Feeds:
Posts
Comments

Posts Tagged ‘Richard A. Shweder’

A Mumbai pavement

The drive up the section of the Western Ghats from Mumbai towards Panchgani was much less scary than the last time we came. Instead of the single track, with two way traffic winding alongside vertiginous drops into the valleys below, we wound our way serenely up and down three-lane dual carriageways higher and higher into the mountains, past the same river and in sight of the same lakes as before.

Even so it was a longer drive than expected, more than five hours, because of the dense volume of traffic leaving Mumbai.

The closer we got the more peaceful it became. Unlike Mumbai, Panchgani had not changed all that much – slightly busier perhaps, but still much quieter, much slower, than Mumbai.

I’m publishing a couple of poems relating to this place, one that I love the most in India. One is the reposting last Monday of the story of the burial of my wife’s grandma and the next one tries to capture the emotional impact of this most recent visit.

This post has a different purpose.

Bougainvillea in Panchagani

The value of this visit did not just reside in revisiting old haunts, like grandma’s grave, Table Land or my wife’s old school, important as those experiences were.

This post is going to try and record something much harder to define. It is something that belongs among those strange coincidences and sudden leaps of faith that led to my becoming a psychologist and choosing the Bahá’í path. It didn’t involve anything so dramatically life changing but it had something of the same strange unsettling power.

Panchgani is much colder than Mumbai, though I did not really notice this until after sunset. We hadn’t thought to bring any warmer clothes than those we had been wearing at sea level.

As the sun was setting and we sat on the patio of the Prospect Hotel where we were staying, the conversation became an ever more intense exploration of spiritual issues with like-minded souls (I’ll not share their names for fear of embarrassing them). Two of them were as deeply interested in spiritual psychology as I am. Rarely have I ever had the chance to meet with psychologists with a spiritual bent, probably because such people are as almost as rare as the Phoenix, for reasons I have explored elsewhere on this blog. The sense of rising energy became stronger every moment as the exploration continued and I did not notice at first how much I was shivering.

At last I apologised for breaking the flow of the conversation saying that I had to go to my room to get my dressing gown, the only warm garment I had with me. Immediately, I was offered a warm sweater, which I gratefully accepted, and sat down again to immerse myself once more in the refreshing flow of conversation.

As we spoke many books were mentioned. I threw into the mix at various points the recent books I’d read about Shoghi Effendi through the eyes of the pilgrims who visited Haifa in his lifetime, and at least one book from long ago – Schweder’s Thinking Through Cultures – which I blogged about a long time back.

One of my companions mentioned a book I’d never heard of: The Forty Rules of Love by Elif Shafak. I wrote the title and the author down, but didn’t think much more of it at the time. I noticed that the sweater had not done much to diminish my underlying sense of shaking which clearly wasn’t to do with feeling cold anymore. It didn’t feel like shivering anymore: perhaps it had never been only that.

I had to entertain the possibility that some other seismic change was taking place at an altogether different level, something perhaps to do with the territory we were treading together or the connection that was active between us all or maybe both.

Anyway, once the intensity of the conversation died down, the rest of the visit, though memorable for the beauty of the place, the hospitality of our hosts and tranquility of the whole environment, lacked anything quite so dramatic.

We were very sad to leave the following day after so short a stay.

It was only later that a synchronicity occurred that suggested that the conversation in Panchgani might have had more to it than I thought.

I was lamenting to my wife that I should have brought more books. I had finished the two massive tomes I’d brought with me. I thought they’d last the whole trip and possibly beyond. Three weeks, with not much other work to do, can gobble up more pages than I realized.

A few hours later there was a knock on the door.

‘It’s a parcel for you,’ my sister shouted.

‘For me?’

‘Yes, for you.’

I went to the door and signed for the package the postman handed over.

I looked at the label. It was from the person who had recommended the book by Shafak. I could tell immediately the parcel contained a book.

You will have already guessed which book it contained. You’ve got it: The Forty Rules of Love.

As usual I checked out the reviews. One of them referred to it as a children’s book, not my usual diet. Other reviews and a quick glance inside the book itself quickly dispelled that delusion. I don’t know (m)any children who would read their way through this book.

Even more convincing was my web search of the topic and the discovery of the entire list of 40 rules in condensed form. Some of them were amazingly resonant. I’ll deal with the issue of whether they are expressed in this way by either Shams or Rumi later.

Take Rule 6 for example: ‘Loneliness and solitude are two different things. When you are lonely, it is easy to delude yourself into believing that you are on the right path. Solitude is better for us, as it means being alone without feeling lonely. But eventually it is the best to find a person who will be your mirror. Remember only in another person’s heart can you truly see yourself and the presence of God within you.’

One sentence in particular struck a chord with me: ‘Solitude is better for us, as it means being alone without feeling lonely.’

Ever since childhood, with its experiences of stays in hospital for surgery before the days when parents could remain close, I have felt that in the end I cannot be absolutely sure that, in times of need, I will have someone there to support me. I learned the importance of self-reliance early and have practiced it often. This, combined with my introversion, means that loneliness is not a feeling I’m familiar with. I don’t generally feel lonely when alone. I invent, or perhaps naturally possess, purposes to pursue by myself. I love the company of like-minded hearts as the Panchgani episode illustrates, but I can use books, writing, art and nature as satisfactory substitutes for quite long periods of time if necessary. So, I relate to that point, though admittedly in my fashion. I’m not so clear about the mirror idea.

I also found I related pretty strongly to Rule 9 as well: ‘East, west, south, or north makes little difference. No matter what your destination, just be sure to make every journey a journey within. If you travel within, you’ll travel the whole wide world and beyond.’

