Clinical Handbook of Mindfulness (96 page)

issues, owing both to their disorganized structure of verbalization and

the presence of thought contents that are apparently meaningless or

have a complex and obscure meaning that is hardly understandable for

therapists.

Last but not least,

•
the general feeling of non-acceptance and foreignness to

schizophrenic people’s way of being
, which concurred in creating

a social stigma affecting and holding back clinical research, and has been

playing a definitely negative role in the attempt to engage in a psychother-

apeutic process with these patients.

Although in the past this state of things has actually been impeding the

care of schizophrenic patients, we now believe that a possible alternative

may be in the reminding of psychiatrists about their existential responsibility

for taking care of others, not just curing them.

Taking care in the sense of attending to someone, avoidance of forcing

them to adapt to an everyday pace that does not belong to them or prevent

them from planning their own existential development path. As Bruno Cal-

lieri said, such responsibility consists in “
feeling the inward duty to recover

a dimension of otherness to the alienus. . ., not quieting our conscience

Chapter 18 Mindfulness and Psychosis

345

like the Pharisee in front of the troublesome and demanding dimension

of an intersubjective relationship
.”

In this view, acceptance, compassion and a non-judgmental mindful atti-

tude are inescapable not only in handling disturbing thoughts and emo-

tions, but first of all in dealing with such severe patients, who owing to

their unfathomable manifestations are also likely to have received through-

out their existence continuous signs of non-acceptance, rejection and deser-

tion, which fed further on their constitutively strong sense of non-belonging.

A compassionate attitude will increase therapists’ awareness of the impor-

tance of the suspension of judgment (epoché), strengthening their wish to

cultivate listening instead; not as a skill to learn, but rather as a dimension

of intersubjective responsibility
(Callieri, 1984a)
where the other-from-self can be understood. Listening to who is asking for help paves the way to

understanding their message, which is rich in contents, plans and intercon-

nected truths that, though often tangled, do reveal another way to “be-in-the-

world”; saying it Mundt’s way a disturbed wilfulness, revealing great difficulty

in developing the self, the object world and processes of social reciprocity

(Mundt, 1985).

When analyzing the key components of a relationship from this point of

view, particular notice should be given to the
state of mind and attitude

of a therapist
the moment he/she
meets
a mentally ill person, particularly

a schizophrenic, as the moment of the encounter has extraordinary human,

clinical and therapeutic implications.

Running into certain psychotic manifestations for the first time can no

doubt give a feeling of foreignness, as they are alien to the usual categories

for relating to others and the world. The symbolic meaning of delusions,

certain absurd behaviours, the intrusion of the far-fetched, the reporting

of sensory experiences that are actually hallucinations, the contact with an

apparently far away inner world are dismaying experiences for psychiatrists,

who instinctively take an objectifying attitude, characterized by an aseptic

neutrality, justified by their necessity to observe and explain
(Callieri, 1985,

1993a, 1984b).
Enduring such an attitude would prevent the development of a genuine dialogue and affect the therapist’s possibility to see the one in front

of him/her as an
alter
, rather than an
alienus
; another who is constitutionally

similar to us, with whom a process can begin, leading to being together like

fellow-men (socii), rather than one in front of the other, which is a typical

stance for studying or observing.

Let us think of
Weltuntergangserlebnis
: the extraordinary and upsetting

schizophrenic experience of the end of the world, admirably described by

Bruno Callieri, where an attempt to establish an order through epitomiza-

tions will end up in an ego-world relationship melting away and total loss of

contact with logic, as well as any other element commonly characterized by

a continuity value. In a kaleidoscopic series of images, the patient will prove

to be radically out of any structures of meaning the therapist might ever share

(Callieri, 1993b).

In front of such an experience, the only alternative to reifying and tak-

ing cognizance of alienity is asserting that person’s
presence
. Being with the

other
(mitsein)
can convey the sense of sharing of an experience that may

not be understood in its components and symbols, yet is happening in that

particular moment that can therefore be shared
(hic et nunc)
, as long as such

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Antonio Pinto

experience is not considered as a private dimension. This would allow recog-

nition of the other person’s suffering in the same existential matrix as one’s

own.
Being there
can thus be a sign of shared
Humanitas
but also a
thera-

peutic element
: the presence of the other, a fellow-person, can help bridge

that broken
ego-world relationship
and allow the conveyance of structures

of meaning to be connected to symbols and contents that would otherwise

be incomprehensible. In this way
Lebenswelt
(lifesworld) is given back the

existence of an individual put away by the social world
(Mitwelt)
, offering

his/her
willingness
, which until then was “frozen” owing to psychotic rigid-

ity, the possibility to unfold and tend to the object
(protensio)
again.

Cognitive-Behavioural Therapy as an Adjunct

to Standard Care

The use of CBT as an adjunct treatment for psychotic patients seems to have

provided, in recent years, the necessary tools for shifting what we described

in theory in the previous paragraph to a clinical framework. Indeed, CBT for

psychotic patients seems to have seized and overcome some of the issues that

had been thwarting attempts to structure therapy interventions that could

give adequate consideration both to the characteristics of this kind of patient

and to the need for types of interventions that could be standardized and,

therefore, reproduced.

