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For Visual Illusions – go to http://www.lottolab.org

It seems a good idea to republish this sequence from almost six years ago to complement the recently completed sequence on transcending the crocodile within and providing more detailed background to its thinking. This is the last of six.

Only Our Simulations to Go  On

At best we never achieve more than a simulation of reality. Even something as apparently clear-cut and concrete as colour is no exception. What we perceive as red is really nothing more than a wavelength of light and our experience of red is a coded response that has been allocated quite arbitrarily. We could just as well have experienced the “red “ wavelength as blue! More abstract things are of course even more liable to be the product of construction and elaboration in the brain-mind system which habitually fills in the gaps in experience as best it can to make sense of it all. For present purposes three aspects of this simulation concern us most: experiences, beliefs and flexibility.

Experiences are the raw material of the mind. They are what we access of the inner and outer worlds through our senses, albeit modified by the interpretive activity of the brain. Experiences range from mainstream to the extremely idiosyncratic. Dreams are about as idiosyncratic as experience gets for most of us unless we are placed in strange, extreme and possibly frightening circumstances. For some people however dreams seem to become part of their waking reality.

Beliefs are the ideas we form usually on the basis of experience. We often make heavy emotional investments in our important ideas. These then colour experience in turn and can even distort it at the time it happens or in memory. Again beliefs range from the conventional to the extremely unusual. Even the most middle of the road person can find their way of looking at the world morphing into strange and frightening shapes as a result of such things as prolonged isolation.

Experience suggests that most people manage to negotiate their way through the world without too much of a problem on the basis of the models of the world they have developed. Many people whose experiences and beliefs are well outside the usual run of the mill rub along quite well. There are relatively small numbers of people whose beliefs and experiences are not only unusual but also very troubling. These are often the people mind-workers have to deal with. The majority of them have only short-lived difficulties.

Much of my work, before I retired, was with those who are stuck in their difficulties. Their experiences are unusual, troublesome and intractable. It is in helping people deal with this intractability that the model of mind-work I am proposing here is most useful.

Steering between Rigidity and Chaos

Most of us live somewhere between rigidity and chaos. Our models of the worlds are sufficiently malleable to respond flexibly to the shifts and changes of the world around us. If systems of thinking are too unstable or unformed we will be unable to make sense of our world and make reasonable responses to it. If they are too fixed and too compelling we cannot adapt when circumstances require it. The antidote to such unhelpful fixity is the flexibility which comes from reflection, relatedness and relativity.

Complete fixity, which often though not always in psychosis results from the kind of high emotional investment and simplification of thinking that feelings such as terror can induce, makes therapeutic work of the kind I am describing difficult. Someone who believes that their survival is in doubt is unlikely to see too much point in a leisurely exploration of their inscape! If the terror, or whatever is driving the investment that is creating the fixity, can be somewhat reduced, then conversation becomes possible. I suspect that medication, where it works, achieves its effect by calming someone down.

Increasing our Leverage

Once conversation is possible two powerful tools, implied in all that has been said above, become available. First, some space can be created between consciousness and its contents, and secondly there is a chance for more than one mind to be brought to bear upon the experiences. The space can be used for people to compare notes as equals – as two human beings, both with imperfect simulations of reality at their disposal, exchanging ideas about what is going on, with no one’s version being arbitrarily privileged from the start. There is a wealth of information that suggests most strongly that this process of collaborative conversation (Andersen and Swim), of consultation in the Bahá’í sense (see John Kolstoe), of inquiry (see Senge), of interthinking, can achieve remarkable results: Neil Mercer talks of the crucial function of language and says:

it 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.

I feel that the conditions that I have sought to describe in this sequence of posts go a long way towards making effective interthinking possible. Effective interthinking and mind-work are closely related activities. Neither can happen at their best and most constructive in the absence of good relationships, reflection, relativity and relatedness.

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One hour’s reflection is worth seventy years’ pious worship.Mirror 1

Bahá’u’lláh: quoting a hadith in the Kitáb-i-Íqán

It seems a good idea to republish this sequence from almost six years ago to complement the recently completed sequence on transcending the crocodile within and providing more detailed background to its thinking. This is the fifth of six.

