Mindfulness and psychosis

At the 2008 BABCP National Conference held in Edinburgh, Amy McArthur, Gordon Mitchell and I led a half-way workshop on “Acceptance and Commitment Therapy for Psychosis”.

The workshop represented a distillation of our understanding of the field currently, and some of the clinical methods that we use for running groups and doing individual therapy in our services.

A description of the workshop is below:

Acceptance and Commitment Therapy (ACT) is a contextual CBT that uses mindfulness and values-based behavioural activation strategies to help people develop a workable relationship with internal experiences as part of a direction of increasing life meaning and vitality. ACT involves an experiential approach to therapy, based upon empirical principles of behaviour change. Clients are guided through exercises and metaphors to develop a present moment focus, clarify personal values and explore the functional utility of coping strategies. There has been promising evidence to suggest ACT can help people who are distressed and/or disabled by psychosis to learn a mindful and accepting stance toward unusual experiences, reducing the impact of symptoms, and improving social functioning (Bach & Hayes 2002; Gaudiano & Herbert, 2006). This workshop will present an ACT approach to psychosis, including how the problems of psychosis are conceptualised in this model and modifications to mindfulness and acceptance techniques for this population.

We had excellent attendance for the workshop and it was obvious that a fair number of CBT therapists have an interest in mindfulness and ACT approaches for helping people distressed and disabled by psychosis.

There is a description of the workshop available here (on the contextualpsychology.org website). On the same page is the workshop handout, as well as the audiorecordings of the presentations.

The great divisions in modern Britain

This week I have been reading the extracts (published in the Guardian) from Polly Toynbee & David Walker’s new book, Unjust Rewards. The book is a contemporary look at class divisions in British society.

The first extract “Meet the Rich” is based upon group interviews with City workers, and their views on disparities in wealth and opportunity in the UK. Predictably, the attitudes reported from these City workers were ill-informed, intolerant or full of self-serving justifications for their position and wealth:

One woman banker described escaping from a provincial town where the main employer was the public sector: “If you aspire to anything beyond that you’re not going to live [there] any more, and that’s the choice you make.”

They had chosen a life that would make them rich while others, making different and morally equivalent choices, had abdicated their right to complain. “Some of these are vocational, things like nurses . . . It’s accepted – they go into it knowing that that’s part of the deal.” Another said: “Many people, like teachers, don’t do things for the pay. But you won’t find a teacher that works as hard as we do.” This was categorical, evidence unnecessary. They spoke of heroic all-nighters drawing up contracts for clients in time zones on the other side of the globe, a Herculean effort that justified fat pay. But did they work 10 times as hard as a teacher on £30,000 a year or, in the case of some lawyers and bankers, 100 times as hard? Such disproportionality did not enter their scheme of things.

What is reported is almost a parody of itself, “Guardian journalist finds out that rich people think that money spent on poor people is wasted”, were there going to be any surprises?

The second extract “Breathless with Amazement” is more touching and in its way heartbreaking. It recounts a visit to Oxford University by a group of high-achieving high school students from a poor London borough, a number of the students from minority backgrounds and none of whom have had family members experience further education. For these kids the trip opens their eyes to the possibilities of what can happen with academic success, but as the article contends, without a change in the disparities of opportunity, the chances are slim that any of them will make it to Oxbridge.

They left the gleaming spires with a vision of university as a place of pleasure – a new thought and perhaps the most important one at this stage in their lives. Would any of them make it back to Oxford after their A-levels? Their teacher thought two of them were in with a chance as they were exceptionally clever. But it would depend on admissions tutors appreciating how much they had overcome in how short a time. Several were Afghan refugees, who in the course of the two days, had talked movingly of American gunships firing on their towns and villages. One boy was African-Caribbean, UK-born and in care for years. In year 9 he barely attended school and was shunted from pillar to post, but once settled in year 10 he had become pupil of the year and was now destined to do well, despite everything. Would an Oxbridge tutor ever hear these stories – and get to assess how their potential stacked up against the attainment of a young person who had no obstacles to overcome?

ACT in the UK symposium, BABCP National Conference Edinburgh 2008

Acceptance and Commitment Therapy had more of a presence at the British Association for Behavioural and Cognitive Psychotherapies National Conference this year, with pre-conference and half-day workshops, and several symposia on ACT and ACT-related research. Also, for those interested in the broader contextual approach to CBT there were workshops and symposia on Behavioural Activation, as well as a keynote speech by Christopher Martell on “Twenty Years of Behavior Therapy: Trends and Counter Trends”. It seemed that, compared to recent BABCP conferences, there was much more on offer for the behaviour analytically inclined clinician.

