Clinical Handbook of Mindfulness (98 page)

ability to be loved and accepted, their difficulties in interpersonal relations;

of others’ behaviour towards them and of others and their behaviours in

general.

It will also be important to get more information on patients’ opinion on

their own disorder, (making sure to focus on “problems” rather than symp-

toms), their reaction towards it and their symptoms.

Discussing these matters may cause specific dysfunctional assumptions to

emerge and, if identified, they would no doubt help decode and better under-

stand the content of certain delusions and hallucinations, besides explain-

ing the reason for the patient’s apparently inexplicable behaviours (Fowler,

Garety, & Kuipers,
1995;
Bedrosian & Beck, 1980).

Furthermore, since clients’ negative experiences and convictions about

themselves often produce issues of stigma and consequences for personal

and social adjustment, such as isolation and lack of social skills, thera-

pists encourage them to identify their negative schemas and more effective

assumptions and behaviours will be gradually discussed and introduced later

on
(Perris, 1989).

This work of exploration and understanding can be done harmoniously

integrating mindfulness within a cognitive-behavioural approach. Coherently

with the extensively validated CBT procedures for psychosis, initial work

shall be done (at least with some patients) exclusively’ “within delusions,”

while any cognitive defusing techniques shall be put aside. Whereas it will

be possible to give attention to what comes after delusional ideas, that is,

their emotional and behavioural consequences on patients.

Another possible step is highlighting the subtle, yet fundamental dif-

ference between ruminations (which cannot lead to solving a problem

and are therefore a source for ongoing and self-feeding stress and anxi-

ety) and a problem-solving oriented thinking, providing that patients are

shown attention and interest in the ideas and issues that cause them suf-

fering, as well as in their private truths
(Lorenzini & Sassaroli, 1992),
making sure to never make them feel judged or ridiculed. They shall also

be shown a willingness to accept and share the troublesome situations

they find themselves in (no matter how plausible they are), trying to find

together a sense that can be reconnected to significant moments of their

evolution.

Here is an example of what can be said to patients:

I understand that the things you told me about represent a problem for you.

Though if at the moment there does not seem to be a way to solve them,

although having tried to find one, it is pointless to ceaselessly think about

them, or you would feel even more worried, distressed and anxious. It would

be more useful to learn how to distract yourself, letting all those troublesome

thoughts go. Then, when you feel ready and want to, we can go back to

them. I know it is not easy, if I had the same problem myself I would as well

think about it all the time but, in all fairness, I know it would be useless.

Mindfulness can be of help here
.

Chapter 18 Mindfulness and Psychosis

353

A delusion can contain a patient’s whole life and all its issues, thus, delu-

sional thinking might be the patients’ only way to find explanations about

how the world works, while at the same time preventing the deepest cores

of their identity to collapse into fragments. It is therefore crucial not to run

the risk of leaving them destitute of the importance of what they believe

in, until they have developed some new interpretation key (Lorenzini & Sas-

saroli,
1998).

A non-judgmental, mindful attitude shall be shown towards patients’ states

of mind and actions, which will nurture their self-esteem and sense of per-

sonal worth.

Patients can be very tense and anxious owing to the great discomfort origi-

nated by their delusional ideas and, since stressful situations may in turn trig-

ger relapses or reinforce symptoms
(Morrison, 1998),
they will be helped not by being overwhelmed by ruminations and problems that cannot be solved

straight away, but by taking advantage of the practice of keeping anxiety at

a minimum and of an increased ability to accept and tolerate it for what it is

(Williams, 2002).

We believe that, at this stage, patients will be more willing to temporarily

set certain thoughts aside, becoming more aware that if they are not over-

whelmed by them but allow them smaller space and time during the day,

their suffering can be reduced.

In this way we address the following purposes:

• narrowing the existential gap between patients and the rest of humanity,

caused by feeling alone, not being understood and/or being negatively

judged for their way of thinking

• sharing their “private truths,” creating an opportunity to work together

on them

• nurturing their hope for an actual solution of the problem they have been

long been going through

• increasing their willingness to accept the idea of cognitive defusion, as

it does not require them to give up any of those parts of themselves and

their history that lay beyond delusions and represent the centrepiece of

their existence itself.

Proposing a Change

As soon as a therapeutic relationship is well-established and a patient can

feel the closeness of his/her therapist, as well as his/her sincere willingness

to help, he/she can be guided to the possibility to detach from disturbing

thoughts and emotional states.

As we mentioned in the previous paragraph, patients are not required

to be more or less aware of being ill. In fact, from a therapy viewpoint, it

can be seen as a success, or at least a good outcome if they just accept to

freely talk about their delusional ideas and hallucinations without hesitating

or being afraid. Indeed, patients are often afraid to lay themselves bare; they

may in fact worry about being negatively judged because of their “strange”

thoughts or the unusual sensory phenomena they experience. They can also

feel ashamed or embarrassed about being eventually called crazy. Their lives

have taught them that their thoughts can make others become distrustful

354

Antonio Pinto

and hostile, insomuch that they can be threatened and verbally or even phys-

ically assaulted. In fact, forced hospitalizations have often occurred as a con-

sequence of patients’ behaving coherently with their view of the world or

of their attempt to find confirmation of or share the existence of the voices.