Three Crucial Factors

There are at least three other crucial factors in the mind-work process over and above what we have dealt with in the previous posts: Reflection, Relatedness and Relativity. They are qualities that the mind-worker must have from the start. The names for these qualities are used in an existential model of mind-work. (Reflection is also a core quality of the Bahá’í spiritual process and has been discussed at length in other posts on this site, as has consultation which can be fairly described as a process of group reflection.)

Reflection, relativity and relatedness as discussed here are the antidotes to three forces of fixity – drowning, dogmatism and disowning — which I discussed in detail in the article on The Art of Reflection (there I discussed in depth collaborative conversation, a term I borrowed at the time from Anderson and Swim) in This is Madness. The forces of fixity are common when we function in survival mode. Psychotic experiences in people who need help from Mental Health Services are very threatening. Being in survival mode is therefore very much the norm for many of them. Creating a situation that feels safe is of paramount importance. Otherwise it can be very difficult to mobilise the forces of flexibility.

Reflection, Relatedness and Relativity are the core of the mind-work process. They will need some further explanation. They are what the mind-worker models and what the client can either develop further or discover how to use. If the mind-worker lacks them the process of mind-work is likely to remain locked in unproductive disputes that tend to drive the client further into his private world. The client may or may not demonstrate them at the beginning but should increasingly do so as the mind-work progresses.  The better the mind-worker models them the more likely it is that the client will begin to use them too. These qualities are what consolidate and generalise the process of change. They ensure that the process of mind-work becomes a permanently transformative one. If the client does not develop these abilities there is likely to be no real sustainable progress.

These three capacities combine with the relationship aspects in different ways – trust, containment and authenticity – each of which contributes something special and important to the therapeutic process. They may have an order of importance which is discussed later in that without Trust it may be impossible to develop Containment and without Trust and Containment Authenticity may be impossible. Eventually the client will certainly need to acquire and evince Reflection, Relatedness and Relativity, without which he will never make his own any clarity that comes from the mind-worker.

What, in the Relationship, Makes Change Possible?

The Plane of Authenticity

Clarification and Congruence (see earlier posts) are two sides of a square mind-space, so to speak, which is completed by Reflection and Relativity, two concepts which are also related. The combination constitutes what we might call Authenticity.

Let’s take reflection first. Reflection is the capacity to separate consciousness from its contents (Koestenbaum: 1979). We can step back, inspect and think about our experiences. We become capable of changing our relationship with them and altering their meanings for us. We may have been trapped in a mindset. Through using and acquiring the power of reflection, we do not then replace one “fixation” with another: we are provisional and somewhat tentative in our new commitments which remain fluid in their turn. Just as a mirror is not what it reflects we are not what we think, feel and plan but the capacity to do all those things. Knowing this and being able to act on it frees us up: we are no longer prisoners of our assumptions, models and maps.

The principal focus of reflection in mind-work is often upon our models of reality and upon the experiences which give rise to them and to which they give rise in return. This is especially true of “psychosis.” The capacity to reflect increases the flexibility of our models in the face of conflict and opens us up to new experiences: the adaptation and change that this makes possible enhances the potential usefulness of our models and their connected experiences. It is the antithesis of drowning where we are engulfed in our experiences and sink beneath them.

The ability to reflect, one part of our repertoire of tools for transformation, enables us to achieve our own clarification without depending upon another mind-worker. If a mind-worker does all the reflecting she is just giving people fish: if she can help someone discover how to reflect, she has taught him to fish. In combination with its sister quality, relativity, it becomes a powerful tool indeed. The antidote to chronic dogmatism, another of the forces of fixity, is relativity. Being dogmatic seals us off from new evidence which makes it hard to change our minds even when we are wrong.