I participated in the ACT in the UK symposium, which was held on Saturday morning. The details of the presenters are below. Unfortunately Frank Bond was unable to present at the symposium as scheduled; similarly so for Tom Ricketts, although Giselle Brook presented in his place. The powerpoint presentations as well as audio are available for each presenter.

Saturday 19th July 2008, BABCP National Conference Edinburgh

Acceptance & Commitment Therapy: ACT in the UK
Convenor: Simon Houghton, Sheffield Care Trust, UK

Chair: Joe Curran, Sheffield Care Trust, UK

Group ACT for OCD: Development of the approach and initial findings

Tom Ricketts, Sheffield Care Trust, UK. Presenter: Giselle Brook  [Presentation (.ppt)  Audio (.mp3) ]

Abstract:

A significant proportion of clients with OCD are known not to respond to traditional exposure and response prevention (ERP) with alternative treatments such as cognitive therapy pr medication seeming to offer little additional benefit. A group treatment based on ACT was developed and delivered to a number of clients that had failed to respond to ERP. This presentation will describe the group process and report the initial clinical outcomes of this approach.

Measuring psychological flexibility and mindfulness skills with people who hear distressing voices

Eric Morris, Institute of Psychiatry, King’s College London & South London & Maudsley NHS Foundation Trust, UK  [Presentation (.ppt)  Audio (.mp3) ]

Abstract:

This study involved validating the Acceptance and Action Questionnaire-II (AAQ-II) with a sample of people who hear distressing and disabling voices. The relationships of psychological flexibility and mindfulness skills with general distress, social functioning, topography of voices, symptom distress, beliefs about voices, and thought control strategies are explored.

Living successfully with pain: The role of illness representations, catastrophising and acceptance in chronic pain functioning

Sujata Bose & Tammy Spencer, NHS Tayside, UK; David Gillanders, University of Edinburgh, UK (presenter)    [Presentation (.ppt)  Audio (.mp3) ]

Abstract:

Background: Psychological factors are known to influence adjustment to chronic pain. Beliefs or appraisals relating to pain, as well as catastrophising responses to pain have both been found to influence adjustment. Recent research has shown the importance of acceptance in living successfully with pain. Acceptance is a behavioural construct defined as willingness to experience pain whilst continuing to engage in important activities. The present study examined how appraisals relating to chronic pain interact with the processes of catastrophising and acceptance to influence physical and emotional functioning.

Method: 153 individuals attending NHS pain clinics and pain support groups completed validated questionnaires measuring appraisals of chronic pain, catastrophising, acceptance and emotional and physical function. Path analyses were conducted to investigate direct and moderated relationships between pain related appraisals, catastrophising, acceptance and emotional and physical functioning.

Results: A range of direct and moderated relationships are described, with important differences between the psychological variables associated with emotional dysfunction and physical dysfunction. Whist some direct relationships between appraisals and both emotional and physical functioning were observed, catastrophising moderated the relationship between appraisals, acceptance and emotional functioning. By contrast, acceptance moderated the relationship between appraisals, catastrophising, and physical functioning.

Discussion: The findings suggest that different psychological processes many underlie successful emotional and physical functioning in chronic pain. Interestingly, appraisals relating to the controllability of pain do not show significant relationships with either emotional or physical functioning. The clinical and theoretical implications of the results are discussed, as are directions for further research.

Psychologists involved in torture: Martin Seligman’s unwitting contribution?

A while ago I wrote about the disturbing allegations by Jane Mayer of the role of US psychologists in developing interrogation methods that involved torture, apparently used at the detention facility in Guantanamo Bay and elsewhere.

Jane Mayer has written a book-length account of her investigations,The Dark Side: The Inside Story of How the War on Terror Turned Into a War on American Ideals, and there is an interview on the Democracy Now! website around her central allegations.

Part of the interview concerns the role of Martin Seligman, the famous psychologist who developed the theory of learned helplessness and more latterly the leading proponent of Positive Psychology. It has been claimed that Seligman’s theory of learned helplessness contributed to the design of the methods of torture, and that a training program to help captured military personel resist the effects of torture and learned helplessness was “reverse-engineered” to assist the interrogation of detainees.

The role that Martin Seligman personally played in this process is somewhat unclear (despite the reaction of some of the blogosphere). He has stated that the allegation that he provided assistance in the process of torture is completely false, and that his only involvement with the psychologists who developed the torture methods was when he gave a lecture to the military in a different context:

“I gave a three hour lecture sponsored by SERE (the Survival, Evasion, Resistance, Escape branch of the American armed forces) at the San Diego Naval Base in May 2002. My topic was how American troops and American personnel could use what is known about learned helplessness and related findings to resist torture and evade successful interrogation by their captors. I was told then that since I was (and am) a civilian with no security clearance that they could not discuss American methods of interrogation with me. I have not had contact with SERE since that meeting.”