Not only have my tendencies in this direction been reinforced by the spiritual path I travel, in that Bahá’u’lláh, the Founder of the Bahá’í Faith, both quotes ‘Alí, Muhammad’s successor in the Seven Valleys (34):

. . . . reflect upon the perfection of man’s creation, and that all these planes and states are folded up and hidden away within him.

“Dost thou reckon thyself only a puny form
When within thee the universe is folded?”

and in the Hidden Words (from the Arabic 13) directly urges us to recognise that if we ‘turn our sight unto’ ourselves we may find God standing within us, ‘mighty powerful and self-subsisting.’ This same idea is echoed in the Quaker phrase used by George Fox who spoke of ‘that of God in every man.’

Poetry also has reinforced these tendencies within me. I’ll quote just two examples, the first from an Anglican priest.

The best journey to make
is inward. It is the interior
that calls. Eliot heard it.
Wordsworth turned from the great hills
of the north to the precipice
of his own mind, and let himself
down for the poetry stranded
on the bare ledges.

(R. S. Thomas: ‘Groping’ page 328, Collected Poems)

And the second from a Jesuit priest looking at the dark side of that immensity, something which puts many of us off such explorations:

O the mind, mind has mountains; cliffs of fall
Frightful, sheer, no-man-fathomed. Hold them cheap
May who ne’er hung there.

(Gerard Manley Hopkins: No worst, there is none)

I don’t think it’s something only priests tend to do, by the way, but maybe not all poets – only poets who are also priests perhaps. I must check out George Herbert and John Donne: I don’t remember anything of quite that kind in their work, though I’m fairly  sure Thomas Traherne came pretty close. I may just need to revisit every other poet on my shelves in case a find a black swan poet of the interior who isn’t a priest: my first ports of call will probably be Henry Vaughan, a 17th Century medic and mystical poet, David Gascoyne, whose later poetry became distinctly mystical, followed by Wordsworth and Eliot as Thomas points firmly in their direction. One of my favourite Wordsworth poems, – Ode on the Intimations of Immortality from Recollections of Early Childhood – according to some, owes a debt to Vaughan, something else to tease out if possible.

That’s enough for now. Next time I’ll close in on the question of the Rules’ origin.

Advertisements

Read Full Post »

Skyblind v4

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.

Thinking thro CulturesRelativism

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.

Mind & BrainBrain-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.

Mindfulness booksThis 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.

amygdalaFocusing 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 »

Thought Potholing

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 and the relationship between trauma and psychotic experiences. This is the fourth of five instalments.

Thinkung thro CulturesIn working with Ian, as described last time, we later discovered that there were two anniversary effects that triggered a resurgence of the hostile voices: these related to two traumatic army experiences whose pain he was never able re-experience and integrate, preferring instead for the voices to get worse at that time of year. It was the lesser of two evils for him, even though it risked relapse and consequent hospitalisation sometimes. What the later discoveries revealed was that the loss of his partner was triggering his awareness of an earlier pool of pain he seemed to know nothing about at that point, and couldn’t bring himself to deal with later even when he knew it was there. Without all this additional information it would have been impossible to make sense of Ian’s psychotic experiences.

We have not come to the end, though, of ways to think through others.

Shweder, in his intriguing book Thinking Through Cultures, continues his list of ways of doing this:

(c) `thinking one’s way out of or beyond the other’, `passing through the other or intellectually transforming him or her . . . into something else . . . by revealing what the life and intentional world of the other has dogmatically hidden away, namely, its own incompleteness’ — `[this] properly comes later, after we have already appreciated what the intentional world of the other powerfully reveals and illuminates, from its special point of view’; and

(d) `a situated and perspectival observer, thinking while there in an alien land or with an alien other, trying to make sense of context-specific experiences’ when `the process of representing the other goes hand-in-hand with a process of portraying one’s own self as part of the process of representing the other, thereby encouraging the open-ended self-reflexive dialogic turn of mind.’

A concrete way of expressing this would be to liken the reality of another person to a cave. I join them in their cave. I notice it has stalactites which I have never seen before in my cave. I say: `My goodness! How interesting! Your cave has pointed things hanging from the roof. I’ve never seen those before. My cave doesn’t have them. I wonder how that has come about.’ The observation of the discrepancy, expressed in this way, involves non-judgemental reflection both on their world and on mine. This would hopefully result in two kinds of learning: we both might learn something about our worlds and a habit of reflection might be acquired or enhanced in one or both of us.

In short, this means that, after mastering the worldview of the other person in its own terms, we may reach a point where we can share the ways our world-views differ, in the hope that this will help us both reflect upon our models of reality and make good any omissions and distortions.

Altamira Cave Painting

Altamira Cave Painting

Another long example might illustrate both these ideas to some degree.

I have drawn on a 30 page long transcript of a sequence of letters for the account given below. What has been omitted therefore far exceeds what has been included. At the time they were written the writer was living in London and planning to move to Hereford. I described this young lady first when I spoke of how her hospitalisation story triggered my own unconscious material.

Dealing with Demons

Mary (19.9.94): `I’m getting quite long bouts of despondency these days. Sometimes I feel OK and I feel I can cope with the voices, but then I just seem to sink and I lose my spirit. I feel I’m never alone because I’m being watched all the time, but I couldn’t be more lonely.

`Time goes so slowly. I do go out for walks but my walks never give me peace of mind or relief, they’re a kind of compulsion — sometimes I think I want to go back home but part of me tells me to keep walking. And some times I can’t leave a particular part of the street or go home until I’ve been given a sign — like three buses going by or two dogs or whatever.’

