Collaborative Conversation Explored (5/5): more theoretical context

In the light of my latest sequence on the importance of relationships and the next post in the sequence dealing in part with consultation, it seemed worth republishing this sequence from 2016.

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.

Relativism

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.

Brain-Mind-Meaning Relationships

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.

Another term that has been used is interthinking (see Mercer). Mercer feels this process can achieve remarkable results. He talks of the crucial function of language and says:

[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 amplifies mindfulness which ‘puts mental space between the will and the unwanted urges that would otherwise overpower the will.’

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.

Focusing on Emotion

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.

References:

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.

Read Full Post »

Collaborative Conversation Explored (5/5): more theoretical context

In the light of my latest sequence on trauma, it seemed worth republishing this sequence from 2016.

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.

Relativism

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.

Brain-Mind-Meaning Relationships

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.

Another term that has been used is interthinking (see Mercer). Mercer feels this process can achieve remarkable results. He talks of the crucial function of language and says:

[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 amplifies mindfulness which ‘puts mental space between the will and the unwanted urges that would otherwise overpower the will.’

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.

Focusing on Emotion

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.

References:

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.

Read Full Post »

Making Sense of Mental Illness – a Bahá’í Perspective (2/3): Reflection and Consultation

PTSD and war

Before we plunge further in from where we got to last time, I need to look briefly at what is known about the impact of war trauma on those affected by killing other human beings. This will help clarify just how disabling the effects of Ian’s experiences were likely to be on someone who was already undoubtedly very vulnerable.

There was an in-depth look at this in a television documentary in the wake of the Falklands War. The programme adduced a wealth of evidence that most human beings have a powerful and deep-seated aversion to killing other people. Approximately 98% of us are to varying degrees averse. For example, there were soldiers in the days of muzzle-loading muskets, who died with their muskets in their hands, the barrel full of undischarged ammunition balls. They had faked reloading without firing, so reluctant were they to risk killing anyone. Others, using rifles, were known to aim to miss or to wound slightly rather than to kill.

There are two outliers, representing about 1% in each case, who have no such inhibitions. One such exception is, not surprisingly, the psychopath. The other exception, which is very surprising, is an otherwise morally and emotionally normal individual who has no compunction about killing.

Psychologists, to their shame, devised training methods, using probable battle scenarios, that made rapid and automatic shooting to kill seem easy and unproblematic. These scenarios were practiced repeatedly until the lethal reaction was instinctive. What no one predicted was how traumatic many soldiers found it, to be confronted in battle with the consequence of their training: a dead soldier they had killed without a moment’s thought. As with Ian, the post-traumatic reactions were often devastating, with guilt and horror as key components of flashbacks and nightmares. In his case the signs of trauma were the unrelenting voices, a waking nightmare in effect.

Some of the horror of this is captured in Keith Douglas’s poem of the Second World War, How to Kill.

Keith Douglas

Under the parabola of a ball,
a child turning into a man,
I looked into the air too long.
The ball fell in my hand, it sang
in the closed fist: Open Open
Behold a gift designed to kill.

Now in my dial of glass appears
the soldier who is going to die.
He smiles, and moves about in ways
his mother knows, habits of his.
The wires touch his face: I cry
NOW. Death, like a familiar, hears

And look, has made a man of dust
of a man of flesh. This sorcery
I do. Being damned, I am amused
to see the centre of love diffused
and the wave of love travel into vacancy.
How easy it is to make a ghost.

The weightless mosquito touches
her tiny shadow on the stone,
and with how like, how infinite
a lightness, man and shadow meet.
They fuse. A shadow is a man
when the mosquito death approaches.

This is an equally disturbing but different kind of trauma from the kind captured in Wilfred Owen’s poems, such as Dulce et Decorum Est.

The intense guilt Ian harboured about his army experiences was too hard to bear and he had buried it. However, his subsequent guilt over throwing his alcoholic partner out of the house because her drinking was consuming his income from three jobs and he couldn’t cope any longer, reactivated the earlier even more intense guilt, because he thought she might die on the street, meaning that he might in a sense have killed her.

During the first period of therapy he felt that he was dealing only with his guilt about her, and that this was the main problem in terms of his voices. This was hard enough. Only later did he come to realise, by the impact of an anniversary effect I’ll come to in the next post, that the far darker army experiences, that he hadn’t yet dealt with, lay still active in this respect underneath.

What use is religious practice here?

There is much evidence that faith and religion are beneficial to mental (and physical) health. They reduce amongst other difficulties: depression, anxiety, suicide, & psychosis. The protectors they provide include: greater meaning and purpose, higher self-esteem, social support, less loneliness and more hope. (Harold Koenig at al. in Religion and Health’ Chapter 15)

My focus now will be on two aspects: reflection and consultation. Buddhism offers the most obvious example of powerful reflective processes. There is also a wealth of information that suggests most strongly that the 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.