CBT (opportunely revisited and adapted to these patients’ specific needs)

starts from a fundamental premise: all kinds of patients, regardless of pre-

sented symptoms, can to some extent improve their subjective perception

of well-being and, as a consequence, the quality of their lives (Perris and

Skagerlind, 1994). This can only be possible if the achievement of a strong

and solid therapeutic alliance is identified as a core factor to therapy success

and is therefore set as a high-priority goal. Taking advantage of their role,

therapists can try to get to represent a “safe base” for patients, structuring an

acceptance-oriented relationship (Bowlby J., 1988). Only afterward will ther-

apists try to develop, along with patients, a programme for achieving specific

shared goals.

Collaborative empiricism, as well as giving importance to patients as think-

ing beings who are able to express sensical and meaningful ideas, are the

ingredients that make it possible to access a wide range of both cognitive

and behavioural techniques, allowing therapist-patient pairs to reduce cur-

rent symptoms or at least prevent them from thwarting an acceptable and

satisfying standard of living.

Let us outline two different CBT based approaches to this matter:

a)

The first one is based on the idea of discontinuity between normal and

abnormal functions and involves an important psychoeducational com-

ponent. Its main purposes are: strengthening coping strategies, distanc-

ing from and correcting psychotic symptoms, training in a wide variety

of social skills and psychosocial rehabilitation techniques (Tarrier et al.,

1990).

b)

The most normalizing one is based on the idea of continuity between

normal and abnormal functions and sees psychotic symptoms as the

extreme end of an experiential continuum (both delusions and hallu-

Chapter 18 Mindfulness and Psychosis

347

cinations). It aims at doing the greater job “within delusions,” in order

to seize the existential issues in them, the personal meaning underlying

delusional ideas and hallucinations and re-enact the history of patients’

development to help them go back to their living path (Kingdon and

Turkington, 1994).

Recently, there has been substantial evidence for the effectiveness of CBT

for psychosis. Since the end of the 90 s, several randomized controlled trials

have been conducted
(Kingdon & Turkington, 2005).
Some data from these findings are summarized below:

The London-East Anglia group published positive findings (Kuipers et al.,

1997). They showed benefits for CBT over usual treatment in the treatment

of people with stable psychotic symptoms.
Tarrier et al. (1998)
in a well-designed methodologically robust study tested CBT against supportive coun-

selling and routine care. Their results showed that both CBT and supportive

counselling (SC) were significantly better than standard treatment as at 3

months. CBT had a significant effect on positive symptoms whereas SC did

not. Significantly more people who received CBT showed an improvement

of greater than fifty per cent in positive symptoms. Relapse rate and time

spent in hospital were significantly worse for the treatment as the standard

group. However, it was found, after one year, that the results from this brief,

intensive therapy of this study were not significantly different from support-

ive therapy after discontinuation of therapy. In Italy,
Pinto et al. (1999)
carried out a randomized study of CBT in people who were beginning treatment

with Clozapine. The CBT group showed a significant effect in terms of overall

symptoms.
Sensky et al. (2000)
compared nine months of CBT with befriending (designed to be a control for “non-specific” therapy factors including time

spent with subjects) in an RCT. At the end of therapy, both groups had made

substantial improvements in depressive, positive and negative symptoms. In

the CBT group, further gains were made in the subsequent nine months,

whilst the befriending group scores began to return to their previous levels.

Durham et al. (2003)
have found positive but modest results using a group of CBT trained therapists who had limited training and supervision in CBT

for psychosis.
Gumley, O’Grady, and McNay (2003)
have also shown positive benefits on relapse.

In summary (we refer the reader to specialized literature on this sub-

ject), many studies have shown therapeutic effectiveness resulting from

an integrated pharmacological and psychotherapeutic treatment on out-

come and relapse prevention of psychotic symptoms. Meta-analyses (Zim-

mermann et al.,
2005)
and more than twenty randomized controlled trials

confirmed the effectiveness of CBT in reducing persistent positive symptoms

in schizophrenia
(Turkington, Kingdon, & Weiden, 2006).

Creating a Mindful Atmosphere to Overcome the “Loss

of Intersubjectivity”

One of the first things to take into account is that this particular type of

patients lacks an intersubjective dimension, that is the event of encounter

and communication (Binswanger,1928). This is considered to be one of the

main obstacles to understanding and taking care of these people: corollary

of such structural limit is the issue of therapeutic alliance, for example, the

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Antonio Pinto

difficulty in establishing a stable therapeutic relationship, which is necessary

for any structured programme to be started.

This issue has long been considered as one of the main hindrances to the

cure of these patients.

On the contrary, we believe that the therapeutic alliance should be consid-

ered as a high-priority goal to be achieved with specific tailored strategies,

rather than as a requirement for treatment; an initial lack of compliance,

which may often be a characteristic of the pathology itself, cannot therefore

be a sufficient reason not to try adequate strategies.

A Therapist’s Role

Thus, therapists have a key role, as they themselves are required to become

tools for therapy. Indeed, as mentioned before, a mindful and compassionate

attitude towards the patient can indirectly contribute to convey the essence

of a mindfulness-based approach from the very beginning of a treatment,

before explicitly goal-oriented psychoeducational phases can begin.

From the first crucial phases of the encounter, therapists must help their