Category Archives: Clinical Psychology

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.

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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.

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Filed under Clinical Psychology, Mental Health, Politics, Psychology

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.

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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.

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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)

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Street slang or thought disorder? A tough call.

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?

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Foreign-trained clinical psychologists in the UK: More tips to get through the SoE

Another post about surviving the British Psychological Society’s Statement of Equivalence in Clinical Psychology (see previous entries on this site)….

Joalida Smit writes a personal reflection in Clinical Psychology Forum (Number 169, January 2007) about the “feelings of professional inferiority as the result of subtle mechanisms of ‘othering’ inherent in the SoE”. At the close of her article (a lot of which I could relate to) she lists a number of basic suggestions that would have been helpful when planning to start the SoE:

1] Settle in first – relocation is a huge personal investment. Don’t start before you have stability (externally and internally) .

2] Be realistic – the SoE takes mental and physical energy, don’t expect to make strides in your “real” job until the process is completed.

3] Be practical – have a structured, task focused approach.

4] Don’t get sucked into the emotions of what this further training implies.

5] Beware of the SoE Summer School – refer to 4 above.

6] Don’t make it personal – the SoE requirements do not say anything about you as a person.

7] Don’t expect the Society to make it personal – follow procedures, don’t try to jump the system (it only leads to frustration and anguish).

8] Hold the ambivalence – don’t let the anxiety get the upper hand.

9] Be careful of paranoia – “the Society” are people too.

10] Hold on to yourself and your skills – after all that’s why they gave you the job.

11] Don’t lose your voice – despite your Trust’s investment and support, you have to speak up if things are not working for you. People will listen.

12] Buy a car – you will be required to travel. Public transport is not a good idea.

13] Remember to enjoy the journey – after all, you are getting paid to learn more.

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Filed under Clinical Psychology, Psychology, United Kingdom