Their weird and bizarre, sometimes restless behaviours indeed scare and puz-

zle people around them, who in turn feel threatened.

Thus, the first step with these patients is get to persuade them that they

can freely talk to us, since we will consider their thoughts equally valid

as those of any other person. Perris has already talked about conveying to

patients and their families the importance of an approach based on learning

how “
to substitute symptoms to treat with problem to solve
”
(Perris, 1989).

The normalizing approach of CBT for psychosis represents the conceptual

basis to start from: delusional beliefs and hallucinations differ only quanti-

tatively from processes that are common among all individuals (Kingdon &

Turkington,
1991, 2005).
Hence, delusional thoughts can trigger emotional and behavioural responses, just like any other kind of thoughts, becoming in

turn an actual source of discomfort.

It is though commonly acknowledged that many problems cannot be

solved immediately, nor in the desired way, yet it is possible to find ade-

quate strategies to keep stress derived from a persisting unresolved issue at

a minimum.

There is no doubt that delusions and hallucinations, as well as their emo-

tional and behavioural consequences, represent the biggest issues for psy-

chotic patients, who, with time, developed their own personal ways to react

to or avoid them. Indeed, both pharmacological and psychosocial interven-

tions in general have often been programmed in an attempt to extinguish,

or at least dramatically reduce symptoms but, paradoxically, in certain cases

symptoms ended up being exacerbated
(Morrison, 1994;
Morrison, Haddock,

& Tarrier,
1995)
and in others, little or no result was reached, while, on the other hand, new maladaptive behaviours and unpleasant sensations arose.

Thus, it would be very useful if patients could learn how to deal with such

material in a new way, if it were suggested to them that, very often, the most

stressful and disturbing consequences they experience are not triggered by

symptoms, but rather by their response to them.

A typical example is the so feared and fought hospitalization, which on

most occasions is not executed due to a relapse, but because of the way

patients behave as a reaction to the voices (bothering others, hurting them-

selves/others and so on)
(Rogers, Anthony, Toole, & Brown, 1991).

For this reason, it shall be explained to patients that the core of their issue

is not a symptom but the way they choose to respond to it:
voices
or
thoughts

do not have the power to autonomously operate on reality, so they cannot

harm them, nor anyone else.

We ask patients to perform an accurate description of their symptoms, feel-

ings and sensations in general, paying attention to any subsequent reactions.

They will surely notice how some of their behaviours respond to certain phe-

nomena and aim at exercising some sort of control over them. Drug, alcohol

or medication abuse, for instance, reflect their need to lower the high levels

of tension and anxiety that are triggered by troublesome situations, while

obeying the voices may make patients feel safe from eventual frightful con-

sequences
(Birchwood & Chadwick, 1997).

Chapter 18 Mindfulness and Psychosis

355

In other words, patients can gradually gain greater awareness of their own

responses to the voices or to stressful thoughts, yet they will be invited not

to oppose, but rather just notice them, as they will flow away themselves,

gradually becoming less intense and eventually disappearing, just like any

other feeling. It would indeed be impossible to hold feelings back, even if we

wanted to, yet patients might have never had the chance to experience this.

Mindfulness needs to be explained to patients, what it is for and how it can

represent a new possibility for them to deal with stressful experiences. The

practice of mindfulness can help them to not be overwhelmed by the images,

unusual thoughts and unpleasant feelings they continuously run into. There

is in fact no way to prevent anything from getting into our minds, so the

real challenge is to learn not to try and hold feelings back (they are doomed

to pass away) but relate to them in a different way: attentively addressing

feelings and sensations, even the unpleasant ones, being curious about them

instead of fighting against or avoiding them or trying to make them disappear

(Chadwick, 2006).
Encouraging patients to carefully and curiously observe their feelings and sensations will lead them to see how they continuously

change; indeed, as an example, voices will seldom be found to persist for a

consistent length of time.

After mindfulness has been explained, patients shall be invited to spend

some time focusing on their breath and body, with no lessons, but just being

guided towards an increase of their level of awareness. Then, their attention

shall be gently brought to whatever comes up, not opposing any kind of

sensation, be it pleasant or not. We shall remind them that as they address

sensations or anything else that may come up, simply noticing them without

judging, their stress decreases. Practically, patients are able to awarely accept

the experience of hallucination for what it is, without adhering to its con-

tent but instead keeping sufficiently detached from it; bearing in mind their

project of life and plans and stay focused on their sources of well-being and

satisfaction, and they will gradually realize that they can achieve their life

goals, regardless of their unusual sensory experiences.

We highlight the importance of staying anchored to their values and core

life purposes, as this can be an effective tool not to be entangled in rumi-

nations or chain reactions. Patients who bear in mind what is important

to them (interpersonal relations, achieving and maintaining some degree of

autonomy, economical independence and so on) feel more motivated to keep

focused on the behaviours that are useful for achieving their goals, rather

than letting their choices and behaviours follow the urge of delusional beliefs

(Pankey & Hayes, 2003).
Hence, any patients not having clear ideas on this matter must be helped identify possible goals to be achieved.

We emphasize once again the importance of integrating goal-oriented CBT