Mindfulness for Distressing Psychosis

Professor Paul Chadwick

Institute of Psychiatry

King’s College, London

Mindfulness • Origins in Buddhism• Mindfulness-based intervention is psychological

practice that sit outside Buddhism• Not a set of beliefs (not an ‘ism’) – nothing that

you are asked to believe (empirical) • Practice of easing distress/suffering by learning

to relate to experience in a different way• Swept physical and health care worldwide: (i)

100s of millions in research grants, (ii) 700 journal publications in one year!

Mindfulness for psychosis

• And yet…mindfulness for psychosis very slow to develop

• UK & USA: very little research and clinical practice

• Very pleased to collaborate with staff at Serralta Rehabilitation Unit & University of Balearic Islands: Ovidio Fernàndez, Antoni Mayol, Enric Munar, Josep Luís

Why are things so slow?

• Widely held perception that meditation is harmful for people either vulnerable to, or currently experiencing, psychosis

• Small literature on meditation & psychosis – not evidence-based

• Parallels between subjective reports of meditation states and psychosis

• General reluctance to bring developments to people with psychosis

Adapting mindfulness

1. Not ‘should we offer Mindfulness’, Yes or No2. “How can we adapt mindfulness practice to be

safe, acceptable and therapeutic for people with psychosis”

3. Intention is to support clients to develop a new relationship with distressing voices, thoughts, images, feelings

The practice• 10 minutes• Avoid long silence: Guidance every 30-60 seconds• Refer to psychotic experience during guidance• Establish an anchor (body, breathing)• When voice, thought etc in foreground – stay with it until

fades/passes. Not attempt to pull awareness away• Rest awareness in breathing when not drawn by voices,

images etc.• When get lost, reconnect with body & breath, and open

out again• Combines focussed attention with open awareness

A model to guide the process

Fear of changing relationship

Omnipotence of voices (Chadwick & Birchwood)• Bauer (1979): Voices are imbued with a

‘terrifying and compelling quality’ and individuals feel ‘caught in their power’

• 80-90% of voices experienced as omnipotent • Linked to depression• If working therapeutically with distressing voices,

need to address omnipotence early on

Testing metacognitive Beliefs

• Metacognitive beliefs are fears about consequences of changing relationship, letting go of coping

• Kathy: “Unless I react to my voice and images I will lose contact with reality and my family altogether”

• Sue: “If I stop fighting the voices they will come back in a new way, even stronger, more powerful, and I wouldn’t know what to do”

• Mindfulness practice as a behavioural experiment• Practice & Guided reflection after each practice aimed at

new metacognitive insights (John Teasdale)• Sue: “When I can let go of fighting I feel calmer, more

peaceful, more in control”

What is mindfulness really?

• ‘What is Mindfulness, really…we see people who say, “I’m being very Mindful”, and they’re doing something in a very methodical, meticulous way. They’re taking in each bit of food and they’re lifting, lifting, lifting; chewing, chewing, chewing; swallowing, swallowing, swallowing…but he may not be Mindful at all. He’s just doing it in a very concentrated way; he’s concentrating on lifting, on touching, on chewing, on swallowing. We confuse Mindfulness with concentration…Mindfulness is always combined with wisdom’

(Ajahn Sumedho, 1992, pp. 31-32)

Maximising learning

• Meditation practice and guided learning equally important

• Actively supporting metacognitive insights that alter relationship with psychotic experience, and support self-acceptance

• Vital because clients with psychosis don’t suddenly stop reacting: Chris 2 or 3 times in 10 minutes

Mindfulness group format

• Two 10 minute practices

• Socratic questioning to support discovery after each practice to maximize learning

• CD for home practice

• 3 minute breathing space (MBCT)

• Conceptualize as therapy, not skills class

• All groups follow Yalom’s (2005) Theory and Practice of Group Psychotherapy.

Mindfulness groups: Study 1

• Clinical service, people with complex presentations, high risk, long-standing unremitting psychosis

• 6-7 weekly sessions plus home practice• N=11 (7m, 4w, mean age 33, 10 unemployed, 1 student)• All distressing paranoia, 5 voices, 5 other halls (>2 yrs)• Primary outcome CORE: significant pre-post

improvement • Encouraging finding given literature – meditation harmful

[Behavior & Cog Psychoth, 33, 351-359]

Pilot Study 2

• N=22 (13w, 9m) all unemployed; mean age, 41, duration of illness, 17.7 years

• All distressing voices > 2 yrs, 19/22 distressing paranoia

• Therapy: twice a week for 5 weeks plus home practice, followed by 5 weeks home practice

• Primary outcome CORE: Significant pre-post improvement (n=15)

• Significant pre-post improvement in mindfulness of distressing thoughts & images – but not voices

[Behavior & Cog Psychoth, 37, 403-412]

Pilot 3: CBT + Mindfulness• One 10 min practice plus CBT (Omnipotence &

beliefs about self)• Unremitting distressing voices >2 years

(average 14 years)• 64 began a group (26m), mean age 41: 88%

schizophrenia/SAD; 8% psychotic depression• Primary outcome CORE: 54% showed reliable

clinical change at follow-up

(Dannahy et al, Journal of Behaviour Therapy & Experimental Psychiatry, 2011)

Measuring Group Process

Rank order from most-least helpful statements from Yalom relating to 8 therapeutic factors: some examples

• Helping others and being important in their lives (Altruism)

• Belonging to and being accepted by a group (Group cohesion)

• Learning how to express my feelings (Catharsis) • Learning to respond mindfully to thoughts,

feelings or voices (Guidance)

Group process: Findings

Mindfulness & Universality (Discovering that others have similar problems) consistently rated two most important

So group process is important, as well as learning specific mindfulness skill

A new relationship with psychosis?

• CORE indicates clinical improvement – but a new relationship with psychosis?

• Qualitative study (Abba et al., 2008: Psychotherapy Research, 18, 77-87)

• Describe psychological process of freeing themselves from tyrannical relationship with psychosis

The tyranny of psychosis

• Powerlessness & fear

• Struggling for some quality of life & at times very survival

• Little or no hope

• Sense of self defined by psychosis as: bad, different, abnormal, worthless

• Main focus of attention & energy – even when absent

Experiencing how to relate differently to psychosis

Centering in awareness of voices, thoughts,

images in the moment

Allowing voices, thoughts, images to come and go

without reacting/struggle

Reclaiming power through acceptance

Opening awareness to include

the unpleasant

Beginning again and

again

Anchoring awarenes

s in breath

and body

Not trying too hard

Concent-rating

gently on what is present

Re-connectin

g with present

experience

Letting go of judgement, fight, worry,

analysis

Seeing my role in

alleviating distress

Catching myself in habitual reactions

Relaxing into a

peaceful, calm state

Recognizing consequenc

es of reacting

Realizing emotional

consequences of letting

go of habitual reactions

Accepting voices,

thoughts, images

Accepting myself

Feeling more in

control of my mind

Deflating psychosis

Knowing I am more than my

psychosis

Discovering that I am

not different

Gracias

¿Alguna pregunta?