It is not surprising that Reflection and Relativity are interconnected. By placing our models and assumptions mentally in brackets or inverted commas, which is a necessary first step towards reflecting upon them, we inevitably acknowledge, at least implicitly, that we have no monopoly on the truth, that we understand and experience the world at best imperfectly from a particular viewpoint or perspective which is only relatively true. This is not the same as saying there is no truth out there and any viewpoint is as good as any other. We refine the usefulness and accuracy of our simulations of reality partly at least through a process of comparing notes with others in consultation or, as I call it here, collaborative conversation.

We can, and as mind-workers we must, become almost as sceptical of our own position as we tend to be of other people’s.  Any other posture is unhelpfully dogmatic in this context. The extent to which I should then explicitly endorse the client’s position is still an issue of debate. Peter Chadwick, for instance, in his book Schizophrenia: a positive perspective, contends that it would not have been at all helpful to him to have staff endorse his beliefs in supernatural influences at the time he was experiencing extreme psychotic phenomena, even though he still holds those beliefs to be valid now that he is well: had they been endorsed by staff at the time he might have killed himself.

Authenticity matters because without it the clarity necessary for effective action and coping is unlikely to become possible. Client and mind-worker could well remain in a warm and sympathetic muddle that leads nowhere. As we will see in a moment though, without the warmth of an accepting relationship, authenticity and its resulting clarity can seem far too dangerous to risk.

Without a clear sense of uncertainty about absolute truth radical authenticity of the kind required here may prove impossible. An example from my own work serves to illustrate this well. A client was convinced the devil had a purpose for him. He was very concerned about whether I believed in the devil or not. He pressed me in almost every session for an answer. In the end, concerned to be congruent, I told him I did not. He broke off mindwork. I reflected on this afterwards. It became apparent to me that I had spoken from a position of dogmatic and unreflecting identification with my views about the devil. It would have been more authentic to acknowledge that, as a fellow human being struggling to make sense of the world, I couldn’t know for sure whether the devil existed or not. I could have shared with him, if he had pushed me further, that I had chosen to operate in my own life on the assumption that the devil did not exist. This would not, I think, have broken the relationship in a way that made further work I possible.

The Plane of Trust

Relativity shares a space with Relatedness. This term was chosen because it began with an ‘r’! Perhaps openness is a better word. Ernesto Spinelli (1st Edition: 1994) uses the expression “ownership.” Either way, along with Warmth, Encouragement (both discussed in earlier posts) and Relativity, it helps develop Trust, a crucial component that the client must eventually bring to the therapeutic process, and along with Empathy, Solidarity and Reflection it helps the client develop the ability to contain, rather than disown or act out, his inner experiences. The relation between Trust and Containment we will return to in a moment.

First of all we need to know what Relatedness is. Relatedness, in this context, is the capacity to consciously acknowledge and relate to what we are experiencing. It is the antidote to disowning, the last of the forces of fixity. It makes us sufficiently accessible to relationships with people and things to learn to accommodate to as well as assimilate experiences, to make appropriate adjustments to our selves or to our circumstances. If we disown parts of experience we become a prey to it, just as Ian was a prey to his repressed pain which turned into hostile or destructive voices. Anything we disown controls us while eluding our influence to change it in any way. What we are open to we can affect even though it may also affect us directly in its turn.

Trust comes first. We need to trust someone sufficiently to feel the strength flow into us from her Solidarity, to be able to know that she understands how we feel but will not therefore dump us or summon undermining and unwanted help, and to see how she feels confident enough to open up to what she feels about us and subject it to careful Reflection.  This is what gives us the opportunity to learn that we can contain our experiences and change our relationship with and understanding of them.

How do we develop Trust?

First of all, we need to feel the warmth of the mind-worker, her unwavering and unconditional valuing of us. Next, we need to sense her relativity, that she knows the incompleteness and inadequacy of her understanding and can suspend judgement and criticism indefinitely until it is really constructive to share (not impose) it. Then, we need to experience her encouragement, which unfailingly rewards our efforts to apply what we have discovered to our problems. Last but by no means least, we need to see her relatedness, her unthreatened openness to all experience, which allows us to become more aware of other dimensions of our own experience.  These things together make it possible for us to trust other people, our experience and ourselves. Without this making and sustaining change becomes almost impossible.

