potholing

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

Some years ago I posted a series of attempts to describe my work in the NHS as I experienced it. Since then I have been also attempting to use poems to approach the same experiences from a different angle. Because my poems tend to come from a darker place than my prose it seemed only right to publish the poems alongside the more positive feel of the republished mind-work posts. It felt as though that would be more balanced, more true to the experience as a whole. So, what doing is to follow up a prose post with a poem after a day or two, but they need to be read together to get a more complete picture of what was involved in the work I did. Above all else I would hope to convey the reality of this area of experience more completely by tackling it this way, and do more justice to the courage of those who suffered. They are stronger than we realise for bearing the unbearable so bravely. 

Using Conversation: a Surface Approach

Following on from his comments about trust and the importance of being helped to work on issues in-between sessions, Ian also 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, and therefore in his view autonomous and beyond his influence, 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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