Me (7.10.94): `Your loneliness is obviously a major source of pain. The pain will feed your demons further and your isolation gives them plenty of growing room. [In using the term `demons’ I am trying to speak of her world using a word that carries both her connotations and my rather different ones: she picks up on this later] . . . . . I feel you need to discuss this as a matter of urgency with anyone who might be able to help – perhaps you are already doing so.’

Mary (19.9.94): `The voices are continuing to tell me I’m really evil and everyone hates me. They say I look like the devil. I’ve been avoiding going to Church because I feel kind of “unclean” and demonated. When I did go a few weeks ago I got really distressed because during the sermon all those blasphemous thoughts started racing round my head and they were sounding out all over the church and I was terrified I’d be chased out and be ex-communicated, so I had to go back home.

`I feel painfully conscious of my loneliness whenever I attend Mass. And anyway my spirit seems to have died — so I’m getting all confused about whether I still believe or not.’

Me (7.10.94): `To have spiritual problems on top of everything else is very hard indeed. It is not unusual though for someone who has been on the receiving end of so much pain so young to conclude that they are evil. [Here I am trying to blunt the power of her feeling of being evil by contextualising it rather than arguing with it.] Obviously, people’s religious beliefs have to be the result of their own free choices. Perhaps though I could offer one idea from my own “rattle bag.”

`Though people often highlight punishing notions from their spiritual traditions, my own reading of many such traditions and ideologies has led me to a very different conclusion about the ground of being than the Old Testament or fundamentalist Islamic one. The fundamental universal law of all great systems of belief seems to me to be love. [I expanded on this much more in my letter but don’t include it here.]

Mary (14.10.94): `I found your thoughts on spiritual matters very uplifting. I actually felt quite relieved! I was brought up a Catholic — as you know guilt and punishment seem to be central themes of this Religion.

`The impulses to harm myself are becoming a bit more difficult to control recently. It’s happening through the day and not just at night anymore.

`You must think it’s terrible saying this, but the last time I harmed myself (a couple of days ago), I almost enjoyed it. I felt kind of high afterwards, like I’d rid my body of some terrible disease. I saw myself being released from my mental prison, and the voices were with me not against me, they were on my side spurring me on. I felt like an anarchist burning down buildings, whoever joins in becomes your friend — you all support each other. So it was like I was the leader in a violent gang-riot and all these strangers were applauding me as I smashed the windows of the Police-station. For about half-an-hour I was almost triumphant.

`Then I felt sick at what I’d done and how good it had made me feel. I got very depressed and had about three baths that night to try and “cleanse” myself.

`I did feel though that I was releasing evil spirits from inside my body. Sometimes I wonder whether I’m possessed by evil spirits. When you talk about my “inner demons” — is this what you mean? [She was not going to let me fudge this issue any longer!] I get frightened when I start thinking about things like this, so I’d better change the subject.’

 

Illustration by Sandro Botticelli: Dante and Virgil visit the first two Bolgie of the eighth circle (For source of image see link)

Illustration by Sandro Botticelli: Dante and Virgil visit the first two Bolgie of the eighth circle (For source of image see link)

Me (31.10.94): `Because I’m still pressed for time I can really take up at length only the question you raised about demons. This is a tough one to get down on paper. It would be much easier to discuss it face to face.

`I use demons to mean anything that a person experiences as evil and tormenting and by which they sometimes feel driven to do things they do not really want to do. I believe trauma and stress make one vulnerable to demons in this sense. Some people believe demons are spirits outside them: other people believe they are parts of their own being which have turned against them. [I am trying to offer alternative possibilities without implying that she’s mistaken.]

`I do not mind which position a person takes about their origin because from a psychological point of view roughly the same courses of action apply, it seems to me. Emotional pain feeds demons as does self-hatred. Healing emotional wounds and improving my opinion of myself will reduce the hold demons have on me. The worst thing to believe is that the demons are all-powerful, all-knowing and undefeatable. When people believe demons come from outside it is often the case that they also believe those other things about them too. If you believe they are part of you, it’s easier to cut them down to size and realize that they can be controlled, contained, even conquered. . . . .

`It is hard to convey these ideas in a letter. . . . . I can only say that my own experience of working with people suggests that if a victim of voices can only feel safe enough to work through traumatic pain, the demons will fade to a point where they are no longer a serious problem. Success includes the art of defying them without vilifying them in a supportive environment which facilitates healing and self-esteem.’

Mary (6.11.94): ‘Thank you for explaining what you mean by demons. I am quite confused by what is inside me and what is outside me. I feel that my inner evil is a kind of magnet which pulls in fear and horrible experiences and thoughts etc. — otherwise why would it all keep happening? There must be something about me which attracts even more evil.

`I’m very confused about everything — past and present.’

(17.11.94): “I heard today that I’ve got to go into hospital on December 5th to have an operation. Everything is getting too much. I keep having this feeling of wanting to hide and just let the world carry on and go past for a while.

`And when I’m feeling down like this the voices and everything that goes with them just escalate and I don’t even want to stand up.’

(24.11.94): `My nights are completely controlled by fear. I can’t even describe it. I just get this feeling I’m being hunted and I’m going to hell.’

Me (12.12.94): `I am a bit unclear as to whether this letter will arrive when you are still in hospital or whether you will have come out again by now. I hope you receive it fairly soon and I hope the surgery went ok.

