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 the experience with Ian, 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 in addition included references to later research that sheds further light on, for example, neuroplasticity, emotion focused therapy, and the relationship between trauma and psychotic experiences. This is the last of five instalments.
We began this sequence of posts with a bit of theory. I wouldn’t be me if I didn’t end it the same way.
So, now for a discussion of the relevance to this work of relativism.
I see some value in Shweder’s description of relativism, in his mind-opening book Thinking Through Cultures and operate from within that frame of reference when I am engaged in collaborative conversation: `Relativists are committed to the view that alien idea systems, though fundamentally different from our own, display an internal coherency that can be understood but cannot be judged (page 114).’
As a result, I seek to know as much as I can about the context of another person’s thinking in order to make it intelligible, and I have generally found that sufficient information leads to coherence: other people remain unintelligible usually because I know too little about their frames of reference. As a result I too contend that individuals `can look at the “same” world and yet arrive at different understandings” (page 120). As a result I seek to `provide [a]. . charitable rendition of the ideas of others, placing those ideas in a framework that makes it easier to credit [them], not with confusion, error, or ignorance, but rather with an alternative vision of the possibilities of . . . life’ (page 121). I find this approach hard to live up to but can see no better one to use for these purposes.
Shweder provides further useful hints: `. . . since speakers always mean and convey more than they say, meaning is revealed by making explicit the relationship between the said and the unsaid’ (page 186).
He goes on (page 197):
In drawing inferences from what was said to what was unsaid, participants need to be informed, and in fact become informed, about things that were never mentioned,’
and (page 198):
. . . to construct the meaning of discourse in a communicative array, as either a participant or an observer, involves referring the explicit content of speech (what was said) to two indexed levels, the context and all the relevant prior background knowledge needed to make sense of what was said’ .
What is said (page 218) is not `isomorphic’ with `what is meant.’
I find I have to work very hard at eliciting all the necessary background information that would make an initially incomprehensible statement intelligible. Many people I work with leave me to fill in far more about their background and assumptions than I can possibly do. Perhaps they fear to say too much or perhaps they assume too much: perhaps both. The account of the work I did with Ian illustrates the truth of this I think: with hindsight I can see ways in which we might have done a better job of helping him transcend his problems: but then hindsight is always 20:20.
Trauma and Psychosis
All too often I am unable to fill in the missing pieces at all. Whenever I have managed to do so I have been struck by the link between earlier mental pain and the experience of voices. Sometimes when the person has not themself been able to provide the link the family has done so. I did not yet know what to make of those people whose lives and selves have been laid waste by demons and who yet fail to provide through their own story or the stories of their families any apparently traumatising situations.
At the time I was doing the work I have described in this sequence I had only the evidence of one article in the Schizophrenia Bulletin to suggest that trauma and psychosis were in anyway strongly linked (see Benjamin, No 1 in the reference list below). A lot more work on this has been done since.
For example an article in Schizophrenia Bulletin of 29 March 2012 (Reference 2) Varese et al write, after examining 36 studies:
This review finds that childhood adversity and trauma substantially increases the risk of psychosis . . . . Furthermore, our findings suggest that if the adversities we examined as risk factors were entirely removed from the population (with the assumption that the pattern of the other risk factors remained unchanged), and assuming causality, the number of people with psychosis would be reduced by 33%. The association between child-hood adversity and psychosis held for the occurrence of psychotic symptoms in the general population, as well as for the development of psychotic disorder in prospective studies; the association remained significant when studies were included that corrected for possible demographic and clinical confounders. The analyses focusing on the effect of specific traumas revealed that, with the exception of parental death (although this association became significant after the exclusion of a potential outlier), all types of adversity were related to an increased risk of psychosis, indicating that exposure to adverse experiences in general increases psychosis risk, regardless of the exact nature of the exposure. This meta-analysis found no evidence that any specific type of trauma is a stronger predictor of psychosis than any other.
Even though it is something I have dealt with earlier on this blog, I cannot resist another foray into the heartland of reductionists, but for a slightly different reason from my usual one: the mind-brain relationship. Dennett, in his materialist thesis Consciousness Explained, proposes an interesting model which excludes the `soul’ (which Shweder, much to my satisfaction, includes – page 256). None the less, within his argument he summarises a position with which I find myself in almost complete agreement (page 218-219): he asks how do behaviour programmes `of millions of neural connection-strengths get installed on the brain’s computer?’