The Plane of Containment

This mind-space comprises empathy, solidarity (both discussed in an earlier post), relatedness and reflection. If someone is standing beside us in our struggles, giving us comfort, understanding what we are going through, and showing an open and reflective attitude to the revelations we share, it helps us to contain what might otherwise be too scary and/or disturbing to contemplate. What we cannot contain, we find it almost impossible to reflect on and process. Containment therefore plays a central role in the therapeutic process.

In our culture we are all too prone to either repression (convincing ourselves we’re not experiencing something when we are) or acting out (expressing whatever we are currently experiencing and ignoring the consequences until it is too late). Containment is the creative third way and a key to change.

An inability to contain experiences of a disturbing nature accounts for much substance abuse, self-harm and dependency on mind-altering subscription drugs. Containment is often not possible outside a set of supportive relationships of the kind I am attempting to describe.

Furthermore, if we cannot trust anyone, and perhaps least of all ourselves, we cannot contain what frightens us or threatens to overwhelm us. So perhaps without Trust there is no Containment. And without Trust and Containment, Authenticity will be impossible, I suspect. Any life-lie will seem a tempting port in the storm of life if distrust and disowning rule the mind.

In the next post I will attempt to pull this all together.

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It seems a good idea to republish this sequence from almost six years ago to complement the current sequence on transcending the crocodile within and providing more detailed background to its thinking. This is the fourth of six.

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

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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It seems a good idea to republish this sequence from almost six years ago to complement the current sequence on transcending the crocodile within and providing more detailed background to its thinking. This is the third of six.

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

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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It seems a good idea to republish this sequence from almost six years ago to complement the current sequence on transcending the crocodile within and providing more detailed background to its thinking. This is the second of six.

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).

kenmare-reflections2

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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It seems a good idea to republish this sequence from almost six years ago to complement the current sequence on transcending the crocodile within and providing more detailed background to its thinking. This is the first of six.

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?BM & PH

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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Depression

‘Drugs are having a positive effect for some people – but they clearly can’t be the main solution for the majority of us.’ Photograph: Alamy

For various reasons I needed recently to look into the current state of thinking about depression. As a result I stumbled upon this article by Johann Hari with which I strongly resonate. The closing paragraph hits a very important nail exactly on the head:

If you are depressed and anxious, you are not a machine with malfunctioning parts. You are a human being with unmet needs. The only real way out of our epidemic of despair is for all of us, together, to begin to meet those human needs – for deep connection, to the things that really matter in life.

Below is another short extract: for the full post see link.

I started to research my book, Lost Connections: Uncovering The Real Causes of Depression – and the Unexpected Solutions, because I was puzzled by two mysteries. Why was I still depressed when I was doing everything I had been told to do? I had identified the low serotonin in my brain, and I was boosting my serotonin levels – yet I still felt awful. But there was a deeper mystery still. Why were so many other people across the western world feeling like me? Around one in five US adults are taking at least one drug for a psychiatric problem. In Britain, antidepressant prescriptions have doubled in a decade, to the point where now one in 11 of us drug ourselves to deal with these feelings. What has been causing depression and its twin, anxiety, to spiral in this way? I began to ask myself: could it really be that in our separate heads, all of us had brain chemistries that were spontaneously malfunctioning at the same time?

To find the answers, I ended up going on a 40,000-mile journey across the world and back. I talked to the leading social scientists investigating these questions, and to people who have been overcoming depression in unexpected ways – from an Amish village in Indiana, to a Brazilian city that banned advertising and a laboratory in Baltimore conducting a startling wave of experiments. From these people, I learned the best scientific evidence about what really causes depression and anxiety. They taught me that it is not what we have been told it is up to now. I found there is evidence that seven specific factors in the way we are living today are causing depression and anxiety to rise – alongside two real biological factors (such as your genes) that can combine with these forces to make it worse.

Once I learned this, I was able to see that a very different set of solutions to my depression – and to our depression – had been waiting for me all along.

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