`Because I look upon hell as a state of mind many people experience in this life rather than an exclusively post-mortem penal colony, I believe the torment you experience is already about as bad as it can get short of physical torture. You may feel that you are hunted but hell is where you already are in one sense. It can’t get any worse mentally at least. Don’t let the voices fool you that they can do any worse. You’ve been hit with their best shots and survived! They’ve nothing better in their armoury. If you can hold onto this and build on it you can cut the voices down to their proper size.’ [Again, from within the terms of her world, I was seeking to open out a small consolation, a way of diminishing the power of the voices.]

Mary (16.12.94): `Thank you for your thoughts on the voices and the fear of hell. I do see what you mean, I think I even agree with you — well, I want to agree with you because I really understand what you’re saying and I’ve almost come to think that myself, but I’ve still got a niggling doubt and I do think a lot about the possibility of things being even worse and more nightmarish.’

We both were doing our best to respectfully acknowledge the world the other lived in. It is obvious that neither of us was completely successful, but I think that the effort was none the less worthwhile. Hopefully it helped both of us cultivate our capacity for ‘the open-ended self-reflexive dialogic turn of mind’ Shweder advocates.

The next and last post attempts to pull some remaining threads together.

Read Full Post »

Griefwork v2

In 1995 I apparently gave a long talk to some meeting or other, after which the content of my talk was published by the BPS Psychotherapy Section. I have no memory whatsoever of giving any talk but I do remember writing the article. It seems worth publishing on this blog, with some updates in terms of one of the practical examples, a much shorter version of the original article as it complements with useful background the Approach to Psychosis sequence I republished some time back: I’ve also tried to reduce the psychobabble, though maybe not enough for everyone’s taste!  I’ve in addition included references to later research that sheds further light on, for example, neuroplasticity and the relationship between trauma and psychotic experiences. This is the third of five instalments.

In the last post, I started to explore the next interpretation of thinking through others described by Shweder in his book Thinking through Cultures(b) `getting the other straight, of proving a systematic account of the internal logic of the intentional world constructed by the other’ for `strong and persistent’ feelings `must after all be based on something real, which it may perhaps be possible to discover.’

Talking to Ian

Talking to Ian

It needs a long illustration to convey its relevance so this is why I began to share Ian’s experience last time.

At first he found it difficult to trust me. Within the psychiatric system, trust is an issue which, with people who hear voices, frequently slows down the piecing together of the picture. He asked if he could bring his key-worker from social services with him and I agreed. Even then he found the going very rough. `The questions you asked were painful. And I didn’t want to answer them. I didn’t see the point in answering them.’ Gradually over a period of three or four sessions he became more able to disclose some of what was in his mind both about the voices and about his past.

For him there seemed to be two breakthroughs. One was early on.

I knew there was something wrong with me. But I didn’t know what it was. And it seemed so simple when it was explained to me that it seemed too simple, if you know what I mean. But it worked. I bargained with the voices. I kept my promise to them and talked to you, and things got gradually better.’ It wasn’t a question of shouting them down: `I just talked to them quietly. I told them I knew they were unhappy and that I would do something about it. 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.” I asked them if they could let me sleep. It took a coupla nights. Then they give me a break.

We wrote him a letter at about this point to help him hold on, in between sessions, to what he was beginning to grasp during the session itself. We said, in part:

We felt there was a pattern in what you were telling us. It looks as though, when life is interesting and/or enjoyable, the voices are either not there or quite friendly. For example, this seemed to be the case most of the time when you were in the army and was true for several years after you were discharged on medical grounds. When things get difficult and lonely however the voices seem to turn nasty.

It doesn’t look as though your feeling that you must have done something to upset them is not correct. It’s more as though they feed off your unhappiness, uncertainty and distrust of other people to cut you off even more from the outside world and tempt you into dangerous courses of action. In fact, they may sometimes even simply be the expressions of those feelings, arising from within you as a result of your emotional state.

Certainly, they often play on your fears and your feelings, and what they say may seem to reflect the way you feel so well that you come to believe it’s true. But it’s only true to your emotional state rather than true to the world as it is. If you can learn to build on the ways you cope with the world so that you deal with your feelings better, the voices may not turn nasty so often: they may even not turn nasty at all.

Remember how we described the way the army teaches people not to be aware of their feelings? When life goes badly wrong and you have no powerful distractions, like parachute jumping, and no close companions to help you pretend you don’t feel bad, then you have only the voices to rely on and they turn very sour. In fact, they turn into tempters and tormentors.

Although it will be hard to unlearn the lessons of the army about how not to feel and about how to look `macho’, as you put it, it is possible to do so over time and with support. In the meantime, it may help to remind yourself, when the voices are at their worst, that they are feeding off your pain and loneliness to make you believe what feels true but is not.

As Ian found pictures easier to absorb than words we captured the core point in the letter in a diagram.

Voices Flowchart

 

As later understanding revealed, our view of his army life was coloured by his rosy presentation of it at this stage. None the less, the letter eased things forwards somewhat. Our idea that acceptance and integration of difficult feelings would be a possible solution only worked for more manageable negative feelings. As we found later, there were feelings that were too dark for him to contain and so he reverted to repression and hallucinations as preferable ways of coping.

Negotiating with Voices

At first he used a pattern of negotiation with the voices which took a vague form: it became more precise and specific as time went on. He told the voices that if they left him alone for a time in the day, he would give them all his attention in the evening. It worked. They gave him a break.

. . . not having the voices talking to me so much enabled me to think. And I could think for periods of time. And I could think about what I was going to say to the voices because they’d give me time to think about it. And it also give me time to think about exactly what I was going to talk to you about. Once I could see where the problem was I could bargain with the voices. And talking to you showed me where the problem was. So, I was able to deal with the voices in a positive way.’ He felt that earlier advice from staff had not been helpful: `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 because I can get in touch with them” I’d felt that all along.

