In 1995 I apparently gave a long talk to some meeting or other, after which the content of my talk was published by the BPS Psychotherapy Section. I have no memory whatsoever of giving any talk but I do remember writing the article. It seems worth publishing on this blog, with some updates in terms of one of the practical examples, a much shorter version of the original article as it complements with useful background the Approach to Psychosis sequence I republished some time back: I’ve also tried to reduce the psychobabble, though maybe not enough for everyone’s taste! I’ve included in addition references to later research that sheds further light on, for example, neuroplasticity and the relationship between trauma and psychotic experiences.
In 1988 a young woman persuaded her GP to refer her to me. She had carried a diagnosis of schizophrenia since she was 16. Before that she had had a twelve year history of sexual abuse at the hands of her father which went undisclosed and unnoticed at the time. She wanted to talk about the abuse to someone. An OT and I saw her together, with some trepidation. After all, psychosis and psychotherapy weren’t supposed to mix.
I allayed my fears with an article that argued that, although ‘schizophrenia,’ a label that is increasingly questioned nowadays, was not in itself amenable to a `talking cure’, people with this diagnosis could benefit from counselling for other problems. We plunged in.
It took more than a year for her to begin to describe the abuse, so painful was it for her. She could focus on it for no more than ten minutes in each hour at first. After that she became overwhelmed with terrifying hallucinations of her father, hallucinations which impinged upon all her senses – smell, touch, hearing, taste and vision. The only way she learned to determine afterwards that he had not really been there was to observe that she had no marks upon her body. Generally it would take the rest of the session to help her regain control of her own mind.
As the months went by she could bear to reveal more of her painful story, though always in small instalments. Her fears about telling it diminished, but, at the time of writing, she still had not really come to terms with the emotional pain and the anger. She did not wish me to share any of the particulars of her story.
She was able, eventually, to break free of an abusive marriage. She gained greater control over other hallucinations.
What set me wondering was how working on the trauma was releasing her from what were supposed to be the virtually autonomous symptoms of an illness process. Her experience did not seem to gel with the theory.
I was given confidence to pursue it further by the work of Paul Chadwick and the advice of Max Birchwood, though the road I eventually followed developed some distinct characteristics of its own. I would like to share some of these.
I would also like to share some of the experiences of three other people who have agreed to let me tell their stories, at least in part, and who have also helped reshape my thinking along the way. I think in doing so they have also reshaped me. Perhaps therapy should always also change the therapist, but I was not taught to think so in my official training.
The phrase `collaborative conversation’ is derived from a paper by Anderson and Swim (1993) where it is used of the student/teacher relationship. They state of the learning process that: `. . .new meaning and change evolve through . . . a conversational, process.’ They add: `Everything (knowledge, meaning, beliefs, feelings) is . . . a product of . . a community of persons and relationships.’ Both the phrase and the assumptions which lie behind it have helped formulate the concept of `collaborative conversation’ as presented here.
The concept of Bahá’í consultation has been even more influential. A succinct statement of its purpose also conveys a great deal about its methods and assumptions: `the adversarial method, . . [is]. . fundamentally harmful to [the] purpose [of consultation]: [which] is, arriving at a consensus about the truth of a given situation and the wisest choice of action among the options open at any given moment’ (Bahá’í International Community: 1995. Cf also Kolstoe). It is a process of non-adversarial decision-making which assumes that: (a) no one person can formulate anywhere near an adequate representation of the truth, (b) groups of people, if they pool their perspectives in a collaborative fashion, formulate increasingly accurate but never foolproof approximations to the truth, and (c) today’s formulation, no matter how useful, may be out-of-date by tomorrow. This means that client and therapist play out their roles on a more equal basis — delusions are not located only in the client. More of this below!
Reason (1988) in a book called Human Inquiry in Action refers to `critical subjectivity’. This is a state and process in which what we believe is subjected to the corrective influence of other beliefs through a process of discussion. It requires that `we do not suppress our primary subjective experience; nor do we allow ourselves to be overwhelmed and swept along by it; rather we raise it to consciousness and use it as part of the inquiry process’. . . .`[A]ll co-operative inquiry at its best works to enhance . . . experience towards a critical subjectivity . . . . .’ There is a dynamic relation in this method between experience, group reflection and action plans leading to different and informative experiences.
Heron, in a discussion of validity in the same book, states: `. . .the agreement sought between inquirers is not total unanimity., but the illumination of a common area of inquiry by differing individual perspectives.’ These factors are also characteristic of the process of collaborative conversation in a clinical context. It still operates even-handedly in that no one’s subjectivity is to be suppressed and no one is to be engulfed by his/her subjectivity either, if at all possible.
Shweder too, in his stimulating book Thinking Through Cultures, is liberating in his approach. He is looking at the assumptions of hard-line scientists who believe only what can be derived directly from observation: I will call them positivists for short! He elaborates the case that although positivists may think God is dead and therefore there is no God, it does not necessarily follow that there are no gods. Nor should we enthrone our own god above every one else’s. Shweder builds on this position.
Science is as subject to these strictures as any other belief system.
He argues that the ideas we have about reality shape our experience of reality: this is equally true for scientists, mystics, the so-called mentally ill and poets. Reality, though indispensable, is in itself inaccessible. Accordingly, it is a core aphorism for the position advocated here (page 66) `that the objective world is incapable of being represented completely if represented from any one point of view, and incapable of being represented intelligibly if represented from all points of view at once.’ His `doctrine’ is (page 68) `the relativistic idea of multiple objective worlds, and its commandment is participation in the never-ending process of overcoming partial views’.
An illustration of this `doctrine’ at work in the context of clinical collaborative conversation might help here.
Louise was an articulate woman who has been hearing distressing voices for nearly two years in the context of a painful divorce at the end of a self-denying marriage. She had intermittent contact with the psychiatric services prior to that. Part of her experience of voices involved a young girl of about seven who, Louise felt, was about to be murdered by a man whose voice she heard threatening the little girl. She flickered between being an observer and being the little girl. She sometimes suspected, sometimes was convinced, that she had been the little girl in a previous life. Sometimes she settled for believing the little girl was someone else who had been, or was going to be, murdered. She drew upon some kind of metaphysical or supernatural explanation to account for her experience in either case.
The positivist temptation was to use a cognitive approach to test out whether her belief in ghosts or reincarnation could be shaken. This is not necessary. In my view, these kinds of beliefs are to be respected. Many people who hold to them firmly, survive perfectly well outside the psychiatric system. It is not in these beliefs that the problem lies.
I prefer to seek to arouse a person’s curiosity about why those experiences should be coming their way. Why should she have been distracted by experiences of such a kind at all? If reincarnation is true, why, out of all the lives she must inevitably have lived in the past, had this one surfaced to torment her? Why this ghost out of all the invisible millions thronging around her? I attempt to stimulate inquiry into the personal meaning of these experiences.
Those who came to me had taken their experiences of this kind very personally indeed. They did not distance themselves from them at all. These phenomena call into question the fabric of their selfhood. It is this threat that must be addressed if the person is to grow. Many people hear voices and experience apparently supernatural events without becoming engulfed by them. Those who cannot so distance themselves fail because too much of their inner being resonates to the vibrations of the voices. It is that part of their inscape that has to be explored.
More of that next Monday.