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.

]]> http://quixotism.wordpress.com/2008/06/28/understanding-psychosis-from-a-psychological-perspective/feed/ quixotism http://quixotism.wordpress.com/2008/06/24/acceptance-like-learning-to-ride-a-bike/ http://quixotism.wordpress.com/2008/06/24/acceptance-like-learning-to-ride-a-bike/#comments Tue, 24 Jun 2008 14:57:42 +0000 quixotism http://quixotism.wordpress.com/?p=63

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.

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)

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”.

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.

Nice little article in the British Medical Journal last week (written by several clinicians from the OASIS service), about a difficulty that can arise in assessing young people who might have the early signs of psychosis: putting their unconventional speech in context. (The use of unusual words and phrases as part of a pattern of disorganised speech can be evidence of formal thought disorder, a symptom of psychosis).

The authors describe the case of a young man whose use of street slang in the assessment interview made him appear more thought disordered than he actually was. Thankfully the clinician had the foresight to check the urbandictionary.com and discover that many of the words the man used were “legit”, rather than neologisms (there is a quiz in the article to test yourself on how you would classify the words, as slang or neologism). The authors describe the detailed assessment procedures the team used to further ascertain the presence of an at risk mental state (pdf).

The article made me think about what happens in routine mental health assessments in less specialised settings: how often do clinicians misclassify heavy use of slang as evidence of thought disorder?

Also in the news today - a couple of men had “a drunken christmas punch up” at the Amundsen-Scott South Pole station, resulting in one having injuries serious enough to need medical evacuation to a hospital in New Zealand. Just as well it was summer over there, so that the injured fellow could be flown to hospital relatively easily (at great expense, which was the not-so-interesting angle the Australian press took).

I wouldn’t think it was the first time that things got a bit heated at the South Pole, so to speak. Bad puns aside, there are some fascinating articles here about the psychology of wintering at the Antarctic, for you not-so intrepid explorers out there.    

Interesting news today as the Guardian reports that the Egyptian government plans to pass a law to have copyright on the country’s ancient monuments and museum pieces.

How this is going to be enforced is not clear, but one suspects the law is aimed at extracting cash from (amongst so many others) big Hollywood studios. Perhaps that remake of Cleopatra might be put on hold then.

Apparently private individuals will also have to ask for permission to build replicas. I guess I’m gonna rethink my plan to build the Sphinx as a garden ornament…

Another moment to test the compassion of the Australian public, as the news has broken that David Hicks is to be released from prison, albeit under a control order. Although the Federal Police regard Mr Hicks as an ongoing danger it would seem that he currently poses little risk to others, considering his mental state (Sydney Morning Herald, 24/12/07):

DAVID HICKS’S mental condition is so fragile that - only five days before his scheduled release from jail - he suffers from agoraphobia and retreats to the kind of solitary confinement he endured for five years in Guantanamo Bay.The former Muslim extremist has suffered panic attacks and has ventured into the sunshine, in the prison yard, only once since his return to Australia in May this year to serve the balance of his nine-month sentence at Yatala Labour Prison in Adelaide. He could not cope and preferred the enclosed prison and artificial lighting, where he felt more safe.

Is it any surprise to read that Mr Hicks experiences panic attacks and agoraphobia, after his incarceration at Guantanamo Bay?   Imprisoned without trial for 5 years, kept in solitary and tortured with impunity, his case was a convenient political football for the Howard Government’s war on terror (until suddenly it wasn’t). His treatment is a sobering example of what any Australian citizen could experience if they are caught ideologically on the wrong side. Regardless of the legality of Mr Hick’s actions, Australia’s government was willing to trade away the country’s humanitarian values for political reasons.

I hope that Mr Hicks can be supported to lead a productive and peaceful life on his release, after all, isn’t this what Australia really stands for - a fair go?  

“I saw the best minds of my generation destroyed by madness, starving hysterical naked…” - from “Howl” by Allen Ginsberg

Louis Menand writes a great article about Jack Kerouac and the Beats in the latest New Yorker (read it here), discussing the myths and realities about the creative process of this loose collection of writers and poets. Well worth checking out.

Anyway, for your viewing pleasure, here’s Kerouac reading from “On the Road” on the Steve Allen Show in 1959 (check the jazz phrasing so evident in his writing):