He had not felt though that it would turn out to be as easy as it was:

I didn’t think I could get in contact with the voices so easily. I thought it would take a lot longer. But I found that it happened pretty quickly.

In Memory of Lance Sergeant Dan Collins v2

The Effect of Emotional Pain

The other breakthrough, built upon early work to get him more in touch with his emotions, came a dozen sessions later. This is the one which relates most strongly to the issue of creating a `systematic account of the internal logic of the intentional world constructed by the other’

I knew something was bothering the voices. And I think it was over the split up with my partner. And the pain that that caused which I hadn’t dealt with. I just pushed it to one side. I hadn’t come to terms with it. I still loved my partner. And I was still hoping that somehow we could get together. But I’ve give up that idea now. And I’ve put her in the past. Because I was sad inside and because I was still hanging on, really, the voices kept plaguing me. They were feeding on my unhappiness.

This was not an easy process. At the beginning, he explained:

I hurt so much that I thought it wasn’t worth being well. 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.’

Later it seemed `a price worth paying. Getting your feelings back is a painful thing and it really hurts. Makes you cry. But once you done your crying and you’ve realised that that’s real, then you come to terms with it. You can put it in the past without worrying about it.’

In fact there was still a great deal of work to do at this stage. None the less he was able to describe very clearly the way emotionally-loaded events or actions were related to the voices for him:

I had to deal with the feelings. Feelings were something I’ve always suppressed. [The voices] kept feeding on my suppression. I kept saying `No. I didn’t do that’ or `No. This hasn’t happened’ and they kept getting worse and worse until it got unreal.’

And even though a painful process of emotional re-education still lay before him, the voices had almost completely gone:

I haven’t had ’em for eight weeks. I’ve had ’em for a short period, calling my name. But they soon went.

He summarised his progress in the following way:

I didn’t recognise myself that the problem lay there [i.e. in the way he was dealing or failing to deal with his emotions]. I thought it was just schizophrenia. Jumping under a train was looking very attractive. But it doesn’t look attractive now. I haven’t got any voices at all. I’m not taking any medication for the voices. And I’m sleeping better. I’m eating better.

At the time of my talk Ian had been voice-free for up to three months at a time, only had relapses for a day or so at a time and was on reducing levels of medication. He had bought a car and was driving again. He had not had a hospital admission for almost a year, in contrast to the previous pattern of four or so per year. A voicework group, which was set up largely at his instigation, had been instrumental in facilitating and consolidating his gains. The group exemplified the characteristics I am describing to an even greater degree than the individual work.

We later discovered that there were two anniversary effects that triggered a resurgence of the hostile voices: these related to two traumatic army experiences whose pain he was never able re-experience and integrate, preferring instead for the voices to get worse at that time of year. It was the lesser of two evils for him, even though it risked relapse and consequent hospitalisation sometimes.

What these later discoveries revealed was that the loss of his partner was triggering his awareness of an earlier pool of pain he seemed to know nothing about at that point, and couldn’t bring himself to deal with later even when he knew it was there.

I learned to respect people’s choices in this respect. He was not the only person I worked with who chose admission to hospital in preference to re-experiencing unbearable pain.

Sadly, a year or two later Ian’s continuing cigarette habit exacerbated his emphysema, the same illness as had killed his grandfather. It strangely echoed his mother’s death from tuberculosis: she died before he was two years old. (See below for a brief history of his life up to the point at which we worked together on his difficulties.)

I visited him in the hospice in his last weeks of life. As he lay on the bed with his oxygen cylinder close by, I asked him the same question again as I had asked him during our video recording.

‘Was the gain from our conversations worth the pain you had to go through during them?’ In the video he gives an unqualified affirmation. When I spoke to him in the hospice, as he was dying, he said the opposite. The gain had not in the end been worth the pain. I shall return to that issue in the last of this sequence of posts.

What remains true though is that without all this additional information it would have been impossible to make sense of Ian’s psychotic experiences.

Next time I’ll be exploring further examples of ‘thinking through others.’

Talking to Ian

Talking to Ian

For those interested in the full back ground to his psychotic experiences and how far back in his life traumatic events and situations began helping to shape his sensibility I have included at the end here a brief summary, which I helped him write, of his life up to the point I worked with him. It took a lot more time than I describe to glean all this information. It also indicates that Ian’s initial portrayal of army life was not as rosy as our letter to him suggested, based as it was on his earlier accounts of himself.

Ian’s Biography

By the time I was 14 months old my mother was dying of tuberculosis and I was failing to thrive. I was abandoned by my dad. My aunt rescued me and took me to live with her. She applied to the courts to adopt me. My dad, at the 11th hour, began to contest this. The proceedings dragged on until I’d started school. My situation with my aunt was not secure until I was six years old.

When I was seven my grandfather died suddenly. I was extremely close to him.  The pain of that still haunts me.

When I was nine I was walking to school through a farmyard, when I saw the farmer hanging in his barn. Shortly after that, the voices started, but they were nice and friendly, and kept me company as I walked the hills near home.

I went down the mines as soon as I left school. I wasn’t happy with that and joined the army. Within the first couple of years, I think, I was stationed in Hong Kong. A bullying sergeant major triggered a psychotic episode. The voices turned nasty. I heard the voice of the sergeant major mocking and insulting me all the time. I faked my way out the army hospital by denying I was hearing voices any longer.