It is the special combination of both these processes that is unique to the Bahá’í Faith as far as I am aware, though variations of each alone can be found in other either religious or educational/therapeutic contexts.

After I qualified and became a member of the Bahá’í community, fully integrating my understanding and practice of these processes into my clinical repertoire took a couple of years. I came to feel the benefits of that were considerable.

These weren’t the only factors I tried to accommodate. The hardest to digest was the belief that the mind is not dependent upon the brain. I have dealt with that in detail elsewhere.

The easiest was the notion that not only is the spiritual core of all religions essentially the same, but also humanity is in essence one: we are all part of the human family and all interconnected, not just at a material level but at a spiritual one as well. This is relevant here. This concept of unity not only serves to dispel any residual sense we might have that someone with a diagnosis of schizophrenia is somehow a different kind of being from us, but it also clarified that being inwardly divided, as many of us are, is not only a betrayal of our own essential inner oneness but an obstacle to our connecting with others, not just as a therapist but in any relationship. Similarly a community that is at odds with itself with find it hard to connect with everyone on a harmonious basis. I will be returning to that point.

My shorthand description of reflection is to say that it involves separating consciousness from its contents. Consultation, in similarly brisk terms, is the dispassionate comparison of notes, with the emphasis here on the word ‘dispassionate.’

Reflection

In discussing the nature and power of reflection I usually start with Peter Koestenbaum’s book, New Image of the Person: Theory and Practice of Clinical Philosophy.

Reflection, he says (page 99): ‘. . . releases consciousness from its objects and gives us the opportunity to experience our conscious inwardness in all its purity.’ I will look more closely at exactly what this might mean in a moment. Before we move on from his take on the matter, what he says at another point is even more intriguing (page 49): ‘The name Western Civilisation has given to . . . the extreme inward region of consciousness is God.’

I am quoting this upfront so that, if you find what I’m going to say from a faith perspective hard to accept, this might help.

In earlier posts I have discussed how psychosis is a very rigid and inflexible state of mind. I believe it is simply at the end of a continuum along which we all are placed. We all to some degree at times overvalue our beliefs, our perceptions, our simulation of reality. This can bring about a degree of attachment to them that makes us inflexible and highly resistant to contradictory evidence or different perspectives. This does not create a huge problem if our take on reality is not also destructive or frightening or both.

Fixity in the face of often extremely unpleasant phenomena causes an unacceptable and virtually inescapable amount of distress to the sufferer and of anxiety in his friends and family. The distress is what brings the sufferer to the attention of the psychiatric services. Psychiatry then applies the label schizophrenia. This label, in my view, mixes up the content of the experiences with the person’s relationship to those experiences in what can be a most unhelpful way.

Just as it is important to separate our perceptions (voices, visions and other internally generated experiences in other sensory modalities) from our understanding (beliefs, models, assumptions, meaning systems etc), it is crucial also to separate out, from the nature of these experiences in themselves, this loss of perspective and flexibility which I am calling fixity.

I have examined elsewhere on this blog the various ways that this fixity can be dispelled. Here I plan to focus simply on reflection. This is not because they are irrelevant. One, which I term disowning, by which I meant discounting or suppressing uncomfortable contents of consciousness such as pain, grief or guilt, was something Ian described in in the process of our shared reflections: he saw himself as increasingly ‘recognising’ his feelings rather than ‘repressing’ them.

My focus though will be on how reflection enables us to contain unpleasant material in consciousness, giving us time to think about and explore it, prior to integrating it.

Bahá’u’lláh, the Founder of the Bahá’í Faith, in the Kitáb-i-Íqán (Book of Certitude) quoted a hadith from the Islamic tradition: ‘One hour’s reflection is preferable to 70 years’ pious worship.’

‘Abdu’l-Bahá

His son ‘Abdu’l-Bahá, explored this in a talk he gave at a Friends’ Meeting House in London in 1913. He spoke of reflection, meditation and contemplation as virtually equivalent concepts. He went on to explain their power (Paris Talks – pages 174-176):

This faculty of meditation frees man from the animal nature, discerns the reality of things, puts man in touch with God. . . .

Through this faculty man enters into the very Kingdom of God. . .

The meditative faculty is akin to the mirror; if you put it before earthly objects it will reflect them. Therefore if the spirit of man is contemplating earthly subjects he will be informed of these. . . .

What he says for me maps onto Koestenbaum but in more directly spiritual terms. It explains why reflection, also connected with meditation and contemplation, is so powerful from a Bahá’í point of view.