Brains, he claims, require a form of `training’, which includes the `repetitive self-stimulation’ of inner speech. The `successful installation’ of these programmes `is determined by myriad microsettings in the plasticity of the brain, which means that its functionally important features are very likely to be invisible to neuroanatomical scrutiny in spite of the extreme salience of its effects.’ He adds (page 221): `We install an organised partially pretested set of habits of mind . . . in our brains in the course of early childhood development.’
I feel that, though difficult, the modification of these `habits of mind’ can be accomplished by adults with consequent changes to the `microsettings’. One means for accomplishing such changes is collaborative conversation.
[I]t enables human brains to combine their intellects into a mega-brain, a problem-solving device whose power can be greater than that of its individual components. With language we are able not only to share or exchange information, but also to work together on it. We are able not only to influence the actions of other people, but also to alter their understandings. . . . . Language does not only enable us to interact, it enables us to interthink.
I’d like to slightly alter the wording of one sentence there to capture the essence of what I think I’m describing:
We are able not only to influence the actions of one another, but also to alter one another’s understandings.
My sense is that collaborative conversation, and the interthinking it promotes, can change the wiring of the brain.
There is clear evidence that individuals can do this, working with a therapist.
For example, in The Mind & the Brain, Jeffrey Schwartz and Sharon Begley draw on Schwartz’s work with patients suffering from Obsessive-Compulsive Disorder who had agreed to combine the therapy with regular brain scans. This work showed (page 90) that “self-directed therapy had dramatically and significantly altered brain function.”
His model involves four stages for learning to manage obsessions and compulsions (pages 79-91). He speaks of ‘the importance of identifying as clearly and quickly as possible the onset of an OCD symptom.’ At that point it is important to ‘Relabel’ it: this means recognising that the symptom is not you but your OCD.
The next step is ‘Reattribution.’ This goes slightly further than Relabelling: ‘the patient then attributes [the symptom] to aberrant messages generated by a brain disease and thus fortifies the awareness that it is not his true “self.”’ Furthermore:
Accentuating Relabelling by Reattributing the condition to a rogue neurological circuit deepens patients’ cognitive insight into the true nature of their symptoms, which in turn strengthens their belief that the thoughts and urges of OCD are separate from their will and their self.
This gives patients the chance to Refocus their attention onto ‘pleasant, familiar “good habit” kinds of behaviour.’ Keeping a diary of such activities and their successful use was also found helpful as it ‘increases a patient’s repertoire of Refocus behaviours’ and ‘also boosts confidence by highlighting achievements.’
There is one more extremely important step if this approach is to succeed more often than it fails: Revaluing. ‘Revaluing,’ he explains, ‘is a deep form of Relabelling. . . . . In the case of OCD, wise attention means quickly recognising the disturbing thoughts as senseless, as false, as errant brain signals not even worth the grey matter they rode in on, let alone worth acting on.’ One patient of his described them as ‘toxic waste from my brain.’
There is one last consideration to bear in mind. Pattern breaking in this way requires determination and persistence. As Schwartz puts it (my emphasis), ‘Done regularly, Refocusing strengthens a new automatic circuit and weakens the old, pathological one – training the brain, in effect, to replace old bad habits . . . . with healthy new ones. . . . . Just as the more one performs a compulsive behaviour, the more the urge to do it intensifies, so if a patient resists the urge and substitutes an adaptive behaviour, the [brain] changes in beneficial ways.’ He feels we are ‘literally reprogramming [our] brain.’
He concludes (page 94):
The changes the Four Steps can produce in the brain offered strong evidence that willful [i.e. willed], mindful effort can alter brain function, and that such self-directed brain changes – neuroplasticity – are a genuine reality.
In case we miss the full implications of this work the authors spell them out (page 95):
The clinical and physiological results achieved with OCD support the notion that the conscious and willful mind cannot be explained solely and completely by matter, by the material substance of the brain. In other words, the arrow of causation relating brain and mind must be bidirectional. . . . And as we will see, modern quantum physics provides an empirically validated formalism. that can account for the effects of mental processes on brain function.
While OCD is not the same as the hallucinatory experiences that can, in the presence of other difficulties, lead to the label psychosis, the evidence that willed effort can change the brain surely must apply here as well. As collaborative conversation leads to deliberate and conscious behaviour change, I am sure that it will also alter the way the brain is wired.