The army didn’t know what to do with me. As they reckoned people with schizophrenia were antisocial, they decided a solitary job within the army would be the best thing for me. They came up with what they felt was the ideal solution: they’d train me to be a sniper. You spend long periods alone and when anyone comes along to disturb you, you kill them – a great idea in their view. There’d be none of that stressful social contact!

At least two incidents in which I was involved in the army left me with strong feelings of guilt. The pain of the deaths I caused, I know now, set up the later experiences of psychosis.

I was discharged from the army after I was seriously injured walking towards a bomb in Northern Ireland. I did this deliberately. It was part of a pattern. From time to time I felt I didn’t deserve to live so I put myself in danger. If I lived I felt I was meant to live and maybe I deserved to do so. When the feeling built up again, as it kept on doing even in civvy street because the guilt about the deaths never left me, I’d play the same kind of Russian Roulette.

Once out of the army I used to do this by lying down on a railway line in the early hours of the morning. If no train came within a certain period of time, I reckoned I deserved to continue living.

After leaving the army my marriage broke up and I ended up living with someone with a serious drink problem. I held down three jobs, working all hours, in order to make ends meet and finance her habit. Eventually, I got completely exhausted and depressed. I couldn’t cope any longer and threw her out.

That didn’t finish it though. I was so convinced that she would die on the streets, I felt like I’d killed her. I became tortured by guilt. I shut himself away in my room with my dog. I survived on frozen chips for six weeks, until my boss became so concerned he got the police to break in. They found me completely psychotic, they say. I think I was determined to die this way. They sectioned me. That began an eight year history of sections, medications, with long and frequent admissions, until I felt that life had nothing to offer me.

[At the end of this eight year period the video interview, from which I took the extracts I quote in the posts, took place. He didn’t want to be fully in shot because of the tremor the medication had caused him.]

Read Full Post »

The Changeling

In 1995 I apparently gave a long talk to some meeting or other, after which the content of my talk was published by the BPS Psychotherapy Section. I have no memory whatsoever of giving any talk but I do remember writing the article. It seems worth publishing on this blog, with some updates in terms of one of the practical examples, a much shorter version of the original article as it complements with useful background the Approach to Psychosis sequence I republished some time back: I’ve also tried to reduce the psychobabble, though maybe not enough for everyone’s taste! I’ve included in addition references to later research that sheds further light on, for example, neuroplasticity and the relationship between trauma and psychotic experiences. This is the second of five instalments.

At the end of the last post I explained that those who came to me had taken their psychotic experiences very personally indeed. They did not distance themselves from them at all. These phenomena called into question the fabric of their selfhood. It is this threat that must be addressed if the person is to grow. Many people hear voices and experience apparently supernatural events without becoming engulfed by them. Those who cannot so distance themselves fail because too much of their inner being resonates to the vibrations of the voices. It is that part of their inscape that has to be explored.

Thinkung thro CulturesThinking Through Others

Louise, whose experiences I described last time, responded to the curiosity I sought to evoke with a slightly bewildered kind of interest. She became more questioning of her family and her childhood. She did not relinquish one jot of her conviction that the hallucinatory child she was experiencing, and the man who threatened her, had or would have some real existence outside her own mind. And why should she?

Shweder, in his excellent exploration, Thinking Through Cultures, argues strongly against the assumption of superiority that can underlie positivist approaches to the reality of others and advocates `transcendence without superiority, scorn, or cynicism’. Transcendence does not necessarily destroy what it replaces, anymore than Einstein can be said to have abolished Newton!

Shweder builds on his premises (page 97):

Cultural psychology assumes that intentional persons change and are changed by the concrete particulars of their own mentally constituted forms of life.

He claims a new aim has been defined for psychologists (page 100):

That aim for cultural psychology is to conceive imaginatively of . . . . intentional worlds and . . . . intentional persons interpenetrating each other’s identities or setting the conditions for each other’s existence and development, while jointly undergoing change through social interaction.

I believe all participants in any form of therapeutic conversation, good or bad, can testify that their identities interpenetrate, at least to a modest degree. This is not achieved by language alone or even mainly. Partners in this kind of dialogue come to occupy a common or shared space which is constructed as much by what is done as by what is said.

The degree to which they can set the condition’s for each other’s existence is limited by many factors, including the shortness of time, the environmental conditions prevailing and the degree to which the exercise of power is restrained. To put someone on a Section marks a momentous escalation in the use of power. Milieu treatment also is well above the snowline on the Everest of power.

By comparison with these collaborative conversation seems to pale almost into insignificance. It gains though by its capacity to prolong its influence over far greater expanses of time, albeit less intensively, and it can enlist the far more willing participation of those engaged in it. This willingness is in itself a potent catalyst for change within the context of this pattern of social interaction.

Our Less Conscious Selves

Shweder outlines four interpretations, in the anthropological context, of the phrase `thinking through others’, all of which can enrich our clinical practice. He describes thinking through others (pages 108-110) in the sense of:

(a) `using the . . . self-consciousness of another . . . person — his or her . . . articulated conception of things — as a means to heighten awareness of our less conscious selves’;

heartsurgeryWe can ignore this dimension at our peril: whether we intend it or not our ‘less conscious selves’ can be triggered big time.

One fairly simple example from my own experience should serve to illustrate this convincingly.

Mary, whom I describe in more detail below, is tormented constantly by voices. She is a young girl who is visually handicapped and has a long history of hospitalisation for surgery, starting in early childhood. According to her own account, her first admission was for surgery at the age of three or four. Her parents claimed that neither of them could stay with her, she says. She remained in hospital for several weeks, consoled only by visits of a fairly brief duration.