The mirror analogy along with Bahá’u’lláh’s various references to the human heart as a mirror, led me to ask: what are the possible similarities between consciousness and a mirror?

Basically, a mirror is NOT what is reflected in it. In the same way, consciousness is not its contents. We are not what we think, feel, sense, plan, intend, remember, imagine and so on. This is also known as Disidentification in Psychosynthesis. In Jessica Davidson’s very brief summary, the affirmation exercise this form of therapy uses reads like this:

I have a body and sensations, but I am not my body and sensations. I have feelings and emotions, but I am not my feelings and emotions. I have a mind and thoughts, but I am not my mind and thoughts. I am I, a centre of Pure Awareness and Power.

Less controversially for most people I suspect, I would prefer to affirm that I have sensations, but these change from moment to moment so I cannot be my sensations. I am the capacity to sense. And so on with feelings, thoughts, plans, memories and imaginings, including our ideas about ourselves and what or who we are. Assagioli’s final affirmation was, as I remember, ‘I am a centre of pure consciousness and will.’

Reflection enables us to find meaning in what we are tempted to call ‘madness.’ It gives us the freedom to examine it even if only in our own minds. Psychosis is almost always meaningfully rooted in a client’s experience.

How might reflection help us find meaning?

Reflection helps counteract the fixity of attachment to the contents of consciousness that characterises what is called the ‘psychotic’ experience. The crucial stepping back relates not just to the experiences themselves, such as visions and voices, but to the explanations the sufferer has created for the experiences, which then cease to be delusional.

What Ian thought was just schizophrenia had meaning. Understanding and integrating that meaning released him from his voices. To understand his psychotic experiences he had to neither suppress them nor surrender to them: he had to contain them so he could examine them.

Recognising that they were simply the contents of his consciousness enabled him to step back, experience and think about them. They no longer had power over him.

I will sharing some of his thoughts on this in the final post.

Consultation

But there is one step further we can go.

When Ian loosened his identification with his experiences, he was able not just to think about them, he could also compare notes with others about what they might mean: he could consult in a Bahá’í sense of that undervalued word.

The Bahá’í International Community, which represents the Faith at the United Nations, quotes Bahá’u’lláh on consultation (The Prosperity of Humankind Section III): ‘In all things it is necessary to consult. The maturity of the gift of understanding is made manifest through consultation.’

What might He mean by that. Paul Lample in his excellent book Revelation and Social Reality puts forward his view: (page 199):

Consultation is the method of Bahá’í discourse that allows decisions to be made from the bottom up and enacted, to the extent possible, through rational, dispassionate, and just means, while minimising personal machinations, argumentation, or self-interested manipulation.’

Key words and phrases here are: ‘from the bottom up’ which I take to mean not imposed in some condescending fashion by those who feel superior; ‘dispassionate’ meaning objective and detached (something I’ll come back to in more detail in the next and last post); and ‘minimising . . . manipulation,’ so no ulterior motives or advantage seeking creep in.

Later he adds further illumination (page 215):

[C]onsultation is the tool that enables a collective investigation of reality in order to search for truth and achieve a consensus of understanding in order to determine the best practical course of action to follow.… [C]onsultation serves to assess needs, apply principles, and make judgements in a manner suited to a particular context.’

The key concept here is the ‘collective investigation of reality.’ This means that all parties involved in consultation are comparing notes, sharing perspectives, without undue attachment to their own point of view and not in an attempt to win an argument but with a sincere striving to understand reality better.

Just as the client needs to reflect, so does the ‘therapist.’ It is a two way street. And the therapist needs to model what she wants the client to learn: reflection. If she does not consultation is not possible. She must be as detached from her conclusions as she wants the client to be. If both client and therapist can reflect together as equals they are genuinely consulting. They can achieve a higher level of understanding, a better simulation of reality, together, than they ever could alone.

We are now ready to explore the impact of these processes on Ian and to examine some other important factors and considerations. More of that next time.

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Collaborative Conversation Explored (5/5): more theoretical context

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.

Relativism

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.

Brain-Mind-Meaning Relationships

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.

Another term that has been used is interthinking (see Mercer). Mercer feels this process can achieve remarkable results. He talks of the crucial function of language and says:

[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 amplifies mindfulness which ‘puts mental space between the will and the unwanted urges that would otherwise overpower the will.’

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.

Focusing on Emotion

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.

References:

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.

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An Approach to Psychosis: Fitting It All Together (6/6)

It seems a good idea to republish this sequence from almost four years ago to complement the current new sequence on collaborative conversation. This is the fourth 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.

To see how Visual Illusions work – go to link

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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An Approach to Psychosis: Fitting It All Together (6/6)

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. 

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.

To see how Visual Illusions work – go to link

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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