Whatever the truth is, post-September 11 has been a dark period for human rights, democracy and psychology. It appears that psychological models for understanding human distress have been used by the unscrupulous to devise methods to harm and terrorise those deemed to be “the enemy”.  Martin Seligman may not have been involved in this, but sadly it seems that the fruit of his intellectual efforts have been, in a manner contrary to their stated purpose.

Even MPs struggle with the stigma of mental illness

Despite there being accurate information more available to the general public, it appears that stigma of mental illness continues to affect the lives of millions of Britains, including the powerful and influential.  A recent survey has found that 1 in 5 British MPs  have experienced a mental health problem but fear to disclose this because of stigma and discrimination:

An anonymous questionnaire completed by 94 MPs, 100 Lords and 151 parliamentary staff has revealed that:

• 27% had personal experience of a mental health problem including 19% of MPs, 17% of Peers, 45% of staff
• 94% had family or friends who have experienced a mental health problem
• 86% of MPs said their job was stressful
• 1 in 3 said work-based stigma and the expectation of a hostile reaction from the media and public prevented them from being open about mental health issues.

The report is critical of the law forcing MPs to give up their seat for life if they are sectioned under the Mental Health Act for six months. By comparison, if an MP is physically incapable of working for six months due to a serious illness they would not be forced to stand down. The majority of MPs who responded thought this rule was discriminatory and urgently needs to be changed.

Challenging and changing the mainstream response to those who experience mental health problems involves persistence, courage and clout. Changing the law to reduce discrimination is part of this.

A compassionate view involves recognising that these problems and the stigma attached to them are not the issues of faceless “other people”:if not directly experienced by yourself, then in all likelihood it is a family member, friend, or workmate who struggles with this.  There is a good op-ed piece here about the survey, and it is worth checking out the comments below – the number of jokes at the expense of those experiencing mental health problems AND who happen to be MPs suggests we still have a long way to go as a society.

Psychosis from a psychological perspective

I recently sat in on a presentation about psychological interventions for serious mental illness at an international conference , where the audience was mostly made up of US health professionals working in psychiatric settings.

What was interesting (or to be more accurate, disconcerting) for me were the number of comments from the audience expressing surprise that the problems of a “brain disorder” like schizophrenia could be amenable to psychological therapy. It seemed surprising for some of the audience that engaging a person in discussing the meaning and impact of their psychotic experiences (such as hearing voices or persecutory beliefs) could be of benefit.

Now this wouldn’t have been surprising 15 years ago, but things have certainly moved on, at least in Australia and the United Kingdom (my two frames of reference). It made me think about how your view of the world is structured by assumptions, and how much influence the unhelpful assumptions of an illness model of schizophrenia may have on the care that people receive from mental health services. The worst aspects of the “schizophrenia as brain disorder” explanation lead to invalidating people because they have unusual experiences, encouraging a passive approach to living, and not considering the influence of social and psychological influences upon peoples lives.

Sadly, it appears that the work of British psychologists in developing psychosocial models of psychosis and more effective talking therapies has not yet permeated the healthcare culture in some parts of the US. What gives hope is that despite the diligent work of drug companies it appears that the general public at least remain less convinced by causal biological models of schizophrenia, preferring psychosocial accounts.

There certainly was interest from the audience in understanding psychosis from a psychological perspective, and the presenter spent most of the time discussing normalisation and the dimensional view of symptoms. This was of value, but also a shame, as these things are really the basic assumptions of a cognitive behavioural approach to psychosis and there was not much time to then discuss more detailed therapeutic methods. This information is also more broader than one particular therapeutic model and should be considered part of a working clinician’s understanding of psychosis.

Where can someone start if they want to understand a contemporary psychological view of psychosis? Below are several sources that are worth checking out:

Richard Bentall’s book, “Madness Explained”, is an excellent and comprehensive discussion of the limitations of the diagnostic approach and reductionism in understanding psychosis, and value of psychological models and research to address some of the problems with a strict biological account. There is a summary presentation of the arguments in the book available on the MIND website.

Several years ago the British Psychological Society’s Division of Clinical Psychology produced a useful summary of psychological research, “Recent advances in understanding mental illness and psychotic experiences”, hosted here.

The Schizophrenia Guidelines website, designed to help UK health services implement the NICE Guidance for Schizophrenia, is a good resource for seeing how these psychological perspectives can influence care.

Acceptance…. like learning to ride a bike

I found a nice little video on youtube recently of Kevin Polk describing the contingency-shaped nature of Acceptance and Commitment Therapy (or Acceptance & Commitment Training, as they call it in the program at the regional centre of the Veteran Affairs in Togus, Maine USA). A nice metaphor that ACT is like learning to ride a bike, no amount of instruction can replace actually being shaped by doing it. This rule-governed vs contigency-shaped distinction gets to the heart of what ACT is about (I have previously discussed this here, in relation to therapy supervision).