As a result of my conversations with her, I had to have early recourse to my supervision group. Within the first few weeks of seeing her, I was already experiencing reactivations of my own early hospitalisations (for more background see links). They were much less traumatic than hers appear to have been. One took place at the age of three for a tonsillectomy and the second at the age of four for the removal of an abscess in my ear. They were of relatively short duration. In both cases my parents could not stay there with me for reasons of contemporary hospital policy, which were unintelligible to me at the time.

While I was familiar with that history and had worked on it in my own therapy I was not aware of the hook her story had lodged in me. At least not until I brought up the situation in my supervision. The undertow of feeling that was threatening to carry me away concerned my feelings of abandonment and my passionate desire not to abandon this young girl whose story seemed genuinely tragic in comparison with my own more mundane circumstances. I was all too familiar with my own pain and imagined it horrendously magnified in her.

My awareness of my less conscious self was heightened to an almost paralyzing and definitely aversive degree. I wanted to be relieved of any responsibility for her at the same time and for the same reasons as rendered me incapable of contemplating withdrawing my commitment! In my experience, people whose selves have been overwhelmed by voices frequently rattle the cage of my own demons.

I can well understand why medication seems, to those people who have the power to prescribe, such a reasonable response to such extremes of suffering, especially if it triggers their own subliminal stuff. Incidentally, I believe that some drugs can sometimes be helpful but that they are used too often, too soon and in too large a quantity. They are also far too frequently used in a way that implies they are all we need.

Discovering the Real

The next interpretation of thinking through others described by Shweder is (b) `getting the other straight, of proving a systematic account of the internal logic of the intentional world constructed by the other’ for `strong and persistent’ feelings `must after all be based on something real, which it may perhaps be possible to discover.’ In simpler terms, there must be some intelligible reason for even the strangest experiences.

Incidentally, this perspective was crucial to my starting this blog: everybody means something is an affirmation of what I believe to be a fact: if we try hard enough everyone’s subjective reality, no matter how bizarre, can make sense to us as their attempt to make sense of their very different experience. This is not the same as agreeing with it, of course.

Talking to Ian

Talking to Ian

It needs a longer illustration here to convey the relevance of this. I could have produced a snappy vignette which seemed to prove that I do exactly what I am describing here. I prefer to give you enough background to enable you to decide for yourselves, bearing in mind that what I now think I was doing evolved as an idea in stages over time through the experiences I shall be describing.

Ian was a 50 year old man with an eight year history of being tormented by voices telling him to kill himself and fly with them to far-off places. Describing his experience of the voices he said:

I was living in a dream world. I’d got the voices nearly all the time. They were so loud that I couldn’t hold a conversation. And I couldn’t listen to the radio. They just blocked everything out. The voices were plaguing me so much that if I tried to think about something they’d side-track me. And I’d start thinking about what they were saying to me, and start thinking about doing something about it. I couldn’t think in a straight line. It was just going round and round in circles. They used to wake me up at night. They got loud when I was ill. I thought they were spirits, come from the spirit world for me. I didn’t think that I was going to hurt myself by jumping under a train. I thought it would just be a few seconds of confusion and then it would be all over. I didn’t mind if being dead was just black and nothingness. And if it was flying with the voices all round the world, I didn’t mind that neither. It was better’n what I had.

He was on medication when I first saw him:

It wasn’t having any effect at all. I was on quite a high dosage. I was on 100 mgms of Haldol a week, and 600 mgms a day of Chlorpromazine.

His view of his future was bleak:

Just the voices, and hospital, really, and medication. That’s all there was in life. I couldn’t see any point in any thing. And I couldn’t see any point in doing anything else. I thought it was just schizophrenia. 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. So that jumping under a train was looking very attractive.

Thursday’s post will go into more detail of what then took place.

Read Full Post »

VoicesIn 1995 I apparently gave a long talk to some meeting or other, after which the content of my talk was published by the BPS Psychotherapy Section. I have no memory whatsoever of giving any talk but I do remember writing the article. It seems worth publishing on this blog, with some updates in terms of one of the practical examples, a much shorter version of the original article as it complements with useful background the Approach to Psychosis sequence I republished some time back: I’ve also tried to reduce the psychobabble, though maybe not enough for everyone’s taste! I’ve included in addition references to later research that sheds further light on, for example, neuroplasticity and the relationship between trauma and psychotic experiences.

Background

In 1988 a young woman persuaded her GP to refer her to me. She had carried a diagnosis of schizophrenia since she was 16. Before that she had had a twelve year history of sexual abuse at the hands of her father which went undisclosed and unnoticed at the time. She wanted to talk about the abuse to someone. An OT and I saw her together, with some trepidation. After all, psychosis and psychotherapy weren’t supposed to mix.

I allayed my fears with an article that argued that, although ‘schizophrenia,’ a label that is increasingly questioned nowadays, was not in itself amenable to a `talking cure’, people with this diagnosis could benefit from counselling for other problems. We plunged in.

It took more than a year for her to begin to describe the abuse, so painful was it for her. She could focus on it for no more than ten minutes in each hour at first. After that she became overwhelmed with terrifying hallucinations of her father, hallucinations which impinged upon all her senses – smell, touch, hearing, taste and vision. The only way she learned to determine afterwards that he had not really been there was to observe that she had no marks upon her body. Generally it would take the rest of the session to help her regain control of her own mind.

As the months went by she could bear to reveal more of her painful story, though always in small instalments. Her fears about telling it diminished, but, at the time of writing, she still had not really come to terms with the emotional pain and the anger. She did not wish me to share any of the particulars of her story.