Its efficacy depends upon the presence of various motivating or facilitating factors. It is not possible to generate an exhaustive list of these, but trust was mentioned by Ian as a key component, and, in my view, in the light of dissonance theory, the person’s involvement in collaborative conversation has to be seen by them as something they are choosing to do, not something that is forced upon them.
Some limiting factors are apparent from the backgrounds of the two examples of collaborative conversation I shared with you. For example, both people depended for their survival in the community upon a large network of professionals. Sadly, as professionals we were often pulling in different directions at the same time, were absent when we should have been present, or present when we might better have been absent, and often with well-intentioned insensitivity we encumbered our clients with our idea of help.
Later work on Emotion Focused Therapy (EFT – Reference 3)) suggests ways in which that approach would have been very relevant to the difficulties experienced by the people I was working with, and would have further potentiated the efficacy of what we were doing together. Les Greenberg writes:
. . . . . the challenge of any effective psychotherapy, be it of trauma, anxiety or depression is to transform amygdala reactions so that innocuous reminders of past experience are not seen as a return of past loss, failure or trauma.
I’ve dealt with the role of the amygdala at great length elsewhere on this blog (see links for more information), so I won’t unpack it further here, except to say its main function is as an intensely powerful danger warning system.
He goes on:
Evolution however has blessed humanity with more negative basic emotions than positive ones, in order to aid survival. An important conclusion to be drawn from an evolutionary point of view is that negative emotions are often useful. Anxiety, anger, sorrows and regret are useful or they would not exist. Unpleasant feelings draw people’s attention to matters important to their well-being. However when unpleasant emotions endure even when the circumstances that evoked them have changed, or are so intense that they overwhelm, or evoke past loss or trauma they can become dysfunctional.
In Greenberg’s view insight is not enough:
Although re-appraisal or insight provides people with a new way of thinking or deeper understanding of the reasons they feel the way they do, cognitive change of this nature is unlikely to reconfigure the alarm systems of the brain, or the emotion schematic networks that have been organized from them.
He argues for a deeper process of emotional re-education:
Emotion coaching is aimed at enhancing emotion- focused coping by helping people become aware of, accept and make sense of their emotional experience. Coaching is defined in general as involving a mutually accountable relationship in which both client (trainee) and therapist (coach) collaborate actively in the creation of an educational experience for the client who is an active participant in the process. Emotion coaching entails a highly collaborative relationship involving both acceptance and change . . . . . The goals of emotion coaching are acceptance, utilization and transformation of emotional experience. This involves awareness and deepening of experience, processing of emotion as well as the generation of alternative emotional responses. In emotion coaching a safe, empathic and validating relationship is offered throughout to promote acceptance of emotional experience. An accepting, empathic relational environment provides safety leading to greater openness and provides people with the new interpersonal experience of emotional soothing and support that over time becomes internalized . . . . . In this type of relational environment people sort out their feelings, develop self-empathy and gain access to alternate resilient responses based on their internal resources. Emotion coaching is a collaborative effort to help clients use their emotions intelligently to solve problems in living by accepting emotion rather than avoiding it, utilizing both the information and response tendency information provided by it, and transforming it when it is maladaptive.
Looking back I can see how we were attempting to achieve this but were not fully aware that we were doing so. Also I was unaware of the existence of this model at the time. It was not registering on the therapeutic radar.
This is perhaps why Ian on reflection, as I mention in a previous post, did not feel the gain was worth the pain. That left me feeling uneasy, in the aftermath, about the use of the approach and alerted me to the need to forewarn people of the difficulties they might encounter, so that consent to continue would be better informed than in Ian’s case.
On balance, though, I strongly suspect that even in those early days the approach did bring significant benefits. Hopefully you would agree.
1. Benjamin, Lorna (1989) Is chronicity a function of the relationship between the person and the auditory hallucination? Schizophrenia Bulletin. She observed that a high proportion of people in her study had experienced a trauma of some kind prior to the appearance of their voices.
2. Filippo Varese et al (2012) Childhood Adversities Increase the Risk of Psychosis: A Meta-analysis of Patient-Control, Prospective- and Cross-sectional Cohort Studies, Schizophrenia Bulletin.
3. Les Greenberg (2004) Emotion–focused Therapy, Clinical Psychology and Psychotherapy.