Dr Polk and his colleagues treat veterans for PTSD using ACT and have a program that makes the approach more accessible by describing the skills as “Let Go, Show Up and Get Moving” in valued directions. They presented their work at the recent ACT Summer Institute IV in Chicago, and I was impressed by how simple and elegant the approach was, while still being consistent to the model. It was also impressive how many groups they had run in just a couple of years. Here is a potted description of their program:

The Intensive Outpatient PTSD Program (IOP) – ACT is presented to a cohort of veterans in a “workshop” format across 14 classes (groups) in five days. All aspects of ACT (Let Go, Show Up, and Get Moving) are experienced in the 14 sessions. Veterans who have graduated from a week-long cohort are offered unlimited follow-ups in the form of additional groups or individual “coaching” via the phone or in person. The program conducts 26 cohorts per year.

Acceptance and Commitment Therapy in Early Psychosis

Recently, with my colleague Joe Oliver, we presented our work (at the ACT Summer Institute IV) on developing acceptance and commitment therapy to help young people recovering from a first episode of psychosis. We titled our presentation “ACT Early”, and described the work we have been doing in developing groups and individual therapy for this population.

Conference Abstract:

The stance of acceptance and committed action may allow for flexibility in response to persisting psychotic experiences, as has been suggested in ACT studies with the seriously mentally ill (Bach & Hayes, 2002; Gaudiano & Herbert, 2006). There is also the exciting potential for researching the impact of ACT in the early phase of psychosis – helping first episode clients to recover from psychosis through the development of a more mindful approach toward unusual experiences and critical appraisals, and committing to values-based actions.

More specifically, the use of ACT may:

[1] foster the development of a psychologically flexible stance toward anomalous experiences,

[2] enable a “values-based” recovery,

[3] reduce the impact of “fear of recurrence” of psychosis through development of mindfulness and self as context,

[4] enable individuals to notice the process of self-stigmatisation, contexts where this operates as a barrier, and commit to valued directions in the face of these appraisals, and

[5] improve relapse prevention plans through the use of mindfulness and committed action.

We describe a group program we have developed, as well as individual work with young people who have experienced a first episode of psychosis. In addition there is discussion about a pilot ACT/mindfulness group for people experiencing at risk mental states, who may be in a prodromal phase of psychosis.

The .pdf of this workshop is here: act-early-morris-oliver-2008 and the audio recording of our presentation is here (.mp3 format, 30MB download)

“Prozac Nation”? Try Placebo Nation…

Freedom of information opens up the file drawer on Prozac, with The Guardian reporting today that Prozac and similar antidepressants are no more effective than placebo for mild to moderate depression:

“Prozac, the bestselling antidepressant taken by 40 million people worldwide, does not work and nor do similar drugs in the same class, according to a major review released today.

The study examined all available data on the drugs, including results from clinical trials that the manufacturers chose not to publish at the time. The trials compared the effect on patients taking the drugs with those given a placebo or sugar pill.

When all the data was pulled together, it appeared that patients had improved – but those on placebo improved just as much as those on the drugs.

The only exception is in the most severely depressed patients, according to the authors – Prof Irving Kirsch from the department of psychology at Hull University and colleagues in the US and Canada. But that is probably because the placebo stopped working so well, they say, rather than the drugs having worked better.

“Given these results, there seems little reason to prescribe antidepressant medication to any but the most severely depressed patients, unless alternative treatments have failed,” says Kirsch. “This study raises serious issues that need to be addressed surrounding drug licensing and how drug trial data is reported.” “

The study is published here.

Treating depression is a serious, and lucrative, business (hence the industry-standard practice of consignment to the file drawer for negative results, that this study managed to dig up). The cultural effect of Prozac seemed to fuel the business nicely as well, remember all the triumphalist stuff in the 90s about Prozac being part of a new wave of psychopharmacological tinkering with our very beings?

I’m sure critics of this study will wade in with various statements about the need to correct chemical imbalances in depression, etc. another area where rhetoric (and advertising) is not quite square with the evidence.

As Prof Kirsch has written previously : “listening to Prozac, but hearing placebo”.

The UK is “an endemic surveillance society”

As a country with the the world’s largest CCTV network and a government keen to propose various intrusions on civilians’ privacy, is it any surprise that Britain achieved the rating “endemic surveillance society” by civil liberties watchdog Privacy International? (along with such privacy luminaries as the United States, Russia, Singapore and China)

I guess that we can be reassured that the UK government knows how to safeguard the personal data of citizens… unless you: receive child benefit, receive a pension, are learning to drive, or have accessed healthcare, of course.