She was able, eventually, to break free of an abusive marriage. She gained greater control over other hallucinations.

What set me wondering was how working on the trauma was releasing her from what were supposed to be the virtually autonomous symptoms of an illness process. Her experience did not seem to gel with the theory.

I was given confidence to pursue it further by the work of Paul Chadwick and the advice of Max Birchwood, though the road I eventually followed developed some distinct characteristics of its own. I would like to share some of these.

I would also like to share some of the experiences of three other people who have agreed to let me tell their stories, at least in part, and who have also helped reshape my thinking along the way. I think in doing so they have also reshaped me. Perhaps therapy should always also change the therapist, but I was not taught to think so in my official training.

Inquiry in ACtionTheory

The phrase `collaborative conversation’ is derived from a paper by Anderson and Swim (1993) where it is used of the student/teacher relationship. They state of the learning process that: `. . .new meaning and change evolve through . . . a conversational, process.’ They add: `Everything (knowledge, meaning, beliefs, feelings) is . . . a product of . . a community of persons and relationships.’ Both the phrase and the assumptions which lie behind it have helped formulate the concept of `collaborative conversation’ as presented here.

The concept of Bahá’í consultation has been even more influential. A succinct statement of its purpose also conveys a great deal about its methods and assumptions: `the adversarial method, . . [is]. . fundamentally harmful to [the] purpose [of consultation]: [which] is, arriving at a consensus about the truth of a given situation and the wisest choice of action among the options open at any given moment’ (Bahá’í International Community: 1995. Cf also Kolstoe). It is a process of non-adversarial decision-making which assumes that: (a) no one person can formulate anywhere near an adequate representation of the truth, (b) groups of people, if they pool their perspectives in a collaborative fashion, formulate increasingly accurate but never foolproof approximations to the truth, and (c) today’s formulation, no matter how useful, may be out-of-date by tomorrow. This means that client and therapist play out their roles on a more equal basis — delusions are not located only in the client. More of this below!

Reason (1988) in a book called Human Inquiry in Action refers to `critical subjectivity’. This is a state and process in which what we believe is subjected to the corrective influence of other beliefs through a process of discussion. It requires that `we do not suppress our primary subjective experience; nor do we allow ourselves to be overwhelmed and swept along by it; rather we raise it to consciousness and use it as part of the inquiry process’. . . .`[A]ll co-operative inquiry at its best works to enhance . . . experience towards a critical subjectivity . . . . .’ There is a dynamic relation in this method between experience, group reflection and action plans leading to different and informative experiences.

Heron, in a discussion of validity in the same book, states: `. . .the agreement sought between inquirers is not total unanimity., but the illumination of a common area of inquiry by differing individual perspectives.’ These factors are also characteristic of the process of collaborative conversation in a clinical context. It still operates even-handedly in that no one’s subjectivity is to be suppressed and no one is to be engulfed by his/her subjectivity either, if at all possible.

Thinkung thro CulturesShweder too, in his stimulating book Thinking Through Cultures, is liberating in his approach. He is looking at the assumptions of hard-line scientists who believe only what can be derived directly from observation: I will call them positivists for short! He elaborates the case that although positivists may think God is dead and therefore there is no God, it does not necessarily follow that there are no gods. Nor should we enthrone our own god above every one else’s. Shweder builds on this position.

Science is as subject to these strictures as any other belief system.

He argues that the ideas we have about reality shape our experience of reality: this is equally true for scientists, mystics, the so-called mentally ill and poets. Reality, though indispensable, is in itself inaccessible. Accordingly, it is a core aphorism for the position advocated here (page 66) `that the objective world is incapable of being represented completely if represented from any one point of view, and incapable of being represented intelligibly if represented from all points of view at once.’  His `doctrine’ is (page 68) `the relativistic idea of multiple objective worlds, and its commandment is participation in the never-ending process of overcoming partial views’.

Practice

An illustration of this `doctrine’ at work in the context of clinical collaborative conversation might help here.

Louise was an articulate woman who has been hearing distressing voices for nearly two years in the context of a painful divorce at the end of a self-denying marriage. She had intermittent contact with the psychiatric services prior to that. Part of her experience of voices involved a young girl of about seven who, Louise felt, was about to be murdered by a man whose voice she heard threatening the little girl. She flickered between being an observer and being the little girl. She sometimes suspected, sometimes was convinced, that she had been the little girl in a previous life. Sometimes she settled for believing the little girl was someone else who had been, or was going to be, murdered. She drew upon some kind of metaphysical or supernatural explanation to account for her experience in either case.

The positivist temptation was to use a cognitive approach to test out whether her belief in ghosts or reincarnation could be shaken. This is not necessary. In my view, these kinds of beliefs are to be respected. Many people who hold to them firmly, survive perfectly well outside the psychiatric system. It is not in these beliefs that the problem lies.

I prefer to seek to arouse a person’s curiosity about why those experiences should be coming their way. Why should she have been distracted by experiences of such a kind at all? If reincarnation is true, why, out of all the lives she must inevitably have lived in the past, had this one surfaced to torment her? Why this ghost out of all the invisible millions thronging around her? I attempt to stimulate inquiry into the personal meaning of these experiences.

Those who came to me had taken their experiences of this kind very personally indeed. They did not distance themselves from them at all. These phenomena call into question the fabric of their selfhood. It is this threat that must be addressed if the person is to grow. Many people hear voices and experience apparently supernatural events without becoming engulfed by them. Those who cannot so distance themselves fail because too much of their inner being resonates to the vibrations of the voices. It is that part of their inscape that has to be explored.

More of that next Monday.

Read Full Post »